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Identifying and responding to populations who are vulnerable to poor sexual and reproductive health (SRH) is crucial during the COVID-19 pandemic. The pandemic has given rise to new context-driven vulnerabilities, emerging due to wide-scale changes to the delivery of sexual and reproductive healthcare and broader psychosocial impacts. We outline such vulnerabilities and actions for continuing to monitor and respond to their emergence.

New vulnerabilities emerging from changes to service delivery

Public health messages to reduce non-essential use of NHS services may have impacted SRH, with reports of cessation of pre-exposure prophylaxis (PrEP) and contraception during early lockdown. Closure of some smaller SRH clinic services may disproportionately impact those who require face-to-face consultation but rely on service proximity. For example, those with physical or learning disabilities, or living in coastal and rural areas and reliant on public transport.

Remote delivery of SRH services has included telephone and digital-based approaches, combined with postal and pharmacy-delivered interventions. Expansion of online STI testing services may improve overall uptake, with public health messaging promoting testing during the pandemic. However, reliance on postal delivery and return may impact testing-to-treatment times, creating new vulnerabilities among those struggling with abstinence during this window. Those without a private postal address may also be deterred from using online services.

Lack of access to devices, telephone credit or the internet may also hinder remote service use. This may particularly affect those living in poverty or destitution; or those without the digital, literacy or English language skills needed to navigate online services. Remote access may also be hampered by privacy concerns, although anecdotal reports suggest that changes to remote early medical abortion provision have improved access. This has even been the case for those with abusive partners.

New vulnerabilities emerging from wider psychosocial impact

Difficulties in accessing SRH provision may interact with the wider psychosocial impacts of COVID-19. Ongoing school closures combined with the closure of walk-in clinics has left school-age adolescents reliant on online services, which may be difficult to access due to privacy issues. It is heartening that 76% of services that responded to the British Association for Sexual Health and HIV’s (BASHH) Clinical Thermometer survey ‘identified young people requiring face to face care as their top priority’ (1). This has been in response to reduced uptake among young people of adolescent age – distinct from those aged 20-24 years, amongst whom no decrease in uptake has been noted.

The risk of sexual exploitation has also increased, especially for adolescents, children, women, disabled people and those who identify as LGBTQ+ (2). Financial destitution may have increased the risk of transactional sex in exchange for food, shelter, drugs etc. Commercial sex workers, for whom sex work may be their only source of income, have been forced to make difficult decisions about continuing to work (3). Anecdotal evidence suggests that they are taking greater risks and are at increased risk of assault (4).

The COVID-19 pandemic has seen an increase in reports of domestic abuse (5), which may be fueled by financial hardship, reduced access to support networks and greater time spent at home (6). Opportunities to identify safeguarding concerns may be limited by the reduction in face-to-face services. Conversely, anecdotal reports suggest antenatal services may more effectively identify domestic abuse, as partners are not permitted to attend due to COVID-19.

Looking ahead

The collective efforts of all SRH stakeholders are vital to identify and respond to emerging new vulnerabilities, particularly as some service changes become the ‘new normal’. Equally, it is important to recognise and campaign to maintain changes in provision which have improved access and uptake. Data capture is vital to support both efforts. As a community we must remain flexible, and learn from each other. Improved telephone safeguarding skills, already implemented by some services, are vital. In addition, new measures to re-open some walk-in services and conversely enhance remote provision for complex cases ordinarily seen in clinics, may be necessary. We must continue to offer delivery choices and to identify and reduce barriers to care. Many who are facing new vulnerabilities are already rightly being recognised by BASHH as having priority for access to face-to-face care (1). It is critical that these new vulnerabilities are accounted for by commissioners and providers as services are restored and transformed.

Written by

Dr Ahimza Thirunavukarasu, [ST4 Public Health Registrar, London & South East Deanery] 

Dr Natalie Edelman, [Senior Research Fellow, School of Health Sciences, University of Brighton] 

Dr Natalie Daley, [ST4 Public Health Registrar, West Midlands Deanery]  

Natalie, Ahimza and Natalie are members of the FPH Sexual and Reproductive Health Special Interest Group.  

(1)https://members.bashh.org/Documents/COVID19/Principles%20for%20Recovery%20of%20Sexual%20Health%20Draft%2008.06.2020%20-%20for%20website%20upload.pdf

(2)https://shellfoundation.org/news/how-to-retain-safeguarding-measures-during-covid-19/

(3)https://www.bbc.co.uk/news/uk-wales-52706165https://www.bbc.co.uk/news/av/uk-england-hampshire-52937603/coronavirus-sex-workers-at-greater-risk-of-assault

(4)https://www.theguardian.com/society/2020/apr/12/domestic-violence-surges-seven-hundred-per-cent-uk-coronavirus

(5)https://www.bmj.com/content/369/bmj.m1712

(6)https://members.bashh.org/Documents/COVID19/Principles%20for%20Recovery%20of%20Sexual%20Health%20Draft%2008.06.2020%20-%20for%20website%20upload.pdf

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Since the outset of the first industrial revolution, the West Midlands has built a track record of “can do” inventiveness and innovation. It’s what powers us to bounce back from adversity. Our region’s people are resilient and accustomed to working in ways we now call “agile”.

There is a determination to rebuild from this pandemic stronger than ever. As a mark of our ambition, the West Midlands Mayor, Andy Street, has put forward a £3bn package of urgent investment for the Government’s consideration. It proposes immediate action on everything from active travel to community health and wellbeing via 5G connectivity.

While big investments in active travel infrastructure and fuel poverty retrofit insulation of homes will undoubtedly have public health impacts, we are especially interested in the proposed Radical Health Prevention Fund. Here are plans for a £23 million investment in community-based health promotion and prevention of ill-health and community-based diagnostic centres. The intention behind putting forward these investments is to kick-start an upgrade in prevention work, with a focus on reaching groups in our society most at risk.

For us, recovering from COVID-19 means reconnecting with communities – rethinking how we live and work to protect our environment at the same time as we grow our economy. The potential for improving health and wellbeing and reducing inequalities is invigorating.

As the coronavirus response showed, we are fortunate to have an active, competent public health workforce able to work alongside key workers elsewhere in the system. Working with the NHS, local government, social care, voluntary sector and many more, they can and do target key drivers of health inequality.

The £10 million investment sought to equip public health with cutting edge advances in digital and data driven health will lead to a healthier workforce and more engaged citizens in the West Midlands.

Our recent experience has demonstrated just how much the public needs greater access to diagnostic and treatment services and our public health service needs access to the results faster. In our region there are significant health inequalities and there is a need to provide quicker access to diagnosis and treatment to those with life threatening conditions. This is an essential part of prevention, helping everyone to stay healthy longer and helping people of working age to remain in employment as long as possible. On both counts, the economy benefits, and quality of life is better.

We foresee people getting tests done in their daily commute or during their daily shop, with centres in everyday places like transport hubs and shopping centres. The proposed first location for a new centre combines both – the Grand Central retail complex above our busiest railway station.

The £13 million investment will help embed diagnostic and treatment services throughout the community and redefine care pathways to improve accessibility of screening.

We have come through a COVID-19 wave of infection at great cost – in lives lost, personal trauma and a broken economy. The future is unknowable, but we must be prepared for a second wave of this coronavirus or the next novel, unforeseen threat to the public’s health or the intensifying health risks associated with climate change.

In the past, our discussions around health have too often been limited to hospital patients and new treatments. In future, we want people to think and talk more about wider determinants of health, upstream interventions and preventive approaches as well. Only then will we fully embrace all the pillars of public health: health promotion, health protection and equitable access to healthcare supported by science, data and academic public health.

From now on, national and local agencies need to operate as one, seamless system, with Central Government working in collaboration with Local Government, local NHS organisations and local communities. Surely now, there must be a recognition of how inequality leads to increasingly unfair outcomes within our society – with no greater unfair impact than disproportionate rates of death.

The greater impact of the pandemic to date on those who are socioeconomically deprived or from black, Asian and minority ethnic groups has been stark. Resources must be directed to those communities that most need them. In future, we want to work to protect vulnerable groups by working with them, fully engaging communities in decision making and utilising the skills and expertise they offer.

In recovery from this gravest of threats, we have a second chance to get things right. That means taking this window of opportunity to step our efforts up not down. We must work together to get the funding right, the data sharing right, the contact tracing right and the involvement of local communities right. The West Midlands region will build on its unique heritage and distinctive strengths and seize the opportunity to reset, rebuild and recharge our region so we come back even stronger.

 

Written by

David Kidney – Chief Executive, UK Public Health Register and Executive Chair of the proposed West Midlands Health Technologies Cluster

Lisa McNally, Director of Public Health, Sandwell

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Writing a blog about Coronavirus, I confess to feeling slightly odd that I am not reporting from the frontline of the NHS. As a medically trained Public Health consultant, my name is down on the reserve list to get back in to scrubs if more resources are required. However, I am also incredibly aware that the job I am doing in my shed cum office at the bottom of the garden, is providing Public Health support in a way that I could only hope might be possible when I was an over enthusiastic Public Health registrar. 

I work for a company who are pioneers in providing health and insurance services to millions of people living in emerging markets. People who have previously been excluded from traditional health insurance models and who lack access to decent healthcare. The company has developed simple, affordable mobile delivered health insurance for people in developing countries, where there is often little or no public health system. And the reason that I work in my garden shed for them is because they also provide a mobile Health service (mHealth) – teledoctors and digital public health programmes – to millions of people across the Globe. My role is to design and write tailored and relevant health programmes, and to work with the technical brains of thcompany to get them out to as many people as possible, across as many digital channels as people are able to access.  

As I write, Coronavirus cases are increasing in many of the countries where we work, with particular cause for concern in Bangladesh and Pakistan. From a teledoctor perspective, we have increased capacity and are braced for high demand for these services, not least because people are unable or unwilling to utilise their local clinic for non-coronavirus health issues. In Pakistan, we are partnering directly with the Government to bolster their health service offer. For our health programmes, we are running as fast as we can to get information out on prevention, local guidelines, dealing with symptoms, mental and physical wellbeing, with some myth busting thrown in for good measure. I have to write an easily understandable, actionable message in 160 characters or less to fit the parameters of our SMS allowance (never have words seemed so valuable or so long!). Cultural context must be accounted for and the fact that my English version will be translated by our local teams in to languages such as Bengali, Urdu and Twi, before being sent out to millions of people who do not have an NHS equivalent, and who have limited reliable sources of information beyond this SMS delivered to their mobile phone.  

Coronavirus has also been the catalyst for putting out our health messages to people who do not have insurance in the countries where we work. Through websites, apps, Facebook, Instagram, and WhatsApp, these evidence based health messages are translated into visual images that allow people with smartphones the opportunity to gather reliable knowledge as to how we can all effectively fight this pandemic. 

In the UK, I think that we are still wary of digital health. We have heard about virtual doctor surgeries and the concerns that they are not as effective as in person consultations. I think that as we become more comfortable with technology, these concerns will diminish. This global pandemic is in a way aiding this adoption process. In the Countries where this mHealth service is working, we are already filling a gap where the number of doctors per head of population is simply not compatible with offering everyone who needs it an in-person consultation, particularly in the face of a global pandemic. Furthermore, providing accurate, personalised, health information to millions of people through their mobile phones has the potential to revolutionise our approach to ensuring population health. For coronavirus, these messages are designed to encourage people to keep safe and well by following the best guidelines, based on the best evidence that we have.  

If I am called back to the NHS frontline, of course I will go. But whilst I am in my shed, if our work is able to alleviate even a small amount of the stress on overstretched health systems around the world in the coming months, I am very grateful and proud to have had the opportunity to contribute to such an essential endeavour. 

Written by Rebecca Cooper

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The recent guidance published by the UK Government on mental health and wellbeing during Covid-19 was a welcome addition to the various guidance and resources provided to support us to manage the pandemic.

There is no public health without public mental health, and communicable disease control is no exception.

Direct impacts of the virus through illness, loss of loved ones, and anxiety around contagion are mixed with the effects of control measures – self-isolation, social distancing, and changes in social and material circumstances can all have a detrimental effect on mental health and wellbeing and also have the potential to widen existing inequalities in mental health.

As public health professionals, our role is to manage the acute response to the virus and mitigate its short-term effects, and also to ensure that wider systems are in place to protect against collateral damage and support the ‘recovery and repair’ phase and beyond. From a public mental health perspective, this means providing advice and guidance on how to maintain wellbeing during the pandemic, ensuring access to further support when required (including maintaining access to services for those currently receiving care), and using the opportunity created by the pandemic to embed resilience and wellbeing at a population level over the longer term.

As well as limiting the harm directly caused by Covid-19, we need to be vigilant for where control measures may exacerbate existing adversity or place people at additional risk. Where someone’s home is not a place of safety, or when they do not have ready access to essentials such as food and medicine, social distancing and self-isolation may place them at greater risk of harm. In addition, now is a good time to consider information about the impact of stress and social isolation on harmful health behaviours (e.g. smoking, alcohol and substance use), mental health and even the immune response.  It may also be appropriate to examine the links between external stressors and the incidence of domestic violence and child abuse.

While much of the current focus is understandably on mitigating the harmful impacts of the virus, a number of unexpected positive impacts have emerged as a result of social distancing measures. Communities have mobilised to support those who are alone and vulnerable. Increases in remote working have led to improved air quality and better work-life balance. Innovative use of technology has widened access to events and the arts. Exercise has been reframed as an opportunity rather than a chore, with people keen to enjoy being outdoors. Sustaining improvements in social capital once the pandemic is over and harnessing these benefits in a way that includes everyone, particularly the most marginalised, is key to promoting cohesion and wellbeing in communities.

Because we are part of the populations we serve, and have the same challenges, worries and limitations this also means being a role model. Looking after our own wellbeing is something we often neglect particularly in times of crisis, but now it is especially important. While much of the world slows down, workload has increased for many working in public health, whether at home or in the office and whilst we may secretly want to be, we are not superheroes. We are parents, carers, spouses, friends. Some of us may be vulnerable or even extremely vulnerable to the effects of Covid-19, or have loved ones that are. And just like anyone else, we can be scared, anxious, exhausted and overwhelmed.

Our own health and wellbeing is vital to being able to give the best service we can, and so taking our own advice becomes as much a matter of good public health practice as one of individual necessity. Those of us with management responsibility also have a duty of care to our teams, and to ensure that we model good practice as well as support them to stay well and healthy at work.

The Public Mental Health SIG is collating information and resources on maintaining and enhancing mental wellbeing and on mental health more generally, in times of Covid-19, which can be found here.

This addresses the wealth of evidence and good practice currently available to support and improve population mental wellbeing, which can be drawn on in relation to both the acute response and the legacy impact of Covid-19.

While the ‘normal’ we go back to may look quite different to the one we left behind, we know what works – the challenge will be in how we apply that knowledge to take care of ourselves and others.

Written by Lina Martino, Chair of FPH’s Public Mental Health SIG

With thanks to Professor Sarah Stewart-Brown (Professor of Public Health, Warwick University) and Dr Vaishnavee Madden (Consultant in Public Health, Ealing Council)

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Summary
Each day that public health in England fails to adhere to basic public health control methods the cost to the country grows. Public health’s reactions to the epidemic have been hesitant, limited, centralised and unconventional. It is as though the senior staff still think this is an influenza epidemic. Now is the time for an ambitious public health response. The government say they are following scientific advice. Our public health leaders should listen to colleagues in the far east and to Public Health Directors in our own local authorities.

Public health in England is quite capable of seizing the opportunity and rapidly

  • Reorienting its purpose from mitigation to control and elimination
  • Setting up a robust case finding and contact tracing function at local authority level
  • Devolving disease controls to local authorities to allow divergent and locally appropriate responses to future outbreaks
  • Requiring the control of travel where necessary
  • Explaining that control must precede easing of physical distancing measures and this will be achieved quicker in some parts of the country than others
  • Explaining the key role each member of the public has if they become unwell.

Introduction
According to the Office of Budget Responsibility (OBR), the GDP in the UK will shrink by 35% in the second Quarter 2 of the fiscal year on account of the COVID-19 lockdown. The cost during the period of ‘full lockdown’ from 23rd March to 7th May will be about £92 billion. This is equivalent to £2 billion a day (1). Is there anyway the public health measures in the UK could have reduced the lockdown period and saved some of this cost? What strategy will minimise costs in the future?

Different countries have used alternative approaches. The successful ones so far have gone for elimination not mitigation. Elimination requires rapid isolation of all known cases and contacts, which in turn requires prompt identification of cases and contacts within hours not days. Successful control means universal physical distancing is not necessary because targeted isolation of cases and contacts is sufficient to curtail the epidemic. This level of control has been achieved in countries using this approach (2–6). How successful has public health in England been in each phase of the epidemic?

Phases
The COVID-19 epidemic can be considered to have three phases – (i) the containment phase which seeks to eliminate the virus infection from the population, followed if this fails by (ii) the mitigation phase, which in many countries including the UK has matured into a suppression phase, which seeks to minimise the effects of the epidemic by suppressing transmission, followed when successful by (iii) the control phase which seeks to re-establish containment.

Containment phase
WHO declared the outbreak was a Public Health Emergency of International Concern on 31st January and in the UK the containment phase was abandoned seven weeks later on 23rd March. The first case was identified on 1st January and by 23rd March 5,683 cases had been identified including 335 hospital deaths. Public Health England (PHE) has not published details of what exactly it did during this phase, but one can assume it was case finding, contact tracing and isolation of travellers from infected countries. Apparently, this activity stopped when the containment phase was abandoned. The failure to contain the epidemic at this stage has cost the country a massive sum both in terms of health and socio-economic wellbeing.

Mitigation phase
The lockdown began on 23rd March. It has succeeded in supressing transmission to the extent that the NHS has not been overwhelmed. Five weeks into the mitigation phase while the rate of new deaths is falling there is no control of the epidemic. Control requires an understanding of the state of the epidemic from surveillance, complete case finding and contact tracing. What could have been done to gain control of the epidemic during this phase?

Surveillance
For the first time since the start of the epidemic on 23rd April PHE published a COVID-19 surveillance report describing details of the available surveillance data (7). The report, updated weekly, contains no analysis and minimal commentary. It contains no mention of:

  • An estimate of the number of actual rather than known cases by age and sex
  • The number of contacts traced per case by risk category, average time since case identification, test result and trace failure
  • The specificity and sensitivity of the tests in use
  • An estimate of the number of asymptomatic cases
  • The current reproduction number for each region
  • The number, size and location of outbreaks.

These figures are required to gain an understanding of the epidemic and its control. Some countries provide these estimates on a daily, weekly or fortnightly basis.

Case finding and contact tracing
No system of notification and control

Case finding and contact tracing were abandoned at the start of the mitigation phase for no publicised reason. Perhaps public health wanted to reserve tests for NHS cases. Testing never has been an essential component of case finding in public health and a shortage of tests is not a valid excuse to stop contact tracing. The European Centre for Disease Control (ECDC) has updated guidance on contact tracing with or without testing (8). PHE still has not provided similar information needed to build up the system here:

  • A case definition and recommended follow up actions
  • Contact definitions and recommended follow up action
  • A streamlined notification system including a database system such as the WHO’s Go.data tool to assist staff at local level and staff centrally
  • Instructions for 111 call centres, GPs, hospitals and care homes to use the database.

Too little, too late
On 24th April the Government announced the recommencement of case finding and contact tracing in England. A meagre 18,000 people will be involved initially. Much reliance seems to be placed on a new and untested smart phone application. The number to be recruited seems symptomatic of the inability to appreciate the need to control the epidemic and how to do this expeditiously and at scale.

The number of people required to successfully identify, test and contact trace varies from local authority to local authority (9). The number of staff required will fall as the number of new cases falls, which in China in provinces other than Hubei was 5.5% a day after the peak of cases (5). A recent report taking into account changes in case definition suggests a decay rate of 18% a day (10). In two weeks’ time by 6th May the numbers will be 1.6/1000 population or five times the number proposed by the Government (Table 1). Staff numbers required will be less if the decay rate is nearer 18% so the numbers for the 6th May in Table 1 are conservative. If our lockdown measures are less effective than in China then the staff numbers required will need to be somewhat higher.

Table 1 – Personnel required to test and trace contacts by English region

table1

Not going local
If contact tracing had been built up from the start, it is clear from the regional figures in Table 1 that the East of England, the North West, the South East and the South West with half the number of deaths for their size as compared to the other regions would have been able to handle the number of cases by now. The economies of these regions which represent two thirds of the nation’s population could have been gradually resumed between 22nd April and 28th April.

The remaining high incidence regions should have been able to take control soon after 6th May. There would not have been the need to maintain economic shutdown after that date if the contact tracing system had been built up and working.

The socio-economic cost of the public health strategy so far
The cost of the lockdown from 23rd March to 7th May will be about £92 billion. The lockdown could have been eased 14 days earlier in the low incident regions if they had taken control of the epidemic then. This would have saved £15 billion of the lockdown cost (Table 2). Each day the lockdown continues past 7th May will cost an additional £1.7 billion.

Table 2 – Estimate of cost of delayed control of epidemic in England

table2

Getting back on track – the potential gains
The control phase
Each day the control phase is delayed will cost the country £2 billion. But the control phase can only safely be initiated when the mitigation phase has reduced new cases to a level which can be handled by case finding and contact tracing.

This phase will be difficult and will need to last until herd immunity stops transmission. It requires rapid 100% case finding and contact tracing, an ability to enforce quarantine and travel restrictions and local knowledge and resources to investigate and deal with outbreaks.

Case finding and contact tracing
For case finding and contact tracing to be effective:

  • Every new case must be found and isolated within 24 hours and the source of the infection identified if possible
  • All close contacts need to be identified within two days and isolated for 14 days or until a negative test result
  • Isolation needs to be monitored daily to ensure compliance.

The following points need to be emphasised: –

  • Testing is helpful but not necessary to identify cases, which can be done on a symptoms only basis. The workload will be higher as two thirds of suspected cases will not actually have the virus but manageable (9). Clinical judgement is required as the test is not 100% sensitive with a proportion of false negative results inevitably emerging.
  • Unlike influenza the longer incubation period of Covid-19 allows contact isolation to be the key to successful control. Basically there are three days to find and quarantine the high-risk contacts (11).
  • Contact tracing apps would help but are not essential; the higher the uptake the easier will be the listing of contacts. Again the number of volunteers required to undertake the work is manageable. Table 1 does not assume an app will be available.
  • Management of case identification and tracing contacts can only be done at local authority level as the amount of detail of the local population, geography, community, health staff and laboratory is only available locally.
  • Travel restrictions between regions will be needed if the source of more than a handful of new infections comes from outside the region.

Outbreak investigation and control
Until a vaccine provides herd immunity the control phase will be punctuated by local outbreaks with the potential for one or more very large outbreaks. As already appreciated in New Zealand which has just entered the control phase these outbreaks will need to be anticipated and dealt with expeditiously (12). Local teams will help each other when necessary.

What preparations have been made to set up these control measures?
It appears that the system is trying to keep controls at central and regional levels, presumably because they have no staff of their own at local level (13). It is difficult to see how control is possible unless:

  • local authorities who have the local experts available including directors of public health, health visitors and environmental health officers are given responsibility for case finding, contact tracing, enforcement of quarantine and travel restrictions
  • surveillance is available at regional level.

Lifting the lockdown and cutting costs
Every day control is delayed will cost £2 billion. Control will be achieved in different regions at different times. Lockdown can be lifted as soon as the epidemic is under control in each region. The local economy can then emerge. To wait for the last region to achieve control will frustrate the rest of the country. Decentralised decisions about universal physical distancing measures will reduce costs.

Conclusion
Here is an identifiable public health strategy, other than the one the Government seems to be adopting, which would save a lot of money, allow restrictions to be eased in different parts of the country depending on the state of infections, and allow us to remain generally on top of the pandemic until a vaccine becomes available. Our public health leaders should listen to colleagues in the far east and Lewis, the Dauphin “Strong reasons make strong actions. If you say, ay, the king will not say no.” (Shakespeare; King John, Act III, Scene IV).

Written Dr Cam Bowie, retired director of public health, Somerset and professor of community health, Malawi. cam.bowie1@gmail.com. Axminster, EX13 5BL

References
1. OBR. Coronavirus reference scenarios [Internet]. Office for Budget Responsibility. [cited 2020 Apr 29]. Available from: https://obr.uk/coronavirus-reference-scenario/

2. Ng Y. Evaluation of the Effectiveness of Surveillance and Containment Measures for the First 100 Patients with COVID-19 in Singapore — January 2–February 29, 2020. MMWR Morb Mortal Wkly Rep [Internet]. 2020 [cited 2020 Apr 7];69. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6911e1.htm

3. Song J-Y, Yun J-G, Noh J-Y, Cheong H-J, Kim W-J. Covid-19 in South Korea — Challenges of Subclinical Manifestations. N Engl J Med. 2020 Apr 6;0(0):null.

4. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA. 2020 Apr 14;323(14):1341–2.

5. Leung K, Wu JT, Liu D, Leung GM. First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment. Lancet Lond Engl. 2020 25;395(10233):1382–93.

6. Cowling BJ, Ali ST, Ng TWY, Tsang TK, Li JCM, Fong MW, et al. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Health. 2020 Apr 17;

7. PHE. Weekly COVID-19 surveillance report published [Internet]. GOV.UK. [cited 2020 Apr 25]. Available from: https://www.gov.uk/government/news/weekly-covid-19-surveillance-report-published

8. ECDC. Contact tracing: Public health management of persons, including healthcare workers, having had contact with COVID-19 cases in the European Union – second update [Internet]. European Centre for Disease Prevention and Control. 2020 [cited 2020 Apr 28]. Available from: https://www.ecdc.europa.eu/en/covid-19-contact-tracing-public-health-management

9. Bowie C, Hill A. Re: Is it possible to implement the proposals in the Editorial ‘Covid-19: why is the UK government ignoring WHO’s advice? (1)’. 2020 Apr 29 [cited 2020 Apr 29]; Available from: https://www.bmj.com/content/368/bmj.m1284/rr-9

10. Tsang TK, Wu P, Lin Y, Lau EHY, Leung GM, Cowling BJ. Effect of changing case definitions for COVID-19 on the epidemic curve and transmission parameters in mainland China: a modelling study. Lancet Public Health. 2020 Apr 21;

11. Baker M, Kvalsvig A, Verrall AJ, Telfar-Barnard L, Wilson N. New Zealand’s elimination strategy for the COVID-19 pandemic and what is required to make it work. N Z Med J. 2020 03;133(1512):10–4.

12. Rapid Audit of Contact Tracing for COVID-19 in New Zealand [Internet]. Ministry of Health NZ. [cited 2020 Apr 30]. Available from: https://www.health.govt.nz/publication/rapid-audit-contact-tracing-covid-19-new-zealand

13. Pollock AM, Roderick P, Cheng KK, Pankhania B. Covid-19: why is the UK government ignoring WHO’s advice? BMJ. 2020 30;368:m1284.

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The Project

Barnet Public Health Team, RCN, and Middlesex University worked together to develop a local authority hosted public health placement specifically for pre-registration nursing.

Nursing Context

It is increasingly important for nurses to understand and recognise their role and contribution to public health. Nurses make up a significant body of professionals working in public health, supporting communities with disease prevention, assessment, education, and evaluation of population health. This move from nursing an individual or small group to the wider community is an opportunity to influence change at a strategic level.

To prepare pre-registration learners for the future workforce a variety of learning experiences in practice including public health is essential. While this has always been implicit within curricula there is a need for more emphasis and direct learning opportunities. The NMC (2018) Standards framework for nursing and midwifery education require all registrants to have an understanding and knowledge of public health agendas and associated health promotion strategies . It is in this context that the pilot project was devised.

First placements

Two child health field student nurses have both completed five weeks placements. With more planned for other field students. The placements were positively evaluated by the students and the public health team.

The students reported

“When out in placement we need to use evidence-based practice to give rationale to the care we are giving to our patients. When the opportunity to spend five weeks of our placement in Public Health we jumped at the chance…

Public Health is all about our community. The decisions made for healthy eating in schools, prevention of diseases through immunisation programmes, flu vaccinations, community centres and support for families, social prescribing, smoking cessation to name just a few…

Listening to the impact that the healthy schools project has had on school children was inspiring. Growing their own vegetables at school AND being able to eat the produce! Healthy lives start with healthy children. Educating from young the importance of a nutritious diet will have positive outcomes for future generations”.

The Learning

The students reported the whole system learning was key to understanding the needs of local families and provided an opportunity to consider more expansive learning regarding the young people who will be in their care:

  • Attending foodbanks
  • Understanding infection control on a local population level
  • Focussing on the health promotion and illness prevention occurring in Barnet
  • National initiatives related to the wider social determinants of health.

The Public Health perspective

Having students on placement in public health is a learning opportunity for staff as well as the students. The students bring their recent theoretical learning and the staff can find this interesting and learn too for example discussions about the projects they undertook meant that staff could update themselves on breastfeeding support or staff retention practices in the NHS.

The University perspective

The evident success of this placement as a learning environment for the 2 students so far is exciting. Both considered the transferable skills gained, including enhanced communication, developing a more social model of health and being aware of the public health team roles. This includes the knowledge that public health may be a career choice in the future.

Widening the learning opportunities for the learners is a key objective for the university. With the main campus located in Barnet, the collaborative working with our local authority supports a key university aim to be actively involved in the community.

Benefits for Nurses in Public Health

It can be a challenge for nurses working in public health to meet the NMC revalidation requirements and thus retain registration.

Facilitating student nurse placements is one way of demonstrating how they meet The Code’s requirement to support learners.

This full placement was only possible as there was an NMC registered nurse to undertake the Practice Assessor role within the public health team.

Conclusion

The local authority and HEI were committed to the project and demonstrated the benefits of this collaboration.

This pilot was a success. All involved were able to see the value and reciprocal learning for everyone.

Next steps

  • To continue to offer this experience to more nursing students in Barnet.
  • To present this experience to public health teams and HEIs in the hope to inspire others to consider this student placement opportunity.
  • To develop a toolkit for other localities to support the introduction of this type of placement

 

Written by Pam Hodge, Middlesex University

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Poem by Toomfoolery

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An enduring memory from my time as a Public Health Registrar was the Director of my local Health Protection Agency telling me (during a particularly interesting and high profile outbreak) that Public Health was the arena where “medicine meets politics.” At the time, I thought that he was mainly referring to the fact that he was getting phone calls every 5 minutes from local politicians wanting assurances that this outbreak was under control, and that the very successful and globally renowned local business would not be shut down permanently. But in hindsight, as my career has taken me increasingly in to the political arena, I have begun to appreciate just how much of my work as a public health professional overlaps with the world of politics.

My involvement in all things Political began fortuitously as my love of working in a Local Authority declined. I have never been very good at keeping opinions to myself, and the move from an NHS training programme (where I was generally allowed to argue my case, and decisions were more often than not made on available evidence) into a Consultant post in a Local Authority (where the arguments I made were filtered through Political persuasion) was always going to be tricky. I worked with a great Public Health team in the County Council, many of whom had weathered the Political arena for some years already and were far wiser than me when it came to working with our allocated Cabinet Member. Our Cabinet Member was also well seasoned and knew what she wanted and how she wanted it – I frequently disagreed, both from a Political (ideological) standpoint and from the available evidence base. When the 2015 election saw another defeat for my Political Party of choice, I threw in the officer towel (continuing to be very grateful to all colleagues who stayed the course!) and decided to play to my opinionated strengths. I became active in my local Labour party, and in 2017 was elected as the first Labour Councillor on Worthing Borough Council for 41 years.

In Politics, one of the first things I learned is that our evidence base in Public Health will only get you so far. The arguments that you make to achieve your goals are as much about the relevance to your audience and the zeitgeist of the day, as they are about what the data tell us. I am eternally grateful for my instructions in the art of reading statistics (lies, damned lies etc.), but I have had to learn that my local constituents need to know what that statistic will mean for their family, not a thousand families. Our understanding of the wider determinants of health (I am constantly recommending anything written by Sir Michael Marmot to any colleague who will listen) is one of the areas that I treasure most from my training and work in both the NHS and Local Authorities, but there is nothing quite like sitting with a local family who are about to go in to emergency accommodation because they cannot find any affordable housing in the area, to nail the lesson that a home is at the heart of a human’s wellbeing.

In our area, as with most of the UK, we have seen an increasing use of foodbanks as austerity and the introduction of Universal Credit have cut people’s ability to provide for themselves and their families. A National Government has enforced austerity for 10 years now, leaving Local Government finances at an all-time low. In spite of the frequent soundbites from Government benches that the deep cuts to the public purse were absolutely necessary, there are numerous economists who have argued that this drastic response to the financial crisis was unnecessary and has penalized the poorest in our society for the problems of our deregulated financial system.

Local Authorities like mine, now find themselves in a bind. The pairing down of the State might fit with the councils ideology, but the reality on the ground is that we are hugely under-resourced and failing to provide adequate social care, education, public health, housing, waste management, or transport infrastructure. As a Public Health Consultant, seeing on a daily basis in my local area what this Political ideology has taken from our population’s health and wellbeing, I find that the translation of our statistics, reports and research is more pressing and relevant than ever. Public Health needs a strong voice in the Political arena, and it is my privilege to be one of those voices.

Written by Rebecca Cooper, Public Health Consultant

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On the 7th November 2019, the Children (Equal Protection from Assault) (Scotland) Act 2019 received Royal Assent. This Act abolishes the defense of reasonable chastisement, thereby prohibiting the physical punishment of children, and so brings Scotland in line with its obligations under the UN Convention of the Rights of the Child to protect children from all forms of violence.

On the day of this legal change, I traveled from Scotland to England, and crossing the border I was very aware that while children in Scotland would benefiting this Act, children in England would not. English children will continue to be denied full legal protection from violence.

Changing the law is a tool to improve public health – this is my experience of the process that led to this change in legislation.

Finding allies

A group of children’s charities – NSPCC Scotland, Barnardos Scotland, Children’s 1st, and the Children and Young People’s Commissioner for Scotland came together in a coalition and together they commissioned a systematic review, published in 2015, on the effects of physical punishment of children (https://learning.nspcc.org.uk/media/1117/equally-protected.pdf)

The systematic review showed that the evidence could not be any clearer – physical punishment has the potential to damage children. The number one recommendation of the report was that all physical punishment of children should be prohibited.

In 2016, shortly after the Scottish Parliament election, the coalition of children’s groups approached John Finnie, a Member of the Scottish Parliament (MSP), to consider taking forward a Members Bill to give children equal protection from assault – by prohibiting physical punishment of children. They chose to approach John Finnie because he had previously showed support for this issue before the end of the previous Parliament session by trying to get an amendment into a different Bill.

Using public health evidence & responding to consultation

In 2017, John Finnie’s proposal for a Bill to give children equal protection from assault went out for consultation. At that time the Scottish Government did not support legal change to give children equal protection from assault. However, the consultation had over 650 responses – 75% of these were supportive and many submissions cited the 2015 systematic review on the effects of physical punishment of children, and other public health evidence. After this consultation the Scottish Government changed their position and decided to support the Bill. I heard it said that it was the public health argument – rather than the children’s rights perspective – that influenced the Scottish Government to change their position.

Further engagement in the political process & working with the media

In September 2018, the Bill was introduced into Scottish Parliament and in the year that followed there was much public health advocacy in support of the Bill as it made its journey through the Parliament. This advocacy fit with the Faculty of Public Health (FPH) in Scotland’s Healthy Lives, Fairer Futures Call to Action (https://www.fph.org.uk/about-fph/board-and-committees/a-call-to-action/) priority on preventing adverse childhood experiences, which enabled the FPH to support the Bill. Advocacy on behalf of the FPH included submitting written evidence in support of the Bill, sending a briefing paper to all MSPs ahead of a key debate, as well as sending an open letter to the leaders of all the Scottish political parties before the final debate on the Bill. I found writing a first-person article in one of the Scottish national newspapers (https://www.thenational.scot/news/17502438.tamasin-knight-a-law-that-justifies-assaulting-children-harms-health/) helpful in increasing awareness that protecting children from physical punishment is a matter of public health concern.

On the morning of the final debate, several FPH members attended a gathering outside Parliament to demonstrate our support for the Bill, and this gathering was featured in the national print and broadcast media. The passing of the Bill was reported positively in the press, with calls for the rest of the UK to follow Scotland’s lead and introduce similar legislation (https://www.theguardian.com/commentisfree/2019/oct/03/the-guardian-view-on-scotlands-smacking-ban-follow-the-leader)

Wales has since passed legislation to protect children from physical punishment (https://endcorporalpunishment.org/wales-prohibits-all-corporal-punishment/). While the children of Scotland and Wales will have their rights under Article 19 of the UN Convention on the Rights of the Child upheld, children in England and Northern Ireland will not. The difference living a few miles apart can make.

Written by Dr. Tamasin Knight
Consultant in Public Health Medicine
NHS Tayside

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I and my wife have been adopting strict social distancing practices for a week. We are both in the group that has been told that it needs to be shielded for at least 12 weeks.

I have been following the evidence about Covid19 very closely and because of my assessment of the literature, I and my wife started strict social distancing shortly before it became national policy.

Part of my response to a feeling of some helplessness as a pensioner confined to home has been to ensure that I have contributed on-line to the professional debate about how to combat the pandemic. My portfolio career in retirement has included roles with the Faculty – I am the Treasurer – and with the BMA on many committees and this has facilitated this aforementioned activity. Indeed I agreed today to join another BMA committee on Covid19. Gradually my diary which had been a sea of cancelled meetings is being replaced by on-line (unpaid) work!

I am deeply appreciative of the work done by PHE and other public health staff in planning for the epidemic and attempting to control it. The pressure on the public health and national health service will be immense over the coming weeks and months but I am confident they will rise to the challenge.

The goodwill shown by my local community in suburban London has been heartwarming. It looks like we may have secured a mechanism to reliably receive a home delivery of food. My wife and I were quite emotional about the support that has been arranged by the United Synagogue and offered to all sheltered members in its community.

Social isolation is a real issue. I have made a point of trying to contact all people we know who are also in the moderate to high risk groups requiring sheltering. I am preparing for seeing many repeats on TV.!

My wife is a pianist and musician and thought she may not be able to continue working. However virtually all the people she teaches have already agreed to have their lessons by Skype or Facebook! Maybe her choirs might also be able to reform!?

My sons and their partners live some distance away but are in regular contact. My 5 year old granddaughter whose school closes tomorrow, has begun regularly calling us from Leeds after she returns from school. Seeing her happy face is always a comfort.
Ellis Friedman
March 19 2020

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