1. Derby GP Specialty Training Programme 24 th March 2010 Mike Sandys Acting Director of Public Health

2. Areas to be covered:  Infectious Diseases  Role of Public Health Specialist  Epidemics and Pandemics  NHS Screening Programmes

3. Public Health is  “The science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society”

4. History of Public Health Specialist  Chadwick - 1843  Duncan of Liverpool  Snow – 1854  Pre-74: Medical Officer for Health (going back to the days of Duncan)  1972: Faculty of Public Health set up

5. Routes to accreditation Faculty Training Scheme/MPH/Part A/ Part B Generalist defined register Specialist defined register

6. 10 competencies  Surveillance and assessment of the population’s health and well being  Promoting and protecting the population’s health and wellbeing  Developing quality and risk management within an evaluative culture  Collaborative working for health and well being

7. 10 competencies  Developing health programmes and services and reducing inequalities  Policy and strategy implementation  Working with, and for, communities to improve health and well being  Strategic leadership for health and well being  Research and development to improve health and well being  Ethically managing self and others

8. Role of Public Health Specialist  Promote  Prevent  Protect

9. Promote  Health Improvement  Needs Assessment  Partnership Working

10. Determinants of Health

11. Prevent  IFR  Service Development  Clinical Effectiveness  Screening Programmes

12. Protect  Vaccination and Immunisation  Emergency Planning  Health Protection

13. Infectious Disease: an historical perspective  Bubonic plague. Killed one third of the population (1.3million deaths) between 1346 and 1350 Britain.  Late 1830’s – small pox epidemic killed 42,000 in Britain  Major sanitary reforms brought the traditional scourges of population health (diphtheria, cholera, TB) under control

14. Burden of infectious disease  40% of people consult their GP each year because of an infection  Infections account for 70,000 deaths a year  Infections put 150,000 into hospital each year

15. Notification of Infectious Diseases  The statutory requirement for the notification of certain infectious diseases came into being towards the end of the 19th century  Diseases such as cholera, diphtheria, smallpox, and typhoid had to be reported in London from 1891, and in the rest of England and Wales from 1899  Originally the head of the family or landlord had the responsibility of reporting the disease to the local 'Proper Officer' but now this is restricted to the attending medical practitioner, either in the patient's home or at a surgery or hospital.

16. Notification of Infectious Diseases  The prime purpose of the notifications system is speed in detecting possible outbreaks and epidemics. Accuracy of diagnosis is secondary, and since 1968 clinical suspicion of a notifiable infection is all that is required. If a diagnosis later proves incorrect it can always be changed or cancelled  Statstics were collected nationally at the Registrar General's Office, who already collected data on births, marriages and deaths. The Office was later known as the Office of Population Censuses and Surveys (OPCS) and now as the Office for National Statistics (ONS), but in 1997 the responsibility for administering the NOIDs system transferred to the Communicable Disease Surveillance Centre (CDSC), now the Health Protection Agency (HPA) Centre for Infections (CfI).

17. Reporting Procedures  The Proper Officers are required every week to inform the HPA Centre for Infections (CfI) details of each case of each disease that has been notified.  The Information Management & Technology Department within the CfI has responsibility for collating these weekly returns and publishing analyses of local and national trends.  The attending Registered Medical Practitioner, should fill out an official Formal Notification certificate (from a pad supplied locally) immediately on diagnosis of a suspected notifiable disease and return it to where the pad was obtained (this could be the Local Authority (LA), Primary Care Trust (PCT) or Health Protection Unit (HPU)).

18. List of Notifiable Diseases Diseases notifiable (to Local Authority Proper Officers) under the Public Health (Infectious Diseases) Regulations 1988: Acute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery Food poisoning Leptospirosis Malaria Measles Meningitis Meningococcal septicaemia (without meningitis) Mumps Ophthalmia neonatorum Paratyphoid fever Plague Rabies Relapsing fever Rubella Scarlet fever Smallpox Tetanus Tuberculosis Typhoid fever Typhus fever Viral haemorrhagic fever Viral hepatitis Hepatitis A Hepatitis B Hepatitis C other Whooping cough Yellow fever

19. Local contacts: Local HPA office: Health Protection Agency East Midlands North Team City Hospital Hucknall Road Nottingham NG5 1PB Tel: 0844 225 4524 Fax: 0115 9693523

20. Health Protection Agency  Created in 2002/03 to ‘act as a source of national expertise and to provide key services at national regional and local level  At a local level this maximised the use of scarce CCDC resources at a time when PCTs (303 of the in those days) were coming into being  Polonium, Swine flu

21. What the HPA/On call does:  Investigation  Contact Tracing  Epidemiology/Mapping

22. What to refer  Environmental Health Hazards (individual)  NOIDS/Epidemics  Environmental Health Hazards (neighbourhood)

23. Public Health Law  Public Health (Control of diseases) Act 1984  Statutory responsibilities lie with the local authority not the health service  Section 35 – go to a JP to order a person to be medically examined if a person is suffering from a notifiable disease, in the interests of that person, or in the public interest to do so  Section 36 – same but groups of people  Section 37 – removal for treatment.  Although normally talk about section 47/9 of the Mental Health Act 1983

24. Public Health Law  Public Health (Infectious Diseases) Regulations 1988 – provide immunisation services but not for mandatory immunisation  Public Health (Aircraft) Regulations 1979  Not updated since Human Rights Act passed, being re-written but progress slow.

25. Further information and resources regarding Notifiable Diseases can be found at: www.hpa.org.uk Communicable Disease Handbook – Hawker & Begg

26. Epidemics and Pandemics  Pandemics in 1918/19, 1957, 1968, 2009

27. Swine Flu 2009  Early days  Wave 1  NPFS  Wave 2

28. Swine Flu 2009 – Early Days  Initial cases rung through to HPA for swabbing, tamiflu and contact tracing (F3000)  Sets a new requirement on the HPA to ‘contain’ an emerging disease  Issues around contact tracing capacity, call centre capacity

29. Swine Flu 2009 – Phase 1  Pre National Pandemic Flu Service (NPFS)  Local system in place (DHU/Adastra)  PSD paperwork faxed through to DHU/PCT  Worked for us, not sure if worked for GPs

30. Swine Flu 2009 – Phase 2  National Pandemic Flu Service (NPFS) set up late July  GPs left dealing with young children  Took pressure off primary care but risks around inappropriate prescribing, missing other important illnesses

31. Swine Flu 2009  Gold, Silver, Bronze levels of command Gold (Strategic Level) The level of management which comprises senior strategic decision makers from the key organisations involved. It directs the overall multi- agency response, authorises expenditure, and ensures long-term resourcing and expertise. Gold Command is in overall command and has responsibility and accountability (with regard to the individual agencies) for the incident or event. Silver (Tactical Level) The level of management comprising senior representatives from the key organisations involved. Silver Command manages the implementation of the policy established at the strategic level. It determines priorities in obtaining and allocating resources and plans and co-ordinates the reporting point for operational activities. Bronze (Operational Level)The management of the immedicat ‘hands on’ work undertaken at the site(s) of the emergency or other affected areas. Bronze (Tactical) Commanders will be deployed to take charge of specific operational tasks or areas of responsibility within their service.

32. Health in Derby

33. Joint Strategic Needs Assessment  Expected increase in ages 75+ and 85+ population  1 in 5 children are living in poverty  One quarter of people are estimated to smoke  Ranked 34th worse nationally of 354 LAs for alcohol-harm related hospital admissions  NHS Derby City has the highest elective crude admission rate to Trauma & Orthopaedic speciality in the EMSHA region  Approximate 10 year inequalities gap in male and female life expectancy

34. On the plus side ….  Derby is least deprived of the three major cities in the East Midlands region  In 2008, had a lower overall unemployment rate compared to East Midlands and National averages  Estimated 27% of people eating their 5-a-day, higher than seen in the East Midlands and England  1 in 5 people achieving 30+ minutes moderate intensity exercise or active recreation 3 times per week

35. On the plus side ….  One of the best uptake rates of the HPV vaccine (to protect young girls from cervical cancer) in the UK  95% of children were immunised from Diphtheria, Tetanus and Polio by their 5th birthday  76% of the population were vaccinated against seasonal flu during 2008/09

36. Cancer Screening Programmes  Breast  Cervical  Bowel  Prostate  Chlamydia

37. Breast Screening Programme  The NHS Breast Screening Programme provides free breast screening every three years for all women in the UK aged 50 and over. Around one- and-a-half million women are screened in the UK each year. Because the programme is a rolling one which invites women from GP practices in turn, not every woman will receive an invitation as soon as she is 50. But she will receive her first invitation before her 53rd birthday.  There are around 80 breast screening units across the UK, each inviting a defined population of eligible women (aged 50 to 70) through their GP practices. Women are invited to a specialised screening unit, which can be hospital based, mobile, or permanently based in another convenient location such as a shopping centre.

38. Breast Screening Programme  Women under 50 are not currently offered routine screening. This is because film mammograms are not as effective in pre-menopausal women. as the density of the breast tissue makes it more difficult to detect problems, and also because the incidence of breast cancer is lower in this age group. The average age of the menopause in the UK is 50.  The programme in the UK has screened more than 19 million women and has detected around 117,000 cancers.  The World Health Organisation's International Agency for Research on Cancer (IARC) concluded that mammography screening for breast cancer reduces mortality. The IARC working group, comprising 24 experts from 11 countries, evaluated all the available evidence on breast screening and determined that there is a 35 per cent reduction in mortality from breast cancer among screened women aged 50 - 69 years old. This means that out of every 500 women screened, one life will be saved.

39. Cervical Screening  Cervical screening is not a test for cancer. It is a method of preventing cancer by detecting and treating early abnormalities which, if left untreated, could lead to cancer in a woman's cervix (the neck of the womb). The first stage in cervical screening is taking a sample using Liquid based Cytology (LBC).  All women between the ages of 25 and 64 are eligible for a free cervical screening test every three to five years. In the light of evidence published in 2003 the NHS Cervical Screening Programme now offers screening at different intervals depending on age.

40. Cervical Screening  The new intervals are: Age group (years)Frequency of screening 25First invitation 25 – 493 yearly 50 – 64 5 yearly 65+Only screen those who have not been screened since age 50 or have had recent abnormal tests  The NHS call and recall system invites women who are registered with a GP. It also keeps track of any follow-up investigation, and, if all is well, recalls the woman for screening in three or five years time. It is therefore important that all women ensure their GP has their correct name and address details and inform them if these change.

41. Cervical Screening  Women who have not had a recent test may be offered one when they attend their GP or family planning clinic on another matter. Women should receive their first invitation for routine screening at 25.  This is because changes in the young cervix are normal. If they were thought to be abnormal this could lead to unnecessary treatment which could have consequences for women's childbearing. Any abnormal changes can be easily picked up and treated from the age of 25. Rarely, younger women experience symptoms such as unexpected bleeding or bleeding after intercourse. In this case they should see their GP for advice.  In June 2009 the Advisory Committee on Cervical Screening reviewed the policy of starting screening at age 25 and agreed unanimously there should be no change in the current policy.

42. Bowel Cancer Screening  Third most common cancer in the UK, and the second leading cause of cancer deaths, with over 16,000 people dying from it each year.  Regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer by 16 per cent.  Bowel cancer screening aims to detect bowel cancer at an early stage (in people with no symptoms), when treatment is more likely to be effective.  Programme hubs operate a national call and recall system to send out faecal occult blood (FOB) test kits, analyse samples and despatch results. Each hub is responsible for coordinating the programme in their area and works with up to 20 local screening centres.

43. Bowel Cancer Screening  The NHS Bowel Cancer Screening Programme offers screening every two years to all men and women aged 60 to 69. People over 70 can request a screening kit by calling a free phone helpline when the programme reaches their area.  GPs are not directly involved in the delivery of the NHS Bowel Cancer Screening Programme but they will be notified when invitations for bowel cancer screening are being sent out in their area. They will also receive a copy of the results letters sent to their patients.  Men and women eligible for screening will receive an invitation letter explaining the programme and an information leaflet. About a week later, an FOB test kit will be sent out along with step-by-step instructions for completing the test at home and sending the samples to the hub laboratory.

44. Prostate Cancer  All screening programmes cause some harm. This could include false alarms, inducing anxiety, and the treatment of early disease which would not otherwise have become a problem.  When considering population screening programmes the benefits and harms must be carefully assessed, and the benefits should always outweigh the harms.  Until there is clear evidence to show that a national screening programme will bring more benefit than harm, the NHS will not be inviting men who have no symptoms for prostate cancer screening.

45. Principals of Screening Programme  In 1968, Wilson and Jungner of the World Health Organisation developed ten principles which should govern a national screening programme. These are:  The condition is an important health problem  Its natural history is well understood  It is recognisable at an early stage  Treatment is better at an early stage  A suitable test exists  An acceptable test exists  Adequate facilities exist to cope with abnormalities detected  Screening is done at repeated intervals when the onset is insidious  The chance of harm is less than the chance of benefit  The cost is balanced against benefit

46. Chlamydia  Type here

47. Resources and further reading: www.cancerscreening.nhs.uk ‘Screening – Evidence & Practice’ Angela Rattle & Muir Gray