What’s new in the August PHOF update?

This is the latest in a series of blogs summarising what we learn each time we update the Public Health Outcomes Framework (PHOF).

The PHOF sets out a vision for public health, desired outcomes and the indicators that will help us understand how well public health is being improved and protected.

The outcomes reflect a focus not only on how long people live, but on how well they live at all stages of life.

Today we have published updates for 11 indicators in the tool as well as adding more inequality information to 12 indicators. Full details on everything that has been updated can be found on our indicator updates page.

Antibiotic prescribing in primary care by the NHS has decreased

Antibiotic prescribing in primary care by the NHS was 1.04 items per STAR-PU (Specific Therapeutic group Age-sex Related Prescribing Unit) in 2017, a reduction from 1.08 items per STAR-PU in 2016. STAR-PU is an adjusted rate that removes confounding effects of age and sex in the comparison of prescribing between different geographical areas. This method allows for more accurate comparison of prescribing. The aim is to reduce antibiotic use, as overuse and incorrect use are major drivers of antimicrobial resistance (AMR).

Reduction in proportion of prisoners with mental illness or significant mental illness

The percentage of prisoners who had a mental illness or significant mental illness (aged over 18) decreased in 2017/18 to 6.98%, compared with the previous year’s 9.24%.

This indicator is only available at England level.

 Reduction in both first time entrants to the youth justice system and first time offenders

The rate of first time entrants to the youth justice system (aged 10-17) decreased to 292.5 per 100,000 in 2017, from 331.0 per 100,000 in the previous year. Similarly, the rate of first time offenders decreased to 166.4 per 100,000, compared with the previous year (218.4 per 100,000 in 2016). Both values reduced compared with the previous year and these reflect the longer term decreasing trend based on the five most recent time points.

Both these indicators show variation by deprivation and show that the most deprived deciles had higher rates than the least deprived deciles.

Uptake in flu vaccinations increased in older people (aged 65+) and individuals at risk, and a new indicator definition has been published for children (aged two to three years)

The percentage uptake for flu vaccination in adults aged 65 and over rose to 72.6% in 2017/18, an increase compared with 70.5% in 2016/17. However, this value remains lower than the government ambition of 75% uptake for this group. Vaccine uptake has tended to fluctuate around the 70% level in recent years.

Similarly the percentage uptake in at risk individuals (aged six months to under 65 years, excluding pregnant women) increased compared with 2016/17, rising from 48.6% to 48.9% in 2017/18. However, this was short of the ambition of 55% uptake for this group. Vaccine uptake in this group has tended to fluctuate around the 50% level. Close monitoring across all the target groups will continue.

Flu vaccination coverage in children aged two to three years old is a new indicator definition. This replaces the previous indicator which also included children aged four.  In 2017/18, children aged four (in school year reception and aged four to five years old) were offered vaccination as part of the schools delivery programme instead of in a GP setting. Uptake in children aged two to three years (combined) was 43.5% in 2017/18.

If you’d like to view the data for your local area, visit our webtool at www.phoutcomes.info, and if you’d like to send us any feedback please do so via phof.enquiries@phe.gov.uk.

Drug misuse deaths fall but still remain too high

The ONS has published the latest figures for drug-related deaths in England and Wales, covering all deaths registered in 2017.

It reports that there were 3,756 deaths last year due to drug poisonings – the highest since records began. This includes poisonings from both legal medicinal drugs (accidents and suicides) as well as deaths from all illicit drug misuse, which has actually seen a fall (from 2,596 to 2,503) for the first time since 2012. The most significant, and continuing, rise is in cocaine deaths, up 16% to 432, a near fourfold increase since 2011.

There are significant variations across the country, which can be explained by differences in rates of drug use and wider health inequalities.

What continues to concern us is that some regions are showing larger increases in recent years. Drug misuse in the North East accounted for 83.2 deaths per 1M population, a further 7% increase from 2016. This contrasts with a significant fall in London by 24% to 24.6 deaths per 1M.

This blog looks at some of the report’s main findings and the actions we’re taking to tackle these issues.

Reasons for high numbers of deaths

Although deaths from heroin and/or morphine have fallen a little, over half (53%) of all deaths related to drug poisoning still involve an opiate.

This is likely still due to an older generation of long term heroin users with failing health and higher overdose risks.

40-49 year olds have the highest rate of drug misuse deaths but rates have fallen in all age groups except the very oldest (50-69 and 70+), perhaps further supporting the idea of an ageing cohort at greatest risk of overdose death.

We also know that around half of opiate-related deaths occur among those who have never or have not been in drug treatment for several years. People who are in treatment and prescribed medicines are:

  • less likely to inject drugs
  • less likely to overdose
  • less likely to contract blood-borne viruses such as HIV and hepatitis C
  • more likely to be tested and treated, or vaccinated against hepatitis B

These treatments can reduce harm and provide drug users with the stability and safety to build their recovery. UK clinical guidelines highlight the crucial role opioid substitution treatments, like methadone and buprenorphine, have in preventing drug-related deaths.

It’s vital that drug services do all they can to make their services as accessible as possible and increase their efforts to engage those most at risk.

And local areas will want to continue to expand their provision of naloxone to prevent opioid overdoses becoming opioid deaths, especially if the threatened availability of further potent opioids, like fentanyl, becomes a reality.

Treatment centres need to be flexible to emerging threats

Cocaine

These latest figures for 2017 show a significant increase in cocaine related deaths from the 371 deaths registered in 2016 to 432. This continues a rise seen from 2011 when there were about a quarter as many deaths.

Part of this increase will be due to crack use – post-mortem testing cannot differentiate powder cocaine and crack cocaine so they are reported as one. We know crack use has been increasing in some areas and is often associated with heroin users, making users doubly vulnerable to dying.

Public Health England is working with the Home Office in an England-wide investigation, including an in-depth review in six localities with high crack prevalence. The work will improve our understanding of the reasons behind the increase in crack use and lead to better local responses to the problem.

Fentanyl

These latest figures for 2017 show increases in deaths involving the potent opioids, fentanyl and fentanyl analogues, from 58 to 75 and from 1 to 31 respectively.

Many of these will relate to overdose deaths in late 2016 and early 2017, primarily in Yorkshire and the Humber, that involved heroin mixed with fentanyl.

PHE continues to work with drug testing labs and local drug services to get more rapid and detailed information on confirmed and suspected cases of fentanyl. And we have provided local areas with target figures for their provision of naloxone, the opioid overdose antidote.

Synthetic cannabinoids

The continuing news of problems with synthetic cannabinoids (SCRAs) in certain areas of the country is something we are very concerned about and we have been actively supporting local areas and national government.

Deaths involving new psychoactive substances (NPS) are very low compared with heroin (1.0 deaths per 1M population compared with 20.5 per 1M respectively) and they halved in 2017, from 123 to 61, following the introduction of the Psychoactive Substances Act. However, the main falls were in deaths involving the cathinone stimulants and other NPS – SCRAs are now involved in one third of all NPS deaths.

Reducing the harms caused by NPS and new patterns of drug use will remain a priority. Our pilot drug health harms intelligence system, RIDR, is helping frontline staff better understand the harms of new substances and be able to respond and treat patients more rapidly.

Medicines

An increasing number of deaths involve some prescription and over-the-counter medicines, like codeine, antidepressants and pregabalin. Some may be the result of misuse and of suicide but PHE’s prescribed medicines review will help us understand how prescribing may be contributing to the availability of these medicines and to accidental overdoses.

Ecstasy

Despite recent reports of increased ecstasy use and higher tablet strengths, reported deaths from ecstasy fell slightly for the first time since 2010.  Widespread publicity on high-strength ecstasy tablets and safer drug use messages may be a contributing factor.

In summary, while reported deaths from illicit drugs have fallen for the first time in 5 years, numbers remain far too high.  Continued easy access to drug treatment, proactive targeting of those most at risk of harm and an expansion of naloxone provision is critical in addressing drug related deaths.

Support must also go beyond treatment services to address the wider circumstances of those most at risk. In last year’s drug strategy, the Government committed to the drug misuse prevention and treatment agenda and, if we are to end the avoidable and tragic waste of lives, local authorities must continue to invest in these areas.

 

Health Matters: Addressing health inequalities in the East Midlands

Health inequalities are a social justice issue, and the challenge of addressing them is core to public health practice. In England, people living in the least deprived areas of the country live around 20 years longer in good health than those living in the most deprived areas. Reducing health inequalities means giving everyone the same opportunities to lead a healthy life, regardless of where they live or who they are.

Local authority public health teams are faced with having to increasingly meet this challenge, and it is made even more difficult as they are under growing budget pressures. It is therefore essential that the limited resources are deployed in a way that maximises opportunities to address inequalities for those at greatest risk of poor health.

PHE’s evidence report on health inequalities in the East Midlands provides a regional view of this challenge, and the ways in which local public health teams can work more systematically towards improving health and wellbeing for the population of their region.

Life expectancy in the East Midlands

The average life expectancy at birth across the East Midlands in 2013-15 was 79.3 years for males and 82.9 years for females, both of which are significantly lower than the national average. Healthy life expectancy was 62.5 years for males, significantly worse than the national average, and 63.5 years for females, which is similar to the national average.

Further, the impact of the social gradient on health inequalities is clearly demonstrated, with males in the most deprived areas of the East Midlands living for 8.6 years less than males in the least deprived. For females, the gap is 7.1 years.

In the East Midlands, the gap between life expectancy and healthy life expectancy is referred to as the ‘window of need’, and is the number of years that an individual can expect to live in ill health. In 2013-15, the window of need in the East Midlands was 16.8 years for males and 19.4 years for females. This makes the proportion of life spent in poor health over one fifth for both males and females, with 21% of life lived in poor health for males and 23% for females.

Understandably, the reduction of the window of need is one of the main focal points of public health activity in the East Midlands. However, the challenge continues, as the size of the window of need has increased on average for both males and females.

The changes in preventable mortality in the East Midlands

Overall, preventable mortality in the East Midlands is decreasing, and PHE’s evidence report presents these changes between 2001-03 and 2013-15, including reductions of:

  • 50% for cardiovascular disease (CVD)
  • 15% for cancer
  • 14% for respiratory disease

On the contrary, preventable mortality from liver disease has increased by 37%.

There is considerable variation in preventable mortality from the major causes of death across the East Midlands local authorities, with an urban-rural divide where the urban areas of Nottingham, Leicester and Derby have significantly lower life expectancy than the average for England. For each preventable cause, these three urban areas consistently have the highest preventable mortality rates in the region, as they are associated with the highest levels of deprivation.

Upgrade in prevention and public health

The number of years that people spend living in ill or poor health in the East Midlands is driven by multiple risk factors including obesity, alcohol and drug use, diet, and occupational risks, which will also be driven by the wider determinants of health.

As such, it is essential that there is a continuation and upgrade in preventative measures – namely public health programmes and interventions – that mitigate the onset and development of preventable illnesses. Ultimately, this will lead towards a narrowing of the window of need in the East Midlands, a decrease in preventable mortality, and a reduction in variation both across the region and in comparison with the national average life and healthy life expectancies.

PHE’s Health Economics resources are available for local authorities and public health teams to use to make the best possible commissioning decisions that are evidence-based, transparent and defensible. They allow these teams to move away from making investment decisions based on historical spending trends, and disinvestment decisions based on simply reducing all programme budgets by the same percentage, commonly called ‘salami slicing’. This is crucial during a time that sees budgets continuously being cut.

The resources also greatly simplify the otherwise often complex decision-making process by highlighting which public health concerns and programmes should be prioritised. Ultimately, this leads to investment in the most needed programmes, which in turn will improve the health of the region’s population and reduce health inequalities.

The latest edition of PHE’s Health Matters, ‘Health Economics: Making the most of your budget’ details these resources and how they can be put into practice by local public health teams.

What promotes uptake and retention in group-based weight management services?

Obesity is fuelling a rise in Type 2 diabetes

We live in an increasingly obesogenic environment, making it harder for individuals to avoid unhealthy lifestyle choices. This leads to greater proportions of the population being overweight or obese, which are the main modifiable risk factors for Type 2 diabetes. For obese people, there is a seven times greater risk of diabetes compared to those of a healthy weight, and for overweight people the risk is three times greater.

Joining a group-based weight management programme is a commonly chosen route for people who want to lose weight. In addition to the many commercial programmes that are available, the NHS offers group-based programmes specifically to individuals at risk of Type 2 diabetes, through the Healthier You: NHS Diabetes Prevention Programme (NDPP).

The NDPP – a national programme for England – aims to identify people at high risk of Type 2 diabetes and refer them onto a behaviour change programme for weight management. Due to the increased risk of Type 2 diabetes for obese and overweight people, these programmes are a central component of many NDPP services.

There is a range of practical, socio-demographic, psycho-social, contextual and behavioural factors that impact upon initial and regular attendance at group-based weight management interventions. Studies have shown that people who access and remain engaged with a programme for longer tend to lose more weight, so, it’s vital that we have a clear understanding of what encourages people to start and remain engaged.

To address this, PHE’s Behavioural Insights team worked with researchers from Staffordshire University to conduct a literature review and behavioural analysis.

The methodology: A literature review and behavioural analysis

First, the team at Staffordshire University conducted a literature review, which looked at the published qualitative and quantitative literature on these programmes, and collated information on the main commercial programmes. They also conducted a behavioural analysis, which investigates the drivers of behaviour using a behavioural framework.

Two behavioural tools were applied to the qualitative and quantitative results in the literature. One tool was used to classify drivers of participant uptake and retention, and the other to identify specific behaviour change techniques – in terms of programme recruitment methods and intervention design – associated with high uptake and retention.

These were then mapped on to the behaviour change wheel’s ‘Capability’, ‘Opportunity’, ‘Motivation’ and ‘Behaviour’ (COM-B) model, which was used as a framework to inform recommendations regarding which intervention components promote uptake and retention.

The findings: The main drivers behind programme uptake and retention

Uptake

The behavioural analysis found that individuals with the motivation to attend, and the knowledge and psychological skills to change their behaviour were more likely to take up group weight-management programmes.

However, it was found that for motivation to be effective, social opportunity is particularly important. Those who perceived a lack of social support from family and friends, or feared stigma from attending the programmes, were less likely to enrol.

Retention

In terms of continued engagement, the main drivers were the positive social influences of group-based delivery, including:

  • social support
  • peer pressure or accountability
  • having a supportive leader

Other important factors were identified as being:

  • the flexibility of group sessions
  • the perceived relevance of sessions
  • the inclusion of educational components

The analysis also found that the main barriers to continued engagement were a lack of social support outside of the programme from family and friends, as well as practicalities of attendance, such as a lack of time and competing commitments. When these factors were mapped to the COM-B model, it was clear that social opportunity was the dominant component in relation to retention.

How can we maximise uptake and retention?

There is an increasing amount of evidence from behavioural insights that the method in which people are invited to take part in preventive health programmes influences participation. As such, there is need for greater consideration and specificity in the reporting of recruitment methods of group-based weight management programmes. Reporting has generally lacked detail to date, making it difficult to discern patterns in relation to uptake.

The behavioural analysis identified a number of key recommendations and intervention components that promote participant retention, including:

• prioritise efforts to foster social support through:
– ensuring the group leader is supportive
– including activities that encourage support between group members
– including activities that involve participants’ family and friends

• include an educational component to empower participants through increasing knowledge

• include self-monitoring and provision of feedback on behaviour where possible, including biofeedback such as heart rate monitoring during exercise

• use graded tasks within programmes to build up sustainable changes in the desired behaviour, such as health-enhancing levels of physical activity, or five or more fruit and vegetable portions per day

• set goals for target behaviours, such as physical activity and diet, as well as for outcomes, such as weight loss and change in body fat percentage

• provide sessions that:
– include exercise classes
– are in a convenient location
– allow flexibility
– allow choice in delivery mode
– are perceived as enjoyable by participants
– provide positive reinforcement

You can read more about the NDPP in our previous edition of Health Matters.

Deadly DNP – Public health matters

Many people will have heard warnings about the risks of using the toxic chemical called DNP (full name 2,4-DINITROPHENOL) for body building and weight reduction. Yet despite these warnings the number of deaths has risen in 2018.

Five cases referred to the National Poisons Information Service (NPIS) between January and June 2018 have ended in death. This is an increase from two cases in 2017 and one in 2016. DNP is one of the most toxic substances that NPIS deals with and we have issued warnings about it in the past.

The NPIS is not made aware of all UK cases of DNP toxicity, whether these are fatal or non-fatal. We are only made aware of cases when they are referred to us by health professionals seeking expert advice. NPIS has recently started to work with the Food Standards Agency to get a more accurate picture of the number of deaths by combining information available to each organisation with that from the Office for National Statistics

The combined NPIS, FSA and ONS data on deaths relating to DNP is provided in a separate column in the table below. These data are provisional as the outcome of coroner’s inquests may not be available for some of these.

Year Fatal cases
(NPIS data only)
Fatal cases (combined NPIS FSA and ONS data)
2011 0 0
2012 1 2
2013 3 4
2014 0 0
2015 6 7
2016 1 2
2017 2 3
2018 (Jan-June) 5 5

DNP prevents energy being stored as fat; instead the energy is released as heat. This increases body temperature which can damage the cells of organs such as muscle, kidney and brain.

The result can be seizures, coma, kidney failure, muscle damage and bone marrow failure. Once these effects have started to develop, they are very difficult to treat and death may occur in spite of the best possible medical treatment.

Several deaths have involved people in the bodybuilding world or those trying to lose weight. Many of these people may have been unaware of the dangers of using DNP.

There is a myth that if used in small amounts, users will be safe. This is not the case. Although toxicity is especially common after overdose, severe and even fatal adverse effects have occurred when the drug has been taken in the doses recommended on websites or by suppliers.

The best way to lose weight is by making long-term changes to diet and physical activity, aiming to lose around 0.5kg to 1kg a week (1lb to 2lb), until you achieve a healthy BMI. The NHS Choices weight loss plan provides lots of useful advice and recipes.

We are collaborating with other agencies to raise awareness amongst healthcare professionals and the public about the dangers of DNP.  The Food Standards Agency’s National Food Crime Unit is highly active in disrupting the supply of DNP for consumption in the UK and has been working with the police,  local authorities and other partners, here and abroad, to restrict the illegal sale of DNP and hold sellers to account.

Symptoms of DNP toxicity include:

  • Fever, dehydration, nausea, vomiting, sweating, dizziness, abdominal pain, restlessness, flushed skin, sweating, dizziness, headaches, confusion, rapid respiration and rapid or irregular heart-beat.
  • These features can progress to seizures, coma and death, despite optimum medical care.

We can all help by passing on this message, and advising people against taking this dangerous substance.

You can get more information on DNP and its dangers from NHS Choices and the Food Standards Agency.

 

 

Improving the diagnosis and treatment of Familial hypercholesterolaemia

What is FH and why is it important?

Familial hypercholesterolaemia (FH) is a common genetic condition that causes high levels of cholesterol in the blood, resulting in an increased risk of heart disease at an early age.

FH affects one in every 250 people. That means that over 200,000 people in England (including children) have FH, though the vast majority are undiagnosed. Without a diagnosis, affected individuals are unaware of their high risk status and so do not receive potentially life-saving advice and cholesterol-lowering treatment.

Identifying people with FH at an early age is vital; treatment to lower cholesterol can give people with FH the same life expectancy as the general population. Without this treatment 50% of men with FH will have a cardiac event by the age of 50, and 30% of women by age 60.

The New FH Implementation Guide

Public Health England (PHE), in collaboration with NICE, NHS England, British Heart Foundation and HEART-UK, has developed a guide to support NHS commissioners and providers to implement the recommendations of the recently updated NICE Guidance on FH.

The Implementation Guide aims to set out practical measures that can be taken to improve the diagnosis and treatment of FH, based on available evidence and expertise.

How can detection and management of FH be improved?

  1. Look at the local provision of specialist services in your area

Access to FH services across the country at present is patchy. Only around a third of the population in England are covered by specialist services that offer genetic diagnosis and specialist management of FH. We are calling on local decision makers and commissioners to look at provision across their region and where FH services are missing, to make the case for investment.

  1. Raise awareness of FH amongst clinicians and the public

Availability of services is just one piece of the puzzle. For people to be offered referral to specialist FH services for genetic counselling and DNA testing, they first need to be recognised as being at risk.

Being aware of the key features of FH, including a family history of heart disease before the age of 60 and/or a very high level of cholesterol in the blood, is crucial for people to be able to recognise their own risk and seek advice if necessary.

  1. Introduce more systematic approaches to case-finding

Many people will have a record of their cholesterol level on their GP records. Systematically searching GP records to identify those with very high cholesterol is one of the cost-effective case-finding methods recommended in the NICE Guidance.

  1. Use the NHS Health Check as an opportunity to identify those at risk

The NHS Health Check offers an excellent opportunity to identify people with FH, and in particular those who might not otherwise have visited their GP. Offering people aged 40 to 74 a cholesterol test as part of the wider assessment, the Health Check guidance recommends that people found to have a blood cholesterol level of 7 or over are referred to their GP for assessment.

Supporting improved outcomes

Joining the dots

The whole healthcare system needs to work together to make sure patients experience a seamless journey from suspecting diagnosis of FH in primary care, to referral for DNA testing, to cascade testing of relatives, and receiving the appropriate preventative treatment and support. Clear pathways should be in place to prevent people from ‘falling through the gaps’ between different provider organisations.

Monitoring and Evaluation

Monitoring progress and evaluating services will be key to ensuring that systems are working well and are improving outcomes for the patients they serve. The Cardiovascular Disease Systems Leadership Forum (CVD SLF) is at present developing national ambitions for the identification and management of FH. This will be a target for the whole community to work towards.

Continued Collaboration

The co-development of the FH Implementation Guide is just a part of wider collaborative efforts to improve identification and management of FH in the UK involving PHE, NHS England, BHF and HEART UK among others, coordinated by NHS England’s FH Steering Group.

What next?

Use the FH Implementation Guide as a way to start conversations about FH in your local area; whether you are commissioners, provider organisations, or front-line staff the guide can support you to put FH on the agenda. Help us to spread good practice by sharing the FH Implementation Guide with colleagues across the health sector.

Middle East Respiratory Syndrome (MERS): Who is at risk?

Whether you’re a health professional or a regular traveller to the Middle East you may have heard of Middle East Respiratory Syndrome, or “MERS”. The risk of contracting the virus remains very low but simple precautions can help visitors stay safe.

What is MERS-CoV?

Middle East Respiratory Syndrome Coronavirus, usually shortened to MERS or MERS CoV, is a respiratory virus first identified in 2012 in a patient in Saudi Arabia.

Public Health England played crucial role in the discovery of this new virus, diagnosing one of the first cases in the world at our laboratories in Colindale in September 2012, a patient from the Middle East.

It was dubbed Middle East Respiratory Syndrome because of the origin of the first cases. Corona is the Latin word for crown or halo, and corona viruses are so named because the surface protein spikes of the virus resemble the ‘corona’ or halo of the sun.

Technically MERS is the syndrome caused by the MERS virus, while MERS CoV would refer specifically to the virus itself, but both terms tend to be used interchangeably.

Are we at risk in the UK?

The risk of contracting MERS-CoV in the UK remains very low. A handful of imported cases have been diagnosed in the UK, all of whom had returned from travel to the Middle East or who lived there and were visiting the UK.

MERS-CoV is a virus that is transmitted between animals and people and has been linked to close contact with camels or consumption of products from camels. It can also be passed from person to person, although this is difficult without close, prolonged contact. The risk of infection with MERS-CoV to UK residents remains very low.

To date, there have been 5 cases of MERS-CoV in the UK. 3 cases were acquired in Saudi Arabia and 2 were acquired from onward transmission in the UK.

What are the symptoms?

Typical MERS symptoms include fever and cough that progress to a severe pneumonia causing shortness of breath and breathing difficulties. Some people with the virus also develop gastrointestinal symptoms, including diarrhoea.

The virus can cause more severe disease particularly in people with weakened immune systems, older people, and those with chronic diseases such as diabetes, cancer and chronic lung disease.

So MERS cases occur mainly in the Middle East?

Following its identification in 2012, cases have continued to occur primarily within Kingdom of Saudi Arabia and the United Arab Emirates, with 97% of cases reported from the Middle East.

Cases associated with travel to the Middle East have also been seen in several European countries (including Austria, France, Germany, Netherlands, Italy, UK, Greece) as well as other parts of the Middle East (Egypt, Iran, Jordan, Qatar, Kuwait Turkey and Oman) and the rest of the world (USA, Malaysia, Philippines, Algeria, Tunisia).

In France, Tunisia and the UK, there has been limited, non-sustained transmission among patients who had not been to the Middle East, but had been in close contact with imported cases.

More recently we’ve seen cases of MERS in South Korea and China, with secondary cases in health care settings linked to a person with a recent history of travel to the Middle East.

What if passengers travel on a flight and sit near someone with MERS?

The risk to airline passengers remains very low, but in the event of a case involving contact with passengers, Public Health England would undertake contact tracing, where we work with airlines to follow-up any passengers who might have been in contact and provide health information and reassurance.

In August 2018 we were advised of a patient who had travelled from Saudi Arabia to the UK who we believed had been infected before travelling.

Although the risk of the infection being passed to other passengers on the aircraft is extremely low, as a precautionary measure we will undertake efforts to contact UK passengers who were sitting in the vicinity of the cases.

How has the UK helped with diagnosing cases?

Public Health England lab staff have developed a series of tools for diagnosis and surveillance of MERS-CoV, giving other scientists the ability to generate genomic sequences and measure antibody responses.

These tools are not only deployed in the UK, but can also support international investigations and responses within affected countries.

In October 2012 we provided virological and epidemiological support to a WHO led mission to Doha, Qatar and we continue to provide virological and diagnostic support to Qatar, most recently in December 2013 when PHE ran a training course to enable Qatari scientists to undertake MERS-CoV testing.

PHE also provides guidance to doctors on identifying and managing cases of MERS-CoV, as early identification and implementation of prompt infection control precautions are very important to limit onward transmission.

What precautions should Middle East travellers take?

We advise travellers, particularly those with underlying or chronic medical conditions, to avoid contact with camels in the Middle East and practice good hand and respiratory hygiene to reduce the risk of respiratory illnesses. Travel advice is available from the NaTHNaC website.

The risk to UK residents travelling to Middle Eastern countries may be slightly higher than within the UK, but is still considered very low.

Why do you recommend avoiding contact with camels?

There is growing evidence that the dromedary camel is a host species for the MERS-CoV and that camels play an important role in the transmission to humans, however the source of infection and transmission modes of MERS-CoV are still not completely understood.

There is still more work needed to understand the role that camels play in the spread of infection, but until more is known we recommend avoiding contact with camels in the Middle East.

Could we see more MERS cases in the UK?

The risk to UK travellers to the Middle East remains very low, and although MERS infection has been ongoing since it was identified in 2012, the UK has still only seen 5 cases.

As we do with all infections, Public Health England continues to provide advice on infection control, urgent diagnostic investigation and identification of contacts of suspected cases in England who may need to be followed up to check on their health.

We also advise healthcare professionals to remain vigilant for severe unexplained respiratory illness occurring in anyone who has recently travelled in the Middle East, as well as any unexplained cluster of severe respiratory illness or healthcare worker with unexplained severe respiratory illness.

Where can professionals read more on MERS?

PHE has published a range of clinical documents and our scientists recently published a paper in Eurosurveillance about our response to the two cases involving passengers with MERS transiting via Heathrow.

 

Health Matters – Your questions on Health Economics and commissioning

We hope our latest edition of Health Matters – on the subject of ‘Health Economics and making the most of your budget’ – will help you and other professionals by compiling key facts, figures and evidence of effective interventions.

In this blog we’ve published the answers to a number of questions we received from professionals across the UK at the recent launch teleconference.

Cost saving and public health

Is cost saving a key priority for public health, and are we setting the bar too high for public health interventions?

Although some interventions do produce cashable savings in the short term, this is a very high bar to set and savings will often be felt over a long time period.

The aim of prevention, however, should not just be to save money, in the same way that it is not the sole aim of treatment. In our tools, we do try to separate outcomes into financial savings, whether it is to local authorities or to the NHS, as well as the wider benefits such as those relating to the value placed on health, productivity gains and the broader economy.

The new Secretary of State has said that he has three priorities: the workforce, technology and prevention. ‘Prevention’ is not just in a traditional sense of how we reduce demand for healthcare services, but how we help people stay well for longer, stay in their own homes and communities for longer, and stay productive in the workplace for longer. It’s very much a broader public health understanding of what we mean by ‘prevention’.

Measuring the benefit of wellbeing using Health Economics tools

Can PHE’s Health Economics tools be used to measure the benefit of wellbeing, as well as some of the more quantifiable and less subjective benefits around prevention?

The most recent refresh of the Treasury’s Green Book – the government’s guide to how economic appraisal and evaluation should be conducted – places a much greater emphasis on wellbeing and we are seeing it rise up the agenda.

To some extent we are limited in terms of what the evidence of particular interventions shows, and most of PHE’s tools currently concentrate on the more traditionally measured aspects of health. However, there is an increasing understanding and dialogue around incorporating wellbeing more broadly into economic evaluations. Therefore, this is not something that we can currently focus on achieving, but in the future we aim to play a much greater part in how we measure the wellbeing benefits of public health interventions.

Use of the Prioritisation Framework by local authorities

Has PHE’s Prioritisation Framework been piloted or successfully used by local government?  

During the initial part of developing the Prioritisation Framework, we ran a number of pilot sites across the country and they used the tool and fed back to us. This was very helpful as it provided guidance on how to improve and streamline the tool, and we have now translated these findings into the supporting materials that are available alongside the tool.

There is also an evaluation taking place, which is being run by the National Institute for Health Research’s School for Public Health Research. They are reviewing and summarising the findings, some of which will be presented at the PHE annual conference in September. It will then be written up and shared, so by the end of the year there will be a comprehensive log of lessons learned.

In addition to this, this edition of Health Matters includes case studies from Shropshire and Durham – two of the pilot sites – which can be viewed as examples in the meantime. You can also view a recorded webinar on the Prioritisation Framework on the Health Economics main landing page on GOV.UK, which includes some reflections on the work done with the framework in Durham, Shropshire and East Riding of Yorkshire.

Incorporating user feedback into Health Economics tools

Is user feedback being incorporated into PHE’s Health Economics tools to make sure they are as relevant and accessible as possible? If so, how is this being done?

Receiving and incorporating feedback is essential to the usability of Health Economics tools, and therefore all of PHE’s tools are equipped with a survey for users to complete. This feedback is helping us understand how to develop better resources in the future.

In terms of the development of Health Economics tools, there is always a steering group of experts and interested stakeholders, often including representatives from the third sector and clinical experts, to help shape the project. There is also a user group, typically made up of people from local authorities, who test the product when it is nearly complete and provide feedback. For a couple of our recent projects, user workshops were held at the start to ensure that user needs were integrated to the development of our tools. This will typically be our way of working going forward. Again, doing these things makes sure that PHE’s Health Economics products are as impactful as possible.

Shifting the case for prevention earlier in the life cycle

Should the case for prevention shift to earlier in the life cycle, and how can the body of evidence be used in prevention?

We’re interested in prevention across the life course, but particularly early years as the impact across the life course can be very significant. The Best Start in Life tool, one of our ROI tools, looks at interventions aimed at children aged zero to five years old and pregnant women. So, we have started working in this area and will continue to do so, and build up the economic case for prevention at a very early stage in the life course.

This is going to be consistent with one of the themes in the NHS ten-year plan, which is a focus on children and young people.

Health Matters

Read the full edition of Health Matters on ‘Health Economics and making the most of your budget’ here.

Health Matters is a resource for professionals, which brings together the latest data and evidence, makes the case for effective public health interventions, and highlights tools and resources that can facilitate local or national action. Visit the Health Matters area of GOV.UK or sign up to receive the latest updates through our e-bulletin. If you found this blog helpful, please view other Health Matters blogs.

Duncan Selbie’s Friday message – 31 August 2018

Dear everyone

I hope many of you have enjoyed a good and restful summer break.

I am delighted to say that we have a new Chair for the PHE Advisory Board, Dame Julia Goodfellow. Dame Julia was previously Chair of the British Science Association and was also president of Universities UK from 2015 to 2017 and is currently president of the Royal Society of Biology. Dame Julia will be replacing Sir Derek Myers who has been our interim Chair for the past 18 months and I am equally delighted to say that Derek will be staying on our advisory board. Read our press release for more information.

Earlier this year when announcing a new five year funding settlement for the NHS, the Prime Minister asked the health family to come up with a Long Term Plan for the NHS including outcomes and improvements that can be delivered over the next ten years. This is now very much underway and PHE will be leading on the prevention, inequality and personal responsibility strand with senior colleagues from the NHS. We will additionally be contributing to many of the other 13 work streams including those on mental health, cancer, cardiovascular disease and early years and working hand in glove with NHS England and NHS Improvement in making prevention and population health the cornerstone of this new plan. The intention is to have a clear set of proposals across the work streams for the end of September and then to bring these together to develop a clear, costed, ambitious and deliverable plan during October and November. I will be speaking to these themes more at the NHS Expo Conference next week and at our own PHE Conference at Warwick in mid-September.

It is now well established that the home we live in influences our health. When new homes are being built, health and wellbeing should be factored in and this week NHS England announced a new partnership with some of the top housing developers in the country. The Healthy New Towns Network, which was set up in partnership with PHE, is the first of its kind and aims to improve health by creating healthier places that offer better choices and chances of living well. This will also allow new and innovative ways to be explored for tackling some of our biggest health and social care challenges, such as dementia and social isolation. You can learn more on the NHS England website.

There are over 16,000 deaths from bowel cancer in the UK each year and early detection is key to survival. Earlier this month following a comprehensive review of the evidence, the National Screening Committee recommended that bowel cancer screening in England should start ten years earlier and this has been accepted by Government. In the future, people will be invited to screening aged 50, rather than 60 as of now. The risk of bowel cancer rises steeply from around age 50 to 54 so this drop in screening age will over time help spot more abnormalities at an early stage and save lives. The top priority is to roll out the faecal immunochemical home test kit (FIT), a new, more user-friendly test, into our existing national bowel screening programme from the autumn. Our news story has further information.

You might not have heard of it but familial hypercholesterolaemia (FH) is a common genetic condition which affects all ages and one in every 250 people. It causes high levels of cholesterol in the blood, resulting in an increased risk of heart disease at a young age. Without a diagnosis, affected individuals are unaware of their high risk status and so do not receive potentially life-saving advice and cholesterol-lowering treatment. PHE has published an implementation guide with NICE, NHS England, British Heart Foundation and HEART-UK, to support NHS commissioners and providers to implement the recommendations of the recently updated NICE Guidance on FH. Our blog explains more about this and how the health sector can improve FH detection and management.

And finally, congratulations to PHE’s Simon Bouffler, head of our radiation effects department, who was awarded the Weiss medal by the Association for Radiation Research in Belfast. This is awarded to individuals who have made distinguished contributions to radiation science and is of singular credit to him.

Best wishes

Duncan

Friday messages from 2012-2016 are available on GOV.UK 

Global health – what it means and why PHE works globally

Global health is focused on improving health and achieving health equity for all people worldwide – meaning working towards the absence of avoidable, unfair, or remediable differences among groups of people. Many health issues and concerns transcend national boundaries and require collaboration between countries to address them and in this blog we explain the role PHE plays.

Image taken during a joint workshop at Nigeria CDC in August 2018

News is global. We get reports from across the world, from all corners of the globe and we get it twenty four hours a day. With this increase in reporting comes increased public awareness and this is very true for stories focusing on global health, particularly around outbreaks.

You may well have seen on the news that recently there has been an Ebola outbreak in the Democratic Republic of Congo and an outbreak of plague in Madagascar. When you see a word like plague in a news report, you’d be forgiven for feeling shocked and thinking it was a part of distant history, but these reports show us that such diseases remain a current and real threat in other parts of the world.

If we think back as far as 2002-2003, when a Severe Acute Respiratory Syndrome (SARS) epidemic happened, we witnessed the enormous impact and devastation that rapidly transmitted infections (such as flu like illnesses) can bring. This affected not only individual lives, but had economic and commercial consequences and proved how far beyond just stopping the spread and identifying cases we must think when faced with these situations.

Global Public Health – So how do we contribute?

Global Public Health is not just something we do, it’s an important part of PHE’s core business. We act internationally to strengthen global health security, protect the health of the UK’s population and improve health inequalities.

We have the ability to deploy experts, meaning we can share our technical knowledge. This is highly valued by our partners such as the World Health Organization (WHO), the Global Outbreak and Response Network (GOARN) and by Governments in countries we collaborate with, such as Nigeria, Ethiopia, Pakistan and Sierra Leone.  Essentially, we work hard to ensure we contribute fully to a collective international effort.

Image taken during the West Africa Ebola outbreak response
Image taken in Sierra Leone in 2017

Through this work we are learning from other countries and continually gaining new skills, knowledge and experience. This is then brought back to the UK and ultimately strengthens our delivery of services at home.

It’s important that we know we are making a difference, so it was brilliant to have our capacity recognised by IANPHI (the International Association of National Public Health Institutions), naming PHE as one of the world’s foremost public health institutes.

Responding to outbreaks and sharing our knowledge

With this growing capacity comes a greater demand for us to share our knowledge and we now have a team of experts who can deploy anywhere in the world, ready to tackle outbreaks within 48 hours.

They are part of the UK Public Health Rapid Support Team (UK-PHRST), funded by UK Aid from the Department of Health and Social Care, which is a partnership between Public Health England (PHE) and the London School of Hygiene and Tropical Medicine (LSHTM), with academic partnerships with the University of Oxford and King’s College London.

This is really vital work and means that  our expertise is being shared further and further afield.  So far the team have responded to disease outbreaks and threats in Madagascar, the Democratic Republic of the Congo, Sierra Leone, Ethiopia, Nigeria and Bangladesh. You can read more about who they are and the work they do in our blog.

Image taken during the West Africa Ebola outbreak response

The International Health Regulations – what they are and why they matter

Those in the global health world will certainly be aware of the International Health Regulations (IHR), but if you’re not aware, these  represent an agreement between 196 countries to work together for global health security.

The IHR specifically commits countries to ensure their capacity and capability to detect, assess and report global health threats. They identify the need to respond to a range of different hazards beyond infectious diseases, recognising that chemical, radiation and nuclear threats, as well as biological threats can impact on health.

Right now PHE is funded through the UK Aid budget to work in partnership with WHO and with the Governments of Nigeria, Ethiopia, Pakistan, Sierra Leone and Myanmar to strengthen their IHR compliance.

Image taken in Nigeria, August 2018

More than an infectious disease agenda

In 2015, there was international commitment to a number of other agreements, including the Sustainable Development Goals, The Paris Agreement on climate change and the Sendai Framework for Disaster Risk Reduction.

These recognise that climate, environment, education, the rule of law, wealth and poverty, peace and security, agriculture and economic growth all interact as determinants of health and wellbeing.

PHE has recognised that the growing international burden of non-communicable diseases, such as heart disease, diabetes and cancer, also have a global dimension and require global action.

For example, we are seeing increasing progress in lowering smoking rates in the UK, but we see tobacco companies shifting their marketing to less developed parts of the world. Unless we act together, we risk pushing public health problems from countries with strong public health systems to those with weaker systems.

Diabetes gets a lot of air time in the UK, but this is a global epidemic, and to tackle it we need to address shifting dietary and lifestyle factors across the world through collective global action, rather than as individual nations acting in isolation.

Working together both extends the impact of what we know and do in the UK, but also exposes us to the innovation and successes of other countries.

Image taken in Nigeria, August 2018

So what is PHE currently doing?

PHE has active programmes in a number of countries. These span many diverse health topics from health security and emergency response to chemical, biological, radiological and nuclear incidents to tobacco control and other areas of non-communicable disease.

We also work on environmental health, but these are just a few topics and our work goes much further. This is all done closely with other Government departments to ensure the UK’s contribution to global public health is coordinated.

This just scratches the surface of our global health remit, but in summary we act internationally because it is the right thing to do. This work brings benefits back to the UK and allows us not only to learn and further expand our expertise, but to improve our own services.

Building relationships with partners is vital but ultimately, through this work we can save lives, protect people and create a better life for people around the world and at home.

If you are attending the PHE Annual Conference, you can learn more about the UK Public Health Rapid Support Team and controlling outbreaks in the 10:30am session on Tuesday 11 September.

All images in this blog are owned by PHE staff.