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Dear everyone

This week is Mental Health Awareness Week and the focus this year is on stress, which most of us have experienced or been affected by in one way or another. For some, it comes in bouts but for others, it can be a constant burden that can escalate to mental health problems including anxiety, depression, and in serious cases, self-harm and suicide. Suicide remains a tragic reality for too many people in the UK, with one person dying by suicide every 90 minutes. The concerning part is that almost two thirds of these people are not in contact with mental health services, and it is of the utmost importance that we address this.

This week, PHE, the Department for Health and Social Care and NHS England have confirmed funding for the eight sustainability and transformation partnerships that are worst affected by suicide to develop prevention schemes. This is a £25 million, three year programme and is part of the national commitment to reduce suicides in England by 10% by 2021. This funding will help ensure that people are aware of the high quality confidential help that is available in their locality, and for more people to get the tailored care they need as early as possible. We need to do everything we can to offer help to those in great distress and this is a big step towards that.

On Tuesday, PHE published three dental updates including data on the levels of tooth decay in 5-year-old children across England, which showed that levels are continuing to steadily decline. Figures showed that 23.3% of 5-year-olds in England had decayed, missing or filled teeth in 2017, down from 25% in 2015. However, this is still almost a quarter of all 5-year-olds in the country and clear inequalities in oral health remain. In addition for the first time PHE reported on local authority area variations in oral health, focusing on the 30 local areas with the poorest oral health. To reduce these inequalities, local authorities should consider interventions including provision of free toothbrushes and paste, community fluoride varnish schemes and water fluoridation. PHE’s return on investment tool can help guide local authorities on which interventions are most appropriate for their population. Nationally, we are tackling the root problem of tooth decay which is excess consumption of sugary food and drinks, with our sugar reduction programme and our report of the first year results will be published soon.

We have been closely monitoring the outbreak of Ebola in the Democratic Republic of Congo (DRC) and we  are actively deploying the UK Public Health Rapid Support Team (UK-PHRST), a partnership between PHE and the London School of Hygiene and Tropical Medicine, to support the DRC Government in helping to contain and prevent this spreading further. The West African Ebola epidemic that began in 2013 highlighted the shortcomings of the global response to major outbreaks and public health emergencies and the UK-PHRST was established by the UK Government to be on the ground anywhere in the world within 48 hours of being tasked by Ministers. Read about a previous PHE deployment during the 2013-16 Ebola outbreak here.

And finally, I would like to thank Detective Superintendent Nick Walton from West Midlands Police and Robin Brierley, Chair of the West Midlands Anti-Slavery Network, for their inspirational work in tackling health inequalities in some of the most vulnerable groups, including victims of modern slavery, child sexual exploitation, asylum seekers and refugees. They have demonstrated exceptional collaborative efforts across the health and care system including our PHE West Midlands Centre, and the Faculty of Public Health has recognised this by awarding them both with honorary membership of the Faculty for being highly visible leaders in public health. Congratulations to both of them and thank you to our colleagues in the West Midlands Centre.

Friday messages from 2012-2017 are available on GOV.UK

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This is the second in a series of three blogs exploring each stage of the sexual health commissioning cycle. It will focus on the first two stages of the cycle: analysing and planning.

It is essential to spend time on the first stages of the cycle, as it allows you to understand the needs of the population and effectively plan to meet them.

There is a danger that health needs assessments make generic, strategic suggestions to ‘strengthen’ or ‘improve’. However, without ‘SMART’ measures, we will never know whether we have achieved what we set out to do.  Using these stages to determine the tangible things that need to change, and how we plan to make this change, is crucial to success.

Stage 1: Analysing and understanding population needs

In the UK, we have a wealth of data on sexual health service attendance and activity, epidemiology of STIs, HIV and contraceptive use, and an understanding of the population’s lifestyles and attitudes towards sexual health.  The Sexual and Reproductive Health Profile includes a guide to local and national data, and there is  guidance on how to undertake a sexual health needs assessment. PHE Centre colleagues, including sexual health facilitators, field epidemiologists, and knowledge and information colleagues, can assist in accessing and interpreting these data. However, there are some important principles to be aware of.

Activity and diagnoses do not equal need

Determining ‘need’ in relation to sexual health is complicated, as the level of service delivery will inevitably influence STI diagnosis rates and contraception take-up.  For example, increases in service level usually leading to increases in STI diagnosis rates which could be misinterpreted as a higher level of need.

Nonetheless, we all recognise that identifying more infections and treating them to prevent onward infection is good for public health.  Using activity and diagnosis rates alone as measures of need can be inaccurate and misleading, and there is a need to review both testing rates and the proportion testing positive to better understand whether there continues to be unmet needs.

Whilst the public health outcome measures are a good starting point to assess the effectiveness of local services, it is important to be aware that some measures are impacted by access to services and others are not.  For example, chlamydia detection rates will be influenced by service access, but teenage conception figures are  a combination of actual numbers of births and abortions.

With limited resources, it is important to focus on populations in greatest need. Looking solely at activity or diagnosis rates does not tell us about unmet need in the community; not least because it may be that those at greatest risk of poor sexual health are not attending services.

So, how do we understand need?

It is important to start with a detailed understanding of the local population’s demographics, and consider this alongside what we know about sexual health needs of different sub-populations. The National Survey of Sexual Attitudes and Lifestyles (NATSAL) provides data on the characteristics and needs amongst different population groups, including the links between deprivation and sexual health.

Using existing service data

Existing service data provide an insight into the current situation, what may need improving, and where to devote resources.

Comparing the demographic breakdown of service users to the local population will show who is, and is not, accessing local services. We can also look at which groups tend to access which service settings, from specialist services, to GPs, pharmacies and online. This will highlight how people choose to access services.

Some areas have included in their needs assessment a consideration of how people would like to access and interact with services. This can lead to exploration of innovative approaches that ensure services are accessible to a range of populations.

Stage 2: Planning local services and interventions

With increasingly scarce resources, we need to think innovatively about how best to meet population needs. Planning local services and interventions should always start with the patient pathway, with the aim of ensuring people experience integrated, responsive services. It is essential to work with fellow commissioners to map interdependencies and plan to mitigate any risks as early as possible in the process.

Working with both frontline practitioners and the community is crucial at this stage, as it will ensure that the services and interventions you are planning can be effectively and efficiently delivered, are what the population need, and are delivered in a way that meets their needs.

The national specialist sexual health service specification template is an excellent place to start, as this was developed in consultation with commissioner and provider representatives, including the professional bodies. It describes the services any population might expect to have access to and their national standards, and can be amended to reflect local needs.

PHE is often asked ‘What level of  service should I commission?’  This should be informed by the local health needs assessment, and there are a number of ways of understanding whether there is sufficient resource to meet the need, such as waiting times and turnaround times for results and treatment.

However, not achieving the necessary standards doesn’t always mean more resource is required. It may instead be about doing things differently, such as a redesign of processes within a service.

As we all know, sexual health services must be free, confidential and open access, regardless of area of residence. Location of services is crucial to ensuring good access. Talking to the local population will inform how and where people want to access services, and highlight unforeseen factors that influence access.

Maintaining good access to sexual health services with limited resources may require looking at different models and delivery mechanisms. For example, models of delivery that involve greater self-management or appropriate use of online services, making sure that those who need to see a healthcare practitioner face to face are able to, and that specialist services have capacity to see those at higher risk as frequently as clinical guidance recommends. These new models of delivery are starting to emerge across the country, but it is still early days.

Speaking to service providers and clinicians

In thinking about changing models of delivery, it is essential to be clear on the purpose of developing a new approach. It is also important that service design is informed by the current evidence base on effectiveness of interventions.

Speaking to service providers and clinicians can be beneficial as they will have invaluable understanding of, and insight into, how to effectively and safely alter the care pathway.

Whatever model of delivery and configuration of services is settled on, it is essential to articulate this clearly – both to those organisations who you will be asking to deliver the interventions, but equally importantly, to the public so they are clear on what to expect.

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Dr Lauren Cowley, formerly a PhD student at PHE and now a postdoctoral researcher at the Harvard T.H. Chan School of Public Health, tells us about her time working on the front line in West Africa tackling the Ebola outbreak in Sierra Leone and Guinea. All photos were taken by Lauren in the locations she worked.

The news of the recent Ebola outbreak in the Democratic Republic of Congo brings back memories of the  2013-16 Ebola crisis in West Africa which was a shock to the whole world.

It highlighted the importance of investigating and responding to disease outbreaks before they become a global threat. The countries affected, namely Sierra Leone, Guinea and Liberia, suffered major loss of life with a very high case fatality rate, as well as damage to their economy and infrastructure.

During this time, I was in the same position as most – following the news and feeling helpless as I watched the tragedy unfold and worsen over time. Although I was a PhD Student at PHE at the time, the idea of being involved in tackling this outbreak did not cross my mind, let alone travelling to the affected countries to work in the field.

Soon this became a reality for me in November 2014, when I applied to be deployed to Sierra Leone. Suddenly, I was no longer just a spectator. I went from working on national diarrheal outbreaks in the UK, to working on the front line in Africa, responding to one of the biggest, most deadly, and most well-known disease outbreaks in modern day history.

My first deployment: Sierra Leone

In November 2014, I went to Sierra Leone for six weeks to work in the diagnostic laboratory, running blood, swab and urine samples to detect the presence of Ebola.

The symptoms of Ebola, especially at first, can be very generic as they include fever, diarrhoea and vomiting. As such, illness could often be mistakenly ascribed to other pathogens that are less life threatening. This can have major implications if the pathogen causing illness is, in fact, the Ebola virus.

This is why the diagnostic test was so important – it was the only way to categorically identify or exclude cases of Ebola. Diagnostic work is the first step that must be carried out to start and shape the process of case response and clinical management of the patient.

My second deployment: Guinea

My second deployment was to Guinea in June 2015 and was in collaboration with the European Mobile Laboratory and University of Birmingham to provide real-time sequencing of new Ebola cases.

This opportunity came about through social media. I had been in touch with contacts at the University of Birmingham (Nick Loman and Josh Quick) via Twitter, discussing my experiences during my first deployment. At the time, I was in the final year of my PhD, and was somewhat missing the excitement and sense of fulfilment from my first trip to West Africa. Therefore, when Miles Carroll, PHE’s Head of Research, contacted me to see if I would be interested in a real-time Ebola sequencing project, it was an immediate ‘yes’, and I was in Guinea within three weeks of receiving the first email about it.

Using Whole Genome Sequencing in the field

As the Ebola virus is spread through human-to-human transmission, Whole Genome Sequencing was an essential technique to use in surveillance and case response. The highly accurate technique allows the route of transmission to be traced throughout a country and beyond, characterises the infectious agent, and provides a high-resolution view of its evolution.

To find out more about the process of Whole Genome Sequencing, read our explainer blog here.

During the Ebola outbreak, a lack of local sequencing capacity and the difficulties of transporting samples to sequencing facilities far away meant that genomic surveillance was inconsistent. However, regular genomic surveillance is important, as the sequence data can be used to guide control measures, if it is generated quickly enough.

Before being deployed, the team I worked with devised a genomic surveillance system using a novel nanopore DNA sequencing instrument, which weighed less than 100 grams. A nanopore is a protein with a very small hole that allows DNA strands to be driven through it using an electric current. As each nucleotide passes through the pore, the current is affected and this change allows the sequence to be recorded.

All together, our system consisted of three of these instruments, four laptops, a thermocycler, a heat block, pipettes, and sufficient reagents and consumables. In April 2015, the team packed this into regular airline luggage and transported it to Guinea, where they started using the system for real-time genomic surveillance of the Ebola outbreak.

Components of the genomic surveillance system set up in the laboratory in Guinea

Once I joined the team in Guinea, I used the surveillance system to carry out real-time sequencing and analysis of all new Ebola cases for five weeks. We worked in partnership with local Guinean diagnostic laboratories to provide the sequencing results to the National Coordination in Guinea, which was provided by the World Health Organisation (WHO). We were able to generate results less than 24 hours after receiving a positive sample, and the sequencing process itself took as little as 15 to 60 minutes.

Setting up the laboratory

Our laboratory was a small, hut-like shipping container, which we set up at an Ebola treatment centre in what seemed like the middle of nowhere. Despite being in a treatment centre, we were not in danger of contracting the virus within our hut as we were in a ‘neutral zone of containment’, separate to where the patients were staying and the other side of all containment measures. This meant that the virus was contained and prevented, by several measures, from escaping into this zone.

It was completely safe to be handling the samples we were working with, meaning we did not have to wear personal protective equipment. We were only working with the raw extracted genetic material of the virus, and not all the viral machinery that is contained within the viral cell. The virus requires more than just its raw genetic material to effectively infect a human cell.

The shipping container laboratory in Guinea Advanced technologies in resource-limited conditions

Working in resource-limited conditions and setting up our own laboratory meant that we faced inevitable obstacles along the way.

We encountered multiple logistical issues during our time in Guinea, with perhaps the most challenging being the lack of reliable, continuous power. This meant that we had to depend on unreliable electrical generators and uninterruptable power supplies that provide emergency battery power.

Further to this, internet connectivity was consistently poor, which particularly disrupted our ability to send data back to colleagues at the University of Birmingham for analysis. I often couldn’t access the sequencing software, and therefore had to send raw read files. Our Birmingham partners would then send back information about the relatedness of new cases to others already sequenced, and I worked closely with epidemiologists at the WHO to establish transmission chains.

Considering these challenges, I am proud of the work I did within this team, as I think we demonstrated the possibility of conducting such an advanced and impactful process in such resource-limited environments.

How I felt: The differences between the two trips

It goes without saying that it is nerve-racking to be deployed to a country where there is an active, deadly disease outbreak, causing loss of life at a rapid rate. Normally, you would avoid a place like this at all costs, so on my first trip I was cautious and naturally worried.

I felt more comfortable on my second deployment and I was able to enjoy the work I was doing more. Being the fastest sequencing conducted during a major outbreak to date, it felt like I was involved in something novel and important, particularly as it was influencing the scope of future work and decisions.

Despite the excitement of my role, the reality of the situation was that there was death, pain and social disarray all around us. The memory of seeing two doctors dressed in full protective suits feeding a dying 8-year-old girl fresh coconut water, after she had requested it as her last wish, will never leave me.

Everything about Ebola and the reasons behind why we were there is tragic, however being a part of the global effort to fight it was very rewarding and has taught me invaluable life lessons.

This programme of work was awarded the PHE Research Innovation Award in 2016. A current PhD student at PHE has recently returned from Nigeria, where she was a part of a team that successfully applied the same technology Lauren worked on to the Lassa fever outbreak.

Read more from Disease Detectives - keeping track of new and emerging infectious diseases.

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Dear everyone

Our response to the announcement made about breast screening last week has continued at great pace, with every sensitivity and the dedication needed to ensure all those affected receive advice and appropriate follow-up. The helpline is continuing to provide advice with welcome support from Macmillan and Breast Cancer Care.  As of today more than 100,000 letters have been sent to those affected and we are on track to send further letters by the end of May to every affected woman registered with a GP. NHS Screening services will start providing catch up screening invitations from next week. I cannot sufficiently thank all those people within the NHS and across PHE who are working around the clock to put things right and through the external review we will be open and transparent as we fully understand what happened and why.

Following the local elections on Thursday last, I would like to warmly welcome all those, new and returning to their roles within local government. Local government are the front line of prevention and population health. At the upper tier they have a statutory duty to improve the health of the people and at district level they are responsible for providing services that promote health including housing, planning and environmental health. In other words, local government are a part of the health system, not as a stakeholder for the NHS, but as an inseparable partner. Last week was also the first anniversary of the Metro Mayoral elections. In a short period of time the new Mayoral Combined Authorities have changed the landscape of English governance. PHE has been delighted to work with these new bodies as they seek to spread growth and prosperity across the country. This week I met with Mayor James Palmer in Cambridgeshire and Peterborough and Mayor Andy Street in the West Midlands to discuss how we can further support their work on inclusive growth. Our work with these Mayors will be a big priority for us, as they develop local industrial strategies that connect health with wealth.

This week Minister for Public Health and Primary Care Steve Brine MP commissioned PHE to undertake a review of the evidence on minimum unit pricing, which will feed into the development of a new Government alcohol strategy. PHE is also supporting Government plans to improve the lives of children whose parents are dependent on alcohol by managing the £4.5M fund set up to help local authorities develop innovative and sustainable ways of improving alcohol treatment, reducing parental conflict and supporting young carers. You can find out more here.

Today Mayor of London Sadiq Khan has announced new proposals that would see junk food advertising banned from the entire Transport for London network. This ground breaking move is a bold step, and the largest of its kind in the world, in our nation's battle against childhood obesity. Actions such as these are so important to changing for the better our children's everyday experience and a signal to everyone that the tide can be turned.

And finally, Florence Nightingale was described as a social reformer, a statistician and the founder of modern nursing. Tomorrow to coincide with the anniversary of her birth it is International Nurses Day.  Nurses are experts, caregivers, advocates, researchers, innovators and so much more and the selfless job they do cannot be summed up by mere words. The PHE nursing team has published a blog describing some of the work the they have been doing to look after the public’s health locally, nationally and globally. Read it here.

With best wishes,

Friday messages from 2012-2017 are available on GOV.UK

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International Nurses’ Day is celebrated each year on the anniversary of Florence Nightingale’s birth.  Florence herself was described as a social reformer, a statistician and the founder of modern nursing - a blend of public health and nursing that led to huge improvement in outcomes.

This year, the theme for International Nurses’ Day (12th May) is ‘Nurses: a voice to lead – health is a human right.’  Whilst in the public health world we are well aware of the factors beyond health services and health care that impact on the right to health, we also know that universal health coverage and effective health care is a vital contribution to positive health outcomes.  As we approach International Nurses' Day it is timely to consider how the nursing profession can lead change locally, nationally and globally to improve health in individuals, families and communities.

This blog describes some of the work we have been doing at Public Health England to support nurses, and other health and care professionals, both in England and globally. Nurses are the biggest professional health care  group and our ambition at PHE has been to develop nursing practice at all levels and across all settings, encompassing  preventing avoidable  illness, protecting health and promoting wellbeing and resilience, as well as supporting nurses within PHE and across the health and care system to be leaders in this work.

All Our Health

All Our Health, PHE’s call to action for all health and care professionals to embed prevention and health improvement into their practice, has made great strides over the last year, reaching over 170,000 practitioners, adopted by 6 universities and trialled by 3 Trusts. This year we want to double this and reach a minimum of 200,000 practitioners, 12 universities and 6 Trusts. Each individual reached, or supporting organisation, can become a champion of the principles, helping those they care for make the best choices for their own health and wellbeing.

The resources created for All Our Health are designed to make it as easy as possible for a nurse or other practitioner to quickly build their knowledge on a topic they may not feel confident to make an intervention on. We also published some blogs to help health professionals develop their motivational conversation techniques or strengthen local lifestyle referral processes.

Leading Change, Adding Value

To encourage all nurses to take action as part of our commitment to the national nursing, midwifery and care staff framework, ‘Leading Change, Adding Value’, PHE recently made available a 3Ps toolkit (Prevent, Protect, Promote) setting out actions for nurses and nurse leaders on major challenges to health including:

  • obesity
  • antimicrobial resistance
  • cardiovascular disease
  • creating a healthy health workforce
Best start in life

Ensuring children have the best start in life has been a priority for PHE since the start of our organisation’s work.  Nurses and midwives are often the lead health care professional at the very start of life and can be a voice to lead on the rights of the child to the best start in life and to support families to reduce inequalities.

Nationally and internally we are leading a number of  programmes to ensure that nurses can make the biggest possible difference. Whether it's protecting health through immunisation, aiming to prevent future health problems by encouraging positive and protective behaviours, such as good oral health, nutrition and physical activity, or promoting resilience and wellbeing through vital early attachment and development in the under-fives, intervening early where there are problems.

WHO Collaborating Centre for Public Health Nursing and Midwifery

Our international programme is carried out through our World Health Organisation (WHO) Collaborating Centre, our relationships the International Council of Nurses and other partners and through the Global Nursing Now Campaign.

WHO Collaborating Centres exist to support  the WHO's programmes, undertaking research and ensuring evidence and advice of the highest standard is shared to help raise standards everywhere. Since the establishment of the WHO Collaboarating Centre for Public Health Nursing and Midwifery within PHE last year, we have been working hard to establish a comprehensive network of technical advisers and academic support from across England. With this depth of experience and knowledge we have a powerful resource to call upon, enabling us to providing technical advice to national and international organisations.

We have also produced a case study/practice example template and already received 15 case studies and 10 practice examples to be reviewed for hosting on the PHE library service. There is also a network of nursing WHO Collaborating Centres around Europe and the World and this year has seen us forge important links and relationships with them.

Wherever a nurse works, in whatever role, they have the power to protect and promote health, to blend public health knowledge and nursing skills and to provide care and the voice that helps us to achieve health as a human right for all.

Happy International Nurses’ Day!

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Previously, there has been limited research into the trends and patterns in treatment for patients when they are diagnosed with stage IV cancer, compared to those for early stage cancer. A cancer is in stage IV when it has spread far away from the origin into other organs of the body, meaning it is generally more difficult to treat and cure.

The National Cancer Registration and Analysis Service (NCRAS) is one of the best sources of cancer data in the world and now contains enough data for us to analyse trends in treatment for those with stage IV cancer.  This helps us to conduct research that enhances current knowledge and fills gaps, and could ultimately help us win the battle against cancer.

Our latest research

PHE and Cancer Research UK (CRUK) have published a paper in the British Journal of Cancer that investigated variation in chemotherapy and radiotherapy treatment for stage IV lung, oesophageal, pancreatic and stomach cancers.  The research provides us with new information on the type of treatment provided across the population at this stage of diagnosis.

From this, we have learnt that there are differences in the type of treatment that groups of patients receive.  By being aware of these variations, we can use this knowledge to help address the disparities, and ultimately improve patient outcomes.

Existing evidence has shown that elderly patients can be under-treated.  We had previously hypothesised that this could be driven by differences with age and the stage of cancer at diagnosis.

Elderly patients may be diagnosed with later stage cancer and are more likely to have other co-morbidities, they may be frailer, or more reluctant to experience the toxicity and side-effects of chemotherapy. Therefore, simply looking at the numbers of patients receiving treatment does not provide the complete picture.

We’ve made our analysis as strong as possible by considering the differences among patients, and we statistically adjusted for these factors.

When these factors were taken into account we found that elderly patients were still receiving treatment less often than younger patients. Similarly, patients with existing co-morbidities were less likely to receive treatment.

The complex issues at play

When deciding the treatment plan, age and comorbidity are important clinical factors and we have shown significant associations between these and radiotherapy and chemotherapy.

The association with deprivation is less strong than with age and comorbidity, but it is still significant.  We found that more deprived patients were consistently less likely to receive chemotherapy alone, or chemotherapy with radiotherapy, compared with less deprived patients.

It is a very complex issue, and we don’t truly know what is driving the differences in treatment, particularly for deprivation.  The main limitation of this work is that we can’t account for patient choice.

This is particularly important among patients with stage IV cancers as the diagnosis sadly tends to be terminal.  Because of this, patients may choose that they don’t want to experience the side effects of treatment, choosing quality over quantity of life, which may explain some of the variation that we see.

Other potential explanations

There are a number of other potential explanations. One possible reason could be the relationship between the patient and clinician, which may differ for different populations, and could therefore influence the treatment decision.

Another potential explanation may be the difference in perceived risk and benefits of treatment among different groups of the population, which may influence the patient’s treatment choice.  Further research is needed before we can say for certain what patient factors are influencing treatment patterns.

We also analysed the data by performance status, which is a measure of the general wellbeing of a patient. It measures the amount of normal daily activity the patient can continue to do from the time they are diagnosed with cancer.

This analysis showed that for patients who had better general health, there was less variation in treatment even if they were deprived or had co-morbidities.  Therefore, performance status may also help to explain some of the variation we see in our research.  As the data quality improves (it was only available for 52% of cancers in this study), we hope to be able to understand these further.

Looking to the future

This piece of research is vital in helping us to understand the potential drivers of the variations in treatment and will help us work towards reducing these moving forwards. We hope this paper will raise more questions and research within the cancer community and ultimately lead to improving outcomes for patients with stage IV cancer.

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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.

Conception rates for under 18s and under 16s fall to record lows

Both the under 18 and under 16 conception rates fell from 2015 to 2016. These both showed a continuing long term decline, to the lowest rates on record.

The under 18 conception rate has declined by 49% since 2009, to 18.8 per 1,000 females age 15-17 in 2016. The under 16 conception rate meanwhile has reduced by 59% since 2009, from 7.3 per 1,000 females aged 13-15 to 3.0 per 1,000.

A new indicator, including trend data, of the diabetes diagnosis rate estimates 77% of cases are diagnosed

For this update, we’ve added a new indicator, measuring the proportion of the estimated population with diabetes who have received a formal diagnosis.

This indicator has replaced the original diabetes indicator in the PHOF, which just measured the level of recorded diabetes. The original indicator was found to be difficult to interpret since not all cases of diabetes are recorded.

The new indicator is easier to interpret. A value close to 100% indicates a small gap between the formally diagnosed prevalence and the estimated prevalence. It indicates that the system is good at proactively identifying people with diabetes.

Also added to the tool are historic data for this indicator. The estimated diagnosis rate was 77.1% in 2017, an increase from 76.2% in the previous year, although this increase was not statistically significant.

Over 19 years difference in healthy life expectancy between the most deprived and least deprived

Inequality in healthy life expectancy in the PHOF is estimated using a summary measure called the slope index of inequality (SII). The higher the value of the SII, the greater the inequality within an area.

The inequality in healthy life expectancy between the most deprived and least deprived areas in England was 19.1 years for both males and females in 2014-16.

For males, this was an increase from 18.9 years in 2013-15, whereas for females it was a decrease, from 19.6 years. However, neither change was statistically significant.

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.

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Dear everyone

For obvious reasons there is only one matter to cover this week - the failure over many years to invite a large number of women to their final breast cancer screen.

For most of us early detection and treatment are critical for positive outcomes from cancer. We should all be proud that the NHS offers a world-leading breast cancer screening programme with good evidence of benefit over harm, certainly for 50-70 year olds. The AgeX trial is to determine whether that remains the case for older women.

Cancer screening programmes offer hope and reassurance to people, prolonging and preserving life and this means so much. So when things go wrong, we understand how devastating this can be.

You will all be aware of the announcement made about the NHS breast screening programme by Secretary of State for Health and Social Care Jeremy Hunt on Wednesday. PHE identified data anomalies which led us to a thorough investigation into the IT invitation system. From this it was found that a number of invitations to attend a final breast screening test for women aged between 68 and 71 had not been sent out as they should have been.

We know this will be extremely distressing for many. On behalf of PHE and NHS breast screening services, our apology is heartfelt and unreserved. PHE and the NHS are working round-the-clock to offer advice and ensure that every person affected will be offered appropriate follow-up. Arrangements have been put in place to ensure those affected can access services appropriately, and that those already in the system will not have their care disrupted.

The comprehensive review commissioned by the Secretary of State will allow PHE, NHS England, the Department of Health and Social Care and local breast screening services to properly understand what happened and determine what must be done to ensure no recurrence arises in the future.

At the forefront of our thoughts are those people affected and their families and they will remain the focus of our attention and efforts to ensure that all organisations involved carry out the next steps with the efficiency and sensitivity needed.

With best wishes,

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Genomic information is important for a range of areas in public health protection, from tracking infectious disease outbreaks, to identifying inherited disorders, and characterising mutations that underpin the progression of cancers.

Genome: An organism’s complete set of DNA, including all of its genes
Microorgansim/microbe: A microscropic living organism including bacteria, fungi and viruses
Isolate: A culture of microorganisms isolated for study

What are the applications of WGS for microorganisms?

One of the most important roles for genome sequencing is when it is applied to microorganisms, also referred to as pathogens. In this realm it has multiple applications, with the most notable being infectious disease management at both individual and population level.

DNA profiling has traditionally been used to determine the likelihood that genetic material has come from a particular individual or group. In addition to this, WGS also enables:

  • rapid identification and characterisation of microorganisms, providing information on the relatedness of strains, where they have come from and how they have evolved
  • identification of key virulence factors – specific chacteristics that aid the microorganism in causing infection
  • antibiotic resistance profiling – compared with traditional culture methods, WGS can determine which antibiotics microorganisms are resistant to much more quickly
  • detection, mapping and analysis of outbreaks

As a highly discriminatory and accurate technique that is equivalent to forensic-level typing, WGS provides the most robust microbioogical evidence. Scientists at PHE focus on sequencing the genomes of microorgansims, however it is important to note that the technology also has important applications for humans, such as:

  • developing personalised medicine and tailoring medical treatment so that it fits the specific characteristics of the patient
  • characterising cancer tumours to identify the most effective treatment for halting tumour growth with minimal toxicity to the patient
  • diagnosing rare diseases and identifying the causative genetic variant that is responsible for them, leading to further studies of gene targets to characterise disease mechanisms
Surveilling infection outbreaks

WGS has become an integral part of the surveillance of infection disease, including foodborne illness outbreaks.

The genome sequences of bacteria from infected individuals are compared  to identify clusters of related organisms that have highly similar genomes. Once a cluster is detected, the next step involves investigating whether they originated from the same source through finding out about the recent history of infected individuals. The full process is outlined further down.

Analysing microorganisms’ susceptibility to antibiotics

WGS can be used to characterise specific features encoded in a  microorganism’s genome.  This can be used to predict the bacterium’s resistance to antibiotics and can also shed light on specific features that aid the microorganism in causing infection.

As a result, treatment regimens can be tailored accordingly, such as treatments for tuberculosis (TB) when the causative pathogen may be resistant to the first line drugs. Tailoring the patient’s treatment will significantly improve their chances of a full recovery and help reduce the spread of drug resistant bacteria.

The different methodologies

WGS is the umbrella term for DNA sequencing, but there are different methodologies that can be used to sequence the genome, including:

  • Short read sequencing, or sequencing by synthesis (SBS)
  • Single molecule real time sequencing (SMRT)

Short read sequencing is commonly provided by Illumina. It is the predominantly used method responsible for generating more than 90% of the world’s sequencing data, and currently the most effective method for looking at individual differences between genomes. It provides short read data by fragmenting the DNA into small sections.

On the contrary, SMRT does not fragment the DNA prior to sequencing, thus providing very long read data. Although this method is currently less accurate than SBS, some models such as the Oxford Nanopore are small and highly portable, therefore permitting sequencing  in the field.

WGS in the field

PHE scientists took a Nanopore sequencer to Sierra Leone, Liberia and Guinea during the Ebola outbreak to sequence new Ebola cases. Sequencing in the field is faster than shipping specimens back to laboratory in another country, and this is ideal because timely interventions have more impact on public health.

The multidisciplinary process of WGS at PHE

Here at PHE, we have a multidisciplinary team of scientists who carry out the multiple steps of WGS:

Once we have sequenced a new set of  bacterial genomes we compare them to a database of all the previously sequenced bacterial genomes from routine pathogen surveillance at PHE.  As no two bacteria have the same genome by chance, if there is a match the patients from which the bacteria were isolated from may share a common exposure. For a foodborne pathogen like Salmonella it may mean they have eaten the same food or attended the same restaurant.

Epidemiologists use surveillance questionnaires to gather information from the people that the isolates came from, to build up a picture of anything they have in common. This is particularly important for identifying the source responsible for complex, nationally distributed outbreaks, such as a product sold in a major supermarket. With the globalisation of the food chain, this forensic-level analysis is crucial.

The future of WGS

WGS will continue to become technically and economically feasible as time goes on, and will therefore have an increasingly positive impact on the practice of medicine and public health. Pathogen sequencing, in particular, will have an progressively important role in health protection practice as it reduces and manages disease outbreaks more efficiently and effectively allowing better public health control and prevention actions to be put into place.

PHE is already pioneering the development and early use of WGS for the investigation and control of multiple infectious diseases. WGS will continue to be a priority area of focus for PHE in the future, and we will work to be at the forefront of this technology.

Identifying different strains of disease-related microorganisms

At the end of 2016, we began using WGS to identify different strains of TB, the first time that this has been used to diagnose and manage a disease at this scale anywhere in the world.

Where previously it could take up to a month to confirm a diagnosis of TB and the treatment choices, and to detect spread between cases, this can now be done in just over a week at PHE’s Birmingham laboratory. This slows the spread of the disease and boosts the fight against antimicrobial resistance.

WGS is being used to identify strains of TB that are drug resistant, which need to be treated differently to a non-resistant infection. In less than 24 hours, we can find out if a specific infection is likely to be resistant to a particular drug and recommend a different course of treatment.

Sequencing in the field and by the bedside

In future, the application of portable sequencing for infectious diseases and conditions may allow us to test and treat patients at the bedside, rather than needing to wait days and sometimes weeks for results and sending samples between locations.

The implementation of WGS will contribute to achieving the government’s ambition of sequencing 100,000 genomes, a project which will ultimately allow us to better understand major diseases and how to treat them.

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In this blog we look at specialised commissioning and explain how it works and the role PHE plays.  What are specialised services? 

Specialised services support people with a range of unusual and complex conditions. They often involve chemotherapy treatments provided to patients with  cancers, genetic disorders such as cystic fibrosis , complex medical or surgical conditions such as kidney failure or complex mental health problems for example children and young people needing inpatient psychiatric care. Often they involve delivering cutting-edge care, such as proton beam therapy for brain tumours and are a catalyst for innovation and supporting pioneering clinical practice in the NHS.

How are specialised services commissioned?

Most NHS care is commissioned by local Clinical Commissioning Groups (CCGs). Specialised services are one of five areas which NHS England is centrally responsible for directly commissioning, alongside primary care, though this is usually delegated locally, some public health services, offender healthcare and some services for the armed forces.

Figure is taken from the National Audit Office, full information can be found on page 21

How are PHE involved?

PHE provides expert advice to NHS England’s specialised service commissioning function which now has a budget of almost £17 billion – and has increased more rapidly than other parts of the NHS due to increasing demand for new drugs, interventions and other advances in medical technology.

How is PHE's advice provided?

We have staff members working in NHS offices nationally and in centres around the country, delivering PHE advice. Staff from across PHE, not necessarily working in NHS offices, also offer expert advice on many different areas, from health protection to health data.

The advice that PHE provides to specialised commissioning services aims to help the NHS get the best value from its resources in relation to the Five Year Forward View, which focuses on health outcomes, quality and efficiency.

What is the main aim of our contribution?

As we all know, funding is finite and should be spent on interventions which will have the greatest benefit on the health of the population, at the lowest cost.

Example of the benefits we see could be through cure rates or reduced levels of disability in childhood cancers, or through reduced levels of harm from new treatments.

The key question we are constantly asking when looking at specialised commissioning is always ‘how can we generate the most benefits with the most sensible funding?’

Proposals for new innovative treatments also often come through the route of specialised commissioning. This leads to small studies of treatments being carried out in expert centres, but this doesn’t always lead to the best value being found. An example here is an implantable electrical device to manage drug resistant epileptic fits.

The expert advice given by PHE makes a significant contribution to this agenda and helps NHS England to respond systematically to challenges in the use of its resources. The most important contribution we can make is to ensure investments are only made where there is strong evidence that a service is of value to the NHS.

Our focus is on ensuring resources are allocated to where greatest benefits can be achieved, recognising that demand always outstrips resources available.

Examples of PHES contribution:

A particular contribution from PHE has been to provide “deep dive” reports on five of the top spend areas within specialised commissioning involving up to £1 billion (such as Neonatal Intensive Care (NICU), to identify how improvements elsewhere in a pathway could help to reduce demand.

In the case of NICU the most important change identified by this work was the importance that reducing maternal smoking could have on demand for these services (through reducing low birthweight and premature labour) which impacts on need for neonatal care.

Another report on renal dialysis highlighted the impact that improved control of blood pressure and diabetes could have on slowing the demand and need for treatment of renal failure.  The move to integrated care systems and pooling of budgets in local areas as envisaged by the current integrated care system could potentially allow work such as the “deep dive” reports to inform service transformation and the allocation of resources.

Examples of other contributions

Advice supporting the development of a systematic and structured decision support process (including consistent approach to evidence used to make decisions)

Advice to Individual Funding Requests – these are high risk decisions frequently subject to public scrutiny through judicial review relating to funding for services which are not routinely commissioned and for which often evidence is limited or lacking.

Disinvestment from existing services – Current considerations are ongoing about how to construct and implement a fair and feasible process to disinvestment in specialised services.

Honing down the right questions to support evidence based policy making – what exactly is the evidence question PICOS

Data analysis – PHE is the holder of significant population healthcare information e.g. cancer chemotherapy use and in general by using our information source we can help advise on service configurations

You can learn more about specialised services and watch an explainer animation via NHS England.

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