December 2014 PH 1: Northern Region

Live, Work and Train: Due North

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“Live and train in the North East and Cumbria” was at the heart of a 2010 Northern Deanery recruitment campaign to bring trainee doctors to the North East region.

It highlighted the North East not only as a great location to train in, with the opportunity to work in some of the highest rated NHS services in the country, but also as one of the best places to live. The campaign promoted the beautiful countryside and picture perfect sandy beaches; with optional mountain biking and hiking for the more active, as well as a whole host of tasty dining and drinking opportunities. And yes, there was a ‘Top Tip for a Tipple’ article, and most of the food imagery did depict highly calorific fish and chips, but there was a lonesome lobster!

The success of the campaign in selling how great the North East is, and what a great place it is to live, train and work spoke for itself when the Northern Deanery became the top choice for trainees in the UK. But, as with everywhere, there is a flip side. Whilst life is not exactly grim up North, on average our communities do have less time to enjoy that life - whether this is due to a lower life expectancy and/or living longer with periods of ill-health.

The public health challenges in the North East are many and not dissimilar to most places. However, as highlighted in the recent inquiry into health inequity in the North (Due North chaired by Margaret Whitehead), there continues to be a widening of health inequalities, and that age-old North/South divide is deepening. The main causes of health inequalities within and between the North and South remain complex, and include differences in:• Poverty, power and resources needed for health• Exposure to health damaging environments, such as

poorer living/working conditions and unemployment

Heidi Douglas

• Chronic disease and disability left by the historical legacy of heavy industry and its decline

• Opportunities to enjoy positive health factors and protective conditions that help maintain health, such as good quality early years education; economic and food security, control over decisions that affect your life; social support and feeling part of the society in which you live.

Recent austerity measures were identified as a causative factor, with the burden of local authority cuts and welfare reforms falling more heavily on the North than the South; more significantly on disadvantaged than affluent areas; and on more vulnerable population groups in society, such as children.

This is the context in which our work is designed, delivered and evaluated. Like the “Live and train” campaign, there are a number of themes running through our edition of PH1; namely relating to alcohol and food. The “Live and Train” campaign promoted the social benefits of food and alcohol; the articles presented here highlight some of the local challenges relating to alcohol and high calorie/low nutritional value food, and the approaches taken to step up to these challenges.

The health inequalities in the North East are very real and the work presented in this edition; like the impact of welfare reform within communities; the perceptions of vulnerable and disadvantaged groups on health and wellbeing; and evaluations of the influenza immunisation programme, are all firmly rooted in addressing the causes highlighted in Due North.

Looking further afield this edition opens with an invaluable insight into how the North East health protection team is contributing to the national response to Ebola. Dr Tricia Cresswell discusses the complexities in ensuring that there is robust cross-organisational working.

I hope that this publication of PH1 provides an insight into the many communities that live in North East, and what it’s like to train here, as well as providing some examples of our work. If you ever want to head due north, we can all testify to the fact that it is most definitely not grim!

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Ebola Interview with Dr Tricia CresswellEbola virus was first identified during an outbreak in 1976 in Sudan and Zaire.

From 1976 through to 2013, the World Health Organization has reported a total of 1,716 cases.

These cases have originated from at least 34 known outbreaks, primarily in Uganda and the Democratic Republic of Congo - the last one being in 2012 affecting 57 people, and killing 29.

Although the natural reservoir of the infection is not yet proven; fruit bats are believed to be the most likely, and are able to spread the virus without themselves being affected.

Humans are likely to become infected by contact with the bats or a living or dead animal (e.g. a primate) that has been infected by the bats.

Human to human transmission then occurs through direct contact with an affected patient’s blood or bodily fluids or objects contaminated with infected bodily fluids.

The incubation period is between 2-21 days. Initial symptoms are flu-like: fever, headache, joint and muscle pain, weakness, diarrhoea,

vomiting, stomach pain, loss of appetite, cough and sore throat, with some patients also developing a haemorrhagic rash.

In severe cases, patients may go on to develop extensive internal and external haemorrhage, multi-organ failure, and death (typically from shock).

Treatment consists largely of supportive care. Trials of several potential vaccines are ongoing and are being expedited in light of the current crisis. ZMapp is an experimental treatment that can, and has been, successfully tried in the current outbreak.

The product is a combination of three different antibodies that bind to the Ebola virus protein, but it is in extremely short supply.

Current outbreak: International situation

A total of 13,567 confirmed, probable and suspected cases of Ebola virus disease have been recorded in eight countries (Guinea, Liberia, Mali, Sierra Leone, Nigeria, Senegal, Spain and the USA) during the current outbreak (up to 31/10/14). Guinea, Liberia and Sierra Leone continue to experience widespread and intense community transmission of Ebola. By 31/10/14 almost 5,000 people were known to have died from the virus.

Five strains of the virus have so far been identified: the current outbreak is caused by Zaire Ebolavirus.

This strain was previously considered the most dangerous strain with case fatality rates in previous outbreaks of circa 90%.

National situation

While the UK might see cases of imported Ebola, there is minimal risk of it spreading to the general population. A Top Lines Brief, summarising activity within the UK, is being circulated by the Cabinet Office to Local Resilience Forums (LRFs) three times a week. The risk of Ebola to the general public in the UK remains very low and there has still only been one imported case in a returning healthcare worker who made a full recovery.

However, entry screening for Ebola has been introduced at the UK’s main ports of entry for people travelling from Guinea, Liberia, and Sierra Leone and PHE nationally and locally through health protection teams is having to commit significant resources to design and implementation of Ebola policy and strategy documents.

This includes screening and surveillance of returning volunteers and dealing with potential queries from concerned members of the public and healthcare workers.

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We spoke to Dr Tricia Cresswell about her experience of the work required in preparing for a potential Ebola case locally in the North East. Tricia is one of the health protection consultants charged with leading local resilience planning across the NHS and PHE for the North East;

So, Tricia the situation has clearly necessitated a lot of work for the North East Health Protection team, can you tell us about the work you and the team have been involved in, and how this has affected the health protection unit as a whole?

“Yes, the situation has required a large amount of work for the whole team.

“One of the consultants has been extremely busy with work nationally on plans for returning workers who have been to one of the three at risk countries.”

“In addition our centre director has been very involved in leading work nationally, including spending periods of time in London as the national incident director.”

“Currently a number of the team, including a consultant and several health protection nurses are also undergoing training to support airport screening in other areas.”

“Personally, I have been involved locally by chairing the north east joint PHE/NHS Ebola incident management and preparedness team.”

“This means 75% of our consultants are doing Ebola related tasks as a significant part of the working week. Clearly, this puts a lot of pressure on staff dealing with the day job. However, everyone remains committed and motivated as we are aware this is likely to be a longstanding undertaking”

What do you think are the key things that can be learnt from your experiences locally with Ebola preparedness?

“From my point of view, what is absolutely critical about the preparedness planning in a situation such as this one is joint working across key organisations i.e. the NHS and PHE.”

“As with all complex situations, the devil is certainly in the detail! It is only through detailed process mapping and walk through exercises that the key organisations have been able to agree detailed operational guidance. The risk is that this sort of detail can be glossed over by bland assurance statements, but there will only be one opportunity to get this wrong.”

What involvement with Ebola do you think public health registrars might be able to have locally and what advice would you give to them for managing their out of hours work?

“One of our senior registrars who is currently on placement at the north east health protection unit has been heavily involved in the work of the joint PHE/NHS Ebola management and preparedness team. He has been leading on some very interesting work around the critical care response to a case.”

“Other registrars have been approached and volunteered to back-fill the day job of those who are busy working on the Ebola situation, and we are very grateful to the current trainees for their continued support and enthusiasm.”

“Our public health registrars on the out-of-hours rota have been given an Ebola training update, which is likely to require regular refreshment as the situation develops. Our current advice to all of those on call is to have a low threshold for escalating any Ebola query to the second on call and to keep abreast of new guidance as it is circulated.” Finally, if people want to find out more about Ebola or get involved with the work health protection teams are doing, what would you suggest?

“In other areas systems may be different but I would suggest registrars interested in pursuing work related to the Ebola situation should probably contact their public health centre training lead or the PHE centre Ebola lead if they would like to volunteer to be involved.”

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Welfare reform in the North EastDr Jim Brown

The United Kingdom is experiencing a radical programme of welfare reform which aims to save around £18 billion from the annual welfare bill.

As a result the income of households claiming benefit will reduce significantly by an average of £1,615 a year. This has potentially negative consequences for physical and mental wellbeing among those reliant on state benefits.

The North East of England has been significantly affected by welfare reform . It is the region with the highest rate of people subject to the ‘bedroom tax’, which requires individuals in social housing with a supposed ‘spare room’ to either pay significantly more towards rent or move home. Local authorities in the North East have been working hard to understand and mitigate the impact of welfare reform.

A recent conference, ‘What Price? Public Health and Welfare Reform in the North East’, was well attended and provided both insights and potential solutions.

As a public health specialty registrar on a 9-month academic placement at Newcastle University, I was fortunate enough to be involved in a piece of research on welfare reform.

This qualitative study aimed to explore the impact of the bedroom tax on social housing tenants in the worst affected area of Newcastle upon Tyne. It also helped to evaluate an intervention by the local social housing provider to work with employers to develop job opportunities. We undertook a focus group and interviews with service providers, employers and 40 tenants.

Preliminary results indicate that residents affected by the bedroom tax have substantially reduced income, affecting mental health, purchasing power for essentials, and familial relationships.

Participants singled out children and grandchildren as being significantly affected, and some experienced shame and felt increasing levels of stigma particularly from government and the media. Moreover, due to its geographical concentration, the bedroom tax affected the locality as a whole, with participants highlighting that, due to financial constraints, they socialised less, and spent less in local businesses. There was an overwhelming sense that as a result of the bedroom tax, home was regarded as a disposable asset, negating the attachment to home and community that many had built up over years. The overall impact was that participants felt they were no longer managing, “just surviving”.

This study highlighted that the pubic health implications of the bedroom tax are considerable at an individual, household and community level. The public health impact of UK welfare reforms are such that income inequalities are increasing with resulting implications for inequalities in health. Affected individuals have worse mental health. As a result, ‘upstream’ public health interventions, such as income maximisation, anti-poverty and employment programmes are required in order to improve local health, social and economic outcomes.

Activities to address welfare reforms included: • Commissioning a report on the impact in the

North East• Monitoring relevant indicators (such as numbers

affected, terminations of tenancies, homelessness and crime)• Investing in credit unions (for example to offer

loans for white goods)• Creating apprenticeships• Renovating large empty properties to create one-bedroom flats• Funding voluntary organisations• Campaigning nationally

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Access to food in County DurhamDr Susanna Mills

Levels of adult and childhood obesity have been rising in the North East and wider UK, with lower socio-economic groups disproportionately affected.

This has prompted research into the causes of overweight and obesity, and much interest as focussed on the concept of ‘food deserts’.

The phrase was first coined in the 1990s by a resident of a public sector housing scheme and has since gained widespread popularity. It has been described as ‘areas of relative exclusion where people experience physical and economic barriers to accessing healthy food’. However, despite intuitive appeal, whether in reality ‘food deserts’ exist has proved controversial.

Strong links exist between deprivation, obesity, and dietary quality, with an estimated quarter of observed inequalities in UK mortality attributable to inequalities in diet.

During my training placement in Durham County Council, I undertook a food mapping exercise to establish current access to food, and specifically healthy food, in County Durham. This was considered in terms of physical access, affordability, and food provision (range and quality).

In terms of deprivation, a significantly higher proportion of the County Durham population (45.4%) live in the 30% most deprived areas compared to nationally. County Durham also has higher rates of adult obesity (28.6%), and childhood obesity in year 6 (21.7%), compared with the England averages (24.1% and 19.1% respectively). The proportion of the population eating healthily (defined as consuming five or more portions of fruit and vegetables daily) is lower in County Durham (21.4%) than the average for England (28.7%). Improving dietary patterns and levels of obesity are therefore key issues locally.

A range of methods were used to investigate food retail provision and whether ‘food deserts’ exist in County Durham. See below:

The results from this project are currently under analysis, and will be used to develop recommendations to inform future policy making in County Durham for food and health. Leading this project has highlighted to me the value of liaising with a range of experts in local authority teams, such as those in planning and sustainable transport, to drive local action on complex ‘wicked’ issues like obesity.

I have been impressed by the clear potential presented by working in local government for identifying local priorities; using intelligence and expertise to investigate complex issues; and generating enthusiasm across community and professional groups to meet multifaceted challenges.

My hope is that these opportunities will continue to grow as public health becomes further embedded into local authorities.

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Council datasets: information from town surveys and food business databases were used to identify and locate food retail outlets.Mapping software: maps were produced detailing the prevalence of deprivation; obesity; retail outlets; takeaways; and ratio of retail outlets:takeaways.Travel times: travel from residences to supermarkets was mapped using private car, and public transport.Focus groups: community members participated in a set of focus groups to discuss local food access.Street surveys: a market research company was commissioned to undertake on-street surveys with members of the public to establish views and experiences of local food retail.

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Living on hand-outsDr Keith Allan

The way in which many of us access and use food is damaging the health of individuals and decreasing wellbeing in communities.

Having less money to spend on food forces people to find cheaper but less sustainable alternatives to eat, these may negatively impact upon their health and the environment.

It has been estimated that within the UK in 2006-07, ill health related to poor diets cost the NHS £5.8 billion. Socio-economic inequities are at play, with those in more deprived areas shouldering a disproportionate burden.

Additionally the majority of people do not eat the recommended five portions of fruit and vegetables a day.

In many cases this may not be due to a lack of understanding about healthy foods but rather a lack of access to fresh foods at affordable prices. In some relatively deprived areas, where there is demand for good quality fresh foods, what fruit is accessible is seen as “not to be up too much” and often “out of date”.

Against this backdrop of increasing ill health and problematic relationships with food (on a national scale), an increase in the use of food banks has been seen.

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Those using food banks do so as “they are not best able to manage their finances,” (Michael Gove).

Depending upon political background this has variously been seen as a consequence of food prices increasing in real terms (an increase of 11.8% in six years) as new welfare reforms put vulnerable people at risk (the political left) or simply the market driven use of a “free good” from an increasingly efficient service (the political right) or indeed that those using food banks do so as “....they are not best able to manage their finances,” (Michael Gove).

The North East of England has also seen an increase in the use of food banks (the Trussell Trust gave three days emergency food on 741 occasions in the North East in the 2011-12 financial year, rising to 59,146 in 2013-14).

A common reason reported for this by those in food banks, is welfare reform including increased use of sanctions (i.e. removal of benefits payments for claimants failing to comply with benefits conditions) or delays in payments being made (the think-tank Policy Exchange has demonstrated in Smarter Sanctions that up 68,000 people on Jobseeker’s Allowance have their benefits taken away by mistake per annum).

There has also been an increase in people in employment using food banks, suggesting that with increased housing prices, food and utility bills the minimum wage may not be sufficient to live on.

An all-party inquiry launched by MP Frank Field in February to clarify the numbers of people going hungry in Britain and its causes will report its findings later this year, however Field has already noted that food banks show “the weaknesses in society”.

What may be agreed is that food banks should not be necessary.

An approach which reduces inequity, promotes the availability of fresh fruits and vegetables and other produce which also reduces reliance on junk food is necessary. This must go hand in hand with a reform of welfare reform.

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Women’s health and wellbeing perceptions: locally and globally Dr Balsam Ahmad and Julia Bates

The contribution of women to the achievement of global public health targets cannot be underestimated.

It is well evidenced that within families, women are a key influence on the health and wellbeing of their children and partners.

Although geographical differences in women’s health persist, research focusing specifically on women’s perceptions of locality factors influencing their own health and wellbeing is scarce.

Specialty registrars in the North East region independently undertook qualitative research in the UK and in Aleppo, Syria in 2011, which aimed to better understand women’s health and wellbeing perceptions and locality influences on them.

In the UK study fifteen women participated in two focus groups and six individual, semi-structured interviews.

The influence of women’s geographical location in relation to amenities and services and loneliness were recurring factors in the discussion, each influencing lifestyle. It was evident that women in their local context were themselves assets through which their own physical and mental health could be improved.

In the Aleppo study, 20 married women from low income neighbourhoods were interviewed. Women were asked how they perceived their health and how living in the neighbourhood influenced their health.

The findings showed wellbeing to be central to lay women’s experiences of neighbourhood effects. Poor quality housing; over-crowdedness and neighbourhood social disorder comprised additional stressors on top of the multitude of individual and household stressors that affected the wellbeing of women.

Examples of these individual level stressors included but were not limited to: household poverty, low educational attainment and partner violence.

Another key finding was similarities between low income women living in socioeconomically deprived neighbourhoods in their apparent anxiety when describing their health: for many low socioeconomic (SES) women, illness incurred payments they could not afford.

The similarities were most apparent in the accounts of low income working married women who were the breadwinner in their families and who worked in low income jobs. These women viewed health as a resource and illness posed a considerable risk to their livelihoods.

Thematic analysis yielded four key themes: 1. Health and wellbeing perceptions2. Mental resilience3. Low income and choice4. The influence of place

The findings from these two different contexts, highlight the importance of psychosocial pathways in lay women’s perceptions of the influence of neighbourhood SES characteristics on health and wellbeing.

Women’s social circumstances and local environment can operate together to influence their perceived mental and physical health and wellbeing. The position of women as an asset in building healthy local communities should not be underestimated.

Women’s voices should be included in designing health and local services at the neighbourhood level. There is a need for more translational research which transcends academia to inform urban policy and which uses meaningful participatory approaches that involve women.

Women’s voices should be included in designing health and local services at the neighbourhood level.

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PHE as a training locationJudith Stonebridge

In response to the public health structural reorganisation which took place in April 2013, a piece of work was undertaken across the Northern region to review the provision of training placements (including the distribution of educational supervisors) within the new landscape.

The focus of which was to ensure current and future speciality registrars (StRs) could be provided with opportunities and support that would facilitate the attainment of knowledge, skills and experience in line with the requirements set out in the 2010 Public Health Speciality Training Curriculum.

The work highlighted the following:

• Almost half of the educational supervisors in the region were based in PHE teams.

• Some training opportunities previously provided in PCTs were now difficult to acquire in Local Authorities for example screening and immunisation work.

• The work undertaken in PHE centres provide opportunities for a wide range of experience for example work with healthcare data, healthcare service commissioning and design as well as work in relation to screening and immunisations.

The new set up

The local Speciality Training Committee supported the proposal for the development of a placement in Public Health England which broadly related to:

The mandatory three month Health Protection placement continues as a discrete attachment.

• From August 2014 all phase two StRs undertake a 12 month placement at the PHE centre.

• Mop up placements are provided for current more senior trainees who have identified training needs relating to work undertaken at the PHE centre.

• A PHE trainers group has been established to map and allocate potential projects to StRs, co-ordinate attachments and supervision and share good practice in supervision and assessment.

The story so far

Six StRs started placements with the PHE centre on 4th August 2013 with another two scheduled to take up placements over the next few months.

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They are working on a range of projects which include:

• Health Needs Assessments in relation to a range of topics.

• An assessment on the impacts of recent flooding.• Audits and pathway reviews in relation to a range of

programme and topic areas.• Evaluation of school based immunisation campaign in

three local authority areas.• Providing public health input to the Specialist Clinical

Networks.

Feedback from one of the StRs involved:

What next:

• A review of the model will be undertaken at the end of the first 12 months.

• Opportunities for the StRs to link with regional and national work being undertaken by PHE and NHS England are being explored.

• The recently established PHE trainers group is being expanded to allow participation of all public health trainers across the region.

• The potential to undertake some time limited work with the PHE communications team during the placement is being explored.

The rotation seems to be very well organised with a wide range of projects on offer to meet different learning outcomes. I feel confident both about the level of support offered and the possibility to do meaningful work on a significant scale.”

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Just givingHeidi Douglas

A number of registrars are involved in a wide and varied range of charitable activities, this includes being board members and trustees for charitable organisations, and as well as more practical hands on volunteering.

Whitley Bay Big Local (WBBL) is one of 150 ‘Big Local’ initiatives across the country each allocated a £1m budget from the Lottery over a ten-year period by the parent organisation: Local Trust (based in London).

Big Local is a community led initiative creating a project that presents an opportunity for all who live and work in a Big Local area, whatever their age, culture, background, education or skills, to get together with the resources of the extended community and work towards making their town into their ideal place.

As a Whitley Bay resident, participation in WBBL offered me the opportunity to help shape and deliver a plan to help turn around Whitley Bay and halt its decline. I applied to join the WBBL board and after a skills audit of all the board members, I was subsequently appointed as the chair of the wellbeing and resilience theme group.

In my role, I have had the opportunity to use my public health skills set in a number of ways; including working with local businesses and young people in designing a tender that reflected the needs of young people, who are mainly care leavers or coming out of prison (after short sentences) and are placed in B&B accommodation.

It was identified early on that the traditional B&B accommodation in Whitley Bay had diversified their business plans away from the diminishing stag and hen dos, to now focusing on a new income steam i.e. providing the very basics to the most vulnerable.

I discovered that young people’s experiences of B&B were very different, with some being in very homely environments where the staff (who are untrained) do their best to support individuals.

Other B&Bs, however literally kicked young people out after breakfast (no matter what the weather) and did not allowed them back in till 9pm.

This in itself has caused another problem with reports of antisocial behaviour and regular involvement from the local police. Local Authorities have all signed a pledge to not send their care leavers to B&Bs, however we know that locally young people continue to be placed there.

So what are we doing about it? The wellbeing and resilience board put out an invitation to tender for an asset based pilot with young people and B&B owners that improves not only the immediate prospects for young people, but also draws upon the skills of the B&B staff. Alongside this we are working with Local Authorities to change how they commission temporary accommodation.

My engagement in this piece of work has been challenging and I have learnt a great deal whilst being able to practice my skills, especially in relation to part B - dealing with conflict and reaching a consensus.

I have also had the chance to be involved in shortlisting, interviewing and drawing up contracts and evaluation structures, as well as presenting this work to the elected mayor and chief executive of North Tyneside Council.

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The annual reports of theChief Medical OfficerDr Simon Howard

The Chief Medical Officer is independent of Government, and acts as the government’s principal advisor on medical and public health issues.

The role of the Chief Medical Officer dates back to 1855, when Sir John Simon was appointed the first Medical Officer to the General Board of Health. Sir John instituted the tradition of a Chief Medical Officer’s annual report, providing an independent assessment of the state of the public’s health to Government. Since then, the Chief Medical Officer of the day has prepared a report almost every year.

For the first century or so, these annual reports took a consistent form. Each opened with a letter from the Chief Medical Officer which listed notable events affecting the public’s health during the year, and highlighted examples of particularly good or interesting public health practice.

The second section set out statistics, typically covering data such as birth rates, leading causes of mortality, cases of infectious diseases, and vaccination rates. The third section was typically given over to experts, featuring state of the art summaries of current knowledge and practice on topics the Chief Medical Officer felt deserved attention. Over the years, these topics varied from hospital design and safe import of food to factory working conditions and the impact of weather on health.

When Professor Dame Sally Davies was appointed as the first female Chief Medical Officer in 2010, she chose to return to this traditional form of annual report. To meet the demands of the modern media age, each report is split into two volumes: one performs the statistical function of the traditional report, while the second brings together experts to advocate on a particular topic.

Both are primarily aimed at supporting directors of public health and other public health professionals in their roles. Maintaining the (somewhat confusing) historical convention, each of these reports is named after the year of data it discusses, rather than the year it is published. Hence, the 2012 report was published in 2013/14.

From February 2013 to March 2014, I spent time out of public health training to act as the Editor in Chief of the surveillance volume of the 2012 annual report. This was an exhilarating experience, which allowed me to work alongside some of the nation’s foremost public health experts - and some personal public health heroes! The fortunate timing of this Out of Programme Experience meant that I have been involved in some small way in all of the current Chief Medical Officer’s reports to date.

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The current CMO’s first surveillance report - On the State of the Public’s Health 2011, edited by Tom Fowler - was an astonishing compendium of public health data visualised in innovative ways.

The extensive use of ‘cartograms’ - maps whose area is distorted in proportion with the size of the population - allowed an at-a-glance overview of the size of the population affected by health issues.

These maps clearly showed the North/South divide in many aspects of public health, and demonstrated that while some exposures may affect only relatively small geographical areas, they affected a relatively large proportion of the population. See, for example, the cartogram showing air pollution depicted below.

The second surveillance report - On the State of the Public’s Health 2012, edited by me - attempted to build upon the first by examining in greater detail some of the most notable findings. It also focussed on some areas of public health which are sometimes under-considered, such as prison health and sensory disease.

It built on the innovative mapping in the first report though incorporating novel infographics, designed to communicate key messages in simple ways.

Some of these were very widely shared on Twitter. See, for example, the cancer infographic overleaf.

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And, indeed, one image from this volume was featured in the British Library’s Beautiful Science exhibition.

The third surveillance report, On the State of the Public’s Health 2013, is due for publication next year.

The CMO’s first advocacy volume, Infections and the Rise of Antimicrobial Resistance 2011, brought together some of the country’s foremost experts in microbiology and infectious diseases. Using a life-course approach, it discusses the impact of infections of the public’s health.

The discussion of antimicrobial resistance raised national and international awareness of the importance of the topic, directly leading to its inclusion on the National Risk Register.

The second advocacy volume, Our Children Deserve Better: Prevention Pays 2012, used the expertise of paediatricians, academics, economists, public health specialists and children to set out a strong, evidence-based argument for investment in the early years.

The startling economic statistics included in this report received much attention from the Government, who have gone on to adopt almost all of the recommendations made.

The third advocacy volume, published only a few weeks ago, Public Mental Health Priorities: Investing in the Evidence 2013, examined the state of the nation’s public mental health.

Rather than framing discussion of the topic in terms of “well-being”, which is poorly defined and lacks a strong evidence base, this recommended adoption of a conceptual model of public mental health derived from the WHO Public Mental Health framework. It also set out a strong economic case for investment in better mental health.

A rigorous focus on evidence and statistics has made all six volumes produced to date hard-hitting and impossible to ignore. Through careful planning, each has also received extensive media coverage, allowing Dame Sally to highlight some of the most important messages for individuals.

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And working carefully with people and organisations in advance of publication to ensure that recommendations are reasonable and practical has helped to ensure that almost all of the recommendations Dame Sally has made to date have been adopted.

Together, the six volumes contain a wealth of information and expert commentary on all manner of public health topics.

If you haven’t yet read them all, it’s certainly worth dedicating some time to them.

If any public health registrar would like to be considered as an editor for a future report, please contact deputy Chief Medical Officer Professor David Walker through his PA, Aggie Kamara-Kargbo (agnes.kamara-kargbo@dh.gsi.gov.uk).

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The Law Department at Northumbria University provided a half day of training for us on English law and how it relates to our work in public health.

We started by examining general principles, before considering the roles and responsibilities of local government, taking an overview of the English legal system and looking at the specific areas of planning, licensing, environmental permits, environmental health and health protection, and use of information.

We spent much of our training session talking through some practical scenarios which we had constructed as registrars.

All public sector decision-making should be governed by the same general principles: the need for a power (for example from statute); the exercise of discretion (within the constraints of policy); following procedure (which might be statutory or based on custom and practice); acting reasonably; natural justice; and proportionality.

Decisions on planning and licensing make good examples of how these principles are applied in practice. Planning legislation is in place to provide the power for Local Authorities’ decisions, but there is discretion, with the potential for local ‘material’ considerations to be taken into account, and clear procedures to be followed. Social factors could be one of those material

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considerations – for example whether a fast food outlet should be developed close to a school. The Licensing Act sets down a number of licensing objectives, including preventing crime and disorder, public safety and the protection of children from harm – but not the protection of health.

If an application for a licence is made lawfully and there are no objections then the Licensing Authority has to approve it – possibly with conditions.

We examined this further as one of the scenarios: what scope is there for a director of public health to object to a licence application, for example if an area already has lots of bars?

The DPH is certainly able to comment, but any objections have to be set against the licensing objectives: for example health data on alcohol misuse and A&E activity could potentially be used to challenge whether additional premises would compromise public safety.

We also discussed a couple of health protection scenarios – the powers available to public health when managing an outbreak of gastric illness, or when an individual with an infectious disease is not co-operating with treatment but is putting others at risk.

Outbreak management is a competence that is well covered in our training, but the latter scenario is pretty rare (though this does happen, for example with TB: Google the Health Protection (Part 2A Orders) Regulations 2010 if you are interested!).

Overall, we found the session very useful and we would happily put others in touch with Northumbria University.

Public health law trainingGerald Tompkins

In the North East our monthly registrar meetings include a regular training and education session, but there are some topics that need more time, such as the law.

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Safe hands? Decision making on the new health and wellbeing boardsDr Zoe Greaves

In 2012 the Health and Social Care Act established a new player in the forum of public health decision making.

The health and wellbeing boards were designed to play a key role in furthering the integration agenda which has been gathering pace in modern healthcare over the past decades.

Now based in local authorities, membership of public health boards is made up of people from a broad range of disciplines, and is subject to significant variation.

As part of my MSc dissertation I decided to explore the decision making process on these new boards, to better understand the role that they are carving for themselves in the new public health landscape.

Interviews were conducted with the director of public health and the chair of the health and wellbeing board, from a number of local boards.

The study was designed to address two questions: what criteria is applied to decision making and how is this then prioritised?

By establishing this, it was hoped that the research could draw out similarities and differences in the way criteria is applied to the decision making process.

Overall, boards saw their role as being largely strategic. They saw their role as being very much detached from the process of decision making, which they saw as belonging exclusively to specific funding allocations.

Despite this perception, it was found that boards are involved in strategic decision making across a wide range of issues – decision which are described as being made in a constructive and collaborative spirit.

Interviewees recognised the importance of certain key criteria, such as equity and effectiveness, both of which align with criteria shown to be important in public health decision making more widely.

There was also recognition of a need for decisions to align with the strategies of the board and its partners, perhaps reflecting the integrated nature of the new boards.

However, criteria did not appear to be weighted or quantified in the decision process, and decisions described were made by informal analysis of the relative merits of the alternatives before the board at a given time.

Interviewees also recognised that boards are very much in their formative years, so they are still in the process of development. As such, the decision making process is still maturing.

As we approach the 2015 General Election and new Health and Wellbeing boards become recognised as part of the public health landscape, it is important to consider the potential future impact of these boards and of the findings of this study.

There has been some suggestion that funds currently allocated by CCGs may instead become the responsibility of Health and Wellbeing Boards.

This will represent another seismic shift in the way in which local healthcare services are planned and commissioned.

In this climate it is more important than ever that as we move forward, we have a good understanding of the ways in which these boards reach decisions and the priorities around which these are based.

We can be somewhat reassured by the discovery that the criteria underpinning board decision making aligns closely with public health priorities.

However, boards will undoubtedly benefit from support and guidance in developing their decision making process as they mature to meet the future demands placed upon them.

TRAIN

14

WORK

Whilst working at Balance, the North East Alcohol Office, the volume of alcohol displayed in supermarkets was highlighted as an issue. This sparked an idea to assess supermarket compliance with one of the Government’s public health responsibility deal (PHRD) pledges.

PHRD is a partnership between government, industry, academic and voluntary sector experts aimed at developing voluntary agreements to address specific public health objectives.

All five largest supermarkets (‘Top 5’- Tesco, Asda, Sainsbury’s, Morrisons. Co-Op) have made a series of pledges regarding alcohol, which includes:

“We commit to further action on advertising and marketing, namely…. not putting alcohol adverts on outdoor poster sites within 100m of schools…..”

There is debate as to whether a self-imposed exclusion zone of 100m constitutes a responsible attitude towards alcohol promotion. In light of the fact that the guidance on planning applications for takeaways recommends an exclusion zone from schools of 400m, the alcohol

advertising exclusion zone pales into insignificance by comparison.

Although making this pledge certainly had its merits, there was no mention of whether the supermarkets applied the same standards to their own store front advertising. To look into this, I visited a number of stores across the North East and assessed compliance with the pledge.

The 378 postcodes of the stores of the 5 major supermarket retailers were entered into a GIS system and mapped against all primary and secondary schools to identify those that were within 100m of a school. Initially, 10 schools were identified as potentially being within 100m of a supermarket.

After visiting these, it became clear that a number of supermarkets were contravening their alcohol pledge. Three had on-site, outdoor alcohol advertisements, and another had an alcohol advert in a window that was intended to be visible outside.

Clearly, as with all advertising, there is a seasonal aspect to take into consideration. Most of the adverts related to non-alcohol related gifts and seasonal products, and there were a number of adverts promoting wine.

Arguably, if the same stores had been visited during the World Cup or at Christmas, it is likely that there would be more adverts associated with alcohol consumption.

What was clear is that there is still some way for the retailers to go when it comes to taking the responsibility deal seriously.

Alcohol marketing at the school gatesMark McGivern

15

WORK

After all, a pledge means nothing if it isn’t seen through. And if it isn’t seen through, then people lose confidence in it.

There have also been a number of other examples of alcohol advertising in the North of England that wouldn’t meet with the responsibility deal pledges, like advertising alcohol at school bus stops or on school perimeter fences for example.

There is evidence to suggest that exposure of children and young people to alcohol advertising increases initiation of drinking, and encourages heavier drinking among existing drinkers.

Advertising in such close proximity to schools is something that most major producers and retailers have committed not to do, but this limited investigation has shown otherwise. The debate about appropriate restrictions and guidelines on alcohol advertising will continue.

However, if we don’t highlight the lack of compliance by the retail / manufacturing sector with their current pledges, it may be assumed that the current controls are not only being observed, but are enough. By demonstrating that this isn’t the case and taking a stand on alcohol advertising, we can take a small but significant step in the right direction.

These are unlikely to be isolated examples and we’d like to try to compile some more examples from across the North East, and beyond.

If you see any alcohol advertising at the school gates, please send us a picture with details of the location to: info@balancenortheast.co.uk or tweet it to @BalanceNE.

Examples of storefront advertising of alcohol within 100m of a school premises.

16

Although it has been a few years since we experienced a large scale outbreak flu, it remains a significant public health risk.

However, uptake of the vaccine is low amongst key risk groups – in the North East just over half of eligible under 65s and around 42% of pregnant women were vaccinated in 2012/13.

In winter 2013/14, flu immunisation was commissioned from community pharmacies, with the aim of increasing choice and improving uptake. After the campaign an evaluation was undertaken of the Durham/Tees pharmacy scheme to help colleagues decide whether the service should be commissioned again.

The evaluation followed a structure/process/outcome approach and combined quantitative analysis of activity data with a qualitative approach based on interviews with stakeholders – practice staff, pharmacies, Local Medical Committee and Local Pharmaceutical Committee representatives.

Recruiting interviewees and gaining their trust, particularly from the practice side, was at times difficult. This was not helped by someone informing a flu planning meeting that the scheme would be re-commissioned – almost before I had begun the evaluation.

Although the lead consultant overruled this, I still had to make clear that I would be bringing an independent public

health perspective and was not part of the team that had commissioned the service in the first place. The interviews revealed strong views – from the practices’ perspective the pharmacies benefitted from the work practices did (and funded) to identify eligible patients and encourage them to be vaccinated, and was a threat to their income.

Pharmacists saw the scheme as a rewarding and appropriate extension of their professional role – as well as reducing pressure on practices and reaching patients who could not or would not get the vaccine from GPs.

However, the interviews also highlighted practical difficulties which caused friction, for example in ensuring data about pharmacy activity was passed to practices so that medical records could be updated.

There was truth on both sides. Certainly, most of the patients vaccinated by pharmacies had been vaccinated previously in practices – less than 10% were new patients. Furthermore, the scheme was responsible for just 2% of all adult flu vaccinations, so practice activity remained the key intervention in protecting the public from flu.

However, information from patients suggested the scheme was popular with those who used it. There was also widespread support for a collaborative approach across practices and pharmacies, with both feeling this would benefit patients and raise uptake.

Overall, I concluded that the scheme had met the aim of improving choice – but not that it increased uptake. I developed a framework for judging whether to re-commission it, which was based on safety (at the individual and population level), choice, capacity, acceptability, uptake and cost.

However, I felt there was insufficient evidence to make a clear decision one way or the other on the service, and it was decided to continue with the initiative for two more years to gather further evidence.

Evaluating fluimmunisations incommunity pharmaciesGerald Tompkins

WORK

17

WORK

Standing frustrated in the queue to buy my four year old daughter socks in a clothing store got me thinking about just how frequently I seem to come up against the junk-food-at-checkouts-battle with my kids.

Fortunately my post as an Academic Clinical Lecturer enabled me to turn this frustration into action in the form of a research project to investigate this, which will be presented at the EUPHA conference in Glasgow in November 2014.

International research and pressure group campaigning has highlighted the problem of unhealthy food at supermarket checkouts. Anecdotal evidence suggests similar practices in non-food stores, but to date no published research has provided definitive evidence of the scale and nature of this phenomenon.

Unlike supermarkets, such displays may target people who do not intend to purchase food, and at times of the day when they are not considering eating.

Working together with two fourth year medical students on placement within the public health department at Newcastle University, I aimed to investigate the display of food at non-food store checkouts, to classify foods by type and nutrient content, presence of written price promotions, and whether or not food is displayed at child height.

We undertook a cross sectional study of a large indoor shopping mall in Gateshead February-March 2014.

“I’ll have a bag of sweetsand a packet of crispswith my socks please…”Dr Sarah Sowden

Two researchers used a pre-piloted tool to survey the checkout displays of non-food stores, inter-rater reliability of data collection was checked for a random 10% sample of stores. Foods observed were classified as “less healthy” or not, using the UK Food Standards Agency’s Nutrient Profile Model. Child height was defined as the sight line of an 11 year old approximated from UK growth charts. Written food price promotions were recorded.

We found that food was present in 32 (15.6%) of 205 non-food stores. Five of six book/card/stationery stores, five of seven department stores and nearly a third of toy/games stores had food at checkouts.

All displayed “less healthy” food, and 14 (43.8%) of 32 had not “less healthy” options, these almost exclusively being low-calorie drinks, water and chewing gum. “Less healthy” food (4.1%) was more commonly subject to price promotion than not “less healthy” (1.0%). 95.1% of less healthy food types displayed were at child height.

Food at checkouts in non-food stores is common, tends to be less healthy and displayed at child height.

Further research into the drivers and consequences of food sold at checkouts is needed. Public health regulation of the sale of less-healthy foods in non-food stores may also be warranted.

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WORK

As part of my master’s degree I carried out a piece of research on something that I was not only passionate about, but which would also inform public health aims to improve and protect health.

I chose to study the relationship between alcohol and football. The negative effects of alcohol use are well recognised, an example of this in the North East being that hospital admissions for alcohol related liver disease rose 400% between 2002 and 2010 – nationally this figure was 61% .

I’m a football fan and attend games regularly as well as watching them on TV. I have always been aware that alcohol and football seem to go hand in hand.

I was aware that many football clubs started with the local publican allowing them to use the land adjoining the pub, and that players often worked as barmen.

As a young working class man it was normal to go to the match and have a pint. But in those days, I was fortunate to get to half a dozen games a season and most televised football was limited to Match of the Day.

As my son has grown up and started to watch and attend games, I have become alarmed at how much marketing we were actually being exposed to and decided to study this – I was shocked by what I found.

Do we need a red cardfor alcohol marketing intelevised footballAndy Graham

My research set out to consider how often people watch-ing football on TV are exposed to messages about alcohol and found some disturbing results.

The study examined televised broadcasts of games from six different competitions involving English teams, which added up to over 18 hours of broadcast time.

By analysing the visual and verbal references to alcohol in each broadcast, it found that the amount of advertising and sponsorship varied, but that on average, viewers would be exposed to 111 visual alcohol references per hour of broadcast, or around 2 per minute.

Verbal references were much less common, while traditional advertising commercials represented only 1% of broadcast time.

This is interesting because the ‘voluntary’ codes of practice in place to regulate how alcohol is portrayed (should not appeal to youth, should not suggest social success, etc.) are more relevant to this type of traditional TV advertising.

Given that the Carling Cup Final last year included 1,104 visual references to the brand during the broadcast on a Sunday afternoon, we could suggest that the current controls are completely inadequate because they are focused on content, rather than the amount of alcohol advertising.

This issue is important because alcohol marketing works. It is proven to increase the likelihood that young people will start to use alcohol, and use more if they already drink.

Even young children are aware of alcohol advertising, remember it, and have increased expectation about the positive benefits. One study found that some 96% of young people are aware of alcohol advertising.

19

WORK

In addition, we know that quantity of alcohol marketing is more important than content, suggesting the apparently unchecked stream of visual references in this research may be even more important.

This study adds to a growing body of research which suggests that current policy approaches need to be reviewed and that regulation similar to that for tobacco marketing may be in order.

The worry is that so many children watch televised football. The days when Match of the Day was the main source at 10pm on a Saturday evening are long gone.

The advent of satellite TV means that it is now possible to watch live football on most evenings and as well as during the day on weekends. Opportunities to see, and consume alcohol have increased.

This is not just within pubs, but within living rooms, where the cheaper alcohol deals of the supermarkets are very popular.

So if we know marketing works and that young people are influenced, we must ask a question.

Are we sleepwalking into a situation where drinking alcohol is so closely associated with the sporting heroes children see on their television screens, that they are becoming increasingly normalised to become drinkers?

The concern is that the results of alcohol consumption are visible every weekend before and after the match, in the bars and the town centres, where it is normal to drink to excess when watching football, often with children in attendance, but no one seems to question whether this is normal. It is time that someone did question it.

Graham, A. and Adams, J. (2013) Alcohol Marketing in Televised English Professional Football: A Frequency Analysis. Alcohol and Alcoholism, pp.1-6. Medical Council on Alcohol and Oxford University Press.

Research on internal alcohol industry documents has found that:

• Market research is carried out with 15-16 year olds

• Manufacturers aspire to be youth brands• Alcohol producers recognise the

nature of immoderate drinking, but tend to use this knowledge for marketing purposes

• They even state that ‘young men think about four things, we brew one of them, and sponsor two.’

20

WORK

TV chefs and ready meals Dr Simon Howard

Before coming into public health I worked in neurosurgery, in a tertiary referral centre. It’s hard to think of a job in medicine which is more conceptually removed from public health: it deals with only a tiny number of patients each year, requires highly individualized treatments, and most of the team spend most of their waking hours in scrubs. After one particularly testing night shift I went home, microwaved a chicken tikka masala, and slumped in front of the TV. As I flicked through the channels, I came across a certain celebrity chef deriding microwave meals and insisting that we should all eat ‘pukka’ fresh food.

As I sat there mumbling angrily at the TV about ‘not actually wanting to cook when I haven’t slept in 24 hours’, I had a thought: much had been made by supermarkets about efforts to improve the ‘healthiness’ of microwave meals, but how healthy were celebrity chefs’ meals?

My public health MSc dissertation compared the energy and macronutrient content of 100 TV chef’s recipes with 100 ready meals sold by UK supermarkets, and compared both with nutritional guidelines published by the World Health Organization and UK Food Standards Agency.

As it turned out, none of the ready meals met the WHO recommendations; but neither did any of the celebrity chefs’ recipes.

And, perhaps even more surprisingly, the modal colour of the FSA’s nutrition ‘traffic lights’ was ‘green’ for the ready meals, but ‘red’ for the celebrity chefs.

A paper based on my dissertation was published in the BMJ and attracted the attention of the media.

This was my first real-world experience of working with the media, and it was something of a baptism of fire: I spent much of the morning doing live radio interviews for local stations around the country, and a handful of pre-records for national stations - even a couple of live interviews on English-speaking international stations.

Luckily, Newcastle University’s press office had prepared me well, and we had practiced the tougher questions. Even so, there were a couple of heart-stopping moments!

BBC Radio Newcastle asked me to supply a cooking tip (I think the presenters found my garbled attempt to suggest making pancake batter in a squeezy bottle more baffling than enlightening), while the LBC presenter’s lengthy description of the study before she came to me left me scrambling for something… anything… to say!

Towards the end of the day, when the interviews all merged into one, I started to forget whether I’d already made a point in any given interview, and constantly worried that I was about to repeat myself.

All-in-all, things went well - with the notable exception of the Daily Mail, which confused calories and kilocalories and hence drew some extraordinary conclusions.

Overall, the coverage was largely representative of the research, and started an interesting debate. Whilst the experience was nerve-racking, it was great fun, and a wonderful opportunity to build on media training with real-world practice.

Were the options they were recommending really

healthier? A lot of them seemed to use an awful lot of cream, butter, sugar and

chocolate!

21

In the 2013/14 flu season, Gateshead was chosen as one of seven areas across England to pilot the administration of seasonal influenza vaccine (FLUENZ) to primary school aged children.

This pilot was unique in a number of ways. Firstly, it is the only routine vaccination in the UK targeted at primary school aged children to be offered to every child, every year.

It is the only routine vaccination in the UK delivered via intranasal spray and, unlike other childhood vaccination campaigns; the main benefit is to others rather than the individual child. As a result of these differences, the program does not aim to achieve the typical 95% uptake rates, with 60%, or even 30%, coverage being potentially cost-effective.

The aims of the Gateshead pilot were to inform the implementation of the national vaccination programme, inform workforce planning ensuring safety, efficiency and cost-effectiveness and to highlight any potential difficulties for national roll-out of the programme.

The Gateshead model was offered in all primary schools in Gateshead, excluding special schools. It was delivered exclusively by qualified nurses through the school nursing service, excluded all children in clinical risk groups and required the presence of parents/guardians at the vaccination session.

A thorough speciality registrar-led evaluation of the pilot followed.

This included designing and developing the evaluation framework using process mapping, and included data analysis as well as use of questionnaires and focus groups to provide qualitative feedback.

A total of 66 primary schools, with 13,674 pupils took part in the pilot. The uptake rate was 56.9%. There was marked variation in uptake across the schools. In general, uptake was highest in the younger children, of white British ethnicity and with lower levels of deprivation.

Feedback from some headteachers indicated the level of administrative support expected was unreasonable. This partly resulted from the requirement of a parent/guardian to be present and the centralised (e.g. school hall) delivery model. It was clear that the requirement for parental presence had adversely affected uptake rates.

It was also recognised that the approach to staffing the Gateshead pilot was not sustainable, with heavy reliance on reprioritisation of other work, bank staff and over-time. The cost per dose of vaccine was also high, estimated to be around £15 (reflecting the necessity for qualified staff to deliver the vaccination).

For the 2014/15 flu season, the flu pilot is to be extended to include Sunderland and South Tyneside. High risk children and special schools are being included, parents do not have to be present, vaccine administration is not limited to qualified nurses and the vaccination sessions are to be largely delivered in the classroom, based on last year’s feedback.

The evaluation will follow a similar format to last year. It will involve a degree of number crunching, and the use of questionnaires and focus groups. It’s not easy to know at this stage what it will add in terms of programme refinement, but we already have some ideas regarding self-administration and want to pursue opportunities for ‘added value’ during the vaccination sessions.

Gateshead childhood fluvaccination pilotDr Joanne Darke and Glen Wilson

WORK

In our previous lives...

Balsam AhmedResearch Associate

Keith AllanResearch Fellow

Chris Allan Senior Public Health Analyst

Julia BatesHealth and Wellbeing Partnership Officer

Jim BrownGP and Clinical Author

Susanna MillsF2 Doctor

Mark McGivern Health Protection Practitioner

Simon HowardF2 Doctor

Jill HarlandHealth Improvement Lead

Zoe GreavesF2 Doctor

Thanks to everyone who has contributed to this edition of PH1. In the North East we are a small team, and this definitely was a full team effort. In a recent visit from John Ashton, he asked us all to describe our professional background; this highlighted the diversity and the range of the skills and experience we bring to public health, which we share with you below.

For further information about any of the articles in this edition of PH1, or to find out more about public health training in the North East please contact the Editor:

Heidi DouglasE: heididouglas@nhs.net

For information about previous editions nationally, please contact:

Mark McGivern E: mark.mcgivern@nhs.net

© Public health registrars from Health Education North East.December 2014.Articles produced by: Public health registrars from Health Education North East. Editor: Heidi Douglas.Editorial design: Hannah McGivern.

...continued.

Jo DarkePaediatric Trainee

Heidi DouglasIAPT Service Lead

Andy GrahamHead of Tobacco Control – National Support Teams

Gerald TompkinsHead of Social Inclusion

Judith StonebridgePublic Health Specialist and Sexual Health Lead

Sarah SowdenPhD Student

Lorna Smith Physiotherapist