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The health burden of the current pandemic will extend far beyond the direct impact of COVID-19 morbidity and mortality. We must use evidence to mitigate the wider, indirect effects to protect and improve the long-term health of our population.  

The UK has recently recorded increases in confirmed cases, hospital admissions and deaths from COVID-19. A second wave of the pandemic, with severe health consequences, is underway.  

Leadership is needed to reduce both direct and indirect harms to population health. Unfortunately, political and scientific debates have been unhelpfully framed as a trade-off between controlling the pandemic and minimising the wider consequences of our policy response. In fact, we need both a strong direct response to the pandemic and strong measures to mitigate its indirect impacts. However, the role of evidence-based public health leadership has been much clearer in the former than in the latter.     

This lack of clarity matters because the indirect health effects of COVID-19 are substantial. Frameworks published in April and June anticipated and outlined an array of short, medium, and long-term health and equity effects arising from the pandemic and resulting control measures. There is now a growing evidence base modelling the scale of these impacts or demonstrating them in practice.  Some effects have been felt already, and some will be seen in the long term. They include: 

Just as there is evidence that the direct effects of COVID-19 are disproportionately felt by some social groups, there is also evidence that the indirect effects harm some more than others, often reflecting existing inequalities. The initial weeks of lockdown in the UK saw a clear socioeconomic gradient in adversities related to basic needs such as access to food and medication. Consequences for Black, Asian and Minority Ethnic communities have also been profound. Impacts on other groups may be specific to the current crisis: for example, young workers, women, and low earners are more likely to have been employed in sectors that were shut down as part of the government’s response.  

Importantly, there are national and local examples of measures to mitigate potential risks to both short and long-term population health. National and regional initiatives include tenancy protection for rentersemergency accommodation for rough sleepers and job protection schemes.  

A second wave brings an urgent need to draw on this evidence and good practice about the indirect population health impacts of COVID-19 and how to mitigate them. As policies and support schemes change, focus is needed on populations that may become newly vulnerable. But at the time this analysis is most needed, the capacity to carry it out is insufficient at both national and local level.  

Technical advice to UK governments comes from the Scientific Advisory Group for Emergencies (SAGE). SAGE has multiple subgroups ranging from epidemiological modelling, to behavioural responses, to infection control. It does not have a subgroup on wider public health consequences.  

Public Health England should be the organisation best placed to consider wider population health in England. It has produced useful resources to understand and mitigate the pandemic’s impacts. However, it is being disbanded and the future of its health improvement functions remains undecided.  

At local level, Directors of Public Health have an important leadership role. Unfortunately, their teams have seen their long-term resilience eroded by funding cuts, and many frontline staff have been diverted to support the direct pandemic response. Other public services including healthcare, social care, education and housing have an important role here, and are also stretched. 

National, regional and local public health capacity is needed now to help translate evidence of the wider pandemic impacts into concrete action across different sectors. If we fail to learn from the first wave, we risk exacerbating the impacts of the pandemic and doing unnecessary harm to mental and physical health for years to come. 

Written by

Emily Humphreys, Imperial College Healthcare NHS Foundation Trust (@emilyjhumphreys) 

Hannah Barton, Imperial College Healthcare NHS Foundation Trust (@Hannah_EB1) 

Ellen Bloomer, London Borough of Newham  

Fran Bury, Imperial College Healthcare NHS Foundation Trust (@audacityofboats) 

Aideen Dunne, Imperial College Healthcare NHS Foundation Trust (@dunnea9) 

Katie Ferguson, Imperial College Healthcare NHS Foundation Trust  

Suzanne Tang, Imperial College Healthcare NHS Foundation Trust (@suzannestang) 

This article is based on the findings from a series of rapid evidence reviews and consultation conversations with key London stakeholders, exploring the wider impacts of the pandemic and the considerations for recovery, within the context of improving population outcomes. The full report is available here.

This is anything but a typical year and we all want to protect ourselves and those close to us.

Receiving the flu vaccine is more important than ever before because of co-circulation of COVID-19 and flu. The flu vaccine will help reduce pressure on health and social care during a challenging time and by reducing transmission of flu, help to protect some of the most vulnerable in our community. Those most at risk from flu are also most vulnerable to COVID-19. We must do all we can to help protect them this winter.

Therefore, the Health and Social Care Workers flu vaccination campaign is more important than ever. The flu virus spreads from person-to-person, even amongst those not showing any symptoms. For frontline workers, there is an increased risk of contracting flu and it’s very easy for individuals to pass the virus on without knowing. Even if they’re healthy, they can still get flu and spread it to the people they care for, their colleagues and to their family. This year, more than ever, we are stressing that getting the flu jab is simple, easy and free to those eligible.

For the campaign we carried out research to understand health and social care workers’ barriers to and motivations for getting the flu vaccination in this unusual environment. The research brought out the need to promote a protection-based message, as well as the message that many with the flu can be asymptomatic. This insight has helped shape our creative, communications, and partner assets to ensure they are effective as possible in encouraging uptake of the flu vaccine. Also, a new range of adaptable materials have been provided to allow communication teams to promote local information or new ways for staff to get vaccinated. We knew the flu vaccination may be offered in slightly different ways than previous years, whether that’s easier access for social care workers or hospitals hosting vaccinations in an outdoor marquee!

Due the current environment and the extended eligibility of the social care workforce, we’ve worked even more extensively with Department of Health and Social Care (DHSC) and NHS England & Improvement (NHS E&I). We want to ensure that all communication opportunities are being used to engage and that the sectors are aligned. This can be seen at campaign launch where NHS E&I released an open letter from senior clinicians, sent to all NHS frontline staff alongside a short video by Chief Nursing Officer, Ruth May, promoting the programme. DHSC also released a video from Deputy Chief Medical Officer, Prof. Van-Tam and sent targeted communications to social care organisations and workers.

The Health and Social Care Workers flu vaccination campaign launched on the 16th September and has attracted widespread positive attention from the start with comment from Secretary of State, content across trade media, social media as well as communications from employers, sector stakeholders and representative bodies. There has already been a huge increase in demand for campaign resources, with some assets seeing well over double the amount of orders compared to the previous year. For anyone looking to deliver their own local Health and social care worker flu vaccination campaign, please visit Public Health England’s Campaign Resource Centre for access to toolkits, campaign resources and more.

Written by Public Health England

A summary  

More than 350 people registered for the Faculty of Public Health emergency webinar on the impacts of a Crashout Brexit on October 19th.  They came from more than 20 countries  and  three continents reflecting the huge international as well as UK interest in this imminent potential disaster.  The webinar was made all the more timely by  growing  concerns about the risks of a crash out,  from foodmanufacturing and haulage sectors. The Prime Minister’s speech on October 16th made the subject all the more urgent and compelling.   

Professor Tamara Hervey, Jean Monnet Professor of European Law at Sheffield University presented current legal implications of Brexit and crash out. The European  Union is a rules-based organisation. The European Parliament must agree trade deal proposals recommended by the European Commission for implementation by January  1st 2021.  So time runs out soon. Key sticking points are fisheries, ‘level playing field’, and the governance of the agreement. We risk a crash out  Brexit by default, or by accident. No deal means trading by the World Trade Organisation’s rules, which do not prioritise health. Tariffs are automatically applied on traded goods. The EU has published over 100 sector-specific stakeholder preparedness notices during the Article 50 negotiations with the United Kingdom, suggesting it is serious that no deal could happen. Even if a deal is struck there is no provision for cooperation on broader public health matters, such as tobacco regulation or communicable disease control. Brexit, and specifically the UK Internal Market Bill, affects Scottish and Welsh government aspirations for Continuity with European regulations and may jeopardise existing public health measures there, such as minimum alcohol unit pricing. 

Dr May Van Schalkwyk reprised some of the concerns of her paper with the FPH president and others and added in a few more up to the minute and with a COVID pandemic now added to the mix. Uncertainty always affects mental health. Multiple shocks as we would potential see with Crash-out Brexit on top of the COVID second wave would compound and accelerate each other. A poor or weak deal would only be marginally better than no deal in terms of the disruption anticipated at our ports and the far reaching negative impacts on our economy. There would be disruption to  trade and to supply chains in many aspects of the  economy and important  institutional  links will be weakened or broken. There is strong possibility of shortages of food,  medicines, and components for manufacturing industry. There will also be the possibility of civil unrest., consequent on food shortage and  continuing austerity.   

Maintaining public morale, is intricately linked to public mental health, and community engagement and involvement, and trust, is vital. The WHO has emphasised that the science alone will not beat the pandemic, and that authorities need courage and empathy, and that community participation will be critical in our ongoing public health efforts – the importance of community involvement will only be heighten in the event of a no deal Brexit.  We also need to maintain communication within the UK,  and internationally. Public health, NHS and care services need to be fully involved in Local Resilience Partnerships.  

Professor Tim Lang highlighted the potential catastrophe ahead for food supplies in the short term. The UK is poorly prepared, totally reliant on private sector food retail supply and just-in-time supply chains.  Food poverty is rocketing. Food resilience is not seen as a government or collective problem but as a more individualised and ad hoc challenge for charity. Even without shortages, the fear of shortage and panic buying are a known possibility from this year’s COVID experience. UK food supplies are heavily reliant on the  EU.  Key foods likely to be disrupted are fruit and vegetables coming in and Welsh and Scottish lamb and beef going out. Under World Trade organisation rules, tariffs are automatically applied.  The average import tariffs  from the EU could be  20%. Welsh and Scottish lamb and beef could attract a 48% charge on export to the EU.     

In a no-deal, the immediate impact will be build up of trucks at Dover; a two minute delay to throughput quickly leads to a lorry queue of up to 7000 trucks, according to the “reasonable worst case scenario”.  

There are public health implications: air pollution and congestion, frustration, anger, local unrest and with sanitary provision only just being considered for truck drivers.   

Tim went on to describe a vision for an alternative vision for a post Brexit Britain, noting the continued absence of the much-delayed (English) National Food Strategy, now expected in early 2021.    

Gary McFarlane, Director for the Northern Ireland Chartered Institute of  Environmental Health described similar concerns for food, environmental and consumer safety. He feared a burgeoning workload for EHOs in local authorities , generally in response to COVID and then with added possible Crashout. Some EU systems are still central to for example, food safety. For example the EU RASFF system provided  vital early warning on  food  safety concerns. In a crashout scenario we could lose this and ist still unclear whether a viable replacement exists. Even as part of the EU food crime still goes on. The EU had not been able to stamp  out food crime, as exemplified by the ‘horsegate’ scandal,  but coming out of the EU  will make control of criminal activity even more difficult. CIEH was concerned that even within the EU inadequate progress had been made with regard to securing healthier diets, for human and planetary health. In the current emergency, CIEH was concerned for all aspects of environmental health control at all UK ports-extension of inspection times, congestion, increased air pollution and poor sanitary conditions.for truck drivers. The concerns that have been articulated in terms of delays at channel ports could/will also apply to ports like Holyhead and Liverpool where goods will move from GB to Ireland and Northern Ireland. And we must remember the potential consequences of no trade deal on the availability and price of food in Northern Ireland if it is coming from GB. CIEH would work with FPH to develop food standards to aim for Tim’s vision of an exemplary food policy for Britain

What can the Faculty of Public Health do?  

In the short term, the Faculty should advocate for, and reinforce the need for actions locally and regionally, funded and supported from central government. They could work with other public health bodies such as CIEH to amplify this message. 

Public health professionals at local authority and regional level should ensure Local  Resilience Forums have active public health involvement. The LRPs should incorporate food resilience planning in their emergency plans. Children’s Safeguarding Boards should also be mindful of the mental health needs of children,  the need to plan for local food insecurity and children’s food poverty and hunger and address it.   

LRPs need to be aware of the state of local public mental health, severely challenged in the COVID lockdowns. LRPS need to plan for more visible and widespread civil unrest in the light of a no-deal Brexit.  

Public health professionals should advocate for greater financial and service support  to local community groups, to enable enhanced mutual aid programmes to be delivered.   

In the longer term    

FPH should continue to advocate for a National Food Policy. This should promote sustainable diets as basis for food policy at all levels – linking nutrition to ecosystems, social and economic criteria. FPH should also support the https://www.sustainweb.org/news/oct20-future- british-standards-coalition-interim-report/.  

Leaving the EU creates an opportunity for public health experimentation, from which other countries can learn, and for attuning policy and law very closely to population needs in Scotland and Wales, where health is a devolved power. But the Internal Market Bill takes away this opportunity, and disrupts the UK’s devolved constitutional settlement in a way which it is difficult to challenge legally, given the way that the Supreme Court treats these constitutional rules. 

FPH will need to reactivate its lobbying to keep the UK as part of the European Centre for Disease Control and Surveillance ECDC and other European  public health institutions like the European Monitoring Centre for Drugs and Drug Addiction EMCDDA, Lisbon.  Our government can pay the subs to rejoin. 

We will also need to see where we can judiciously test the  ‘Do no harm’ criteria  to future trade regulations– even if the lobby seems like it was from a different era.   

The legal implications for public health are in one sense the same as they have always been. Brexit is bad for the NHS and bad for public health

Brexit, in any form, is a form of major social change and transition and has, and will continue to have, major impacts on people’s lives and the wider determinants of health. Public health has a role in keeping health on the agenda at times of transition and at the heart of policy debates and implementation. It has never been more needed. 

Postscript   

Since our Webinar,  EU  negotiator  Michel Barnier has  been in London for a further round of talks;  there is speculation that Prime Minister  Johnson will  hold off any decision on a crashout Brexit until after the  US electionand a large scale national campaign, led by footballer Marcus Rashford to  provide free school meals  has received widespread local authority support– perhaps  providing the impetus fro local  food  distribution platforms of the kind envisaged by FPH. 

Written by

Professor John Middleton, Hon FFPH
President, Association of Schools of  Public Health in the European Region, (ASPHER)  john.middleton@aspher.org 
Immediate Past President,  UK Faculty of Public Health 

Professor  Maggie  Rae  
President, UK Faculty of  Public Health  
President@fph.org.uk  

With thanks to the presenters, Professor Tamara Hervey, Dr  May  Van Zwalwyck, Prof Tim Lang and Mr Gary McFarlane.  

Especial thanks  to the staff team at the UK Faculty of  Public Health who made it happen Mag Connolly, Keith Carter, David Parkinson and  James Gore.  

Thanks also to Paul  Lincoln and  Heather  Lodge, for  PETRA and  Dr Ibraheem Alghamdi for  helpful comments. 

This blog has been prepared for the SIG by Woody Caan, Liam Hughes and Lina Martino in response to World Mental Health Day on 10th October 2020, which emphasized the importance of advocacy for mental health in the era of Covid-19. The Faculty has had a good track record in recent years for supporting public mental health, and recognizing the interactions between mental and physical health in the spirit of “Equally Well”. It is encouraged to tackle Covid-19 through advocacy for integrated policies and better resources for mental health as an integral part of the proposed national investments to fight the pandemic.

Covid-19 has had a deep impact on individuals, families and communities, and on health professionals and their front-line colleagues in all parts of the U.K. As more has been learned about the disease, it has become more apparent that it has generated major mental health issues, and that these are likely to continue for many more months. Some examples are given below:

  • Inpatients have experienced major trauma, with associated mental health symptoms (such as cognitive disruption, anxiety and depression, and for some PTSD) which extend well beyond discharge.
  • Those living in the community with mild symptoms of Covid-19 may experience a “long tail” of reported physical and psychological symptoms including respiratory damage and renal failure, fatigue and muscle soreness, and cognitive impairment and “mind fog”. Often, they report that clinicians do not seem to take their reports seriously.
  • Bereavement is an issue for relatives, friends and the wider community, especially given the constraints of social isolation, and there is good evidence about what can be done to help, at pace and scale (and at low cost).
  • Suicide rates are likely to rise as social uncertainty intensifies, unemployment increases and social protection is scaled back.
  • There are reports of rising mental health pressures on children and adolescents as they return to school, concern that the diversion of health visitors and school nurses into hospital roles will leave schools and community teams under-resourced, and reports of the delayed return of SEND pupils with complex needs.

    The pandemic has exacerbated long-standing health inequalities, including in mental health and wellbeing. A national survey by Mind revealed that existing inequalities in housing, employment, finances and other issues have had a greater impact on people from Black, Asian & Minority Ethnic (BAME) groups than on white people. The reduction in access to health and wider services due to control measures is also likely to have a disproportionate impact on BAME groups and people with severe mental illness.

    The concern of members of the Mental Health SIG is that the mental health dimensions of Covid-19 (and the associated resource requirements) may be missed by policymakers, planners and commissioners. Faculty members are encouraged to reflect on what they can do to reinforce the message that the fight against Covid-19 requires attention to mental as well as physical health.

    Resources on Covid-19 and mental health, including guidance on public and workforce wellbeing, can be found on the SIG’s web page: https://www.fph.org.uk/policy-campaigns/special-interest-groups/special-interest-groups-list/public-mental-health-special-interest-group/mental-health-and-covid-19/

Woody Caan, Liam Hughes and Lina Martino
FPH Mental Health SIG

Climate change has been identified as the greatest threat, and opportunity, for global public health in the 21st century.  It is therefore incumbent on public health consultants, registrars and practitioners to be aware of the action we need to take to reduce this threat and mitigate the consequences.  

The opportunity: According to The Intergovernmental Panel on Climate Change, a warming greater than 1.5°C is “not geophysically unavoidable: whether it will occur depends on future rates of emission reductions.” https://www.ipcc.ch/sr15/  

The challenge: About 80% of known fossil fuel reserves would need to stay in the ground to limit the concentration of CO2 in the atmosphere to 450 parts per million.  This level would in turn give a 50% chance of limiting global warming to a maximum 2°C global average temperature rise.    

The consequences: Poverty and disadvantage are expected to increase as global warming increases; limiting global warming to 1.5°C, compared with 2°C, could “reduce the number of people both exposed to climate-related risks and susceptible to poverty by up to several hundred million by 2050 (medium confidence). https://www.ipcc.ch/sr15/chapter/spm/  

What help is available?  

1. The sustainable development and climate change resources produced by the Faculty of Public Health Sustainable Development Special Interest Group support specialty registrars and their educational supervisors in meeting Faculty of Public Health learning outcomes and offer information for public health consultants and practitioners.  They are available here  on the FPH website. 

2. The Faculty of Public Health have established a Climate & Health Committee.  This is a really important step, and I would like to thank Sue Atkinson – the chair, and our President Maggie Rae for setting it up.  It illustrates the seriousness with which FPH are now taking this agenda.  The Committee aims and objectives are to: 

  • lead FPH’s sustainability and climate change policies. 
  • embed sustainability and climate change in all FPH policy developments. 
  • increase the Faculty’s profile in sustainability and climate change work. 
  • advise on the Faculty’s ethical investment policy and the transition to carbon neutrality by 2030. 
  • promote best practice in sustainability and climate change work across the Faculty. 

3 I recently attended an on-line meeting of the All-Party Parliamentary Group (APPG) on the UN Global Goals for Sustainable Development: – a cross-party group of UK parliamentarians who champion the United Nations Sustainable Development Goals and monitor their implementation.  The meeting was about their assessment of the UK’s progress on delivering the Sustainable Development Goals (SDGs), their investigation and evaluation of the impact of Covid-19 on the SDGs, and a summary of the steps the UK Government should take to ensure the SDGs are at the heart of efforts to build back better.  The report is available here: – Build Back Better.  This is an important report, particularly as it is likely to inform the Government in the lead up to COP26 in Glasgow in November 2021.  You will see that the recommendations are high level.  The questions for us in Public Health are as follows: 

  • Does the report cover all the key Public Health and Climate Change issues? 
  • Is the level of ambition sufficient to enable the UK to reduce the severity of climate change? 
  • What will the role of Public Health be going forward? 

Please feel free to e mail me with your comments at hzross2@myphone.coop.  They will help us to crystallise our thinking about how we Build Back Better (post Covid) for the Faculty of Public Health.   

Other resources:  

The next meeting of the FPH SD SIG will be held on Thursday 15th October from 2pm to 4pm by Zoom. If you have any items that you would like the SIG Committee to discuss, then please do not hesitate to e mail me. 

Helen Ross  

Faculty of Public Health 

Chair: Sustainable Development Special Interest Group 

 e mail – hzross2@myphone.coop 

Clean Air Day 2020

8 October is Clean Air Day. Due to COVID-19 it looks a little different this year, but the need to keep air pollution high on the public health agenda has never been greater. Evidence is emerging around the links between air pollution and COVID-19 outcomes. And during the lockdown we experienced cleaner air and saw massive shifts to low pollution behaviours. Let’s keep up the momentum as we all have a part to play in keeping our air clean.

Public health professionals can play a particularly important role in providing information and advice to people about how to protect their health from air pollution, and we have basic resources for health professionals available to help you in these conversations. The Clean Air Hub https://www.cleanairhub.org.uk/ also provides straightforward public information on air pollution.

Clean Air Day Live on 8 October at 14:30 will be running a session on ‘How Can the Health Sector Tackle Air Pollution?’ to explore the role of the health sector in both cutting air pollution through its own operations, and the role of health professionals in providing air pollution guidance to patients.

We have an unprecedented opportunity to build back cleaner air as part of our ‘new normal’ as we recover from this COVID-19 crisis, so do join in with Clean Air Day and find out more about the part you can play to help maintain cleaner air and protect people’s health, as the need to do so is greater than ever.

There is a detrimental link between the health outcomes of COVID-19 and air pollution. Emerging evidence suggests that air pollution may play a role in making us more vulnerable to catching COVID-19. It also makes those with health conditions that are caused or worsened by air pollution – such as asthma, heart disease and COPD – more vulnerable to complications, even death, if they contract COVID-19. And high air pollution is causing irreversible damage to some children’s health, reducing their lung function and creating a generation who may be more susceptible to future pandemics.

People have also realised that clean air is possible and want it to stay. During the COVID-19 lockdown, levels of NO2 air pollution dropped by 20-30% across the UK, and by up to half in parts of London, primarily from a reduction in private car use. People noticed and appreciated the cleaner air and safer streets. The vast majority of people (72%) believe that clean air is even more important now because coronavirus can affect people’s lungs, and want government and businesses to tackle air pollution more urgently than before the outbreak of the virus.

And behaviour has shifted offering a profound moment of change. During lockdown millions of people changed their routines in a way that reduced air pollution, by working from home and walking and cycling more, and many are willing to continue to do so: 87% want to keep working from home to some extent, half want to walk more and a third would like to cycle more. It is easier to maintain a habit than foster a new one, so we can build on this unique moment to create lasting positive change.

Clean air was one of the few silver linings of the COVID-19 lockdown suffering. Through our collective behaviours we saw and experienced extraordinary improvements in outdoor air quality. On Clean Air Day – and every day – let’s keep doing these behaviours to keep our air clean. Find out how you can advise your patients and the public to protect their health from air pollution and together let’s make 8 October the cleanest Clean Air Day yet.

Larissa Lockwood
Director of Clean Air
Global Action Plan

Climate and health

We held the inaugural meeting of the new FPH Climate and Health Committee on 10th September 2020. Of course like everything else these days it was held remotely by zoom. Slightly strange doing ‘introductions’ around the ‘screen’ rather than round the room, but we have all now got quite used to this way of working. The President came to welcome all the new members and offer her support, which was great – thank you Maggie.

The Board had agreed this new committee at the February board meeting in the recognition that climate change and health is both the biggest threat but also the biggest opportunity of the century. That was before Covid-19 arrived and sent us all (across the globe) into turmoil and for much of the time into lockdown. I write this as we head into the ‘second wave’ and we may all be in lockdown again by the time this is published, but I will try not to get diverted onto Covid!

Importantly Covid has impacted on public health professionals and hence our decision to delay the first meeting of the Climate and Health Committee (C&HC) until now.

I think it was the right decision. We have learned a lot through Covid impacts. It has demonstrated how rapidly change can happen if it needs to and people see the imperative – that in itself is a useful lesson for the necessary change for a sustainable planet. It has also heightened peoples’ awareness of inequalities and BAME issues, of the importance of nature and the environment and physical activity for peoples’ mental as well as physical health. All good PH issues. We agreed to build in more about the environment and biodiversity into the committee’s Terms of Reference

So the first meeting of C&HC was a lively affair with good discussions and challenge about a number of topics. Of course it is early days and much of the meeting was ground setting – such as briefly outlining what the FPH has already done on climate change (CC) and sustainability. There was a recognition that the FPH needs to be more proactive on CC and sustainable development (SD).

The work of the committee will build on the good work already being undertaken by the SD SIG and by other SIGs, such as transport and food. We will aim to utilise the mass of expertise on CC and SD held by our members by working closely with SIGs and other FPH committees and would welcome any offers of support and help.

The Sustainable Development Goals (SDGs) were floated as a potential ‘framework’ for a Climate and Health strategy and action plan, and whilst we recognise there is some criticism of some of the SDGs, overall we thought they were worth exploring further. We need to look also at the key roles of the FPH – as an organisation – in standards and training –and as an advocate for the public’s health, and consider what actions the FPH should take and what needs to be prioritised.

One of the big issues for us is knowing what would be most helpful for the FPH to do to support members – both trainees and existing consultants and DPHs – in respect of taking action and moving the climate and health agenda forward. And we are only too aware of how busy most members are dealing with aspects of Covid. So any suggestions gratefully received. I guess if you are busy with Covid etc you may not even have time to read and respond to this blog! But if you are reading this and do have thoughts on what FPH should do on the CC agenda then please email Sue Atkinson as Chair.

An update from the SD SIG on its work on the opportunities in recovery from Covid-19 showed that a statement on this will be coming shortly. Also ‘watch this space’ on Net Zero NHS (greening the NHS) as Nick Watts, the newly appointed NHS Chief Sustainability Officer (and a member of the FPH and the C&HC) updated us on their work. We also received an update on the PHE changes into the NIHP (National Institute of Health Protection) and how these may impact PHE’s work on CC and SD and related topics such as air quality. The FPH will need to keep a close eye on these changes.

As a committee, our first action was to recommend that FPH support an open letter calling on the United Nations Human Rights Council to recognise the universal human right to a safe, clean, healthy and sustainable environment. FPH signed the letter, and we would encourage FPH members to support the call.

We still need, on the committee, reps from practitioner and from associate members and from ADPH. So if anyone wants to volunteer or has any suggestions or wants to be involved please get in touch.

So much food for thought and much work still to be done. A huge thank you to the members of the committee for great and helpful discussion. Thank you also to Helen Johnston who is the SpR supporting the C&HC through the FPH project scheme, and we will hope to continue this attachment into the future, and of course, thank you to Julian Ryder, from the FPH who is supporting the C&HC. I look forward to working with you all as we progress this important work for the FPH.

… watch this space.

Sue Atkinson
Chair, FPH Climate and Health Committee

NIHP it in the bud!?

So as I and many others predicted some weeks ago, new cases are rising rapidly in the UK and these cases are predominantly amongst the young and the disadvantaged.

The impact on hospitalisation rates and deaths has so far been modest, which is to be expected because of the epidemiology of the disease in the under 40s, but we only have a small window of opportunity before infection rates start significantly rising in persons at much greater risk of experiencing significant morbidity and mortality.

The ‘rule of six’ is a good start but much more needs to be done if we are to achieve the prime aim of preventing significant further morbidity and mortality in the population and the secondary aim of allowing the economy to function at a reasonable level.

This is obviously not easy but i repeat again that the epidemiology of this disease is very helpful in achieving these aims and we need to follow the epidemiology.

Why is the epidemiology so helpful? Because the most at risk group, say people aged over 60 years who represent over 95% of deaths in the UK are usually retired!

So the policy that needs to be followed is simple to describe

  1. Protect the most at risk, especially the elderly and those with underlying conditions, by positively discriminating in their favour by making the safe choice the easier choice for them.
  2. Encourage other people to work in a Covid secure setting. For many this can mean continuing to work from home. So what needs to change?
  3. Visiting to care homes and hospices should be stopped. It is reckless not to learn the lessons of the first wave. We must minimise the risk of introducing the virus into high risk settings by regularly testing staff, preventing visits and adherence to strict control of infection procedures.
  4. Pubs should be closed at 10 pm. Allowing pubs to stay open for long hours encourages drunkenness and disinhibition and therefore non-adherence to viral control of transmission measures.
  5. Change the regulations so that the elderly and others at high risk can maintain a 2 metre rule. So for example in a restaurant, some tables would be obliged to allow 2 metre distancing whilst others could continue to follow the one metre plus guidance. This is an example of positive discrimination.
  6. A public health messaging campaign to encourage those at high risk not to engage in risky behaviour and to encourage the general public to take particular care when they are meeting persons at high risk.
  7. An effective test and trace system.
    5.1 This requires a significant increase in public health staff and others in the test and trace system – as the number of new cases rise the amount of contact tracing work increases.
    5.2 An increase in testing capacity with prioritisation of the testing to those with classic Covid19 symptoms. The test needs to be accessible and provide fast, reliable results.
    5.3 End the reliance on phone contact by ensuring non-responders are visited.
    5.4 Have a more agile local system, with more control over resources and decision making.
    5.5 Integration of the app into the system.
  8. Maintain messages on the fundamental need for hand washing, social distancing and mask washing to prevent transmission.
  9. As lab capacity increases, a prioritised use of this capacity to detect asymptomatic infectious persons.
  10. An effective quarantine system at ports of entry.

It would have been useful to have introduced measures to try to eliminate the virus a policy which has worked so effectively in countries like New Zealand but that opportunity has probably been lost.

We can expect that improvements in hospital management will mean that the mortality rate in hospital will be lower than in the first wave.

Public health messaging will need to be both sensitive and authoritative. We will be disrupting people’s normal lifestyles in important ways.

Ellis Friedman
13/09/20

Dr Helen Walters, an NIHR Public Health Consultant Advisor, introduces four newly launched public health research teams, contracted under the PHIRST scheme, to enable local authorities to rapidly evaluate interventions aiming to improve health and tackle health inequalities in their areas. 

When I was a Director of Public Health in London I knew that my team were delivering innovative schemes that affected large numbers of people. Our hope was that the schemes would improve health and reduce the health inequalities experienced by some highly deprived populations. But we didn’t really know whether they were achieving this. 

Did the Healthy Schools programme working across more than 1,500 schools in the capital improve the health of thousands of children? Did the Healthy Workplace award scheme improve sick leave levels for London’s employers? Would getting the Healthy Streets approach into the heart of the Mayor’s Transport Strategy make any difference to physical activity levels in the city?  

We were basing these schemes on the little evidence that was available, but we could not find a way to get them evaluated to build that evidence-base any further. Public health practice in local government is mainly distant from academic public health research. Local government does not have a culture of undertaking research. It moves fast, and does not have routes into research funding. Golden opportunities to learn and evaluate were being lost. 

The PHIRST Scheme 

The NIHR’s Public Health Research programme (PHR) is experimenting with a new scheme to try and solve this conundrum – the PHIRST scheme. PHIRST stands for Public Health Intervention Responsive Studies Teams. The idea is that the PHR contracts with four academic teams who are ready and waiting, fully-funded, to evaluate schemes that are happening in local government across the UK. 

The timing could probably not have been worse but somehow, despite pestilence and lockdown, we have managed to appoint four teams, and to match them up with four local authorities that are keen to have their schemes evaluated. Issues include:  

  • free school breakfast clubs in Hammersmith and Fulham 
  • citizen-informed design of employment support in Fife 
  • remote provision of drugs and alcohol services in Leeds 
  • reducing exposure to adverts for foods that are high in fat, salt and sugar (HFSS) on the transport system in Yorkshire 

The PHIRST teams are led by prominent public health researchers: Ashley Adamson (Newcastle University), Susie Sykes (London South Bank University), Rona Campbell (University of Bristol), and Katherine Brown and Wendy Willis (University of Hertfordshire). They will work closely with each local authority to co-create the evaluation with the heavy lifting being undertaken by the PHIRST teams and fully funded by the NIHR, starting in September. 

Timely and accessible research for local authorities  

And in a few months the PHR programme will go out to Directors of Public Health and ask for more schemes to evaluate, so we can keep the PHIRST teams busy. If it works the plan is to make this a rolling programme. 

Local authorities have huge opportunities to influence health and health inequalities but without an evidence-base they cannot maximise these opportunities. The hope is that this scheme will provide timely and easily accessible evaluations for those who are still hard-pushed Directors of Public Health so that, in the future, there will be an evidence-base. 

______________ 

For more information please email the PHR programme on phr@nihr.ac.uk 

More information on the PHR Programme is also available on the NIHR website

This blog was first published on the NIHR website.

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