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Food and drink aimed at children and young people 

What children eat in their early years is crucial in shaping their future food preferences and can impact their health later in life. Last week PHE published an evidence review of commercially available foods and drinks aimed at children up to 36 months old. The main findings show clear inconsistencies between national infant feeding advice and how some products are presented, such as foods being marketed as healthy snacks having the highest sugar content and, in some cases, containing as much as confectionery. Snacking food accounts for 34.5% of infant food market spend with the most sugar found in fruit and vegetable based finger foods. Of the 1,120 baby food and drink products reviewed for the report, more than 1 in 4 (28.1%) are targeted at 4 month olds despite advice from the Scientific Advisory Committee on Nutrition (SACN) that introducing solid foods should not happen until around 6 months of age.

In response, our evidence review recommends that the food industry and Government improves the nutrient content of products, ensures that clear, honest and consistent labelling is used in marketing and restrict the implied health claims on baby food products. The full report and recommendations can be read here.

Sugar reduction

PHE’s national diet, obesity and physical activity team received a Best Practice award from the EU Commission for their work on the sugar reduction programme. The award-winning case study was presented at the Vienna Food System’s Conference and to EU member states in Brussels. A well deserved recognition and congratulations to all involved.

Smoking in England

Smoking in England is in terminal decline and a smokefree generation is now in sight, with new data this week showing the number of adult cigarette smokers in England for 2018 is down to 5.9 million, a decrease of 1.8 million from 2013. This means the prevalence of adult smokers in England was 14.4% last year, the lowest ever and this is really positive news in the battle against the nation’s biggest killer.

The picture is complex with the lowest rates among over 65s and the fastest reductions among 18 to 24s, while adults aged 25 to 34 were most likely to smoke (19%). Smoking rates remain stubbornly high amongst people on lower incomes and those experiencing mental health problems and every effort and means to support them quitting is where we need to most focus. You can read more in our blog.

Getting children moving

The latest Change4Life 10 Minute Shake Up campaign started this week, led by PHE and Disney UK with support from Sport England. This fabulous campaign aims to get two million primary school aged children more active by playing games inspired by leading Disney characters including Toy Story 4, Frozen, The Incredibles 2 and The Lion King. The games help children to develop and practice the skills they need to build up key physical attributes of strength, stamina and agility.

Shake Up games packs are being delivered to over 16,500 schools across England with resources available to download for teachers from the School Zone. Local authorities, the NHS and partners will be able to order and download a range of digital and print assets from the Campaign Resource Centre.

Antibiotic resistance

The threat of antibiotic resistance (AMR) continues to grow. A world without antibiotics is one where 3 million common procedures such as caesarean sections and hip replacements could be life-threatening, and patients with complex conditions are put at further risk. AMR bloodstream infections rose by an estimated 35% between 2013 and 2017, and we are seeing an increasing number of infections that are not responding to antibiotics of last resort.

As part of efforts to combat this, PHE has been awarded £5.1 million by the Department of Health and Social Care to advance our work on AMR. This work will have three strands including building a unique linked infection and AMR dataset, a novel mobile modular hospital ward facility to study how the environment can reduce healthcare-associated infection and a new research laboratory facility to identify and evaluate novel therapies to treat infections. This new linked dataset will help clinicians understand when to use antibiotics and aims to improve the antibiotic treatment so that patients receive the right treatment for them first time.

Reducing over-prescribing in people with learning disabilities

The PHE Board recently heard from people with learning disabilities on their priorities for improving their health. They gave a powerful presentation which was a reminder of the health inequalities which continue for them and the potential for changing that. An example of this is in reducing over-prescribing and a study published last month spoke to the success in Cornwall in completely withdrawing psychotropic medication to 46.5% of people with learning disabilities. This was in response to the STOMP campaign run by NHS England and informed by a PHE report which sets out the extent of over-prescribing. You can learn more here.

Stillbirth and infant mortality

In March this year PHE published a stillbirth and infant mortality tool, designed for planners and commissioners working in local government, clinical commissioning groups and across local maternity systems. It uses available data and evidence, broken down to local area level, to model estimates of the possible effects of various factors on infant mortality and stillbirth and can help with the prioritisation of services and addressing risk factors. After receiving and acting on feedback, a new version of the tool went live this week and can be found here.

Best wishes, Duncan

You can subscribe to the Friday message newsletter version which goes direct to your inbox here.

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The secondary care diagnostic interval (SCDI) is the period of time, in days, from a patient’s first interaction with secondary care, which can be a referral, appointment or diagnostic test, to their cancer diagnosis. A short SCDI is not necessarily better, as it may represent the presence of clear symptoms or advanced disease, which result in a quicker cancer diagnosis.

In partnership with Cancer Research UK, PHE has published new data showing the SCDIs for cancer patients in England diagnosed in 2014-2015. The data, from PHE’s National Cancer Registration and Analysis Service (NCRAS) was used to calculate this interval for the first time for nearly all patients with 25 different cancers – including breast, colorectal and liver cancer.

SCDI data can be viewed and downloaded from an online tool, which displays different cancer types by demographic factors and Cancer Alliance. Using this tool, we are now able to understand how these intervals vary across different stages of disease, age, sex, ethnicity, comorbidities, levels of deprivation, routes to diagnosis and in different parts of England, to support initiatives to diagnose cancer faster within the NHS.

This blog outlines 7 things we have learnt from the data.

1. Patients diagnosed after a routine GP referral or via outpatients experience the longest intervals

There is considerable interval variation by different routes to diagnosis. Patients diagnosed via routine GP referrals and outpatients have the longest intervals for all cancers, with the exception of acute lymphoblastic leukaemia, for which Two Week Waits and routine GP referrals are the longest. Patients diagnosed via emergency and inpatients have the shortest intervals for all cancers, apart from breast cancer, for which where emergency and screening patients have the shortest intervals.

Patients diagnosed following an emergency are typically more unwell with more pronounced symptoms, leading to quicker diagnoses. This route is associated with worse outcomes.

2. Late stage cancers have shorter intervals

For all cancers, the interval length generally decreases at more advanced stages, except myeloma and leukaemias (where we don’t have the stage of disease). For example, stage 4 cancers have shorter intervals than stage 1 for all cancers, with the exception of melanoma.

Possible reasons for this include the severity of advanced stage symptoms or attending A&E whilst being acutely unwell, leading to a faster diagnosis.

3. Diagnostic pathways differ between cancer sites

Diagnostic intervals differ by cancer. This can, in part, be due to different cancers having varying diagnostic procedures, some of which happen earlier in the pathway. For example, chest X-rays for lung cancer can be requested via a patient’s GP before a secondary care referral, whereas diagnostics for other cancers happen after secondary care referral, such as colonoscopies for colorectal cancer.

Breast cancer has shorter intervals, as there is a well-defined diagnostic pathway with patients usually presenting with distinctive symptoms, such as a lump in the breast, leading to swift referrals and diagnoses.

4. Patients with multiple comorbidities have longer intervals

The Charlson comorbidity index measures the presence and severity of other diseases a patient has prior to their cancer diagnosis. Generally, patients with comorbidities experience longer intervals than those with none. Possible explanations are that cancer symptoms may be confused for existing health conditions, or that these conditions result in patients being less fit for diagnostic procedures.

5. There is some variation across England by Cancer Alliance

Cancer Alliances drive local changes to cancer services to improve cancer outcomes and patient experience. By bringing together clinical leaders and teams in each of Alliance, they aim to transform treatment and diagnosis in their areas – there are 19 Cancer Alliances across England.

Comparing Cancer Alliance intervals with the national average shows geographical variation, with most sites having a number of Alliances with different intervals.

Prostate is the cancer with the most significant differences from the national average interval. A possible reason for differences is a Cancer Alliance's population characteristics could be different to the overall England population. Bladder cancer, acute lymphoblastic leukaemia and chronic myeloid leukaemia are the only cancers where there are no significant differences between England and any Cancer Alliances.

6. Age, sex and ethnicity have inconsistent patterns of variation

We have shown interval length variation by age, with older patients generally having longer intervals and the oldest age group (over 85 years) having shorter intervals. The latter is at least partly due to more people in this age group being diagnosed via an emergency. Some cancers have no variation by age, including breast, cervical and oesophageal cancers.

For most cancers, the interval length is similar for both sexes. However, males have longer intervals for bladder, kidney and liver cancers, and females have slightly longer intervals for chronic myeloid leukaemia and pharyngeal cancers.

There has been no discernible patterns by ethnicity shown to date. Looking at different cancers, there are some variations but no clear pattern of longer or shorter intervals for any particular ethnic group.

7. There are no differences by deprivation levels

There is no variation between deprivation and interval length for any cancer.

The next steps

This work enables further research, both by PHE and by external researchers, to examine the variation in SCDIs in more detail. It is important for us to understand and address the causes of variation, and identify drivers of unnecessarily long intervals to improve outcomes for patients with cancer.

For more details about our methods, we have produced a Standard Operating Procedure (SOP).

Find out more on the NCRAS landing page.

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Community pharmacies are one of the most frequented health care settings in England, with 1.2 million health-related visits every day.

With their presence in most high streets, many rural communities, and in the places where we shop, access healthcare and enjoy our leisure time, community pharmacies are a local health and social asset interwoven with our daily lives in a way that few other professions can claim.

Pharmacy teams working in all sectors have an important role to play in prevention and embedding public health practice in their everyday role. Their importance was re-emphasised in the NHS Long Term Plan, which refers to the “essential role” of pharmacists in delivering the various initiatives it proposes for the next 10 years.

What are opportunistic interventions?

Alongside their role optimising the use of medicines, community pharmacy teams are increasingly delivering a wide range of public health interventions, from stopping smoking to sexual health services, alcohol interventions, flu immunisations and more.

There are now more than 9,500 Healthy Living Pharmacies (HLPs) in England. One of their key distinctions is having a qualified health champion on site, who uses every interaction as an opportunity for a health-promoting intervention. This approach of ‘Making Every Contact Count’ (MECC) can improve and protect health, reduce premature mortality, and help to reduce health inequalities.

This blog explores how pharmacy teams can play a role in prevention through opportunistic interventions and commissioned services for six public health challenges.

1. Cardiovascular disease (CVD)

The NHS Health Check is a check-up for adults aged 40-74 in England, designed to spot early signs of heart disease, stroke, kidney disease, type 2 diabetes or dementia.

Whilst the programme is mostly provided in primary medical care settings, community pharmacy teams can also deliver checks, particularly for hard-to-reach groups that may not access GP practices. Pharmacy teams can also help to maximise the programme’s impact by:

  • directing eligible people for a check if the service is not available on site
  • providing lifestyle interventions to people who have had a check or those with moderate to high blood pressure
  • directing people to local behaviour change support services (if they do not provide these services themselves) and/or to a GP or the pharmacist in the GP practice, for appropriate clinical management

Pharmacy teams can also play an important role in identifying people with undiagnosed high blood pressure by offering opportunistic blood pressure and pulse rhythm testing.

The NHS Long Term Plan sets out that the NHS will support pharmacists in primary care networks to case find and treat people with conditions that put people at high risk of developing CVD, so that preventative treatments can be offered in a timely way.

2. Smoking

Tobacco use continues to be one of the most significant public health challenges and the largest single cause of premature death in England.

NICE guidance on stop smoking interventions and services recommends the involvement of pharmacy teams in various activities associated with supporting smokers to quit. Community pharmacy-delivered stop smoking interventions offer an effective and cost-effective way to support smoking cessation.

Pharmacy teams can further support smoking cessation by:

  • providing very brief advice for stopping smoking opportunistically
  • routinely discussing stopping smoking with people presenting prescriptions related to e.g. Chronic Obstructive Pulmonary Disease, diabetes, heart disease or high blood pressure, or when selling relevant over the counter medicines
  • supporting national stop smoking campaigns
3. Sexual health, reproductive health and HIV

Pharmacy plays a critical role in the access and provision of sexual health, reproductive health and HIV services across England.

The services available at each pharmacy vary depending on what is commissioned. Examples of commissioned services include:

Some areas also commission additional services, such as ongoing contraception and HIV testing.

Encounters between pharmacy teams and people seeking a service offer opportunities to provide an integrated package of sexual health and reproductive health services, going beyond a single treatment approach.

You can read more about this in The pharmacy offer for sexual health, reproductive health and HIV – PHE’s resource for commissioners and providers.

4. Healthy ageing

Productive healthy ageing entails increased independence and resilience to adversity, the ability to be financially secure, engagement in social activities, being socially connected with enhanced friendships and support, and enjoying life in good health.

To support this agenda, PHE has recently published a Menu of Interventions for Productive Healthy Ageing – a tool that pharmacy teams working in different healthcare settings can use to support older people to lead more independent lives and improve their health.

The menu suggests opportunistic, evidence-based interventions that can help provide benefits for healthy ageing, focused on:

  • preventing falls
  • dementia
  • physical inactivity
  • social isolation and loneliness
  • mental public health
  • malnutrition
5. Mental health

With up to 1 in 4 of the population experiencing mental illness, many people accessing pharmacies will be affected by mental health problems or social conditions that put their mental health at risk. Pharmacy teams can help by using every opportunity to have conversations and offer brief advice to people who they think may be experiencing mental wellbeing issues.

Pharmacy staff trained as mental health champions can also make a positive contribution in creating mentally healthy pharmacies and communities, advocating for the mental health needs of local people and the role of HLPs in promoting individual and community wellness.

Furthermore, community pharmacies can set an example by being a mentally healthy workplace that adopts organisational approaches that assess and manage demands, job control, relationships and more.

6. Vaccination

Since 2015, community pharmacists have been offering the seasonal flu vaccination as an advanced service of the community pharmacy contractual framework, complementing the service provided by GP practices.

Pharmacists who vaccinate people for seasonal flu have been trained to administer the vaccine safely and to deal with adverse situations such as anaphylaxis.

The number of seasonal flu vaccinations provided by community pharmacists has increased year on year. Between September 2018 and March 2019, pharmacists provided 1,431,538 flu vaccinations, helping to reduce pressure on GP practices and increases patient choice.

In some areas of the country, pharmacists have been commissioned locally to provide the shingles vaccine. Where they are not commissioned, pharmacy teams can opportunistically remind eligible people to get vaccinated.

It is evident that pharmacy teams play a pivotal role in improving the public’s health and are a prominent social and health asset within all communities. The examples presented here are just a few of the many areas that pharmacy teams provide opportunistic health-promoting interventions for. Many of these public health challenges are preventable, yet continue to drive morbidity, premature mortality and health inequalities, placing a substantial burden on individuals and their families, communities, the NHS and the economy. As such, for as long as these public health challenges persist, pharmacies will remain a valuable and vital asset to preventing them and promoting health.

Visit the Pharmacy and Public Health Forum publications collection page to see more reports on developing pharmacy’s contribution to public health.

PHE’s report Pharmacy – A Way Forward for Public Health sets out opportunities for commissioner and provider led action at a local level to realise community pharmacy’s role in enabling a healthier nation. It provides a menu of interventions and details how pharmacy teams working in different sectors can engage in PHE’s public health programmes.

There is also a NICE guideline – published in August 2018 – covering how community pharmacies can help maintain and improve people’s physical and mental health and wellbeing.

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The threat of antibiotic resistance continues to grow. A world without antibiotics is one where 3 million common procedures per year, such as caesarean sections and hip replacements become life-threatening, and cancer patients are put at further risk.

Antibiotic-resistant bloodstream infections rose by an estimated 35% between 2013 and 2017, and we are seeing an increasing number of infections that are not responding to antibiotics of last resort. It is clear that innovative new approaches are needed urgently.

New funding for the most advanced data collection

Public Health England has been awarded £5.1 million by the Department of Health and Social Care to stimulate a number of initiatives, including the creation of the most advanced dataset globally on antimicrobial resistance (AMR). These funds will enable us to create a virtual ‘open access’ centre, which will gather real-time patient data on resistant infections, helping clinicians understand when to use and preserve antibiotics in their treatment. This will provide a unique and tailored approach to the huge challenge AMR poses.

Big Data to tackle big questions

There a range of different data sets available that help us interrogate antibiotic prescribing and AMR.

AMR data from PHE microbiology systems, hospital episode statistics, patient level prescribing data, and ONS mortality data are all important tools for government and researchers to monitor and probe the impact of AMR in this country.

What is missing is a way to effectively integrate all this information in a meaningful and secure manner. The new funds will allow PHE to address these challenges by creating a new dataset that is the most advanced globally. The funds will also ensure that the UK leads the development of Big Data methodologies, and essentially enhance our understanding of AMR.

The wealth of data will be used to create an open-access simulated dataset that can be used by PHE, the NHS and external researchers to comprehensively understand the drivers of antibiotic prescribing, and the impact of prescribing decisions on AMR and long-term health outcomes. The project aims to have a simulated dataset available in early 2021.

These insights will also be invaluable for policymakers in shaping guidelines that limit antibiotic consumption to the safest level.

Predicting patient responses to improve and tailor treatment

The concept of precision medicine has been defined as a set of prevention and treatment strategies that take individual variability into account. It is at a basic level tailored medicine and treatment for individuals, taking into account that we are all different with different needs.

While these approaches are often thought of in the context of non-communicable diseases such as cardiovascular disease and cancer, there is also scope to use them within the world of infectious diseases. By understanding which patients develop infections that require hospitalisation or are antibiotic resistant we can target effective treatment to those at most risk.

Drilling down further into the dataset to patient-level data will ultimately enable healthcare professionals to make decisions based on patient history. A complete picture of previous infections, antibiotics prescribed and the outcomes of those interventions, coupled with new insights into the risk factors for acquiring an antibiotic resistant infection, will enable us to predict individual patient responses and give people effective and personalised treatment.

Reducing healthcare-associated infections (HCAIs)

Reducing antibiotic prescribing is just one part of the challenge surrounding AMR – reducing infections in the first place and developing and evaluating new therapeutics are also vital.

Core infection control measures such as hand hygiene, isolation and environmental cleaning have driven down Clostridium difficile and Methicillin-resistant Staphylococcus aureus (MRSA) infection rates in hospital. MRSA blood stream infections now impact 1.5 people per 100,000 of the population compared to its peak of 15.4 per 100,000 in 2004.

However, despite robust infection prevention control practices and relentless focus on driving down HCAIs across the healthcare system, interventions are not having a large enough impact on infections such as E. coli bloodstream infections.

The role of the hospital environment in the transmission of HCAIs is still not fully understood. In order to address this, PHE will establish a flexible modular facility that will simulate a 4-bed ward (a facility that looks like a normal ward, but exists for research purposes), isolation room with lobby and assisted shower room, among other things. To do this, we will draw on our experience of designing, delivering and operating similar modular facilities during the West African Ebola outbreak.

This state of the art facility will drive innovation and evidence-based solutions for a growing challenge, by attracting external researchers and enabling them to trial approaches that would be impractical and disruptive to assess in a working ward environment. We expect the facility to be operational towards the end of 2020, based initially at PHE Porton. The project team will work actively with the research community to identify research questions to improve understanding of transmission and potential interventions that could help reduce the numbers of HCAIs and will include locating the facility alongside NHS Trusts where there are particular HCAI challenges or outbreaks.

Developing and evaluating novel therapies

Active engagement with the research community is also essential to identify and evaluate novel therapeutic approaches, such as those aiming to work by altering the microbiome, through the action of host defence peptides or in conjunction with other components of the human immune system. PHE will provide access to researchers wanting to evaluate such strategies on up-to-date clinical isolates of antibiotic-resistant bacteria, in models for difficult to treat infections, such as biofilms.

Accessing such strains and models can be difficult for researchers, especially those who are new to the field and this will allow a range of novel approaches to be explored.  This open-innovation approach will stimulate research in this area and provide high quality data to support future development of successful strategies.

We need to take bold steps to reduce antibiotic over-use and preserve them for when we really need them. Through this innovative new approach, we seek to build on the huge progress that has been made so far in understanding the impact of prescribing on resistance and in the development and evaluation of new interventions and begin benefitting the lives of patients sooner.

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Listeria outbreak

Nine people have been seriously ill following an outbreak of Listeria linked to pre-packed sandwiches and salads served in hospitals and five of those have very sadly died. Our heartfelt sympathies and condolences are with the people affected and their families and loved ones. Our microbiologists and epidemiologists have been central to understanding and responding to this outbreak working closely with the NHS and the Food Standards Agency. For most healthy people, Listeria causes a mild illness but for the immunosuppressed, it can be extremely serious. Secretary of State Matt Hancock MP made a statement to the House of Commons about this on Monday and made a commitment to look again at the way we provide food in our hospitals, and more on this will follow.

Ebola in the Democratic Republic of Congo

In August 2018 an outbreak of Ebola was declared in North Kivu in the Democratic Republic of Congo (DRC) and has now become the second biggest on record, after West Africa in 2013. The outbreak remains ongoing, with over 2,000 cases reported so far, over 1,400 deaths and cases now confirmed in neighbouring Uganda from people travelling from DRC.

Members of the UK Public Health Rapid Support Team (UKPHRST) deployed shortly after the first cases were confirmed last year alongside other organisations working with the DRC Government and have had a constant presence since. The response is extremely challenging in a region affected by protracted civil conflict and political instability and the situation is constantly changing. PHE’s Dr Olivier le Polain, who is an epidemiologist and deputy director for operations of the UKPHRST has deployed twice to DRC and has spoken about his experiences, the situation and why this is such a complex outbreak. You can read his full interview here on the outbreak and the UKPHRST and more on the incident from the WHO here.

Dr Olivier le Polain working with colleagues in the Democratic Republic of Congo during the ongoing Ebola outbreak.

Putting prevention at the heart of mental health

This week the Prime Minister announced a new push on mental health, putting prevention centre stage. The Number 10 plan aims to drive a step-change in public awareness and provide practical support, in particular for young people. PHE is at the forefront of this work and this October will be launching “Every Mind Matters” - England’s first mental health literacy campaign letting people know what they can do day-to-day to improve their mental health and support others. Following Monday’s announcement, PHE will be developing additional content for young people and parents which will be added to the campaign in 2020.

This week has also been loneliness awareness week, highlighting a problem that affects many people from all walks of life and is also a key issue within Every Mind Matters. As set out in the Government’s 2018 loneliness strategy, we have consulted on updates to our Public Health Outcomes Framework which includes a consideration for a national measure for loneliness, to inform and focus future work on this area. A new campaign called Let's Talk Loneliness was also announced this week by Minister for Loneliness Mims Davies MP which aims to remove some of the stigma around feeling lonely. You can learn more here.

Preventing musculoskeletal conditions

Being in good work is better for your health than being out of work, but for many with long-term conditions such as musculoskeletal conditions (MSK), health issues can be a barrier to gaining and retaining employment. After coughs and colds, MSK is the biggest cause of lost working days in the UK, causing a £7 billion loss to the economy and costing the NHS £5 billion each year and this was recognised in the NHS Long Term Plan.

This week, along with NHS England and Versus Arthritis, we published a 5 Year strategic framework for preventing MSK conditions across every stage of life and you can find out more here.

NHS Providers

The Framework for Population Health in Healthcare Providers published this week by the Provider Public Health Network and NHS Providers sets out principles for a population health approach that NHS Trusts can think about and embed as part of their day-to-day business. The Framework describes a range of ways that Trusts can increase their impact through local partnerships and collaboration, their work on health improvement and prevention, through system-wide approaches to health protection, and as anchor institutions within their local neighbourhood. I was delighted to see this development and commend NHS Providers and the Provider Public Health Network for sharing frontline experience of what works in busy, operational settings.

Patient information on water fluoridation

Tooth decay is still a significant problem for children and adults in England and tooth extraction caused by this is the most common reason for 6-10 year old children to be admitted to hospital to have an operation under general anaesthetic. Tooth decay can be largely prevented by cutting down on sugar and increasing access to fluoride and one way of doing this is through community water fluoridation schemes.

Water has been fluoridated in England for over 50 years and currently benefits around 6 million people. PHE's 2018 Health Monitoring report showed that if 5-year-olds with the most tooth decay drank fluoridated water they would have 28% less tooth decay and be 45-68% less likely to need teeth removed in hospital. To help dental teams talk with their patients about water fluoridation, PHE has worked with dentists to develop a new package of resources including banners for events, posters and conversation starters, which provide which provide information about the effectiveness and safety of fluoridation.

And finally, I will be overseas next week and my next message will be on Friday 5 July.

Best wishes, Duncan

You can subscribe to the Friday message newsletter version which goes direct to your inbox here.

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Health inequalities are avoidable and unfair differences in health status between groups of people or communities. They can include inequality in health outcomes by socioeconomic status or level of deprivation, or by characteristics such as gender, ethnic group or sexual orientation.

They also reflect historic and present-day social inequalities in our population, and reducing them should allow everyone to have the same opportunities to lead a healthy life.

PHE’s Health Profile for England 2018 reported that people in the least deprived parts of England live, on average, 19 more years in good health than people in the most deprived areas of the country.

It also reported wide inequalities in the health of children and in the wider determinants of health: the social, economic and environmental factors which influence people’s mental and physical health.

To support national and local action to reduce such inequalities, PHE has recently published updates to two tools: the Health Inequalities Dashboard and the Segment Tool.

Inequalities in life expectancy are widening, and there is a mixed picture of progress for other key indicators

The Health Inequalities Dashboard shows trend data for inequalities in life expectancy, and for 17 other indicators of health and the wider determinants. These are the key measures selected by PHE to monitor progress in narrowing inequalities within England.

For all indicators, the Health Inequalities Dashboard quantifies inequalities within England as a whole, and now also includes data on inequalities within local authorities for 4 of the 18 indicators.  More data for local authorities will be added over time for as many indicators as possible.

The dashboard shows that inequalities in life expectancy have widened for both sexes since 2011-13. The gap between most and least deprived is over 9 years for males and over 7 years for females.    Inequalities in healthy life expectancy are even wider and have not changed since 2011-13.

Trend in inequalities in life expectancy, females, England, 2001-03 to 2015-17. Source: PHE, Health Inequalities Dashboard

Inequality in premature mortality rates from cancer and circulatory disease (aka cardiovascular disease) have also widened in recent years. Mortality rates for deaths under age 75 in the most deprived areas are twice as high for cancer and four times higher for circulatory disease than in the least deprived areas.

There has, however, been a narrowing of inequality for some wider determinants of health, including children living in low income families, young people not in employment, education or training, and the employment gap between those with a long-term health condition and the overall employment rate.

Mortality from cancer, circulatory diseases, and respiratory diseases are key drivers of inequalities in life expectancy

The Health Inequalities Dashboard shows the gap in life expectancy within every local authority and the Segment Tool provides information on the causes of death and age groups which are driving those gaps. Targeting the causes and age groups which contribute most to the life expectancy gap should have the biggest impact on reducing inequalities.

Almost two thirds of the gap in life expectancy between the most and least deprived areas in England was due to higher mortality rates from circulatory disease, cancer and respiratory disease in the most deprived fifth of areas compared with the least deprived fifth. This reflects the wide inequalities in premature mortality rates from cancer and circulatory disease shown in the Health Inequalities Dashboard.

Scarf chart showing the breakdown of the life expectancy gap between the most deprived quintile and least deprived quintile of England, by broad cause of death, 2015-17. Source: PHE Segment Tool

The Segment Tool also breaks down contributions of a more detailed set of causes of death to life expectancy inequality, for example, the contributions of specific cancers. It can also be used to identify how higher mortality in the most deprived areas amongst specific age groups impacts on the life expectancy gap.

The tool provides this data at local authority and regional level. In many local areas, the key contributors to the life expectancy gap are the same as England – cancer, circulatory diseases, and respiratory diseases. However, there are variations at local level.

For example, the North East and North West regions have the lowest male life expectancy in England. However, the causes of death making the largest contributions to these gaps are different.

In the North West, circulatory disease, cancer and respiratory diseases contribute most to the gap in life expectancy between the region and England. However, in the North East deaths from external causes is the second highest contributor after cancer.

Higher mortality rates from external causes accounted for more than a fifth of the 1.6 year gap in life expectancy between the North East and England. External causes can include deaths from transport accidents and suicide, but in the North East it is deaths from accidental poisoning which are the largest contributor to the life expectancy gap between the region and England.

Scarf chart showing the breakdown of the life expectancy gap between selected regions and England, by broad cause of death, males, 2015-17. Source: PHE Segment Tool

What else is PHE doing to help local areas address health inequalities

PHE, alongside the Local Government Association and the Association of Directors of Public Health, will shortly be publishing guidance and resources to support place-based action for reducing health inequalities in local areas.

This will support new and existing joint action on health inequalities within local authorities, the NHS, and voluntary, community and social enterprise organisations.

Learn more through PHE's segment tool and Health Inequalities Dashboard.

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The nature of the problem

We all know about the harmful effects of alcohol to the drinker. However, evidence is emerging for the harm caused by the drinker to their families, co-workers, the community and society. The actions of drinkers’ impact on the health and wellbeing of others and are sometimes criminal. In response, the health system, the criminal justice system and the welfare system all provide services for those affected, so these harms have a financial cost too.

The scale and nature of the problem in England

PHE has published the results of a national survey of alcohol-related harm to others . This was the first ever national survey on this topic in England and the largest ever survey conducted in the UK. We found that one in five adults had been harmed by the drinking of another person in the previous 12 months.

The most common harms were being kept awake at night and feeling uncomfortable or anxious at a social situation. While these may seem relatively minor, this is not necessarily the case. Sleep disruption, for example, can have a considerable impact on health and quality of life if frequent and long term.

Of more concern, the survey highlighted the burden of violence associated with another’s drinking: 3.4% of respondents said they had felt physically threatened, 1.9% said they had been physically assaulted and 0.7% said they had been forced or pressurised into something sexual. In total almost one in twenty people said they had experienced at least one of these three aggressive harms in the previous year.

It is already known that alcohol is a prevalent feature in violent and sexual crimes. Data from the Crime Survey for England and Wales show that in about half of all violent crimes the victim perceived the offender to be under the influence of alcohol. Data from the Office for National Statistics show that in 38% of cases of rape/assault by penetration (including attempts) the victims reported the offender had been drinking. Alcohol consumption can also increase in victims after experiencing physical or sexual assault.

Several personal, social and behavioural characteristics were found to put a person at higher risk of experiencing harm from another’s drinking. For example, people who were younger, drank themselves at harmful/hazardous levels, were white British, had a disability, were educated and lived in private rented accommodation (compared to owned outright) were at highest risk.

Having children in the household (compared to being young and single) and being retired (compared to being employed) were less likely to experience harm.

Who causes harm and how frequent is it?

While friends and strangers were the people who caused almost half of all harms, the person causing harm varied depending on the type of harm. Strangers were most likely to be the perpetrators of physical threats and physical assaults.

One in five (19%) people who were forced or pressured into something sexual said this was at the hands of a stranger, but 23% said this was caused by the partner they lived with, increasing to almost 40% when including partners who lived elsewhere.

While the number of people who reported being forced or pressurised into something sexual was small in our survey, these findings are supported by other sources. Data from the Crime Survey for England and Wales, for example, show that partners/ex-partners of women commit a higher number of rapes or assaults by penetration (including attempts), than other types of perpetrator.

Most harms (75%) occurred less than monthly but 5% occurred daily or almost daily showing some people shoulder a considerable burden. Harms which occurred daily or almost daily were those which occurred over a long time and/or involved contact with the person causing the harm, such as caring for a person who had an illness caused by drinking. Other research has shown that exposure to heavy drinkers is linked to poorer health, wellbeing and quality of life.

What can be done?

Research on alcohol-related harm to others is well established in some other countries but is relatively new in the UK. As such, more work is needed to fully understand this issue. Individual stakeholders can make a difference. For example, mechanisms are in place for local authorities to reduce persistent alcohol-related noise and services are available which offer support for people caring for a drinker.

However, the biggest reduction in alcohol-related harm to others would likely come from a reduction in alcohol consumption in the population as a whole; reducing an individual’s drinking would reduce the risk they pose to others.

Previous research by PHE has identified that the most effective interventions to reduce alcohol use are personalised interventions targeted to at-risk drinkers, enforced legislative measures, and policies that address alcohol affordability, availability and marketing (insert link).

Finding ways to reduce the levels of unmet need for treatment amongst alcohol dependent adults, and in particular parents, is likely to impact on violent crime, including intimate partner violence; while programmes that reduce sales to intoxicated adults in the night time economy may also have an important role to play in that setting.

Since physical and sexual assault can occur in private settings such as households, supportive approaches working directly with offender groups may be useful to reduce these harms.

Evidence of harm from passive smoking provided the impetus for effective public health action. Evidence presented here, and from other sources, shows alcohol-related harm to others deserves the same attention.

Read the research and analysis here.

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There are many reasons why taking a life course approach to health is important. It’s hard to imagine that we haven’t always known some of the things that we’ve learnt through the power of life course research. For example, just how formative the early years are for laying the foundations for our future health and wellbeing. That there are cycles of disadvantage that cascade across generations. That when health problems occur together, they often have common roots and risk factors. We’ve also learned how cost-effective early intervention and early prevention can be.

What’s the key evidence underpinning the life course approach? - YouTube
Cohort studies and the health of future generations

There is another value to life course research that is growing in importance, as a tool for understanding how the health of successive generations is changing, and what risks we face for the future.

At the Centre for Longitudinal Studies at UCL we run four national longitudinal cohort studies that follow people across life. These are:

UCL is also the home of the 1946 National Study of Health and Development (NSHD).

Using these, and other life course studies, we can investigate how each generation’s health is changing, compared to in previous generations.

Mental health in future generations

Taking a life course approach allows us to understand how mental health problems in mid-life are changing across generations.

In one study, we compared the mental health of participants in the 1970 British Cohort Study at age 42 to that of participants of the 1958 NCDS when they were the same age, 12 years earlier. The younger cohort experienced significantly greater levels of mental distress, and the differences were most pronounced in men.

These findings chime strongly with the first report from the new Deaton review on inequality, which showed that ‘deaths of despair’ – deaths from suicide and drug and alcohol abuse – are now rising among middle-aged Britons.

Source: Ploubidis GB, Sullivan A, Brown M, Goodman, A. (2017). Psychological distress in mid-life: evidence from the 1958 and 1970 British birth cohorts. PSYCHOLOGICAL MEDICINE, 47 (2), 291-303. doi:10.1017/S0033291716002464

Mental health problems also appear to be growing among adolescents. By the age of 14, around 1 in 4 girls in the MCS reported high levels of depressive symptoms (compared to around just 1 in 10 boys) – a statistic which has garnered widespread news headlines. Importantly, in another recent study we compared data from two cohorts of millennials born a decade apart, at age 14. The younger group was made up of members of the MCS while the older group were born in the Bristol area in 1991-92. Levels of depression were substantially higher in the younger generation, and rates of self-harm had risen too.

This rise in mental health problems isn’t just indicative of problems today. We need to plan for the future to take account of the likely knock-on effects on health and wellbeing further down the line.

Overweight and obesity in future generations

The cohort studies can also be used to investigate the change in population overweight and obesity across generations.

Successive generations have become more overweight and at higher risk of obesity, both in childhood and in mid-life. In the MCS, for example, we have found that one in five young people born in the UK at the turn of the century was obese by the age of 14, and a further 15 per cent were found to be overweight.

The child obesity rate has increased almost three-fold in five generations, while adulthood BMI has also risen rapidly across successive generations. Obesity is a leading risk factor for many non-communicable diseases including Type 2 diabetes, for which cases are projected to increase rapidly.

This gives a strong indication to community planners to plan ahead for obesity-related health risks, as well as tackling the problem of rising BMI itself.

Other insights into the life course – population ageing

Findings from these life course studies have informed many other areas of government policy, including how strong the cumulative effects of disadvantage across the life course can be, especially on the risk of poor health at older ages.

Low income across a lifetime poses strong risks for quality of life in older age, as well as life expectancy. Using the 1958 NCDS, we have shown how income inequality has widened within this generation as they have aged. The figure below shows how the income of the richest 10% grew much faster than the incomes of the middle and of the poorest 10% of the cohort across their working lifetimes.

Source: Carpentieri, JD, Goodman A, Parsons S, Patalay P and Swain J. (2017). Lifetime poverty and attitudes to retirement among a cohort born in 1958. Report for the Joseph Rowntree Foundation

Furthermore, by the age of 55, those who had been persistently poor according to their income were also likely to be insecure in many other ways, including in poorer health, with lower rates of employment, and lack of financial security from either pension or home ownership compared to those who had not been poor. As such, these individuals faced a much stronger likelihood of experiencing difficulties in older age.

Source: Carpentieri, JD, Goodman A, Parsons S, Patalay P and Swain J. (2017). Lifetime poverty and attitudes to retirement among a cohort born in 1958. Report for the Joseph Rowntree Foundation

Working together to promote health across generations

Many local authorities are already organised around people and place and will be looking at the health and wellbeing of their residents through a life course lens. However, it’s clear that more needs to be done by taking action early, appropriately and together; and by taking the long view.

Read more about taking a life course approach to the prevention of ill health in this edition of Health Matters.

If you have any questions or would like to discuss how you're taking the life course approach to health and wellbeing, you can get in touch with PHE's life course team via HealthMatters@phe.gov.uk.

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Dear everyone

New Chief Medical Officer and Deputy

It is a pleasure to warmly welcome Professor Chris Whitty’s appointment as the next Chief Medical Officer to succeed Dame Professor Sally Davies. Chris blends a career of science, medicine and public health and we look forward to working with him in furthering the protection and improvement of the nation’s health. Also this week came the news of PHE’s Dr Jenny Harries appointment as Deputy Chief Medical Officer taking up post in mid July. Jenny has been with PHE since our inception as the regional director for the South of England and also more recently as Deputy Medical Director. She has brought great expertise to a number of complex national emergencies from Ebola to the Wiltshire poisonings and has achieved so much in her work in the South of England, as well as being a champion within PHE of diversity and gender balance. Our congratulations to both Chris and Jenny.

Sexual Health

Sexual health has been in the spotlight this week after PHE’s annual report on sexually transmitted infections showed a rise of 5% in diagnoses in England in 2018 compared to 2017.

The report includes trends for individual STIs, with a continued decline in rates of genital warts and increases in diagnoses of gonorrhoea and syphilis. The biggest increase is in gonorrhoea which has risen by 26% and at its highest since 1978. And this week we have published a national syphilis action plan and will be working closely with local government and the NHS on this. The impact of STIs remains greatest in young heterosexuals aged 15 to 24, black ethnic minorities and gay, bisexual and other men who have sex with men.

While a rise in cases is greatly concerning, this is in part down to an increase in testing and attendance at sexual health services, both in clinic settings and online. There was a 7% increase in consultations since 2017 and the National Chlamydia Screening Programme carried out 1.3 million tests in 2018, translating to 29% of young women and 11% of young men getting tested. This speaks to the hard work of clinicians and effective local government commissioning despite continuing pressures on the budget.

You can read the full report here.

Commissioning of sexual health, school nursing and health visiting services

This week Secretary of State Matt Hancock MP confirmed the outcome of his review of commissioning of sexual health, health visiting and school nursing services, announced in the NHS Long Term Plan. This affirms no change to the respective commissioning responsibilities of local government and the NHS, but for sexual health services we want to see every local area adopt a co-commissioning model and to jointly prepare a local sexual health plan. There are good examples of sexual health co-commissioning with proven effectiveness and this will be about ensuring every part of the country puts sexual health up higher up the agenda. For health visiting and school nursing, the commissioning responsibilities will remain with local government working increasingly closely with the NHS to ensure every child has the best possible start in life.

Hearing loss

There are around 11 million people across the UK with hearing loss, which means the partial or total inability to hear in one or both ears, and 50,000 of these are children. The 2018 update to the Health Profile for England projects that by 2031, 14.5 million people, which is approximately 20% of the UK population, will have hearing loss. As part of the latest edition of our professional resource Health Matters on prevention across the life course, we have published a blog which sets out actions for prevention and treatment.

Quit 16 - Reducing smoking in the North of England

Smoking causes 16 different types of cancer. Of the 6.7 million people who smoke in England, almost a third live in the North.  This week a new mass media campaign, #Quit16, targeted at those living in the North East, North West and Yorkshire and the Humber has gone live, highlighting the risks of the different cancers and encouraging smokers to quit. This will run for four weeks and is the culmination of joint working between NHS North of England Cancer Alliances, PHE, local government and the local NHS to put prevention centre stage.

Health data for small areas

PHE’s Local Health tool has been updated this week, containing nearly 70 indicators including measures such as life expectancy, mortality, cancer incidence and hospital admissions. By presenting data for small areas, such as electoral wards, Local Health provides an insight into the scale of inequalities within local areas and you can learn more in our blog.

Best wishes, Duncan

You can subscribe to the Friday message newsletter version which goes direct to your inbox here.

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Working in PHE centres, we see some illnesses regularly and have well-rehearsed processes in place. But some diseases are more unusual than others, for which we must be well prepared.

We don’t often hear about Middle East Respiratory Syndrome (MERS) in this country – a respiratory illness caused by the MERS coronavirus (MERS-CoV), which is mainly found in the Middle East. Since 2012 there have only been five cases confirmed in England. Yet, nearly 1,500 suspected cases of MERS have been tested in labs in the UK since 2012.

Despite the low number of confirmed cases we see here, it’s crucial that we can identify a true case of MERS when it presents and act to prevent further infections from occurring. As well as the importance of protecting public health, failure to control the infection can have a huge impact on a country’s economy.

The MERS outbreak in South Korea in 2015 is estimated to have cost the economy $10billion and led to a temporary reduction in the country’s GDP.

In August 2018, PHE confirmed a case of MERS-CoV in Leeds, in an individual who had recently flown to the UK from the Middle East. It was the first case in the UK since 2013.

As told by the experts

Mike Gent is the Deputy Director for Health Protection for Yorkshire and the Humber Centre, leading on all areas of health protection including communicable diseases, radiation, chemical and environmental threats.

Gavin Dabrera is a Consultant in Public Health Medicine at PHE’s National Infection Service, working on preparedness for Middle East Respiratory Syndrome and other respiratory infections including Avian Influenza.

Roberto Vivancos is a Consultant Medical Epidemiologist with over 12-years of experience in the field of health protection and has led the management and control of numerous outbreaks of infection and the public health response in a number of chemical incidents.

We caught up with them to take a behind-the-scenes look at the plans that kicked in across the country to protect the health of the wider public.

What is MERS and why is it so concerning?

MERS is a rare but often severe respiratory virus. It can start with a fever and cough, which can develop into pneumonia and breathing difficulties. Sadly, around 40% of people who get the infection die of complications. Camels harbour the MERS-CoV virus and many, but not all, cases in the Middle East are associated with close contact with infected camels or camel products (such as raw camel’s milk).

While the causative virus isn’t as contagious as other viruses, such as influenza and measles, it does pose serious consequences, particularly in hospital settings, where the virus can spread quickly between vulnerable people if appropriate infection control measures are not in place.

How do you detect cases of disease like MERS?

MERS is considered to be a high consequence infectious disease (HCID) in the UK. An HCID is defined as a serious infectious disease that has the ability to spread in the community and within healthcare settings, has a high case fatality rate, is difficult to recognise and detect rapidly and lacks effective, specific treatments.

These features mean that coordination at a national level is required to ensure an effective and consistent response and as such, any clinicians that suspect a case of MERS must notify their local PHE health protection team.

In this case, the initial call came from the Emergency Department at Leeds Teaching Hospitals NHS Trust. Healthcare staff at the hospital promptly suspected MERS because of the person’s symptoms and travel history and immediately informed the Yorkshire and Humber Health Protection Team.

The clinical team quickly isolated the individual away from other patients and ensured staff wore appropriate levels of personal protective equipment to protect themselves and other patients. This quick action played a major role in limiting the risk of exposure and spread of the disease.

Once the diagnosis was suspected a throat swab was taken for testing and sent to one of PHE’s specialist regional laboratories. Scientists were able to confirm that the sample was positive for MERS-CoV within 24 hours.

What came next?

The first priority was to convene a national incident team to bring together experts from all the partner agencies involved. These included the relevant NHS Trusts and the Department of Health and Social Care. The benefit of this approach is pooling national expertise and agree the necessary actions to both treat the patient and protect wider public health.

A national incident was declared, led by our national team of respiratory experts in close collaboration with the local Health Protection Teams. As MERS is an uncommon, high-consequence infection, the national team provides specialist advice, and the local teams have the expertise and knowledge to respond to emergencies on the ground and liaise with healthcare stakeholders.

The patient was transferred to the Airborne HCID Treatment Centre at the Royal Liverpool Hospital, one of four national centres commissioned by NHS England in 2018 to treat cases of airborne HCIDs such as MERS, avian influenza and pneumonic plague.

The HCID treatment centres have the facilities to implement the robust infection control measures required for caring for individuals with MERS, as well as trained, specialist staff who provide expert care for these rare conditions.

Besides helping to coordinate appropriate care for patients, the primary role for the incident team is to agree control measures to prevent further cases of the disease occurring. In this incident, contact tracing played a huge part in the incident response.

This involves identifying anyone who may have come into contact with the case whilst they were infectious, alerting them to the symptoms of the disease and letting them know what to do, should they develop any symptoms. It was also important to keep global agencies such as the World Health Organization informed.

What did contact tracing involve?                

Where contact tracing is involved, no stone can be left unturned and we’re constantly aware that the clock is ticking. It’s crucial that the process is timely, detailed and thorough, and this means closely examining the movements of the person in the days they were infectious.

A missed close contact could mean the disease is spread elsewhere in the country – or even internationally. Over the course of the investigation, over 70 people who could have been potentially exposed were contacted.

There were three key groups of contacts that our teams across the country had to trace:

  • The individual’s family
  • Passengers on the plane who were in very close proximity to the individual (as air filter systems protect other travellers)
  • Healthcare workers who had been in contact with the patient (including before MERS was suspected)

We monitored those who came into contact with the patient while they were travelling from the Middle East or while in Leeds and, for 14 days after their last point of contact with the patient. 14 days is the longest amount of time it would take for someone to become sick after being exposed to the virus.

We asked these people to look out for relevant symptoms, such as fever, cough and difficulty breathing, and to contact their local Health Protection Team if symptoms occurred. Appropriate medical help and assessment could then be provided quickly if necessary.

Those who were in sustained, close contact with the individual before MERS was suspected and the necessary, specific infection control measures were put in place, such as healthcare workers at Leeds Teaching Hospitals NHS Trust and the individual’s family, were at an increased risk. Therefore,  we asked them to stay at home for 14 days while we actively monitored their health.

We are very grateful to all of the healthcare staff involved in this incident – not just for the care they provided, but for their patience with the monitoring process. Their cooperation with this ensured that we could contain the risk of transmission as much as possible.

How complex was the flight contact tracing?

Plans for contact tracing plane passengers were in place from previous MERS cases, but it is still a large undertaking. To establish whether there had been any onward transmission of MERS-CoV during the flight from the Middle East to Manchester, passengers who were sat in the vicinity of the individual were contacted by the PHE North West Health Protection Team.

Many of the passengers were dispersed throughout the UK, and PHE’s Health Protection Teams were enlisted from up and down the country, to ensure the passengers received the relevant information and advice.

Were we prepared for this happening?

While we’ve only seen 5 cases of MERS confirmed in the UK to date, we have well established processes to implement in the event of a confirmed diagnosis. Our processes are based on learnings from other countries, such as Saudi Arabia, who have seen 1983 cases since 2012.

Our team carries out surveillance of MERS cases across the globe, in order to help with planning and preparations in the UK. This includes carrying out awareness raising with the public and with healthcare professionals each year around the time of the Hajj – the annual pilgrimage to Mecca – where there is a spike in travel to and from the Middle East.

This coordinated response involved over 100 people working across Public Health England, including roles in contact tracing, infection control advice and laboratory testing, as well as many staff across the NHS. By working alongside the HCID, we not only helped to ensure that the individual received the best possible care, but also that there was no onward transmission of the disease.

Four weeks after their diagnosis, the individual had recovered from their infection and was free to leave hospital and join their family in the Middle East. While the risk of transmission of MERS-CoV to UK residents in the UK remains very low, it is important that we remain prepared for future imported cases and for other high consequence infectious diseases that need to be managed in a similar way.

Read more from our Disease Detectives series

Responding to the public health challenge of the Rohingya crisis 

Using supermarket loyalty cards to trace an E Coli outbreak

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