The Covid-19 knock-on: public health and the impact of delays in non-urgent treatment and diagnosis

Since the beginning of the pandemic, concerns have been raised about the wider public health impacts of coronavirus. In addition to strains on acute NHS care services on the frontline, there are warnings about the additional public health impacts of delays to preventative healthcare measures like screening and routine medical care in the form of pre-planned operations for long-term chronic and non-urgent conditions.

At the outbreak of the pandemic many hospitals took the decision to delay or stop entirely routine pre-planned surgeries and preventative screening and diagnostics. Some even suspended treatment for more urgent care like cancer treatment on a short term basis. While many of these services have resumed since the beginning of the pandemic, albeit with a backlog of patients now to be seen, significant strain on the NHS as we come into the winter months because of  coronavirus is still anticipated. As a result, many hospitals are not working at full capacity in order to prepare for potential increases in admissions due to coronavirus or staff shortages over the winter.

In many areas this has led to a backlog of care, both for those patients already in the system awaiting routine surgeries, as well as those who are yet to be diagnosed but would have been through preventative screening programmes run by the NHS.

Delays in healthcare and routine screening programmes 

Even before the coronavirus pandemic took hold, many NHS hospital trusts were under criticism because of the significant length of waiting times for people who required routine operations, which in some parts of the UK can be as long as three years. Doctors across the UK are now warning that these delays could be increased further unless the NHS receives additional support to increase capacity across all areas of care  not just urgent care in the coming months.

Data released by NHS England in October 2020 showed the numbers waiting over a year for hospital treatment have hit a 12-year high, with almost 2 million patients waiting more than the target time of 18 weeks for routine care.

It has been suggested that delays in diagnosis and routine treatments could lead to an increased number of hospitalisations further down the line, requiring higher levels of care, longer lengths of stay, and increased hospital readmissions.

A reluctance to visit hospitals and use primary care services

Government messages to ‘protect the NHS’ may have had the unintended consequence of discouraging people from seeking urgent medical care when it was required for fear of using services unnecessarily or for fear of contracting the virus when attending hospital or primary care settings.

Research from the Health Foundation found that there had been a significant reduction in the number of GP consultations since the start of the pandemic which has led to concerns about the care of non-covid patients, patients with long term health conditions and also the potential for delayed diagnosis. Primary care consultations also reduced and have remained low consistently since the beginning of lockdown.

Figures have also shown a reduction in the number of referrals, medical tests, new prescriptions and immunisations. While some of these reductions are the result of advice to delay routine referrals to free up capacity for hospitals to deal with the potentially large number of cases of Covid-19, routine referrals have still not recovered to pre-lockdown levels.

 

A potential future crisis for the NHS and a ticking time bomb for public health

Doctors are now warning that the treatment backlog which has been caused by the coronavirus pandemic, in addition to diagnostic delays and screening programmes, may lead to a future crisis of care or significant delays in care for people waiting to receive more routine treatment.

Delays in care have not only been reported in cases of physical health. There have also been significant delays in referrals for those seeking treatment for a mental health condition, an area of the NHS which was already facing significant delays in referral and transfer of care even before the pandemic. Research suggests that incidence of mental illness during the coronavirus pandemic increased. However, the numbers of people accessing services and being referred for treatment have not increased proportionate to this. People with mental health conditions may have been unable to access appropriate support through primary care pathways, which could potentially impact on their long term health and care.

Finally, concerns have been raised about the wider social determinants of health such as employment and poverty. Public Health England (PHE) published a monitoring tool which looks at the wider impacts of the Covid-19 pandemic on population health, and it is likely that the knock-on impact of the virus could have far reaching consequences for public health in the future as the health implications of lockdown, lack of social interaction and rising unemployment could be significant. 

Where next?

While the challenges of the coronavirus pandemic for the NHS will not be going away anytime soon, it is clear that it will be necessary for the NHS and other supporting services to act now to prevent a longer term public health crisis. It is critical that we not only focus on the acute care of Covid-19 patients, but also proactively manage patients without Covid-19, particularly those with time-sensitive, complex and long term conditions who are postponing their care. We must also consider the knock-on impacts of delayed diagnosis for those people who missed out on routine screening or who were unable or too afraid to visit their GP or hospital. This is important not only to sustain health and life, but to preserve hospital and NHS capacity in the future.


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Virtual knowledge: recent webinars on public and social policy

Earlier in the summer, we shared some of the information our Research Officers had picked up while joining webinars on public and social policy.

Since then, we’ve taken part in more of these virtual seminars, and in today’s blog we’re providing an overview of the wide range of topics covered.

Low traffic neighbourhoods

Earlier this month, Project Centre, which specialises in public realm regeneration and sustainability, organised a webinar on the challenges of implementing Low Traffic Neighbourhoods.

Low Traffic Neighbourhoods (LTNs) are a group of residential streets where through traffic is removed or discouraged, and any remaining traffic must operate at a pedestrian pace. The focus is not only to reduce congestion and improve safety by getting traffic back onto main arterial road networks, but also to provide environmental benefits, improve public health, community cohesion and encourage people to spend more, quality time in the areas where they live by making places “liveable”.

This webinar looked at the design and implementation of Low Traffic Neighbourhoods, with guest speakers from two local authority areas (Waltham Forest and the Liverpool City Region), as well as designers from Project Centre who support the implementation of Low Traffic Neighbourhood Schemes. The speakers discussed their own experiences designing and implementing low traffic neighbourhoods and shared potential lessons for those looking to implement their own scheme.

The speakers all emphasised some key elements to effective design and implementation of LTNs they included:

  • LTNs are not just about transport, they can have health and wellbeing, community cohesion and crime reduction and economic impacts for local businesses as people are encouraged and enabled to shop more safely in their local areas.
  • schemes should be done with communities, not to them
  • LTNs should be designed with everyone in mind to bring pedestrians and cyclists “on par” with cars in terms of the use of street space
  • effective data and evaluation can help build a case for wider roll outs.

The new long life: a framework for flourishing in a changing world

This webinar was delivered by the International Longevity Centre (ILC) and included a number of speakers from a range of backgrounds who came together to discuss the impact of longevity and ageing on our engagement with work and the labour market, particularly in relation to digital technology and the changing nature of work post COVID-19. Speakers included Prof. Andrew Scott, Caroline Waters, Jodi Starkman, Stefan Stern, Lily Parsey and George MacGinnis.

Many of the speakers highlighted the difference between the ageing agenda and the longevity agenda, explaining that while many of us will live and work for longer than ever before, the nature of work and the stages of life are changing in a way that for many will be unrecognisable as the “traditional life journey”.

They stressed the need to move away from “traditional linear thinking” about how we age, with education at the start, mid-life being punctuated by work and potentially parenthood, then retirement, and that ageing in the future will be full of more “life stages” and more mini cycles where career breaks, learning and other life “punctuations” will take place at different times of life. It was suggested that the nature of work will change so much that re-learning and at times re-training will be a necessity at multiple points in life, and not just by those who change career deliberately.

Ageing well must, according to speakers, remain high on the policy agenda of future governments to ensure that the growing population of older people can live lives that are enjoyable, purposeful and productive and can contribute to wider society well into what would currently be considered “old age”.

Clearing the air

This has been a year like no other. But while attention has rightly focused on the number of Covid-19 fatalities – more than 800,000 worldwide – there is another hidden killer which has been responsible for more deaths than coronavirus, HIV and malaria combined. Research has found that air pollution caused an extra 8.8 million deaths around the world in 2015.

We’ve written before about efforts to improve air quality, and in July a webinar organised by Catapult Connected Places looked at further innovative ways to understand and tackle air pollution across the globe.

Eloise Marais,  an Associate Professor in Physical Geography at UCL talked about TRACE – the Tool for Recording and Assessing the City Environment – that she is developing using satellite observations of atmospheric composition. Satellites offer more complete and consistent coverage than surface monitors, and satellites can also monitor many air pollutants, such as sulphur dioxide, ozone, nitrogen oxides and fine particulate matter.

But while satellites have a long and well sustained record of recording data – some have been in space for more than a decade – their measurements have limitations in terms of spatial resolution. At the moment, these can only cover city-wide air quality, rather than providing postal code measurements. Eloise explained that, while satellite data has been used to show that air quality improvement policies have been effective in London as a whole, they cannot yet confirm that in some parts of the city pollution levels are not falling. Even so, Eloise noted that spatial resolution is improving.

Later in the webinar, Bob Burgoyne, Market Intelligence Team Lead at Connected Places Catapult talked about the Innovating for Clean Air India Programme. India is home to 14 of the world’s most polluted cities. One of these, the city of Bangalore is especially badly affected, and Bob described a project which aims to improve the city’s air quality and enable a transition to electric vehicles. The Catapult network has been working with academic and professional bodies, and with small and medium sized enterprises in India to measure and demonstrate the impact of pedestrianizing a major street in Bangalore on Sundays. The long term goal is to permanently pedestrianise the street, and to demonstrate active and electric mobility solutions.

Back on track: London’s transport recovery

This webinar, organised by the Centre for London, discussed the impact of the Coronavirus pandemic on London’s transport systems and explored the impact of changes to Londoners’ travel habits on the actions required for recovery.

The event included contributions from Rob Whitehead, Director of Strategic Projects at Centre for London, Cllr Sophie McGeevor, Cabinet Member for Environment and Transport at London Borough of Lewisham, and Shashi Verma, Chief Technology Officer and Director of Strategy at Transport for London.

A major concern raised by speakers was that current trends indicate that car usage is returning to normal levels faster than any other form of transport. Public transport, such as bus and tube, is slowly recovering but its usage is often linked to changes to lockdown restrictions, with surges in use as restrictions are lifted that very quickly level off. Additionally, although it appears that active transport use has increased, this increase tends to be at weekends and is more apparent in outer London.

As a result of these trends, there is a serious concern that levels of traffic in London may exceed the levels experienced prior to the lockdown. Currently, road traffic is at roughly 90% of normal levels, if this rises to 110%, the resulting congestion will result in gridlock and could have major implications for London’s economy.

How should we use grey literature?

This webinar was organised by the CILIP Health Libraries Group, for CILIP members to learn about and discuss how grey literature is used by libraries, and the benefits and challenges of making use of such content.

The main talk was delivered by two members of the library team from the King’s Fund – Deena Maggs and Kathy Johnson – who emphasised the importance of grey literature as a means of delivering timely and up to date information to users, particularly in the context of health and social care policy, where information needs tend to be very immediate.

The session involved discussions about the usefulness of grey literature in terms of Covid-19 recovery planning, as well as the challenge of determining the credibility of content which is not peer reviewed or commercially published.

The speakers gave practical advice around selecting and evaluating such sources, and highlighted the broadening range of ‘grey’ content that libraries can make use of, such as audio recordings, blog posts, and Tweets.


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The dash from cash: can public transport providers balance the needs of staff and customers?

One of the unexpected repercussions of the coronavirus outbreak has been an increased use of card, mobile and contactless payments instead of cash. Concerns about handling money during the pandemic have prompted shops and public transport services to encourage customers to use contactless payment methods. However, many people relying on public transport to access work and health services have no alternative but to use cash.

A brief history of contactless payments

Contactless payments include credit and debit cards, key fobs, closed loop smart cards and other devices, including smartphones. These applications use radio-frequency identification (RFID) or near field communication (NFC) for making secure payments. An embedded circuit chip and antenna enable consumers to make a payment by holding their card or device over a reader at a point of sale terminal.

The first contactless payment was made available in the United States at the end of the 1990s. In the UK the first contactless cards were issued in 2007.

The UK’s public transport contactless revolution began in 2014, when it became possible to access London’s Tube network, Docklands Light Railway (DLR), London Overground and most National Rail services using only a bank card. By 2019, payments with contactless bank cards or mobiles made up 60% of all Tube and rail pay-as-you go journeys in London. Public transport authorities elsewhere in the UK have followed London’s lead.

The move towards cashless payments

Even before the current public health emergency, cash payments in the UK were in decline. In the past few years, there has been a shift towards the use of debit cards, while contactless payments have soared:

  • in the ten years up to 2019, cash payments dropped from 63% of all payments to 34%;
  • in 2017, contactless payments increased by 99% to 4.3 billion;
  • in the same year, 3.4 million UK consumers managed their spending almost entirely without using cash.
  • by 2028, forecasts suggest that fewer than one in 10 UK consumer payments will be made using cash.

The emergence of chip and pin, contactless cards, digital wallets and mobile apps has made many aspects of our lives much more convenient, notably when paying bills, purchasing goods and using public transport.

But although more and more people are moving away from cash payments, 2.2 million people rely almost wholly on cash – up from just 1.6 million in 2014. A Bank of England review in 2019 found that around eight million people  would find life “near impossible” without cash.

How Covid-19 is changing public transport

With high numbers of people in confined spaces and a large number of common touch points such as handrails and ticket machines, buses and trains are potentially high risk environments for Covid-19 transmission. At the same time, public transport is critical for sustaining the economy, and ensuring that people have access to shops, services, work and health care.

Public transport authorities around the world have been responding to the emergency in a number of ways, including increased disinfection and sanitisation, and encouraging physical distancing between passengers. Another key measure adopted by public transport bodies has been an acceleration away from cash payments and towards contactless and mobile ticketing.

While some bus operators have announced that they will no longer accept cash payments, others have warned that drivers could face disciplinary action if they refuse cash. Earlier this year, the trade union representing bus workers called for the abolition of cash payments on all UK buses to reduce infection rates among drivers.

Serving the ‘unbanked’

A recent webinar organised by Intelligent Transport explored the implications of the coronavirus public health emergency for public transport. One of the key points was that public transport operators now need to maintain a balance between protecting their staff while meeting the needs of passengers who may have no alternative but to make cash payments.

The webinar heard that there is a growing sense among public transport operators of a shift in perception concerning cash payments as a result of the global pandemic. However, cash payments remain vital for the 1.3 million UK adults who do not have a bank account (the ‘unbanked’), many of whom are on low incomes. Contactless cards may be unaffordable for lower-income passengers, while many unbanked passengers worry that contactless credit cards could lead to accidental overdraft.

As the webinar noted, public transport providers have been trying to overcome these obstacles. Some have continued to accept cash payments, while others have offered passengers their own prepaid cards that can be topped up with cash in shops or transport stations.

Final thoughts

It’s likely that public transport authorities will continue the drive towards cashless and contactless payment. Lower maintenance costs, speed and flexibility are some of the advantages provided by contactless applications, and transport companies can also benefit from the data on transport usage generated by electronic payment systems.

However, the migration from payments using physical money risks leaving over a million UK citizens behind. In the ‘new normal’ for a world living with the coronavirus, transport organisations will have to find innovative ways to balance the safety of their staff with the needs of their passengers.


Further reading
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Guest post: Economic effects of coronavirus lockdowns are staggering – but health recovery must be prioritised

By Pushan Dutt, INSEAD

In all my years as an economist, I have never seen a graph like the one below. It shows unemployment claims in the US – observe the spike for the week ending March 21. The global financial crisis, the dot-com crash, Black Monday, oil price shocks, 9/11, none of these historic shocks are even visible in the graph.

Figures: US Department of Labor

 

The spike in unemployment claims is the proverbial canary in the goldmine. We should expect a swathe of bad economic numbers coming down the pipeline. The head of the St. Louis Fed expects a 30% unemployment rate and a 50% drop in US GDP by summer. More importantly, as the health crisis rises and crests at different times in different parts of the world, the horrifying numbers on GDP growth, unemployment, business closures are not likely to let up in the near term. Multiple countries are in a recession, and eventually, the whole world will fall into a deep recession.

The plunge from prosperity to peril will be as swift as the switch to lockdown protocols in most countries. We cannot even rely on the data we have to reveal the speed and depth of the crisis since this is collected and updated with lags. For instance, the US monthly jobs report for March collects data in the second week of March, failing to capture the massive spike in unemployment claims that appears after March 12.

In the meantime, sources such as restaurant booking website OpenTable can offer some insights into the magnitude of things. The figures below show the recent plummet in diners eating at restaurants in four countries. Observe a sudden stop in the entire restaurant industry by the third week of March.


Annual % change in restaurant diners from end of February to end of March.

Data: OpenTable

 

Combine a black swan event with missing data, and it is not surprising that markets are swinging violently.

Deep freeze

The question is not one of whether we are in a recession – we are. The more pertinent questions are: how long it will last? How deep it will be? Who will be impacted the most? And how swift will the recovery be?

These questions are complicated and even top economists must admit a lack of confidence in their answers. We are not experiencing a standard downturn. Nor is it simply a financial crisis, a currency crisis, a debt crisis, a balance of payment crisis or a supply shock.

We have not seen anything like this since the flu pandemic of 1918. Even there, identifying the effects of the flu is confounded by the first world war that took place at the same time. What we have here is something different. At its heart, we are experiencing a healthcare crisis with various parts of the world succumbing in a staggered fashion.

To slow down this global health crisis (the “flatten the curve” mantra), we have chosen to put the economy into deep freeze temporarily. Production, spending, and incomes will inevitably decline. Decisions to reduce the severity of the epidemic exacerbate the size of the contraction. While the initial decision to reduce labour supply and consumption are voluntary, this will likely be followed by involuntary reductions in both, as businesses are forced to lay off workers or go bankrupt.

Of course, government policies will attempt to mitigate these effects. Some are using traditional monetary and fiscal policies (cutting interest rates, quantitative easing, increasing unemployment insurance, bailouts). Others are trying out non-traditional methods (direct cash transfers, loans to businesses conditional on maintaining unemployment, wage subsidies).

Public health priority

How long the economic impact lasts depends entirely on how long the pandemic lasts. This, in turn, depends on epidemiological variables and health policy choices. But even when the pandemic ends, the resumption of normalcy is likely to be gradual. Countries will persist with a strict containment regime like in China today, and continue to impose travel restrictions to various parts of the world where the disease continues to spread.

The many factors at play in this complex, interlinked crisis that affects both people’s health and the global economy introduces massive uncertainty into anyone hazarding the pace, the depth and the length of the impact. As a result, we should treat any precise estimates (such as “GDP will decline by X%” or “markets have reached their bottom”) with scepticism.

Especially frustrating is the idea that there is a conflict between academic disease modellers and hard-edged economists saying that steps to slow the spread of coronavirus has trade offs. This could not be further from the truth. Among economists there is near unanimity that countries should focus on the healthcare crisis and that tolerating a sharp slowdown in economic activity to arrest the spread of infections is the preferred policy path. In a recent survey carried out by the University of Chicago, respondents universally agreed that you cannot have a healthy economy without healthy people.

The health crisis has naturally created a crisis of confidence. This, in turn, can have damaging long-term effects with continuing uncertainty leading firms and households to postpone investment, production and spending. Restoring confidence requires a singular focus on containing and reversing the spread of COVID-19.

Slowing the rate that people fall ill with COVID-19 is not the end in itself. It is a means to temporarily reduce the pressure on hospitals and give time to identify treatments and a vaccine. In the interim, we must build testing capacity, perform contact tracing, setup the infrastructure for extended quarantines, rapidly expand the production of masks, ventilators and other protection equipment, build and repurpose facilities into hospitals, add intensive care capacity and train, recall and redeploy medical personnel.

All of this is also the way to restore the economy’s health and economic policy must complement it. In the short run, economic policies should mitigate the impact of lockdowns and ensure that the current crisis does not trigger financial, debt or currency crises. It should focus on flattening the recession curve, ensure that the temporary shutdown has only transient effects, and facilitate a quick recovery once the economy is taken out of the deep freeze.

In the meantime, it’s important to also recognise that this is an unprecedented crisis. Everybody has their role to play, but nobody is infallible and uncertainty is inevitable.

Pushan Dutt, Professor of Economics, INSEAD

This article is republished from The Conversation under a Creative Commons license. Read the original article.


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Rolling the dice with sexual health? New challenges for STI services

Today is the start of Sexual Health Week, which aims to raise awareness about services for the testing and treatment of sexually transmitted infections (STIs). The UK has a strong track record in the provision of STI services. But they are now facing new challenges, including a rise in demand, significant cutbacks in public health funding, and the emergence of infections that are resistant to treatment.

A historical perspective

STIs go back a long way. Syphilis first became widely reported in Europe during the late fifteenth century, while gonorrhoea was first described 3,500 years ago. For a long time, these diseases were incurable, afflicting millions of people and leading to infertility, disfigurement and insanity. Early attempts at treatment with mercury often proved fatal. With the development of penicillin in the 1940s, along with improvements in sex education, the rates of STIs fell dramatically. More recently, new drugs have revolutionised the treatment of people living with HIV.

A growing problem

Today, the instances of STIs are rising. In Australia, rates of syphilis, gonorrhoea and chlamydia are the highest since the 1990s. It’s a similar story in the United States and Canada, while in the European Union reported syphilis cases have continued to grow. HIV remains a major public health concern, with recent data indicating a significant number of new infections in eastern Europe.

In the UK, a 2019 report by the House of Commons Health and Social Care Committee found that overall STIs fell between 2013 and 2017. But more recent figures have revealed worrying developments:

  • In 2017 there was a 20% increase in cases of syphilis in England, and a 22% increase in gonorrhoea.
  • In Scotland, the number of cases of syphilis recorded has reached a 15-year high.
  • Public Health Wales has reported a 79% increase in syphilis cases in the country between 2016 and 2018.
  • The number of people in Northern Ireland diagnosed with gonorrhoea in 2018 was the highest on record.

The committee found that the impact of STIs in England is greatest among young people. Men who have sex with men are also disproportionately affected by STIs, while in black and minority ethnic populations, the rates of STI are higher than in the general population.

Along with the rise in the number of infections, the demand for sexual health services is increasing. At the same time, sexual health services say they are facing unprecedented threats from government cuts to local authority public health budgets.

In 2017, a Public Health England survey highlighted the concerns of commissioners of sexual health services. Respondents raised concerns about a decrease in capacity and an increase in demand, in both primary care and specialist services. They believe the consequences could include a worsening of health inequalities and a shift from prevention to treatment.

Debbie Laycock from the Terence Higgins Trust HIV charity told BBC News:

“The number of people accessing sexual health services has continued to rise, demand is on the increase and we’re hearing day-to-day more and more people are saying they’re being turned away from sexual health clinics. When it becomes harder to get an appointment, this is likely to deter people who don’t have symptoms, but just want a routine test. Those routine tests pick up infections at an early stage and stop them being spread to too many other people.”

Services at “breaking point”

There are concerns that this situation will worsen: from April 2020, previously ring-fenced sexual health, drug and alcohol services, which in England are funded by local authorities, will be competing for increasingly scarce funds alongside other council services such as social care.

The Health and Social Care Committee argues that budget cutbacks are not only bad for individuals’ health, but also increase overall costs to the NHS:

“Cuts to spending on sexual health, as with other areas of public health expenditure, are a false economy because they lead to higher financial costs for the wider health system. Inadequate sexual health services may also lead to serious personal long-term health consequences for individuals and jeopardise other public health campaigns such as the fight against antimicrobial resistance.”

This last point refers to a worrying new issue in the treatment of STIs. In recent months, several cases have been reported of new infections that have developed resistance to antibiotics.

Dr Tim Jinks, head of Wellcome’s Drug Resistant Infection programme, believes that increasing resistance to antibiotics will make treating and curing STIs harder:

“Untreatable cases of gonorrhoea are harbingers of a wider crisis, where common infections are harder and harder to treat. We urgently need to reduce the spread of these infections and invest in new antibiotics and treatments to replace those that no longer work.”

Some health professionals, such as Duncan Stephenson from the Royal Society for Public Health have warned that sexual health services are already at breaking point:

“With continued increases in rates of STIs such as syphilis…and the future threats posed by issues such as drug resistant gonorrhoea, the government is rolling the dice with the public’s sexual health.”

 Sexual health services for people with disabilities

This year, Sexual Health Week is focused on people with disabilities, who often face barriers that prevent access to information and support. To overcome these obstacles, sexual health services need to make changes, such as providing longer consultation periods for people with learning disabilities, and training for health professionals in advising and treating patients with special needs. With sexual health services already under pressure, the challenges of meeting the particular needs of people with disabilities are all the greater.

Final thoughts

In its report, the Commons Health and Social Care Committee recommended that Public Health England should collaborate with the sectors involved in commissioning and providing sexual health services to develop a new strategy. The report’s authors believe that this strategy:

“should help both providers and commissioners in their attempts to deliver sexual health services to a high quality and consistent level, in the face of the challenges of fragmented structures and reduced funding.

The committee also identified priority areas to be addressed by the strategy, including:

  • the provision of services which meet the needs of vulnerable populations
  • testing for the full range of sexually transmitted infections
  • access to pre-exposure prophylaxis (PrEP) for those at risk of contracting HIV
  • preventative interventions within all aspects of sexual health

Sexual health is an important part of physical and mental health, as well as ensuring emotional and social well-being. Modern, rapid testing can reduce the rate of onward transmission, and ensure that patients receive the right care, leading to long and healthy lives. Ensuring that those benefits continue will be the greatest challenge facing sexual health services now and in the future.


Effective clinical management for sexual health services

Effective record-keeping is an understated, but fundamentally important element of sexual health services. Increasingly, sexual health clinics are turning to electronic systems to maintain records, improve services and deliver cost savings.

Lilie is a clinical management software system specifically designed by Idox Health for sexual health services. Its electronic patient record (EPR) system provides fast access to patient information and greatly reduces administrative functions.

The system also provides sexual health services with a range of options, including:

    • patient communication via SMS
    • modules for contraceptive and reproductive health, chlamydia screening, HIV, and prescribing services
    • laboratory test results automatically received and entered into the electronic patient record

This market-leading software is now in use in more than 140 sites.

Further information about Lilie is available from Idox Health.

Treating violence as a disease: can a public health approach succeed?

Knife crime, especially deaths of young people, has been making the headlines in recent weeks. And an approach which has a proven track record in Glasgow is now being adopted by the GLA, MOPAC and the Met police to try to tackle the growing levels of violence being seen on London’s streets. Learning from the experience in Glasgow, the police and other agencies are being encouraged to see violence as a public health issue, related to poverty, wellbeing and social deprivation and which, if identified and tackled early, can be prevented.

Contagion: a new way to think about violence

The Violence Reduction Unit was pioneered by Strathclyde Police (now part of Police Scotland), working with health and social care practitioners. Launched in 2005, the approach aims to make earlier identifications of those at risk of becoming involved in violence, and to take a more holistic view of the reasons for violence of all types. The long-term strategy looked at more social and wellbeing interventions to tackle gang violence in Glasgow, which at the time was among the worst in Europe.

The VRU in Glasgow took its inspiration from a scheme in Chicago, which sought to use a World Health Organisation (WHO) approach to tackling the spread of disease but applied it to communities in the hope of curbing the significant rise in homicides in the city. The approach was three-pronged: interrupt transmission, prevent future spread, and change group norms.

In addition to changing the approach to tackling violent crime, the VRU also used a multi-agency approach, involving social services, health care, housing and employment support, to give people a route out of violence and opportunities to find work or training opportunities. One of the key elements to ensuring the VRU is successful are the relationships these people build with individuals in communities.

Identifying young people at risk

Another important aspect of the VRU strategy is to intervene early to identify children and young people who are at risk of joining gangs or becoming involved in gang violence. Research supporting the creation of the VRU suggested that violence (like a cold) is spread from person to person within a community, that violence typically leads to more violence, and that one of the key identifying factors in someone becoming a perpetrator of violent crime is first being the victim of violent crime themselves.

In order to prevent this, staff from the VRU regularly go into schools and are in touch with youth organisations. They also provide key liaison individuals called “navigators” and provide additional training to people in the community, such as dentists, vets and hairdressers to help them spot and report signs of abuse or violence.

There is also a broad view of what a culture of violence is. Work in schools focuses strongly on contemporary issues such as sexting, bullying and gender-based violence. It challenges the attitudes and beliefs that underpin such violence, and encourages young people to recognise and reject these.

A new approach to drug abuse too …?

In November 2018, the Scottish Government launched its new drug and alcohol strategy. One of the notable additions to the strategy was the acknowledgement that (like violence) drug abuse and addiction should be seen, not as a crime, but as a public health issue – an illness which people need support and treatment for.

Looking at how drug abuse is tackled within the criminal justice system and the interactions of addicts, policymakers have identified that many have had adverse childhood experiences, are exposed to drugs and/or alcohol at a young age, and are also at significant risk of being unemployed and homeless.

Creating a holistic package of support which seeks to identify those at risk and directs them towards a range of services to tackle not just the addiction but other trauma or socioeconomic barriers earlier, will, in a similar way to the VRU, give people a sense of purpose and value, and help them to see an alternate route that will allow them to contribute positively to society and improve their own outcomes.

A new way to tackle social issues in the UK?

Tackling the spread of violence through communities is not an easy task, nor is breaking the cycle of crime that many find themselves trapped within, often as a result of family allegiances or geographic location. It is often the case that either you participate, or you become the next victim yourself. More and more young people are feeling the need to carry knives for protection, due to the high levels of fear of becoming a victim.

Identifying those young people who are at risk of turning towards a life of violence at the earliest possible stage is difficult, but has been shown to be effective in helping to tackle violent gang-related crime. Although it is not the only tactic available to police, used effectively in conjunction with other outreach programmes it can be an effective tool in preventative policing, helping to keep communities safe.

The outcome in Glasgow has been largely positive, following the roll out of the Violence Reduction Unit programme. Whether this approach has the same success in London, operating on a larger scale, with different economic and social variables, and in a very different budget climate, remains to be seen. In particular it is worth noting that the Glasgow approach recognised there were no quick fixes, and was based on long-term planning covering ten year periods.

It is to be hoped, though, that changing the way we think about violence within communities may offer a route to tackling it.


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New year, new high street: it’s time to reshape our town centres (part two)

Dunfermline town centre

This is the second of a two-part blog on high streets and town centres.  In our last post, we highlighted some recent publications that have sought to address the challenges facing our high streets and town centres.

We looked at how towns could work to diversify their retail offer, placing greater focus upon developing experiences and services that are not easily replicated online – such as hair and beauty services, gyms, cinema, restaurants and nightlife.

We also highlighted the benefits of identifying a town centre’s unique selling point (USP), capitalising on the opportunities presented by the widespread growth of technology, and offering various forms of support to local businesses and entrepreneurs.

In this post, we consider how community involvement, good quality inclusive urban design, the promotion of healthy environments and the creation of homes on the high street can all provide ways to promote and support town centres to better meet the needs of local people in a changing retail and economic environment.

A community-focused high street

The town centre has long been considered the beating heart of a community.  As such, it makes sense that any attempt to revitalise them would have local people at its heart.

In Dunfermline, a pilot placemaking project has made use of innovative, interactive methods of engagement with young people to help plan and deliver town centre improvements.

Young people were asked to assess the quality of the town centre and to identify areas where improvements could be made, using tools such as the Place Standard and the Town Centre Toolkit.

There are lots of other great community-focused town centre initiatives. ‘Can Do Places’ aims to engage the local community in order to bring empty town centre properties back into use in various ways, for example, by providing spaces for budding entrepreneurs or supporting community arts and crafts.

Stalled Spaces Scotland is another noteworthy project – with a focus on greening derelict, under- or unused outdoor areas.  As well as improving the look and feel of a town centre, this scheme also aims to involve the local community and schools in the development and use of the spaces themselves.

A healthy and accessible high street

It goes without saying that if town centres are to attract both people and businesses then they must be both attractive and accessible – easily walkable, safe, and clean.  Indeed, amongst its findings, the High Street 2030 report highlights “calls for improved accessibility that is more environmentally-friendly, new public spaces or areas, centres that better serve older people”.

There has also been considerable discussion around how the design of town centres (and urban areas in general) impact upon various vulnerable groups.  We have blogged on this subject on various occasions, focusing in turn on the creation of places that address the needs of older people, people with dementia, autistic people and children.

There has also been widespread discussion of the relative advantages and disadvantages of shared space street design – which has been used by many places in the UK in attempt to revitalise their town centre spaces with varying levels of success.

As well as their role in the creation of inclusive, accessible spaces for all, there has been some focus upon the link between high streets and health.

Last year, Public Health England published guidance on the development of ‘healthy high streets’ – high streets that have a positive influence on the health of local people.  It focuses on elements such as air quality, enhanced walkability, the provision of good quality street design, street furniture, and communal spaces. It argues that the development of healthy high streets will support economic growth as well as community cohesion.

It also approaches the subject of diversity on the high street – recommending that there is an adequate number of healthy and affordable food outlets and limiting the number of alcohol, betting and payday loan outlets.

A high street to call home

Another way of bringing people back into the high street is to have them literally live there.

At the end of 2017, the Federation of Master Builders published a report ‘Homes on our high streets’, which argued that “revitalising our high streets through well planned and designed residential units could help rejuvenate smaller town centres”.

For example, Aldershot, as highlighted in the High Streets 2030 report, has been making use of the Housing Infrastructure Fund to promote residential development in the town centre and has undertaken property acquisition in the town centre, most recently acquiring the former Marks & Spencer  store.

Creating additional homes above shops or in former retail units not only helps to make use of vacant properties and regenerate town centres, but may also help to address housing shortages in many areas.

 Looking to the Future

So while 2019 may present high streets and town centres with some of their toughest challenges yet, there is a wealth of research, experiences and innovative ideas on which to draw.  The newly announced Future High Streets Fund will no doubt be of use to help put these ideas into practice.

And perhaps most importantly of all, local people remain enthusiastic about developing their town centres and wish to see them flourish. As the High Streets 2030 project noted:

The workshops and interactions provided real insight into the challenges faced by town centres. That they are worth fighting for was abundantly evident from the enthusiasm of those participating.”


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Tackling health inequalities: what does the data tell us and how can it help?

Health inequalities in Scotland are significant. Every year we hear about how Scotland has some of the biggest gaps in the health and wellbeing of the poorest and richest in society. In some cases, Scotland has the largest gaps in equality in the whole of Europe. And in many instances, they are rising. Scotland also has the lowest life expectancy of all UK countries.

A number of studies and research projects have been commissioned to try to identify the key indicators and factors that are creating and reinforcing these inequalities, and what sorts of interventions would work best to try and reduce or eradicate them altogether. It is hoped that by conducting research, and compiling data, policymakers can use this to identify groups and geographic areas where health inequalities are significant, and to intervene to reduce them, with data to help back up and evaluate the effectiveness of these interventions. In Scotland, work is being done by a number of organisations including the Scottish Government, Glasgow Centre for Population Health (GCPH) and Public Health Innovation Network Scotland (PHINS).

What indicators and factors are being measured?

Income inequality has a related impact on health inequalities, and the scale of low pay is significant. The relationship between health inequalities, poverty and household income is one which has been explored at length and is often highlighted as one of the main factors which influences health inequalities. Studies which look at income, and also at relative levels of deprivation can provide useful comparison points, with comparable datasets on employment status and income readily available at a national and local level. Data also considers trends over time, comparing pre- and post-economic crash data, as well as relative earnings and expenditure relative to inflation and the rising cost of living. Other factors include age (those under 25 and earning a lower minimum wage for example) and by gender, with more women in lower paid, lower skilled and part time or insecure work.

How usable is the research being created?

The research which examines health inequalities explores a whole range of interrelated factors, and highlights just how complex the landscape of inequalities is. Creating a clear and holistic picture of all of the factors which contribute to health inequalities is not easy. Many studies, while detailed and effective, are niche, and focus on a very limited number of factors across a limited demographic source. As a result, questions have been raised about the utility of this research and its applicability and scalability at a national level. In an attempt to tackle this, combined data sets are being produced which provide opportunities for comparison across data from a range of studies.

The “Triple I” tool from NHS Health Scotland is designed to help policy designers to create effective interventions to reduce health inequalities. A second edition of the tool is due to be released in 2018/19. Triple I aims to provide national and local decision makers with practical tools and interpreted research findings about investing in interventions to reduce health inequalities in Scotland. It does this by modelling the potential impact of different interventions and policies on overall population health and health inequalities.

 

What can be done to act on the data?

While the research being produced is high quality, and thorough in relation to findings, the real question is what can actually be done with the research, and what steps can policymakers and practitioners take to use the findings to inform their own practice.

There are, researchers suggest, significant opportunities presented by the recent research which has been done on income inequality. In particular, they cite the public sector and public sector pay as a key way to reduce the income, and therefore the inequality gap, particularly among higher earners and those who would be considered “working poor” or “just about managing”. In Scotland, significantly more people are employed in the public sector than in any other part of the UK, and there is, researchers suggest, an opportunity to better align and increase low wages to help to reduce the gap.

The adoption of new initiatives, such as the “housing first model”, which is due to be rolled out in Glasgow to help homeless people break the cycle of homelessness, are also opportunities not only to address inequalities, but to ensure that long term help and support is in place to prevent any relapse into chaotic or risky behaviour. In relation to housing first, the savings on front line services such as emergency admissions to hospital, or contact with the police after committing a crime are significant, and while more in depth research is needed to create a full cost benefit analysis model of the scheme and its effectiveness, early studies show that the impact on health and wellbeing on those who had previously been homeless is huge in terms of reducing inequalities and improving wellbeing. However further data on homelessness in Scotland shows how far we have to go, and that housing first is only one mechanism which can be used to begin this process of reducing inequalities among the most and least deprived communities in Scotland.

Alternatively, some have suggested a more radical overhaul of how we distribute welfare and wealth within the country. Research has been coming thick and fast on the subject of a “citizens basic income”, particularly following the trial which was rolled out in Finland (the findings of which have not yet been published). Research on how this could impact on inequalities is not widespread yet, as pilots have been small scale, However, it is suggested that a total overhaul of welfare, replacing it instead with a citizen’s basic income would be a more effective way to reduce inequalities across the board, including in health.

Summing up

Health inequalities are significant in Scotland. Much of the research focuses on the impact of deprivation, poverty and low income on health inequalities and how, in order to tackle health inequalities in Scotland we must also tackle some of the other significant social problems within our communities, including low income and insecure work, and the impact of homelessness or chaotic lifestyles on health.

Data can be used in a number of ways to help inform policy decisions, some more radical than others. But creating a complete understanding of inequality in Scotland is challenging. It is up to researchers and policymakers to work together to create a better understanding of the conditions and factors which contribute to inequality, and what can be done to help tackle systemic and entrenched inequalities in our communities through policy levers and evidence based policy making.

If you liked this article you may also be interested in:

Universal basic income: too good to be true?

A world of evidence … but can we trust that it is any good?

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Social Policy and Practice …. an essential resource for anyone working in public health

We’re proud to be part of the publishing consortium which creates Social Policy and Practice, the only UK-produced social science database focused on social care, social services, public health, social policy and public policy.

So we’re thrilled that during October anyone can get free access to the database via Ovid and Wolters Kluwers’ Health, the internationally-recognised leader in medical information services.

There’s still a few days left of the special offer, so why not test drive it for free!

Addressing priorities in public health

Over the last few years there have been major changes in the public health landscape in the UK. Responsibility for commissioning many public health services moved from the NHS to local authorities, as a result of government reforms.

The King’s Fund has suggested that one challenge of this shift has been bridging the cultures of the NHS and local authorities. In particular there were clear differences in the understanding, value and use of evidence to determine decision-making and policy.

The continuing pressure on local authority budgets has also threatened the focus on prevention and joined up service delivery which is essential for tackling many public health issues.

Recent feedback on Social Policy and Practice has highlighted its strong coverage of many current priority issues in public health, such as:

  • dementia care
  • delayed discharge
  • funding of long term care
  • safeguarding of both children and adults
  • supporting resilience and well-being
  • tackling obesity
  • asset-based approaches

As a UK-produced database you will also find information on topical policy issues such as minimum alcohol pricing, sugar taxes, and the possible impact on the health and social care workforce of Brexit.

A valued resource

Social Policy and Practice has been identified by the National Institute for Health and Care Excellence (NICE) as a key resource for those involved in research into health and social care. And importantly, it supports the ability to take a holistic approach to improving outcomes, by covering social issues such as poor housing, regeneration, active ageing, resilience and capacity building.

Social Policy and Practice was also identified by the Alliance for Useful Evidence in a major mapping exercise in 2015, as a key resource supporting evidence use in government and the public sector.

Social Policy and Practice boasts over 400,000 references to papers, books and reports and about 30% of the total content is grey literature, which is hard to find elsewhere.

The focus is on research and evidence that is relevant to those in the UK. A large proportion of material relates to delivery and policy within the UK and the devolved nations of Scotland, Wales and Northern Ireland, but the database also contains resources of interest from Europe and across the world.


To see for yourself why so many UK universities, local authorities and NHS bodies rely on Social Policy and Practice as a resource, visit Ovid Resource of the Month for instant access.

To find out more about the history of the database and the consortium of publishers behind it, read this article from 2016 which we have been given permission to share.

Are controversial ‘fix rooms’ a solution or a problem?

By Steven McGinty

In August, Glasgow City Alcohol and Drug Partnership (ADP) announced that it had found a potential site for its pilot drug consumption facility.

This new service provides drug users with a place to inject drugs under clinical supervision and discard their needles. Other services may also be offered, including the prescription of pharmaceutical grade heroin (administered under strict controls) and the development of a peer support network.

The site in Glasgow’s city centre would be the first in the UK and it’s hoped that it would be up-and-running by 2018. However, these proposals have been met with a mixed response.

Drug consumption rooms

First established in Bern, Switzerland, in 1986, drug consumption rooms were a response to concerns over the spread of HIV/AIDS, increases in drug related deaths, and the rise of public drug deaths in European cities. They were also part of a wider shift in drugs policy, where traditional abstinence-based approaches were being replaced by harm reduction programmes, which focused on reducing the negative impacts of drug abuse.

Since then, over 90 drug consumption facilities have been opened in countries such as Denmark, Germany, the Netherlands, and Canada.

The case for Glasgow

Approximately 500 drug users inject in public places in the city centre. This small group of people accounts for the majority of discarded needles – a major public health risk for the city – and for many instances of public order problems. As a result, Glasgow City Council, Police Scotland and other agencies are spending significant resources managing drug misuse in the city centre.

Although this small group of public injectors provides challenges, they are also vulnerable and often experience other issues such as homelessness, mental health issues, and recent imprisonment. In particular, they are far more likely to suffer health problems. This includes an increased risk of blood-borne viruses, injecting-related serious infections, and overdoses and drug-related deaths. In recent years, the statistics have shown a decline in the health of Glasgow’s drug users. In 2015, the number of HIV infection cases rose from a consistent 10 to 47 per year. Drug-related deaths also rose from 157 to 170 in 2016.

As Susanne Millar, chief officer of Planning, Strategy and Commissioning for the Glasgow City Health and Social Care Partnership, and chair of the ADP, explains:

People injecting drugs in public spaces are experiencing high levels of harm and are impacting on the wider community. We need to make our communities safer for all people living in and visiting the city, including those who publicly inject.”

What the experts say

Many have welcomed the announcement.

Dr Emilia Crighton, director of Public Health at NHS Greater Glasgow and Clyde, and vice chair of the ADP, argues that Glasgow is decades behind other countries in how it responds to drug addiction. She highlights that the city has been at the centre of high profile cases of anthrax, botulism and HIV infection, and that conventional treatment has not been successful at reducing health risks. She explains:

Our ultimate goal is for drug users to recover from their addiction and remain drug free. However, until someone is ready to seek and receive help to stop using drugs it is important to keep them as safe as possible while they do continue to use drugs.”

David Liddell, Chief Executive Officer of the Scottish Drugs Forum, is also in favour of the new facility, explaining that they have been successful in other countries.

They may seem controversial but when you see that these have been running in many countries in Europe for up to 30 years, you get a different perspective. Holland now has 31 drug consumption rooms and Germany has 24, for example. From these years of practice, clear evidence has emerged as to the effectiveness of these facilities.”

But there has also been some notable criticism. For example, Professor Neil McKeganey, an expert in drugs policy with the Centre for Substance Use Research in Glasgow, argued that the scheme is highly flawed. He believes that David Liddell is wrong, and contends that the proposed facilities are controversial. Professor McKeganey highlights previous research with drug addicts in Scotland which found that only 5% wanted to inject more safely, with the overwhelming majority wanting to receive treatment and become drug free. Professor McKeganey also suggests that ‘supposedly’ safer places to inject will not reduce the rising cases of HIV infection and other drug-related harms.

He warns that although these services have a role to play, “there is a real danger here we are moving steadily away from services to get addicts off drugs.

Final thoughts

There is a growing body of research into the effectiveness of drug consumption rooms. The European Monitoring Centre for Drugs and Drug Addiction has found that drug consumption facilities can deliver a number of benefits, including:

  • increasing access to health and social services;
  • supporting safe and hygienic drug use; and
  • reducing public drug use and associated nuisance.

However, the evidence on whether drug consumption rooms reduce cases of HIV or the hepatitis C virus remain unclear. And research has also shown that some countries can find it difficult to establish a legal basis for facilities – as the recent suspension of a facility in Greece demonstrates.

For Glasgow, it probably is about time that a drug consumption room was piloted. However, it will be important that its impacts are fully evaluated and that resources for drug treatment services are maintained in the coming years.


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