The future of public health: lessons from the pandemic

woman in white and black polka dot shirt with face mask

The Coronavirus pandemic (COVID-19) has impacted all sectors of our society, but none more-so than public health services.

Last month, The Health Foundation hosted a webinar discussing the lessons from the pandemic and the future role of public health. The webinar drew on the findings from The Kings Fund report “Directors of public health and the COVID-19 pandemic”.  It considered the issues facing public health as a result of COVID-19, and proposed steps to rebuild the healthcare sector and begin tackling the problems left as we slowly move out of the pandemic.

Lack of resources

One of the main themes of the webinar was raised by Shilpa Ross of The Kings Fund, who explained that a lack of resources and shortages in public health existed long before the COVID-19 pandemic. The impact of longer term reductions to the public health grant meant that health services were not ready for the pandemic, nor for how long it has lasted. This has had a knock-on effect elsewhere in the NHS. A Care Quality Commission report noted that in July 2021, almost 300,000 people were waiting more than 52 weeks to begin hospital treatment.

On top of this, public health has faced staff shortages. Because so many healthcare services are “fishing in the same pond for recruits,” Shilpa explained that it has been especially hard to fill vacancies. In addition, many healthcare workers have experienced short and long-term effects of the virus, and the additional workloads have left many stressed and burnt out. The disruption to education could further delay the training and employment of potential new healthcare workers.

While the NHS has in some cases set up drop-in sessions for support and made efforts to provide even basic support, such as bottled water to aid hydration, these cannot fill the hole created by healthcare staff shortages.

Widening inequalities

Professor Kevin Fenton of Public Health England argued that “inequalities have defined the pandemic,” and would be the legacy of the last year and a half. A 2020 report by the Institute of Health Equity, commissioned by The Health Foundation, found that in England members of Black, Asian and minority ethnic groups (BAME) were more likely to be affected by COVID-19. The report attributed this partly to people in these groups living in more deprived areas, working in occupations with a higher exposure risk to the virus (such as healthcare or customer service roles), and in some cases living with multiple generations in their home (complicating self-isolation). The authors contended that while inequalities in social and economic conditions were present before the pandemic, they contributed to the unequal death toll resulting from COVID-19.

These inequalities have widened, partly due to the shortage of resources and staff. It has only grown more difficult to address the ever increasing numbers of people needing treatment, both urgent and non-urgent. As a result, the most vulnerable in society have fallen by the wayside.

Changing how public health works

The webinar also discussed how public health can move forward as the country slowly returns to a new form of normal. In addition to the restructuring of Public Health England, a new tax – the Health and Social Care Levy – will put an additional £12 billion into health and social care over the next three years. However, money alone is not enough – the webinar participants agreed that the infrastructures and inner workings of public health must evolve as we move towards a more efficient system of working.

Professor Fenton stressed the importance of engaging with local communities, and that the response towards the pandemic going forward must be grounded in their experiences, and what they need from both the public health system and also local authorities. He noted that while there may be pressure to go back to the way things operated before the pandemic, we must move forward: by understanding what worked and what didn’t, progress and better services can be achieved. Shilpa Ross added that a more targeted and tailored approach to health inequalities has provided more significant results in terms of vaccination and testing rates. This has in turn raised levels of trust within communities that public health teams may not have engaged with before the pandemic. All of this, however, takes up precious time.

Professor Jim McManus, Director of Public Health for Hertfordshire County Council, highlighted the importance of prevention not only for COVID-19 moving forward but other health conditions.  He stated that they must be tackled at a place where they can stop others continuing to be affected, in addition to treating those who are currently being affected.  Robin Tuddenham, Accountable Officer for NHS Calderdale Clinical Commissioning Group, agreed, and stressed that problems like homelessness and poverty should not be seen as separate from health but rather as important factors in the prevention of ill health.

Concluding thoughts

Highlighting the underlying issues and difficulties affecting public health before the pandemic is one step towards addressing them.

The webinar demonstrated that the pandemic has shifted how public health is perceived and valued. It has reminded all of us how important access to efficient, well-supported and high quality healthcare really is. Those working in decision-making roles in the healthcare sector are clearly looking towards the next steps for public health and how to give people the highest quality and most efficient care possible. With this in mind, the pandemic may have created a stepping stone towards a better healthcare system.


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How to make people with learning disabilities feel more included in society

Image: Accessible music technology OpenUp Music/Youth Music Network

This guest blog was written by Val Williams, Professor of Disability Studies at the University of Bristol.

People with learning disabilities can often find themselves feeling excluded when it comes to making decisions about their lives. This can range from everything, from shopping to making music or even bringing up a baby. Sometimes this exclusion can be exacerbated by the kind of support that they receive from social services – but it can also be countered by sensitive personal assistance or support.

In a recent research project, which brought together disabled and non-disabled researchers, we looked at ways to improve this – and how to include people with learning disabilities in decisions.

Part of the project found that by taking active roles in the arts, people with learning disabilities can lead the way towards meaningful inclusion. Beth Richards, an actress with learning disabilities, led part of the research about people with learning disabilities on TV. She found that actors with learning disabilities are often limited to roles which depict the “disability”, the tragic or dependent life of the character, or their effect on others around them. A successful actor with learning disabilities, for instance, told her:

“I wish TV makers would think more creatively and give people with learning disabilities any role – romantic, fantasy, comedy, shop assistants, office workers. I’d like to play James Bond, Romeo, Dobby in Harry Potter or a detective or many other roles.”

The Queen’s Birthday Honours in June 2018 include an MBE to the actress with Downs Syndrome, Sarah Gordy, for her “services to the arts and people with disabilities”. As Gordy said upon receiving the award, “diversity is an opportunity, not a problem”. She is good proof of that.

But there is a lack of accessible information. There is no shortage of talented actors and drama companies supporting people with learning disabilities, but the TV industry and its workings are still shrouded in jargon. Processes such as commissioning, auditioning and scriptwriting tend to exclude those who do not have someone to help them navigate all this.

In another part of the research, my colleague Marina Gall looked in detail at how music making can be transformed by the Open Orchestras approach in which young people with multiple and complex needs are enabled to learn musical skills, play in ensembles and become music makers. A new technological instrument – the Clarion – can be played on computers and iPads, using one’s hand, a small sensor on any part of the body, or via a person’s gaze. It can be adapted to suit most students’ physical needs.

One of the co-founders of Open Orchestras, Doug Bott, told our research team, that the approach is “personalised around the individual young person”. But at the same time, it’s trying to ensure that music is an important part of the curriculum for all young people, and has been immensely successful in changing perceptions of people with learning disabilities. This is not therapy, it’s a route to making music and to performance.

Making decisions

People with learning disabilities also face inequalities and problems in the NHS, as well as in a cash-strapped social care system. For instance, since the Mental Capacity Act 2005 came into force, support staff are legally required to support people with learning disabilities to develop their own capacity to make a decision. What we saw in our data was that people with learning disabilities can be proactive in seeking out this support – and we recorded conversations with personal assistants where people wanted to talk about decisions relating to safety, health or simply about future cooking plans. The skills that a personal assistant needs to have are to listen, look out and be responsive to the people they are supporting.

One of the key messages from our project is that health and social care practices sometimes get stuck. We used the word “institutionalised” for those times when professionals stick to a rigid and inflexible way of doing things, leaving the disabled person without the power to have a voice.

These difficult moments were also highlighted by actors with learning disabilities who helped to interpret our data. Our research benefited from a collaboration with the Misfits Theatre Company in Bristol, showing how sensitive interactions between people with learning disabilities and their personal assistants were often the trigger for good decisions, and giving those with disabilities a feeling of control over their own lives.

But quite small comments can create problems, spoiling an empowering relationship. The theatre company made a brilliant video called A Good Match about their own perspectives and experience of managing relationships with a personal assistant. One of the Misfits actors said: “It’s my house … and I don’t want my (personal assistant) telling me what I can and cannot do.”

 

After looking at a range of activities that can exclude or include people with learning disabilities, we concluded that inclusion happens when three things come together. Sometimes people with learning disabilities are included because of changes to technology, as in the Open Orchestras approach. At other times, they are included better because of new ways of doing something, or through new skills that they may learn – as actors, or as TV performers.

The ConversationBut at the heart of all this is a new belief in the equal value of people with learning disabilities. This is why we recommend that social care services need to focus less on what people cannot do, but instead promote a genuine belief in what people with learning disabilities can do – with the right support.


Val Williams is Professor of Disability Studies at the University of Bristol.

This article was originally published on The Conversation website and has been republished with permission under a Creative Commons licence. Read the original article.

Health Champions – “unlocking the power of communities”

Health Cubes_iStock_000022075266Large

By Heather Cameron

“On the societal level, we must understand that health is not an individual outcome, but arises from social cohesion, community ties, and mutual support.” Dr Gabor Maté

Health inequalities have long been an issue in the UK and despite continuous government commitment to tackling them, they continue to persist.

It is estimated that avoidable illness costs around £60 billion and that 1 in 4 deaths are preventable with the adoption of healthier lifestyles. Calls have therefore been made for radical changes in the approach to public health by improving health and wellbeing outside of the core public health workforce.

This is just the approach of the Community Health Champion model, developed by Altogether Better, which has demonstrated not only the positive impact on health but the social value of such an approach.

What are health champions?

Health Champions are volunteers from all walks of life who are provided with accredited training and support so they can undertake health promotion activities within their communities to reduce health inequalities and improve the health of the local population.

The Community Health Champion role began as a five year Big Lottery Funded programme (Wellbeing 1) in 2008. Over 18,000 Health Champions were recruited, trained and supported between 2008 and 2012, reaching over 105,000 people.

Through a combination of their training and own personal experiences, these volunteers empower and encourage people within their families, communities and workplaces to take up healthy activities, create groups to meet local needs and can signpost people to relevant support and services.

Challenges

While Wellbeing 1 succeeded in reaching many people in need, the programme also raised two specific challenges: in almost all cases, the work being done was invisible to the NHS; and securing ongoing funding to continue the support was difficult.

Peer support was later identified as the most appropriate way of trying to connect communities with health services.

Following this recognition and the success of the original model, further lottery funding was awarded to develop the Champion model and use it to engage champions, communities and health services (Wellbeing 2).

Co-production of health and wellbeing outcomes

The model was applied to health services specifically with the aim of addressing the apparent disconnect between the NHS and community-based services. It helps connect both patients with support in their communities and professional practices with those communities.

Many citizens have volunteered in different ways and in different settings. These include:

  • Practice Health Champions working closely with their General Practice to create new ways for patients to access non-clinical support
  • Youth Health Champions where children and young people are recruited, trained and supported to help young people more actively engage with and influence their own and their community’s health
  • Pregnancy and early years Health Champions who are interested in giving children a better start
  • Health Champions working within a specialist, hospital-based NHS service
  • Senior Health Champions who engage with older people, offering a complimentary approach to more formal programmes

Community-based health improvement initiatives such as this could help to strengthen community-professional partnerships and cross-collaboration among health, social and other services. And this in turn could lead to a reduction in health inequalities.

Positive outcomes

According to a recent evaluation of the Health Champions programme, Wellbeing 2 has resulted in a range of benefits:

  • 86% of champions and 94% of participants in the programme reported increased levels of confidence and well-being;
  • 87% of champions and 94% of participants in the programme acquired significant new knowledge related to health and well-being;
  • 98% of champions and 99% of participants in the programme reported increased involvement in social activities and social groups;
  • 95% of practice staff involved with the programme would recommend it and wish to continue.

Other benefits included reduced social isolation, increased levels of exercise/healthy eating and feeling physically better. One champion reported “this has helped me more than any medication might.”

Success stories  include the work of a cycle champion who has improved her own health and wellbeing, encouraged over 70 other people to improve theirs through taking up cycling, provided cycle training to over 50 people in 6 community groups and provided specific detailed help to 5 people.

Other successes have involved volunteers setting up football training, providing support to women with mental health issues, providing advice and support to ethnic minorities and providing advice on healthy eating.

In terms of monetary value, an  analysis of the social return on investment (SROI) of a series of Altogether Better project beneficiaries found a positive SROI of between £0.79 and £112.42 for every pound invested, highlighting the potential value of these initiatives to funders.

Final thoughts

At a time of increasing demands on health services and with the relentless squeeze on public sector resources, perhaps the move towards greater community empowerment and collaboration across sectors is the right one. After all, as I’m sure we’d all agree, prevention is better than cure.


If you liked this blog post, you might also want to read Heather’s earlier post on social prescribing

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Fighting the cold: working to reduce excess winter deaths

Image from Flickr user FranTaylor under Creative Commons License

Image from Flickr user FranTaylor under Creative Commons License

We may have all breathed a sigh of relief when last week’s cold snap finally eased, but for those working in public health the consequences of the cold weather are still playing out.

Cold weather poses a significant risk to health. There is a notable rise in deaths, and also illnesses and injuries, during the winter period. Indeed, in England and Wales there were 11.6% (18,200) more deaths in 2013/14 during the winter period (December to March) compared with the non-winter period (known as “excess winter deaths”).

Older people, particularly those aged over 75 years old, are most vulnerable to cold weather-related illness. The majority of excess winter deaths occur within this age group and those living on their own or who are socially isolated are most at risk. Other groups at risk include those experiencing chronic or severe illnesses, particularly heart conditions or circulatory disease, children under the age of five, and homeless people /street sleepers.

The reasons why cold weather has such a negative impact on health are complex and interlinked with fuel poverty, poor housing and health inequalities. There can be an increase in circulating infectious diseases, particularly flu and norovirus, and snow and ice can cause falls. Cold weather has also been linked to increased cases of hypothermia, carbon monoxide poisoning (from faulty heating appliances), and mental health problems such as depression and anxiety.

However, there is evidence to suggest that many of these ill effects are preventable. In some northern European countries, such as Finland, the rate of winter deaths is far lower than that in England, despite experiencing much lower temperatures.

To help address this, the Government has published an annual ‘Cold Weather Plan’ (CWP) since 2011 aimed at local authorities, health and social care staff and any professionals working with vulnerable people. The plan operates a system of cold weather alerts, comprising five levels (Levels 0-4), from year-round planning for cold weather, through winter and severe cold weather action, to a major national emergency. Each alert level aims to trigger a series of appropriate actions, which are detailed in the plan. The latest CWP was published in October 2014.

It stresses the importance of year round planning and all-winter action for reducing excess winter deaths and relieving the additional pressures on the NHS and social care which occur during the winter months. Recommended all-year actions include:

  • addressing fuel poverty
  • improving housing and energy efficiency measures
  • raising awareness of preventative actions among staff.

All-winter actions (November to March) include:

  • communicating with the public about what they can do to reduce the risk of cold weather to their health
  • identifying vulnerable clients
  • supporting vulnerable clients to seek appropriate help.

There are also key public health messages which should be communicated with residents/patients, relating to flu vaccinations, keeping homes adequately heated and ventilated, available financial support, and looking after vulnerable older neighbours and relatives.

A guide to communicating effectively with the public during periods of extreme weather was published recently by the Local Government Association (LGA). The LGA have also provided guidance for local authorities on how they can help to reduce the negative effect of cold weather on health. It highlights examples of innovative schemes, including the installation of free temperature sensors and a volunteer ‘winter squad’ to care for vulnerable residents.

Investing in cold weather planning is important – although the media focuses on travel disruption during cold weather, for many of the most vulnerable in our society it can be a death sentence.


Further reading

The Information Service has a number of resources on cold weather planning – a selection are listed below.

Cold weather plan for England 2014: making the case – why long-term strategic planning for cold weather is essential to health and wellbeing

A turn for the better (Liverpool’s Healthy Homes Programme), IN Property Journal, Jul/Aug 2014, pp42-44 (Ref No. A51407)

Staying in touch (social media), IN Local Government News, Vol 36 No 2 Mar/Apr 2014, pp44-45 (Ref No. A49753)

Behind cold doors: the chilling reality for children in poverty

Reducing harm from cold weather: local government’s new public health role

N.B. Abstracts and access to journal articles are only available to members.