CMO Annual Report 2004 by The Good Copy Company

ANNUAL REPORT OF THE CHIEF MEDICAL OFFICER 2004

TOBACCO AND BORDERS DEATH MADE CHEAPER

OTHER TOPICS The impact of chronic obstructive pulmonary disease Realigning food procurement in the public sector Gastroschisis: a growing concern Compliance with patient safety alerts in the NHS Spotlighting local health and initiatives

On the state of public health

Progress report

1 Tobacco and borders: death made cheaper

2 It takes your breath away: the impact of chronic obstructive pulmonary disease

3 A fresh look: realigning food procurement in the public sector

4 Gastroschisis: a growing concern

5 Learning how to learn: compliance with patient safety alerts in the NHS

Spotlighting local health and initiatives

References

ON THE STATE OF PUBLIC HEALTH

CMO ANNUAL REPORT 2004

On the state of public health

Since taking up the post of Chief Medical Officer, in the autumn of 1998, I have used my Annual Report to draw attention to the major challenges in health and healthcare facing our country, particularly those where I have felt that current action is not sufficient to fully address them. I have sought also to identify smaller scale problems: for example, where an adverse trend in the occurrence of a disease is unexplained and is giving rise to concern. This very much captures the spirit of the earliest Chief Medical Officer Annual Reports – dating back to the 19th century – which fearlessly identified problems and actively championed the need for action. This – my fourth Annual Report – comes at the end of a particularly busy year. Progress has been made on two key public health threats which I highlighted in my 2002 Annual Report: second-hand smoke and obesity. Since 2002, there has been widespread public discussion, ongoing media coverage and extensive consultation on these issues, as well as expert analysis and review. This culminated in the production of a new public health White Paper. Choosing Health set out a wide range of proposed actions to improve tobacco control and curb obesity, as well as actions to address other major public health problems of today. Choosing Health puts population health and health inequalities squarely at the centre of the Government’s health policy agenda. I have pushed very hard on the need for action to create smoke-free public places and workplaces. The proposals set out in Choosing Health represent real progress but, in my view, do not go far enough. I want this country to be alongside the best in the world in public health in protecting their populations and future generations from the scourge of tobacco. The consultation on the proposed legislation to create smoke-free restaurants, food-led pubs/bars and workplaces offers the opportunity to strengthen the approach originally planned, should the weight of opinion be behind this simpler and more rigorous option.

This year has also witnessed important developments in the area of infectious disease control. There has been great concern about the frequent occurrence of methicillin resistant staphylococcus aureus (MRSA) infections in NHS hospitals. MRSA is one of the so-called ‘superbugs’, a common bacterium that has become resistant to successful treatment with commonly used antibiotics. The rate of MRSA infection is higher in this country than many other European countries. A range of actions to improve hygiene and infection control is already being undertaken, including substantial investment in cleanliness, the recruitment of new matrons and the establishment of infection and prevention control teams in each NHS Trust hospital. Figures published in June 2005 indicate that these measures are beginning to work: the total number of MRSA blood infections in England dropped by 6.1% in 2004/05 compared with 2003/04. This programme, which is being led by the Chief Nursing Officer, is vital for the safety of patients in NHS hospitals and it is essential that the current momentum is maintained. Tuberculosis (TB) is another infectious disease that is re-emerging and work is under way to implement an action plan which I published in October 2004. Recommendations include: quicker and more effective screening of high-risk groups, DNA fingerprinting to track the spread of the disease in communities and better co-ordination of clinical care. The rate of TB has been rising in England over the last 10 years, particularly in London and other major cities. There are now 13 cases per 100,000 people, and every year around 350 people die from the disease. The long-term goal is not only to reduce TB infections but to all but eliminate the disease from this country. Major planning has also been undertaken to combat the impact of an influenza pandemic. The World Health Organization (WHO) and other international organisations have recently warned that a flu pandemic is both ‘inevitable’ and ‘imminent’. Such

warnings have been largely fuelled by the persistence of a highly virulent strain of bird (avian) flu in Asia. While these warnings aim to ensure countries are prepared for such an event, they have also caused public concern over the nature of the threat and our ability to respond to it. The consequences of an influenza pandemic would be serious, with the numbers of people falling ill and dying being far higher than those associated with ‘ordinary’ winter flu outbreaks. My team has worked tirelessly to bring together the best ideas and expertise, both globally and in this country, to anticipate and respond effectively to an influenza pandemic should one occur. A national plan and other supporting documents were published in March 2005, which collectively provide a proper understanding of the nature of the threat, its likely impact on the United Kingdom and the action necessary to mitigate pandemic influenza when it comes to this country. From August 2005, the two-year Modernising Medical Careers Foundation Programme begins. All junior doctors starting their pre-registration house officer year in August will benefit from this innovative development in postgraduate medical training. Under the new curriculum, junior doctors will need to demonstrate their competence in a number of areas not previously addressed in medical training, including: communication and consultation skills, patient safety, clinical governance and team-working. Trainee doctors will need to show they have learned a range of skills, including the undertaking and use of research, time management and use of evidence and data. The development of the Foundation Programme curriculum for the first two years of postgraduate medical education will help ensure that trainees’ acute clinical and professional skills are secure and robust. It is a curriculum focused on quality of care and ensures that, at the end of their two years’ training, doctors are both confident and competent and so patients will benefit. The issue of how best to quality assure

medical practice came to the fore in the Shipman Inquiry’s fifth report produced by Dame Janet Smith. I have been asked by the Secretary of State for Health to consider the implications of this report and recommend further measures to strengthen procedures aimed at ensuring the safety of patients in situations where a doctor’s performance or conduct poses a risk to patient safety or the effective functioning of services. The proposals will also seek to ensure the operation of an effective system of revalidation (the five-yearly review of a doctor’s licence to practise) and will examine the role, structure and functions of the General Medical Council. At present, this work is at the consultation stage and I have appointed an expert advisory panel to assist me with this task. The United Kingdom has the Presidency of the European Union (EU) in 2005. For the health element of the Presidency, two areas have been chosen that are of great importance in improving health outcomes in all EU countries: tackling health inequalities and improving patient safety. There will be over 20 meetings and summits scheduled between July and December 2005. With the enlargement of the European Union there will not be another Presidency for the United Kingdom until 2017, when it will be shared with two other member states. Our Presidency in 2005 therefore represents a vital opportunity for the United Kingdom to make a significant contribution to the EU agenda, and from the health perspective we want to play our full part. I have selected five new topics for attention in this year’s Report. Firstly, I have reviewed the extent to which the movement of cigarettes across international borders, either through smuggling or duty-free imports, is seriously undermining the traditional effectiveness of price increases to reduce tobacco consumption. It is estimated that up to 25% of all cigarettes and hand-rolled tobacco in this country is not being taxed, leading to concerns about long-term health implications and the need for greater

CMO ANNUAL REPORT 2004

On the state of public health

HM Revenue and Customs co-operation between EU member states to tackle this problem. Secondly, I have emphasised the need for action on chronic obstructive pulmonary airways disease (COPD). COPD is an umbrella term for a number of chronic lung disorders including chronic bronchitis, emphysema, chronic obstructive airway disease and chronic airway flow limitation. It causes 30,000 deaths and 3 million illnesses each year. Much of the burden and suffering from this disease could be reduced by further reducing population levels of cigarette smoking. However, the infrastructure and specialist facilities for treating this condition vary greatly around the country. I call for a greater focus on, and consistent application of, standards of care for COPD. Thirdly, I have drawn attention to the major possibilities of improving health by influencing the food purchasing and procurement policies of public bodies. The public sector, including hospitals, schools, prisons and the armed forces, currently spends between £1.8 billion and £2 billion each year on food. This represents 7% of the UK’s entire food and catering expenditure. With current public attention focused on school meals and the Government announcing an extra £200 million investment in 2005, we have a unique opportunity to turn this situation around and use the purchasing capacity of the public sector to provide healthy, balanced meals which, in the long-term, will help improve the nation’s health. Fourthly, I have highlighted a worrying increase in the incidence of a serious congenital anomaly called gastroschisis, which is present at birth and appears to be increasing in prevalence in babies, particularly those born to young mothers. I have called for more research to investigate the cause of the increase, and for congenital anomaly registers – a vital tool in combating life-threatening and handicapping conditions at birth – to be put on a firmer footing. Finally, I have expressed concern about the relatively slow compliance of local NHS organisations with patient safety alerts that

are issued by the Department of Health and its agencies. Awareness of the problem of patient safety has grown greatly over the last few years and, as illustrated in last year’s Annual Report, it is a worldwide problem. Ours is one of the leading countries working to improve patient safety. It is important, however, that when serious risks to patients are identified, action is taken rapidly to reduce those risks. This action needs to be taken not just on an incident-by-incident basis but as part of a long-term strategy to be implemented throughout the NHS. It is clear that the culture of some NHS organisations needs to change. It is not enough to be aware of the problem of improving patient safety nor to report adverse events when they occur. When alerts are issued, there needs to be commitment from the very top of the organisation to initiate immediate action to address the identified risk, to ensure that all staff are properly and consistently informed, and to establish new procedures and processes of care to sustain the reduction of the risk in question. In compiling this report, I am grateful for the help of a number of colleagues in the Department of Health. I am also indebted to a number of colleagues outside Whitehall in particular Elizabeth Draper, Angela Towers and Sean O’Kelly. I should like to make clear, however, that the conclusions and opinions expressed in the Report are my own. I hope you enjoy reading this Report. Every one of us has a role to play in addressing the issues raised. The progress, described in this Report, on issues highlighted in my previous Annual Reports, shows that public discussion as well as individual and collective action does make a difference in improving health and the quality of healthcare in this country.

Sir Liam Donaldson Chief Medical Officer

CMO ANNUAL REPORT 2004

Progress check

This section aims to report on progress made on some of the key issues covered in previous Annual Reports. It also identifies areas where follow through has been slower and less effective than hoped for or where the problem remains intractable.

Patient safety and clinical standards

Smoking In my 2002 Annual Report, I called for legislation to introduce smoke-free public places and workplaces. This recommendation catapulted the risks of passive smoking, the rights of smokers and non-smokers, and the vulnerability of children to the head of the public debate on health. A high-profile television advertising campaign followed, showing children being subjected to involuntary smoking. This had a big impact on public opinion. Surveys of public attitudes showed strong support for the idea of legislation to create smoke-free workplaces and public places. This issue was followed up in my 2003 Annual Report, with an economic analysis confirming that creating smoke-free workplaces does not adversely affect business and that overall gains to the economy would be significant. In November 2004, the Government published a public health White Paper which detailed a commitment to create entirely smoke-free workplaces, restaurants and pubs/bars that sell food by 2008. So-called â&#x20AC;&#x2DC;drink-ledâ&#x20AC;&#x2122; pubs and bars will be free to choose but they will require a licence to permit smoking on their premises. These measures represent significant progress in tackling the problem of passive smoking but I would like the Government to go even further, as Ireland and other European countries (such as Sweden, Italy and Malta), as well as many states and cities in the United States of America, have done and introduce completely smoke-free enclosed public places and workplaces. It is also disappointing that NHS premises and government buildings are not all yet smoke free, and I hope that there will be significant progress in these two areas over the course of the next year in order to meet the commitment, outlined in the public health White Paper, to have these areas smoke free by 2006.

The longstanding and intractable problem of dealing effectively with poor medical performance was raised in my 2002 Annual Report. During the late 1980s and 1990s, the NHS was dogged by controversy and concern about cases of doctors whose competence, conduct or attitude posed a risk to, or actually harmed, patients. In many such situations, after investigation, it became apparent that the doctors had been a source of concern to their colleagues or managers for some time but no one had felt able to address the problem. Much has improved in this difficult area. As a result of the work of the National Clinical Assessment Authority, together with a stronger culture of clinical governance at local level, good clinical leadership and new Department of Health policies, doctors with problems are now being identified much earlier. Rigorous assessments are taking place and, where possible, these doctors are being rehabilitated or retrained. The number of long-term suspensions has been halved. This is a subject about which I am particularly passionate and it is very rewarding to know that almost all my previous recommendations in this area have been implemented. Saying that, more could still be done to identify and help doctors who are ill, including those with drug or alcohol problems. My 2003 Annual Report called for improvements to blood transfusion services, building on existing work to ensure the ongoing safety of this precious resource. While clinical governance reviews have not yet taken place in every hospital, a toolkit is currently being prepared to introduce better guidelines for blood transfusion and it is expected that this will be completed in October 2005. An agreement has now been reached with all professional bodies that postgraduate education and training programmes for doctors, nurses and other relevant health professionals will place more emphasis on safe, appropriate use of blood and blood products. Hospitals are improving their information technology systems to facilitate better blood stock management,

ensure traceability and routinely monitor blood usage by clinical specialty. Pilot sites have been set up and the Serious Hazards of Transfusion (SHOT) programme will be examining these for 12 months, to evaluate the effect of blood tracking systems on the amount of blood used and the number of transfusion incidents reported. I first published guidance in 2001 to improve the safety of intrathecal therapy for patients receiving chemotherapy and raised it as an ongoing issue in my 2002 Report. This guidance was much stricter than anything previously published: for example, establishing and maintaining a register of named personnel who are certified as trained and competent to carry out intrathecal chemotherapy tasks. Progress has now been made with manufacturers to design and test connectors that will help prevent the wrong drug being injected and, should this prove possible, it will act as an additional safeguard. However, in a later chapter in this Annual Report, I have used the intrathecal injection safety guidance as a case study and demonstrated that its implementation by cancer services was slow and inconsistent.

West Nile virus In my 2002 Annual Report, I highlighted the threat posed by a new and emerging infectious disease problem called West Nile virus. In 1999, the virus broke free of its traditional geographic borders (the so-called ‘Old World’, for example, Africa, India and Egypt) and was discovered in New York City, where 62 people were infected and seven people died. Birds carry the disease and mosquitoes are usually responsible for transmitting the virus to people and other mammals such as horses. Many infected people show no symptoms. When disease does occur, it usually takes the form of a flu-like illness with fever. A small proportion of cases (less than 1%) develop meningoencephalitis, meningitis, encephalitis, or other manifestations of serious illness which may be fatal. The disease has now spread to many parts of North America. In the 2002 Report, I called for a range of

action to prepare for the possibility – albeit small – that the disease might strike in this country and I am pleased to say that a comprehensive contingency plan has now been published. Surveillance of mosquito populations is being carried out. No evidence has yet been found of West Nile virus in either people or horses in the United Kingdom. Enhanced surveillance for patients has not identified any cases, however, the Department for Environment, Food and Rural Affairs has strengthened its surveillance of dead birds and found antibodies against the virus present in birds in Great Britain, suggesting past or present infection with West Nile virus. The departments are liaising to continue monitoring the disease profile and pattern. The Department of Health has also funded a three-year study by the Health Protection Agency to review cases of meningo encephalitis in people in three neurological centres as a further check for evidence of the emergence of West Nile virus infection in this country. The only area remaining to be addressed is the commissioning of valid and reliable tests to distinguish between active and inactive (or post-infection) West Nile virus, particularly in the bird population.

E.coli O157 In my 2001 Annual Report, I drew attention to the risks from a particular type of gastroenteritis. E.coli O157 had caused a very serious outbreak in Scotland in 1996 in which 17, mainly elderly, people died from a food-borne route of infection. My Report urged that the recommendations of the subsequent Pennington Inquiry should be fully implemented. At the time of the 2001 Report, the number of general outbreaks of Verocytoxin-producing E.coli O157 in England had risen from five in 1992 to 10 in 2000; the number of laboratory-confirmed isolates in 2000 was 850, the third highest annual total on record at the time. The most recently available data shows that in 2004 the number was 680, which represents a small increase from figures of 656 in 2003. One death was reported.

CMO ANNUAL REPORT 2004

Progress check

Obesity

Epilepsy

In my 2002 Annual Report, I referred to obesity as a health ‘time bomb’ for this country and urged action across government departments. In response, the public health White Paper, Choosing Health, committed to ensuring that each primary care trust will have a specialist obesity service, providing access to a dietician and nutritional advice as well as support on changing behaviour. The National Institute for Health and Clinical Excellence (NICE) will prepare definitive guidance on the prevention, identification, management and treatment of obesity by 2007. It was also recommended that the food industry should adopt the ‘precautionary principle’ when marketing food to children. Since the publication of the White Paper, all advertising, promotion and sponsorship of unhealthy foods and drinks to children is being restricted voluntarily and this is a situation that needs to be monitored very closely.

In my 2001 Annual Report, I focused on the poor and fragmented services for people with epilepsy and drew attention to the need to reduce sudden deaths from this serious condition as well as to raise public and professional awareness of a disease which I described as being ‘in the shadows’. Since my report was published a great deal of action has taken place, including work by the Modernisation Agency to pilot a redesign of services for people with epilepsy; a long-term conditions National Service Framework, which set new standards for the treatment and care of people with long-term neurological conditions; national guidance from the National Institute for Health and Clinical Excellence (NICE) for the treatment of epilepsy; and incentives within the new general practitioner contract for effective management of epilepsy in primary care. It will be important to ensure that this wideranging action improves outcomes of care for people with epilepsy and the experience of patients of NHS services.

High blood pressure In the past, high blood pressure (hypertension) has been inadequately controlled in the population. Until relatively recently, only around half of the people receiving treatment for it were effectively treated, leaving millions vulnerable to heart attack or stroke. However, there are now fewer people in the general population with untreated hypertension. Since my 2001 Annual Report was published, the proportion of men with uncontrolled high blood pressure (treated but not controlled plus untreated) has now fallen further, from 38% to 32%. For women, it has fallen from 30% to 26%. I also called for a reduction of average salt intake in adults from its then level of 9.5g per day to 6g per day. My view was supported by the Scientific Advisory Committee on Nutrition and the Food Standards Agency. The Agency set a target for reduction of average population salt intake by a third by 2010. Action has been taken to raise consumer awareness and to work with the food and catering industry to reduce the salt content of processed and catered food. Some positive action has been taken but more progress needs to be made.

Academic medicine The record of academic medicine in this country is one of excellence, both in research and teaching. My 2003 Annual Report made a number of recommendations to preserve this precious national resource. Currently, the United Kingdom is ranked second best only to the United States in the quality of our research. Over the past year, whilst clinical academic numbers in medicine have remained stable at the most senior levels, numbers of clinical lecturers have declined a further 17% in 2004 and, overall, clinical academic numbers in 2004 are at 88% of the numbers of clinical academics in 2000. Several key specialties are particularly affected, including anaesthesia (47% decrease since 2003 to current figure of 10 clinical academics), pathology (64% decrease since 2003 to current figure of 12 clinical academics) and radiology (50% decrease since 2003 to current figure of three clinical academics).

This worrying downward trend reinforces the need for continued urgent attention in this area, if this country is to retain its clinical research and leadership role. My Report called for the development of an extensive and creative partnership to ensure that clinical academic medicine is attractive to medical students and junior doctors. Much progress has been made through the work of the Academic Careers Sub-committee of the Modernising Medical Careers Programme and the UK Clinical Research Collaboration. This work, led by Dr Mark Walport and published in March 2005, maps the way forward. It has specifically, for example, redefined the role of the clinical lectureship as highlighted in my 2003 Report. The new schemes are being piloted with research and development funds but longer-term funding will need to come from the education and training levies. I welcome the work of the Sub-committee. It represents a firm step forward in protecting the future of academic medicine. As part of my 2003 Annual Report, I also called for the next Research Assessment Exercise, which is a national exercise to provide ratings of the quality of research conducted in universities to inform allocation of public funds, to use judgement criteria that would ensure excellence is practice based. Draft criteria have now been agreed and are ready for consultation. The next Research Assessment Exercise is due to take place in 2008. Care will still need to be taken to ensure that selection panels use these criteria effectively. Finally, I welcome the work of the International Campaign to Revitalise Academic Medicine (ICRAM), a worldwide initiative with over 40 partners, which has recently published a report detailing five scenarios for how academic medicine could look by 2025. Such work is crucial to stimulate debate and maintain global attention â&#x20AC;&#x201C; and funding â&#x20AC;&#x201C; on the future of academic medicine.

HIV My 2003 Annual Report called for a strengthening of national and local HIV prevention work, particularly in those communities most at risk of HIV, through targeted campaigns highlighting the advantages of HIV testing and a widening of the testing to all attendees of genitourinary medicine (GUM) clinics on their first screening for sexually transmitted infections. I am pleased to say that there has been progress in this area with several campaigns under way, including one for gay men focusing on condom awareness and post-exposure prophylaxis and another targeting African communities living in England entitled Beyond Condoms, which emphasises the benefits of HIV testing. Furthermore, a pilot project setting up community-based HIV and syphilis test sites in strategic areas of England is currently being evaluated. It is hoped that these sites will encourage gay men to access test services who have until now not attended genitourinary medicine clinics. Finally, the White Paper, Choosing Health, dedicated ÂŁ130 million to capital and revenue for genitourinary medicine facilities in England and these monies will be used to make HIV and sexually transmitted infection testing available to a higher proportion of vulnerable people. There have been small improvements in some indicators of access to genitorurinary medicine clinics and to HIV testing. However, some patients with HIV infection still do not realise they have been at risk of acquiring the infection and do not present for testing until late in the course of disease progression. This is especially true for black African heterosexuals (including those from sub-Saharan Africa) and this situation remains very worrying: there has been no improvement in achieving earlier diagnosis in this high-risk group. In summary, the work carried out in relation to the issues that I have focused on in the last few years is very encouraging but sustained commitment is essential. Furthermore, progress in all areas needs to be rigorously monitored, audited and reported on publicly.

CMO ANNUAL REPORT 2004

Progress check

Major issues still outstanding from previous Annual Reports Topic

Annual Report year

Issue

Stroke

2001

Just under half the people who have suffered a stroke still not treated in a dedicated stroke unit.

Alcohol

2001

Effective action to reduce binge-drinking and the harmful effects of alcohol still not in place; further increases in liver cirrhosis deaths have occurred.

E.coli 0157

2001

Small increase in laboratory-confirmed isolates from infections with verocytotoxinproducing E.coli O157 between 2003 (656) and 2004 (678) but a substantial fall since 2000 (850); strengthened control measures needed.

Health inequalities

2001

Many longstanding health inequalities are persisting, although strong action plans now in place.

Doctors with performance problems

2002

Action to identify and help doctors with illness or drug and alcohol problems still relatively weak.

Smoking

2002

NHS and government premises not yet entirely smoke-free.

Smoking

2002 & 2003

Commitment not yet made to extend smoke-free environments to all public places and workplaces.

Academic medicine

2003

Further decline (17%) in numbers of clinical lecturers and serious further falls since last year in some academic specialties, e.g. pathology (64%) and radiology (50%); strong plans in place, rigorous implementation needed.

HIV

2003

Small improvements to HIV testing and diagnosis rates, as well as waiting times for emergency treatment at genitourinary clinics, have been seen but overall rates are still too low and waiting times too long. It is essential that improvements to the service are consistent across all sub-populations.

TOBACCO AND BORDERS: DEATH MADE CHEAPER

CMO ANNUAL REPORT 2004

1 Tobacco and borders: death made cheaper

The reduction of overall smoking prevalence, and particularly prevalence among disadvantaged groups, is being undermined by the widespread availability of cheap tobacco.

A quarter of all cigarettes and threequarters of all hand-rolling tobacco consumed in this country have avoided UK taxes and duties.

KEY POINTS

More cigarettes are traded than any other single product, some trillion cigarettes passing international borders each year.

Price increases have been a highly successful way of helping people become non-smokers: UK budget changes to tobacco duty have saved lives and prevented much serious illness.

From the second half of the 1990s, the impact of tax increases in the UK on tobacco consumption was greatly reduced when cigarettes began to be smuggled into this country on a massive scale.

Smuggling hits Government revenue but also undermines health and health inequalities goals by making cheap cigarettes available to the poorest people.

Other undesirable effects include: law and order and social problems, which arise from the concentration of criminals in certain areas – particularly Dover and East Kent; and the creation of building blocks for organised crime networks and financial support for other serious criminal activity.

The number of smokers choosing to smoke hand-rolled tobacco, instead of cigarettes, as a way to save money is increasing: 57% of hand-rolled tobacco is smuggled and a further 14% is purchased outside the UK.

10 The illicit street price of the most popular UK brands of cigarettes is typically £2.50 – the legal price for the same brand is around £4.89. 11 Tobacco is a uniquely dangerous product: tough action to control its traffic across borders will save lives.

Legal cross-border shopping from low tobacco duty countries accounts for 8–10% of the cigarette market.

A quarter of all cigarettes and threequarters of all hand-rolling tobacco consumed in this country have avoided UK taxes and duties.

CIGARETTES

HAND-ROLLING TOBACCO

DUTY PAID split into premium price, midprice, low and ultra-low price

DUTY PAID

SMUGGLED counterfeit or tobacco industry

CROSS-BORDER SHOPPED

SMUGGLED

CROSS-BORDER SHOPPED

Figure 1 Increase in the use of cheap cigarettes (United Kingdom) 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 0

100

120

Every year, 106,000 people in the UK die from smoking-related disease. Smoking is a major cause of cancer and cardiovascular disease. The difference in smoking rates across socio-economic groups explains around half the health inequalities across these groups. Smoking is the main cause of preventable death and ill health. The devastation caused by smoking is the reason why it is a public health priority. The cost of tobacco is inextricably linked to whether a person is likely to start, stop or relapse his or her smoking habit: the higher the price, the lower the demand. The recent rise in low-price cigarettes, smuggled tobacco and legally bought low-price tobacco products from nearby countries presents a real public health challenge. This section of the Annual Report looks at how the price of tobacco in the UK, a crucial public health lever in reducing smoking rates, has been changed by the balance of this market over recent years. As a result, the impact of UK tax and duty rates in affecting consumption for many smokers has been significantly blunted.

The tobacco market in the UK is made up of six broad sectors: cigarettes (duty paid – split into premium price, mid-price, low and ultra-low price) cigarettes (smuggled – counterfeit or tobacco industry) cigarettes (cross-border shopped) hand-rolling tobacco (duty paid) hand-rolling tobacco (smuggled) hand-rolling tobacco (cross-border shopped).

The United Kingdom context In the United Kingdom, smuggling of tobacco used to be confined to low-level cross-Channel smuggling of hand-rolling tobacco. More recently, smuggling of cigarettes has dramatically increased. Around 75% of smuggled cigarettes are transported by freight and ‘roll-on roll-off’ lorries, with the remainder largely smuggled in vehicles through the Channel ferry ports and the Channel Tunnel (the so-called ‘white-van’ trade). Figure 1 shows how the market has changed over the past 30 years.

1 Tobacco and borders: death made cheaper

CMO ANNUAL REPORT 2004

Figure 2 Disparity in retail price of cigarettes across Europe

Norway €7.87

Iceland €5.71

Ireland €6.25

ourin

oun rie

Source: Morgan Stanley Equity Research. Exchange rate 31 March 2004: £1= 0.67 euro (source: x-rates.com)

Estonia €1.61 Latvia €0.95

Denmark €4.03

Portugal €2.35

UK €6.74

Spain €2.50

Italy €3.50

Croatia €2.22

Belarus €0.92

Ukraine €0.55

Romania €0.80

Serbia €1.17 Albania €1.49 Greece €2.70

Footnote: Data represents price in Euros for a pack of 20 international brand cigarettes (31 March 2004 Exchange rate: £1-0.67 euro source: x-rates.com)

Russia €0.54

Lithuania €1.27

Netherlands Poland €3.90 €1.34 Germany Belgium €3.79 €3.85 Lux. Czech Rep. €3.00 €1.76 Slovakia France €1.70 Austria €5.00 Switzerland €3.40 Hungary €3.14 €2.14 Slovenia €2.07

European Union ei

Finland €4.00 Sweden €4.26

Bulgaria €2.15 Turkey €1.88

Malta €3.48

The key changes for non-duty-paid tobacco – cigarettes and ‘roll your own’ – have come in the last six years. This has halted the UK Government’s push on price as a key measure to reduce consumption. In response, the Government created the Tackling Tobacco Smuggling strategy (March 2000), which focuses on tackling the trade in smuggled cigarettes. While this has successfully reversed the increase in the numbers of cigarettes smuggled each year, these cigarettes still make up around 15% of the UK cigarette market. Moreover, these cigarettes are massively cheaper (about half the price) of the legal market and the strategy does not cover legal cross-border shopped cigarettes from low-duty countries (see Figure 2), which make up a further 8–10% of the cigarette market. Recently, the use of ‘roll your own’ or handrolling tobacco has dramatically increased as it is another way for smokers to avoid the impact of higher cigarette prices (see Figure 3). The current Tackling Tobacco Smuggling strategy does not focus on hand-rolling tobacco. For example, in 1998 a 50g pack of hand-

Cyprus €3.84

rolling tobacco cost £1.80 in Belgium but £7.80 in the UK, and an estimated 5,000 tonnes of hand-rolling tobacco were smuggled from Belgium to the UK in that year alone. Cheap cigarettes, either manufactured or hand-rolled, are also most likely to be consumed by poorer people, the people most affected by health inequalities.

Tobacco control – the problem of cheap tobacco The 10.5 billion cigarette sticks successfully smuggled into the UK market last year, and the further 6.5 billion sticks cross-border shopped, lost the UK Government £3.1 billion of revenue. Indeed, of all the cigarettes smoked in the UK in financial year 2003/04, around a quarter (24%) were unaffected by UK price measures – bypassing possibly the most effective way of controlling smoking rates. The problem with hand-rolling tobacco is even worse. Increasing numbers of smokers have been downtrading from more expensive cigarettes to cheaper hand-rolling

tobacco. Its attractiveness is that little of this is affected by UK tax or duty. In 2003/04, 57% of hand-rolling tobacco in the UK was smuggled, while a further 14% was cross-border shopped. Therefore, of all the hand-rolling tobacco smoked in the UK last year, nearly three-quarters (71%) was unaffected by UK price measures – again bypassing possibly the most effective way of controlling smoking rates.

Figure 3 Increased use of hand-rolling tobacco (United Kingdom) 2004 2003 2002 2001 2000 1999 1998 1997

Cross-border shopping

1996 1995 1994 1993 1992 1991 1990 0 2,000 4,000 Tonnes of hand-rolling tobacco uty- aid

6,000

on-duty- aid

Source: Morgan Stanley Equity Research

8,000

10,000

12,000

In 2002, the indicative limits on cross-border shopping to the UK from the European Union were increased following pressure from the European Commission. An individual can now bring 3,200 cigarettes or 3 kg of hand-rolling tobacco into the UK without paying any UK tax or duty. This is around six months supply for a 20-a-day smoker. Tobacco is a uniquely dangerous product (it kills one in two users when used as intended), yet the current rules in the European Union seek to treat the movement of it across borders by consumers as though it were the same as many other products. According to the latest figures from the European Commission, the price of a packet of cigarettes in the most popular category in Spain is £1.36. The equivalent in the UK is £4.89. A holidaymaker to Spain can legally bring back 160 packs. With cheap flights

available, an English smoker might save, legally, over £1,000 in tax and duty with two trips a year. As well as a ready source for personal consumption, the temptation to sell on such large amounts can prove hard to resist. Recent European Union enlargement has resulted in even lower priced cigarettes becoming available making the differential in prices even more stark. In Latvia, for example, the price of a packet of cigarettes in the most popular price category is 36p; in Poland it is 83p (although limits on crossborder movement for these new Member States are currently set at 200 until their tax/duty systems are in line with European Union rules). In countries geographically close to the European Union, such as Russia and the Ukraine, the price of a premium brand packet of 20 cigarettes in 2004 was 37p and 38p respectively.

Counterfeiting The expansion in illegally smuggled tobacco industry-manufactured products from the mid-1990s created a new market. As work by HM Revenue and Customs, in conjunction with the tobacco industry, has reduced the amount of smuggled industry manufactured tobacco making its way into the UK, so the counterfeiters stepped in to supply the markets that had been created.

CMO ANNUAL REPORT 2004

In 2003/04, 54% of cigarettes seized in the UK were counterfeit, a 260% increase in only two years. The problem with counterfeit cigarettes is not what is in them, but that they are now the prime source of cheap cigarettes in the UK. Counterfeit cigarettes typically come from illegal factories in Eastern Europe and the Far East, predominantly China. It has been estimated that, in 2002, 190 billion counterfeit cigarettes were manufactured in China. Worryingly, the Treasury Select Committee commented in March 2005: â&#x20AC;&#x2DC;We were surprised to learn during our visit to China, the largest source of counterfeit cigarettes destined for the UK, that there was only one UK customs officer, based in Hong Kong, to cover the whole country. We were also surprised to discover that, until our visit, there had been no meetings between UK Customs and the State Tobacco Monopoly Administration, the agency charged with tackling cigarette counterfeiting in China.â&#x20AC;&#x2122;

UK influence on international action The price of tobacco products and the nature of the UK tobacco market is dependent on worldwide factors, as well as European Union rules. There are opportunities coming up which will provide a focus for tackling the issues raised here.

1 Tobacco and borders: death made cheaper

The Framework Convention on Tobacco Control The Framework Convention on Tobacco Control came into effect in February 2005. The first Conference of Parties (countries that have ratified the convention) is planned for February 2006. It is expected that one of the first protocols under the convention will focus on illicit trade. Illicit trade in tobacco is a worldwide problem. The European Union and all 25 Member States could prioritise action in this area and work with other signatories to the convention to produce a comprehensive and effective protocol to end the worldwide trade in tobacco smuggling. The UK could use its Presidency of the European Union to lead the development of a strong common European Union position for the negotiations.

The review of the European Union directive on tobacco tax In 2006, the European Union is due to review its tobacco tax directive. This is an opportunity to set a framework for reducing the difference in tax rates between all Member States while continuing to push up prices. The UK could aim to increase the minimum price allowed for tobacco products across the European Union by increasing the specific (fixed amount of) duty, as well as use the review to question the illogical and health-damaging cross-border shopping allowance for tobacco.

Taxation and smuggling Most countries apply taxes to tobacco products to raise government revenue and to create a disincentive to smoking. Taxation has been one of the most effective health policy measures for reducing tobacco consumption. Smuggling results in less revenue for governments and undermines taxation as an effective health policy to curb consumption.

TWO TYPES OF SMUGGLING BOOTLEGGING LARGE-SCALE ORGANISED SMUGGLING

Publicly, the tobacco manufacturers oppose tax increases. Their rationale has been that higher taxes are an incentive for smuggling and reduce legal, but not total, sales. The reality is that the tobacco companies benefit from smuggling: average tobacco prices are reduced and hence demand increases. Tobacco is an addictive substance and cheap, smuggled cigarettes encourage people to keep smoking when otherwise they might stop. When smuggled cigarettes are tobacco industry-manufactured, the tobacco manufacturers and wholesalers are still being paid for these sales, thus benefitting further from smuggling. There are two types of smuggling: bootlegging – essentially the oldfashioned style of smuggling. It is encouraged by differentials in the price of tobacco products between neighbouring countries, states or provinces. Duty-paid products are purchased in a low-tax area, transported to a high-tax area and sold illegally; large-scale organised smuggling – characterised by the involvement of criminal organisations, a relatively sophisticated system for distributing smuggled cigarettes locally and few controls on the international movement of tax-free cigarettes. Tax-free cigarettes most often enter the illicit market while ‘in transit’. Transit is a concession system aimed at facilitating international trade, which allows the temporary suspension of customs duties, excise and Value Added Tax payable on goods originating from and/or destined to a

third country, while goods are transported through a defined customs area. Cigarettes legitimately move through the ‘in-transit’ regime without bearing tax until they reach their end market, where tax is payable. However, many cigarettes simply fail to arrive at their final destination, having been bought and sold on the black market by unofficial traders. When cigarettes are smuggled, taxes are evaded and the black market price is lower. While avoidance of taxes may be the key motivation for smuggling, smuggling cannot be explained by tax levels alone. Spain and Italy, which have relatively low tobacco taxes and prices, have historically had the biggest problem in the European Union with smuggled tobacco. This lends weight to the theory that environmental factors also have a strong influence: a willing market, the culture of street selling, the presence of local organised crime networks, an active black market and general levels of national or local corruption. The duty-paid market in the UK has also seen a real change since 1997. As price has increased, a new market in ultra-low and low/economy-price cigarettes has expanded. The ultra-low price share of the cigarette market increased from 15% in 1997 to 35% in 2004; the low-price share rose from 15% to 22%. Rather than quitting in the face of price rises, smokers had an alternative route to maintain their addiction without paying more. They could also trade down to hand-rolling tobacco. This expansion in ultra-low/economy-price brands again dents the health impact made by price rises.

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1 Tobacco and borders: death made cheaper

ACTION

RECOMMENDED

The Government should use its Presidency of the European Union (and its health inequalities theme) to promote a comprehensive and effective protocol for the Framework Convention on Tobacco Control to end the trade in tobacco smuggling worldwide. The Government should set a more challenging target for reducing smuggled cigarettes and extending its smuggling strategy to hand-rolling tobacco. The Government should use its influence within the European Commission and with other Member States to address cross-border

shopping for tobacco products, with the aim of reducing the limits to 200 cigarettes or 250g of handrolling tobacco. 4

The Government should look urgently at how to create a tax/duty system for tobacco that minimises the opportunity to avoid the impact of price rises by trading across to another tobacco product (e.g. handrolling tobacco).

Better information systems should be developed to provide high-quality data on smuggling, tax-free imports and cross-border trade.

The Government should produce a strategy to combat counterfeit tobacco products.

The Government should use its maximum influence on the European Union 2006 review of its tobacco tax directive to reduce the difference in tax rates between Member States (including combining the â&#x20AC;&#x2DC;fixed amountâ&#x20AC;&#x2122; of duty).

The new Serious Organised Crime Agency (SOCA) should be given the challenge of breaking the tobaccosmuggling criminal gangs.

IT TAKES YOUR BREATH AWAY: THE IMPACT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

CMO ANNUAL REPORT 2004

2 It takes your breath away: the impact of COPD

COPD is a preventable and treatable disease.

80% of cases of COPD are linked to smoking.

COPD accounts for more than £800 million in direct healthcare costs each year, with a further 24 million lost working days per annum.

Our country’s mortality rate from respiratory disease (including COPD) is almost double the European average and the sixth highest in Europe.

Current health policy is going a long way to tackling the COPD issue, but as the burden increases so too does the need for stronger action.

Survival rates for COPD patients admitted to hospital with acute flareups of their condition vary between 95% and 50% according to where they are treated.

KEY POINTS

Chronic obstructive pulmonary disease (COPD) has no single definition. It is an umbrella term for a number of chronic lung disorders, including chronic bronchitis, emphysema, chronic obstructive airway disease and chronic airway flow limitation. COPD is primarily a smoking-related disease, affecting an estimated three million people and killing over 30,000 each year.

COPD accounts for more than £800 million in direct healthcare costs each year, with a further 24 million lost working days per annum.

£ 80% of cases of COPD are linked to smoking

COSTS

AFFECTS

£800 MILLION TO NHS PER ANNUM

PRIMARILY PEOPLE AGED OVER 45

24 MILLION WORKING DAYS LOST 30,000 DEATHS A YEAR

Chronic obstructive pulmonary disease (COPD) is a progressive and disabling lung disease caused primarily by smoking. It has now become a major health problem, affecting three million people each year and accounting for over 30,000 deaths, 1.4 million general practice consultations and the use of one million in-patient bed days every year. From a worldwide perspective, COPD is estimated to be the sixth leading cause of death, and World Health Organization predictions suggest that it is set to become the third leading cause by 2020. In this country, as infectious diseases decline, the population ages and cigarette smoking persists, the public health burden of COPD is certain to rise. COPD affects not only the lives of sufferers and their families, but also has a high socio-economic impact. The total annual cost of COPD to the NHS has been estimated to be over £800 million, which equates to £1.3 million per 100,000 population. This figure rises alarmingly when indirect costs, for example lost working days

and short and long-term disability care, are taken into account. For example, in the late 1990s, 24 million working days per annum were lost due to COPD, with the cost of lost productivity being estimated at around £2.7 billion. The good news is that there is considerable scope to ease the current burden of COPD by focusing on three key areas: prevention, diagnosis and clinical management. Marked improvements in these areas are possible. Indeed, improvements already in place are having – and will continue to have – long-term benefits for patients, the health service and society as a whole. COPD primarily affects people aged over 45 and is characterised by a chronic, slowly progressive decline in lung function, usually associated with exposure to cigarette smoke but occasionally exposure to air pollution or other noxious particles or gases. In the early stages of COPD, patients are largely free of symptoms but, as the disease progresses, patients report symptoms of breathlessness, coughing, chest tightness

2 It takes your breath away: the impact of COPD

CMO ANNUAL REPORT 2004

Figure 1 Proportion of patients in 229 hospitals who died 90 days after admission with an acute flare-up of their COPD

40 229 30

0 0 5

5 10

10 15

15 20

20 25

25 30

30 35

35 40

40 45

45 50

90 2003

and an increased secretion of sputum. Progressive deterioration in lung function means that symptoms worsen, restricting patients’ lives and effectively leading to premature disability. People with severe COPD may become housebound, socially isolated and depressed, becoming increasingly dependent on carers as well as on social and health services. They may also experience exacerbations, which occur with increasing frequency as the disease progresses, and in many cases, this leads to a worsening of baseline symptoms. Exacerbations, which manifest as a sudden increased breathlessness, often accompanied by wheezing and a feeling of severe tightness in the chest, usually require medical intervention and often hospital care. In the final stages of COPD, following a period of recurrent exacerbations, patients usually go on to develop respiratory failure and become entirely dependent on supplementary oxygen.

Managing the burden A comprehensive national COPD audit was carried out in 2003 by the British Thoracic Society and the Royal College of Physicians. Mortality rates were worryingly high. An average of 15% of patients died within three months of being admitted to hospital with acute exacerbations of COPD. However, there were major differences in mortality rates between hospitals across the country, showing an interquartile range (a statistical measure of variation) for mortality of between 9% and 21%. There were also significant variations across the country in the numbers of re-admissions, the average length of stay and specialist staff numbers. A lack of specialist staff was highlighted by the fact that less than a third of patients were admitted to hospital by a respiratory specialist and fewer than 50% were discharged by one. Patients often report poor quality of life with impaired emotional, social and physical functioning. Psychological disorders, including depression and anxiety, can often go unnoticed. Patient education – of their condition and its treatment – was also highlighted as an area to be improved.

Prevention As COPD is largely due to cigarette smoking, it is almost entirely preventable. National and local policies towards smoking cessation are therefore vital to the primary prevention of COPD. Implementation of the 1998 Government White Paper Smoking Kills has helped to reduce overall smoking rates, helped smokers to kick the habit and increased public awareness of health risks of smoking. New planned legislation will reduce the impact of second-hand smoke. Smoking rates have decreased from 28% of adults in 1998 to 25% in 2002. NHS Stop Smoking services helped 205,000 smokers kick the habit between April 2003 and March 2004. Moving forwards, the new White Paper Choosing Health: Making healthier choices easier, published in November 2004, builds on the 1998 White Paper Smoking Kills, and promises further action to tackle smoking.

Diagnosis, treatment and management The prevalence and socio-economic burden of COPD, together with the individual suffering, highlight a clear need for early diagnosis and effective treatment. As sufferers of a progressive disease, patients with COPD pass through mild and moderate stages before they arrive at the most debilitating, costly and potentially fatal severe stage. Nevertheless, despite this staging, most patients with COPD are properly diagnosed only once the disease has progressed to the moderate or severe stage. This is largely due to lack of proper diagnosis. From a primary care perspective, foundations are already in place for increased use of screening and better diagnosis. Screening for COPD, in the primary care setting, is possible through a simple and non-invasive measurement of lung function called spirometry. Evidence-based guidelines for the diagnosis and management of COPD were published by the National Institute for Health and Clinical Excellence in 2004, with current Department of Health activity centring

CMO ANNUAL REPORT 2004

2 It takes your breath away: the impact of COPD

on increasing general practitioner awareness of COPD and encouraging them to follow the guidelines. The new General Medical Services (GMS) contract and Quality and Outcomes Framework, which has seen an unprecedented level of investment in general practice, is expected to deliver a wide range of high-quality services with better clinical outcomes for all patients, including those with COPD. In addition, several strategies have been introduced which, while not focused specifically on COPD, should help to ensure that key intervention strategies, such as smoking cessation programmes, influenza and anti-pneumococcal vaccinations, noninvasive ventilation treatment for exacerbations and assessment for entry into rehabilitation programmes, are more often employed by healthcare professionals in the NHS. These strategies include the Chronic Disease Management Programme, the National Service Framework for Older People and that for Long-term Conditions.

While there is no cure for COPD, smoking cessation can prevent progression and hence significantly improve prognosis. In addition, medication can help control symptoms, physiotherapy can help clear excess sputum, and exercise-based rehabilitation programmes can help reduce the disability associated with the disease. The combination of these treatments can lead to a general improvement in quality of life for the sufferer. At an individual patient level, the Expert Patient Programme that I proposed in a special report published in 2001, and now being implemented, recognises that many patients â&#x20AC;&#x201C; particularly those with long-term conditions such as COPD â&#x20AC;&#x201C; understand their particular condition better than the professionals charged with looking after them. This programme helps patients to take control of their own care, while providing support to others and training staff appropriately. It is already running successfully in communities throughout England.

Improving the management of COPD patients in hospitals is also possible by introducing strategies that aim to increase the number of doctors and nurses training in respiratory specialties. This will ensure that more patients receive specialist care. Highlighting the benefits to health professionals of non-invasive ventilation to treat patients suffering exacerbations and the provision of pulmonary rehabilitation programmes for those leaving hospital is important, as is educating those who commission these services about the cost-effectiveness of such interventions in the long term. There are other measures that not only can improve the prognosis and quality of life for people with COPD but can also help reduce acute hospital admissions. Pulmonary rehabilitation reduces breathlessness, increases exercise capacity and enhances self-esteem and independence, yet as few as 2% of COPD patients currently have access to it. Similarly, programmes that provide intensive support to allow early discharge from hospital after an acute episode are beneficial and valued by COPD patients. Non-invasive ventilation is a treatment that

can help COPD patients in an emergency by sustaining oxygen levels, where other treatments may be unsuccessful. Although recommended in the National Institute for Health and Clinical Excellence guidelines, this form of treatment is not as widely used as it could be. The Government recently announced the introduction of the new home oxygen service for the management of patients with chronic respiratory disability, including COPD, and respiratory failure. The new service will ensure that patients have access to expert advice and support in making the best use of the latest equipment and allow up to 60,000 patients, both adults and children, to have the confidence and support to manage their symptoms at home, thereby helping to improve their quality of life. It is also hoped that the improved service will help reduce emergency admissions to hospitals, particularly for patients with COPD. The most up-to-date equipment includes: lighter weight cylinders; smaller, more efficient concentrators; liquid oxygen; and portable systems that will enable patients to go out more easily and so lead as full a life as possible.

CMO ANNUAL REPORT 2004

2 It takes your breath away: the impact of COPD

More primary care staff should be provided with training in the use of spirometry as a tool to detect COPD.

A National Service Framework should be formulated for COPD.

ACTION

RECOMMENDED

1 The Government should continue to pursue strong programmes of tobacco control, another by-product of which will be reducing the human and financial cost of chronic obstructive pulmonary disease (COPD).

Consultant expansion programmes should be reviewed against the need for respiratory physicians at a local level, and adjustments made where necessary.

A FRESH LOOK: REALIGNING FOOD PROCUREMENT IN THE PUBLIC SECTOR

CMO ANNUAL REPORT 2004

3 Realigning food procurement in the public sector

At £500 million expenditure on catering and £300 million on food per annum, the NHS is the largest public procurer of food in Europe.

Despite recent progress, considerable scope exists to promote healthier foods and to achieve greater sustainability in food procurement practices across the board.

Standards introduced in 2001 have done little to improve the quality of school meals; the extra £280 million investment announced by the Government in 2005 is an opportunity to turn this situation around.

£10 spent on a local food initiative generates around £25 for the local economy.

The public sector should use its huge financial muscle as a purchaser and procurer to improve the nation’s health and promote a more sustainable food chain.

KEY POINTS

The public sector has enormous purchasing power for the food that it procures across a wide range of institutions (e.g. state schools, hospitals, prisons, Meals on Wheels, armed forces). In total, the public sector spends between £1.8 billion and £2 billion on buying food and catering services, which accounts for 7% of the United Kingdom spend within the catering sector.

Around 1.8 billion meals are served each year from public sector funding.

The NHS is the largest public procurer of food in Europe.

PUBLIC SECTOR MARKET POWER £1.8–2 BILLION PER ANNUM ON BUYING FOOD AND CATERING SERVICES 7% OF THE UNITED KINGDOM CATERING SECTOR 1.8 BILLION MEALS EATEN ANNUALLY

Food and diet have a huge impact upon health. The direct links are widely recognised and the prevention of diet-related diseases and obesity are a priority (as set out, for example, in the recently published Choosing Health White Paper and related Choosing a Better Diet: a food and health action plan). Cancer, heart disease and stroke are the major causes of death in England, and are all diet related. Treating ill health caused by poor diet costs the NHS at least £4 billion each year, in addition to further costs to the economy in sick pay and loss of productivity. The Choosing Health White Paper commits the Government to developing nutritional standards for all foods provided by the NHS, HM Prison Service and armed forces and other public bodies and to increase access to a range of healthier foods taking account of the differing formats for food provision in institutions. The production, processing, packaging, transportation, marketing and promotion, sales and consumption aspects of the food supply chain can all impact on health and the environment. The Department for Environment, Food and Rural Affairs’ (Defra) Strategy for Sustainable Farming and Food identifies how a more effective and connected food chain can contribute towards building healthier and more sustainable communities. Public sector organisations are major employers, purchasers and service providers. Their corporate and social responsibility is for the individuals and communities they employ and serve. It is appropriate that they should protect and promote good health and well-being in all their activities.

Figure 1 Some examples of expenditure on food procurement in the public sector Ministry of Defence

HM Prison Service

NHS

Schools

The public sector has enormous purchasing power. This could influence and achieve improvements in the health of the people that the sector employs and serves, as well as create economic, environmental and social improvements for the nation. Public sector food procurement and provision policies (as well as practices) could make a real contribution to improving the health of our country and to sustainable development.

Note: Direct comparison of these figures is not valid since different methods of collection and analysis of data have been used across the sectors.

CMO ANNUAL REPORT 2004

Public sector market power The public sector spends between £1.8 and £2 billion per annum on buying food and catering services. This is about 7% of the whole United Kingdom catering sector. There are approximately 61,500 outlets and 1.8 billion meals eaten annually. Public sector food buyers have an obligation to secure best value for money. However, having to prioritise budgetary constraints as well as juggling quality, safety and supply means that the nutritional value of food is often pushed to the bottom of the checklist during the tendering process. While public sector food procurement is governed by European Union legislation, it is important to ensure that local producers have the opportunity to benefit as much as possible under the given parameters. The UK-derived content of the food purchased varies enormously. For example, according to industry figures, a public sector catering contractor currently sources only about 15% of their lamb and 25% of their bacon from the UK, while chicken and pork are 80% and 90% UK derived. The majority of dairy, fish, vegetable and bakery products are sourced from the UK, but 75% of fruit comes from outside the country. The NHS is the largest public procurer of food in Europe, with an annual expenditure of some £500 million of which £300 million is spent on ingredients. Overall, this spend is split between NHS Trust local contracts and national contracts negotiated by the NHS Purchasing and Supply Agency (PASA). Over 300 million meals are served each year for patients, staff and visitors in approximately 1,200 hospitals. The budget for patients’ food is, on average, £2.20–£3.70 per day. This supplies breakfast, lunch, dinner and any other drinks or snacks. The NHS purchases a wide range of food products from basic ingredients and commodities, to pre-prepared foods and meals. Food procurement for the NHS includes: 6.3 million loaves of bread per annum approximately 60 tonnes of chips per week

meat contracts, via the NHS Purchasing and Supply Agency, totalling about £12 million annually fruit and vegetable contracts, via the NHS Purchasing and Supply Agency, to the value of around £11 million annually. The NHS Purchasing and Supply Agency spends between £120 and £150 million per annum on food, including approximately £12 million per annum on meat and poultry alone. Fresh fruit, although available, is not widely provided to patients. Statistics available from contracted suppliers to hospitals show that fruit accounts for less than 20% of the fruit and vegetable budget allocated to NHS Trust kitchens.

Examples of healthier options

3 Realigning food procurement in the public sector

policy introduced in a number of NHS Trusts has been very successful. Mealtimes should be protected in all hospitals, for patients and staff, while support and time for those who have difficulty eating should always be available. Another serious consideration is that up to 60% of elderly people admitted to hospital are malnourished. This can lead to delays in recovery from illness, increased complications and extended time spent in hospital. There is a great deal that hospitals can do to identify malnourishment, including increasing patient screening, providing support and improving food to increase the uptake of meals. Hospital food for sick and vulnerable people should be nutritious, appealing and sustainably procured.

Figure 2 Total numbers* of people receiving Meals on Wheels on a ‘snap-shot’ day (31 March) 01/04/2003 – 31/03/2004

131,000

01/04/2002 – 31/03/2003

147,000

01/04/2001 – 31/03/2002

152,000

01/04/2000 – 31/03/2001

146,000

01/04/1999 – 31/03/2000

170,500 200,000

150,000

The Meals on Wheels service began after World War II in response to the large numbers of older people evacuated from cities and the increased numbers who were housebound. The service is now provided for people of any age who are unable to cook their own meals at home and have no other way of getting a hot meal. Social services departments in local authorities are responsible for Meals on Wheels or Community Meals. The Government has not issued prescribed standards or guidance to local authorities. It is a matter for local decision and commissioning. For this reason there is considerable variation in eligibility, meal provision, delivery and cost. Traditionally, freshly cooked hot meals were centrally produced and delivered. An increasing number of local authorities, for financial reasons, are moving towards

100,000

Meals on Wheels

50,000

The type of food purchased by NHS Trusts depends on how the food is prepared and cooked on the premises. Hospital systems include cook-serve (raw materials are prepared and cooked in hospital kitchens for distribution to wards as hot meals), cook-chill/freeze (these are food and meals prepared in advance, then either chilled or frozen and reheated in the kitchen or on the ward when required) or a mix of these two. The use of pre-prepared meals is increasing. Patients choose their meals beforehand and these are either individually plated by kitchen staff and delivered to wards by trolley, or served from large containers on the ward. This bulk service allows for flexibility of portion size and choice, but can result in higher wastage. It is estimated that the value of hospital food waste annually in England is around £45 million. This comprises food preparation waste, unserved meals and food left on the plate. The Better Hospital Food Programme was introduced in May 2001 to improve the quality and availability of meals offered to patients and reduce waste. A snack box service, 24-hour catering and a range of recipes for hospital meals are all part of the scheme. It has met with a mixed response: patients find some of the dishes too ‘fancy’ and the snack boxes have been criticised for containing crisps and confectionery. The proposed trial of a national flexi-menu system, which will introduce an all-yearround menu, may limit the opportunity for seasonal or local foods to be included if it is to be procured nationally. Mealtimes can be disturbed by routine ward checks, so patients do not have the opportunity to eat. The protected mealtime

Hospital food

* This does not include the numbers of clients who pay for the services directly from a private supplier. Source: Referrals, Assessments and Packages of Care returns (RAP); Community Care statistics 2000–2004; Department of Health.

CMO ANNUAL REPORT 2004

pre-packed and regenerated meals (heated meals) and the delivery of frozen meals. Eligibility is determined following assessment by the social services team and some authorities have stricter criteria than others. Those assessed as in critical need may receive hot meals on a daily basis, whereas those in substantial need may receive frozen meals delivered weekly or fortnightly. Delivery is either by local authority staff, or by a voluntary organisation or by a contractor. The Women’s Royal Voluntary Service (WRVS) was one of the first to become involved and is still the largest voluntary sector deliverer of meals. Meals are often delivered by the same person, but the trend towards delivering frozen meals, weekly or fortnightly, is reducing daily human contact for some vulnerable older people who may have relied on that contact when their hot meal was delivered. To some lonely, isolated or housebound older people, the companionship and regular human contact may be as valuable as the meal. Indeed, 19% of people aged 65 years and over have contact less than once a week with their friends or family. There is concern that the quality and quantity of some meals provided may not meet nutritional requirements (a two-course meal is supposed to provide a third of the daily requirements) and some clients rely on supplementary food provided by family or friends. Clients vary in their ability or motivation to heat meals from frozen. Some may not bother to prepare or reheat a meal and eat it, whereas if a hot meal was placed in front of them they would eat it. Some may not have access to the right kitchen facilities or equipment, but they should be eligible for help acquiring these from social services. The National Association of Care Caterers provides standards for Meals on Wheels which have been adopted by their member local authorities and leading manufacturers as a benchmark for standards. These standards include advice about operating and specifying a community meals service, nutritional information regarding the needs of older people and practical advice on how to achieve their requirements, specifications for breakfast and tea and advice on cultural dietary matters.

School meals School meals is perhaps the sector that is most in need of improvement. Obesity is increasingly prevalent among children. Many children fall far short of the recommended nutritional requirements, eating too little fruit, vegetables and fibre and too much fatty, salty or sugary food. Average salt intakes are up to 50% higher than recommended and children on average eat only around two of the recommended five portions of fruit and vegetables per day. Children from the lowest social group tend to eat 50% fewer fruit and vegetables than those from the highest social group. This poor diet not only contributes to ill health, but can impact on learning ability. Schools are required to provide meals – not necessarily hot – to all children who want them and local authorities are obliged to provide free school meals to children of income support claimants. From the year 2000, the Government delegated funding for school meals to secondary schools. Primary and special schools can opt for delegation. Where a school has a delegated budget for meals, the governing body takes on the responsibility for their provision. They can contract back with their local authority provider, contract the service to an outside commercial provider or provide the service in-house from their own kitchens using their own staff. This last option has many difficulties in terms of facilities, skills and resources, but some schools have chosen this option as a means of exerting direct control over the quality, nutritional value and, sometimes, sustainability of their meals. Many local authority catering departments also supply social services, including providing food for looked-after children and young people, who are a particularly vulnerable group. Charges for school meals vary; the average price of a school meal in 2002 was £1.56, and as little as 35–45p of this may be spent on the food itself. This sector has seen no investment in recent years. In fact, the trend has been to drive down costs and a great deal has been lost in the way of skills, staff, kitchen

3 Realigning food procurement in the public sector

infrastructure, facilities and other resources needed to prepare healthy meals from basic ingredients. The combination of these factors has led to increasing reliance on processed and semi-prepared foods which have high levels of salt, fat and sugar and do not provide a nutritionally balanced meal. Freshly prepared meals from locally produced foods have become the exception. The introduction of food-based nutritional standards in 2001 has done little to improve the quality of school meals. There is no clear accountability for these standards. Some schools, which have made improvements to the food they provide, report calmer pupils with increased concentration and better learning. Many children from low-income households may well rely on school meals as their main source of nutrition, as their diets may otherwise be limited. However, across the country, 18% of eligible pupils in primary schools and 27% in secondary do not take up their free school meal entitlement. Better food provision would encourage these pupils to have school meals and thus contribute to narrowing the health inequalities gap. Healthier and more sustainable food provision in school also provides many opportunities to link into curriculum activities and provide other educational activities, thus reconnecting children (and teachers) with food, farming, seasons, the countryside and cooking, as well as helping to rekindle the value of food. In March 2005, the Government announced an additional ÂŁ280 million investment in

school meals, with a commitment to increase the spend on ingredients to a minimum of 50p per meal in primary schools and 60p in secondary schools. This is a superb opportunity to make school meals much healthier by setting nutrient-based standards, to stimulate opportunities for regional and local suppliers and achieve a more sustainable school meals system. As an additional strategy to improve childrenâ&#x20AC;&#x2122;s health, the Department of Healthled School Fruit and Vegetable Scheme is already providing almost two million four to six year olds in state-maintained infant, primary and special schools with a free piece of fruit or vegetable each school day.

Prisons Prison caterers prepare over 82 million meals per year. Catering and procurement standards are set at a national level. Some produce is provided by prison farms and gardens or bought locally, but both the range and amount have diminished significantly in recent years. The Prison Service Order for prison catering services provides guidance for safe, nutritious and healthier catering. Again, owing to the constant juggling of priorities, the nutritional value of prison food is of variable quality. Specific nutritional needs of individuals may not be met. Availability of fresh fruit for prisoners is very limited. In some prisons, the breakfast service is being replaced with a breakfast tray provided the previous evening. Poor diet may be associated with anti-social behaviour.

CMO ANNUAL REPORT 2004

Opportunities for the public sector All public sector bodies, especially those that serve the most vulnerable in our society (for example, children and especially looked-after children, the sick, the elderly, the disadvantaged), have a duty to provide appetising, healthy and nutritious meals, consistent with expert advice. Appetising, healthy food can lead to faster patient recovery times, less malnutrition, better educational attainment, less disruptive behaviour, higher productivity and less food waste. As large employers, all public sector organisations should ensure that their canteens and catering outlets provide safe, sustainable and healthy food for staff. Public sector canteens are an ideal place for employers to exercise their corporate, social and community responsibility and take a proactive approach to informing consumers and thus influencing their eating habits. The environment in which food is provided creates an opportunity to consistently reinforce healthy eating advice and avoid conflicting messages. Many public sector organisations host meetings or events and provide food for them. This is a further opportunity to ensure that healthier foods are available to staff and guests. Vending machines are becoming an increasingly popular method of food provision in many institutions. However, they are traditionally associated with branded foods that can be high in fat, salt or sugar. Just as hospitals do not have cigarette machines, vending machines should be operated offering a range of healthier foods, as many schools have now

implemented. Provision of food by NHS Trusts to hospital staff and visitors is frequently contracted out to franchises and third-party branded operators (for example, Burger King, McDonald’s). NHS Trusts should review all food served on their premises to support staff and visitors who wish to make healthy choices. In a catering setting, opportunities also exist to provide information to consumers about the nutritional content of foods. Locally produced and seasonal food could be served and information provided for consumers to help them ‘reconnect’ with the local farming and food sector. Over one million people work for the NHS and two million for local government. Many of these staff are lower earners: 45% of NHS employees have a basic salary of less than £15,000. The National Food Survey has repeatedly shown that people from lowerincome families have, on average, far less healthy diets than their higher-income counterparts. Some hospitals subsidise staff meals using income generated from visitor meals. They could ensure that only healthier foods are subsidised, thereby encouraging their consumption. People spend up to 60% of their waking hours in their place of work. Provision of healthier food in the workplace could help narrow these health inequalities. Public sector organisations could encourage the establishment of box schemes, food cooperatives, farmers/green markets or other direct-selling initiatives in the workplace, which would encourage consumption of healthier foods, particularly fruit and vegetables. These

3 Realigning food procurement in the public sector

could be supplied directly by local farmers and growers, further improving access to locally produced food for a healthy diet.

Food procurement strategies Not only should the public sector promote healthier foods, it should also address sustainability in its food procurement practices. The wider impact of food production, processing, packaging, transport, distance and waste on health, on communities and on the environment are all important considerations. The associated external costs need to be accounted for. Government policy requires that procurement is based on the principle of value for money. The current definition and interpretation of value for money is too narrow and short-term. Poor diet is a factor in many diseases, which cost the NHS and UK economy a significant and escalating amount of money. Prevention of these diseases through better food and nutrition is a long-term strategy worth investing in. The longer-term health and environmental effects of food supply should be a factor in value for money. Public sector food procurement is strictly regulated through European Union and UK legislation. Equal supply opportunity for all Member States is mandatory and prevents contracts specifying local foods or suppliers. This is often cited as a major barrier to more local, regional or UK sourcing of food. This is defeatist. There is scope to be more creative and interpretive of these rules, and

some other European countries are already doing so. The public sector could be more creative in drawing up specifications for contracts to supply food and catering. For example, specifications to encourage purchase of food from smaller suppliers within the UK and locally, where costs are often competitive, could include dishes or menus that use local and seasonal produce rather than a year-round supply of a particular food. Large-scale contracts could be broken up into smaller chunks to enable smaller suppliers to tender. Smaller suppliers can act as second tier suppliers. Educational links and environmental benefits could be included. The Public Sector Food Procurement Initiative (PSFPI) is designed to help the Government deliver its Strategy for Sustainable Farming and Food, which aims to achieve a world-class sustainable farming and food sector that contributes to a better environment and healthier communities. This initiative is making significant strides towards helping public sector organisations incorporate sustainable development principles in their purchasing policies and decisions. Wider benefits of sustainable food procurement include: improved health, better access to healthier foods and good information, support for local and rural communities and economies, improved animal welfare, sustainable farming with reduced environmental impact, waste and

CMO ANNUAL REPORT 2004

energy consumption, cultural diversity catered for, better performance and productivity, and cost savings to the economy. Procurement activity for the Department of Health-led School Fruit and Vegetable Scheme is undertaken by the NHS Purchasing and Supply Agency that operates under European Union purchasing directives. It provides approximately 110,000 cases of fruit weekly for schools. Figures from September 2004 to January 2005 show that 100% of vegetables and 17% of fruit supplied to the scheme was sourced from UK growers. Several other objectives set out in the Public Sector Food Procurement Initiative are met by this scheme. The proportion of UK-sourced produce is of course subject to seasonal variation. This seasonality should be embraced and incorporated into supply calendars, rather than specifying a standard year-round supply of a particular food. A new scheme, Healthy Start, is expected to replace the Welfare Food Scheme. Under this new scheme, eligible pregnant women (including all under-18s) and mothers and young children in low-income families will have greater access to a healthy diet, particularly by encouraging fruit and vegetable consumption. The national roll out, due in 2006, will provide a further opportunity for local, regional and UK suppliers. By opening up food supply contracts to local suppliers, the public sector would support local economies, local employment,

local regeneration and the environment. It is estimated that £10 spent on a local food initiative acts as a multiplier and generates around £25 for the local economy, whereas the same £10 spent in a supermarket generates only £14. Local sourcing also reduces the need for transport and packaging, with wider environmental and health benefits. The distance food travels, from where it is grown or reared to where it is eventually consumed, is referred to as ‘food miles’. There is an increasing environmental cost associated with food miles, which are on the increase as food is sourced globally and year-round. A recent study into the hidden environmental cost of the weekly food basket found that these costs rise as produce is transported over big distances, and that ‘road miles’ were more damaging than ‘air miles’. The report concluded that food miles are more significant than previously thought. The food that an organisation decides to provide, and how it is supplied and delivered to consumers, has a direct impact upon what is purchased. The food provision and food procurement policies and practices of the public sector should be exercised in order that they can make a real contribution to improving the health of the nation and to sustainable development. By taking a wider perspective on food purchasing policy, there are clear health and environmental benefits that, although not immediately quantifiable in economic terms, will have long-term benefits to all concerned.

3 Realigning food procurement in the public sector

LOCAL FOOD £10 SPENT ON A LOCAL FOOD INITIATIVE GENERATES AROUND £25 FOR THE LOCAL ECONOMY.

THE SAME £10 SPENT IN A SUPERMARKET GENERATES ONLY £14.

CASE STUDIES

Groundwork Wirral

The proximity principle

Groundwork Wirral has established a project working with the NHS in the North West of England to make the supply chain both local and green. Through the North West Supplier Bureau, Groundwork has been commissioned to design and deliver a regional project that will develop strong links with NHS procurement teams, establish procurement opportunity routes and provide tender training for North West businesses. This will help link the NHS and suppliers in a practical way. Food is just one of the products and services being looked at and the project aims to link NHS buyers with local suppliers. A fruit and vegetable distributor in Wirral has recently benefited from the support of this project and has not only improved health and safety for its employees but has also secured further NHS contracts, safeguarding employeeâ&#x20AC;&#x2122;s jobs and increasing profitability.

A County Durham hospital has become the first in the country to award a contract for organic milk. Darlington Memorial Hospital is currently undergoing a trial with a nearby organic dairy farm, Acorn Dairy, to supply it with 5,000 pints a week.The hospital was looking at local suppliers to help deliver its strategy on sustainable development. Acorn Dairy was identified as a dairy that could supply the hospital with organic milk. A trial was set up to see what the benefits were and if patients would notice the difference. The initiative proved successful and the dairy has now been formally awarded the contract. Acorn Dairy is only two miles from the hospital and was, therefore, able to compete on price due to lower haulage costs. An additional benefit of the award is a reduction in food miles which is both good for the environment and for peopleâ&#x20AC;&#x2122;s health, due to lower fuel emissions.

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3 Realigning food procurement in the public sector

Public sector food buyers and providers should be given training and guidance on the impact of food and diet upon health and on the principles of sustainable purchasing.

The Food Standards Agencyâ&#x20AC;&#x2122;s (FSA) current review of nutritional standards in public institutions should be used as a basis for action and the FSA should continue to track progress on reform of public sector food procurement and purchasing.

ACTION

RECOMMENDED

The methodology for demonstrating value for money in government procurement policy should be broadened to include longer-term health benefits and sustainable development.

All public sector food procurers should come together to agree much more creative specifications for contracts to supply food and catering, incorporating nutritional criteria. The new Public Procurement Working Group presents the opportunity to take this forward.

Public sector food purchasers should make local trade groups, business support organisations and local suppliers aware of forthcoming tender and supply opportunities, building on the progress already made through the Public Sector Food Procurement Initiative (PSFPI).

The proportion of high-quality local suppliers of food through public sector procurement should be increased substantially.

The 2005 Government announcement of ÂŁ280 million investment for school meals should be used to ensure a better quality and higher nutritional content of school meals in the future, with nutrient-based standards inspected by the Office for Standards in Education (Ofsted).

GASTROSCHISIS: A GROWING CONCERN

CMO ANNUAL REPORT 2004

4 Gastroschisis: a growing concern

There is a northâ&#x20AC;&#x201C;south divide for gastroschisis: prevalence is much higher in the north of the country.

More research is needed to establish the cause of gastroschisis, the reasons for the trend and the scope for prevention.

Congenital anomaly registers are a precious national resource: without them, babiesâ&#x20AC;&#x2122; lives may be lost and the causes of many anomalies present at birth will not be found.

KEY POINTS

Gastroschisis is a congenital anomaly present at birth in which part of the abdominal wall is missing, allowing the intestines and other organs to protrude through the opening.

With early surgery and specialist hospital care, more than 90% of babies affected will survive.

Gastroschisis has become more common over the last 10 years with much of the increase occurring in babies born to younger mothers.

The geographical coverage of these registers needs to be increased to the whole of England, reporting made more rigorous, and funding for the longer term put properly in place.

With early surgery and specialist hospital care, more than 90% of babies affected will survive.

More research is needed to establish the cause of gastroschisis.

Figure 1 A newborn baby with gastroschisis

PREVALENCE FOR MOTHERS UNDER 20 YEARS IN 1994, RATE FOR ENGLAND & WALES 8.9 PER 10,000 BIRTHS IN 2004, RATE FOR ENGLAND & WALES 24.4 PER 10,000 BIRTHS

Between 2-3% of newborn infants are born with a major congenital anomaly. The term ‘congenital anomaly’ covers a range of symptoms and conditions, from a simple structural defect or an error of metabolism to an hereditary disease or chromosomal anomaly. As a group, congenital anomalies are a significant cause of stillbirth (accounting for approximately 15%) and are responsible for around one-third of all infant deaths each year in England. They also contribute to infant and childhood illness. Structural anomalies such as heart defects often require complex and highly skilled surgery, while chromosomal anomalies, such as Down’s syndrome, tend to result in enduring disabilities that need skilled rehabilitation as well as long-term care and support. A range of factors, not always well understood, cause the majority of congenital anomalies. For this reason, primary prevention remains limited. In order to increase the scope for prevention, it is vital to accurately monitor occurrence and to identify and better understand the causes. Gastroschisis is a congenital anomaly that illustrates this need very well.

The prevalence of gastroschisis Abdominal wall defects are among the commonest structural defects in babies. Gastroschisis is one type and it is characterised by a defect to the right of the umbilicus, with an associated protrusion of the intestines and other organs through the opening (Figure 1). Babies born with this condition are more likely to be premature and their growth may be affected. They nearly always need immediate surgery usually followed by a prolonged stay in a neonatal unit. Gastroschisis is a distressing condition for parents but the outlook for the baby, following treatment, is usually very good with over 90% of cases surviving with few long-term problems. The majority of babies with gastroschisis are diagnosed before birth, which allows time for parental counselling, careful monitoring of the pregnancy and planning of treatment after the birth. Over the past 30 years, there has been a slow increase in the prevalence of gastroschisis worldwide. Reported rates from the European Surveillance of Congenital

4 Gastroschisis: a growing concern

CMO ANNUAL REPORT 2004

Figure 2 Trends in gastroschisis (rates per total 10,000 births with 95% confidence intervals shown over a 10-year period). 6

BINOCAR 2004 provisional

NCAS Confidence intervals

Rate per 10,000 births

Reporting to NCAS by regional registers commences

Table 1 Average three-year prevalence of gastroschisis ranked highest to lowest REGION

PREVALENCE RATE (PER 10,000 BIRTHS)

95% CONFIDENCE INTERVAL

Wales Northern Glasgow Mersey Former Trent West Midlands Wessex South West Oxford North West Thames

6.2 5.2 4.9 4.7 4.7 4.2 3.3 3.3 2.4 1.6

4.6 – 7.8 3.7 – 6.7 2.3 – 7.4 3.2 – 6.3 3.7 – 5.7 3.2 – 5.1 2.0 – 4.5 2.4 – 4.2 0.3 – 4.5 1.0 – 2.2

All BINOCAR registers

4.0

3.6 – 4.4

0 1994

1996

1998 2000 Year of delivery

2002

2004

Source: BINOCAR and NCAS, data for England and Wales 1994–2004

Source: BINOCAR registers 2002–2004

Anomalies (EUROCAT) in 2002 were around 2.0 per 10,000 total births. Similar rates have been reported by the National Congenital Anomaly System (NCAS) for England and Wales with 2.1 per 10,000 births in 2003. Recent data from BINOCAR, the British Isles Network of Congenital Anomaly Registers, however, has shown that the prevalence of gastroschisis from the UK Congenital Anomaly Registers is somewhat higher at 4.0 per 10,000 total births for the period 2002 to 2004 (Figure 2). There has been a significant increase over the past 10 years from 2.5 to 4.4 per 10,000 total births over the period 1994 to 2003 (Figure 2). As the prevalence of gastroschisis is low, the year-on-year variation within each regional register can be wide. The three-year average prevalence rates are shown in Table 1. There was a four-fold difference in gastroschisis prevalence across the different registers, ranging from 1.6 to 6.2 per 10,000 total births.

Recent trends Geographically there appears to be a north – south divide in rates of gastroschisis across the UK: registers covering southern England have a lower prevalence than those covering the Midlands, northern England, Wales and Glasgow (Table 1). Around 40% of babies with gastroschisis are born to mothers under the age of 20 years compared with only 9% of overall births (Figure 3). The median maternal age for mothers having babies with gastroschisis, over the period 1994 to 2004, was 21 years. This compares with an overall median maternal age of approximately 28 years for all births in England. The unmistakable relationship between the increasing prevalence of gastroschisis with decreasing maternal age can be seen in Figure 4. Over the past 10 years, the average prevalence of gastroschisis for mothers over the age of 30 years was less than 1.0 per 10,000 total births, this increased to 2.0 per 10,000 total births for mothers aged 25 to 29 years, to 5.5 per 10,000 total births for mothers aged 20 to 24 years and to 18.0 per 10,000 total births for mothers aged less than 20 years.

Table 2 The different monitoring systems

Name

NATIONAL CONGENITAL ANOMALY SYSTEM (NCAS)

BRITISH ISLES NETWORK OF CONGENITAL ANOMALIES REGISTER (BINOCAR)

Description

A National Congenital Anomaly System (NCAS), operated by the Office for National Statistics (ONS), was established in 1964 in response to the thalidomide tragedy.

The British Isles Network of Congenital Anomalies Registers (BINOCAR) was set up to overcome problems with NCAS. BINOCAR reports results to the Office for National Statistics.

Coverage

System covers all of England and Wales.

To date, system covers only half of England.

Method

Reactive collection of data, based on a voluntary notification system.

Proactive collection of data.

Non-standardised collection/ registration protocols.

Standardised collection/ registration protocols.

Only collects information on live and stillbirths (no information on anomalies associated with terminations/ spontaneous abortions).

Collects information on live births, stillbirths and terminations of pregnancy. Carries out variety of audit (e.g. into perinatal diagnosis) and research projects (e.g. into causes of specific anomalies).

Data

This increasing prevalence of gastroschisis over time appears to be mainly in mothers under the age of 20 years, where numbers have risen from 8.9 to 24.4 per 10,000 births over the period 1994 to 2004 (the provisional figure for 2004 is likely to increase, as data are not yet finalised). Prevalence also increased in mothers aged 20 to 24 years, although not by as much (4.8 to 7.5 per 10,000 births). In all the older age groups of mothers, rates of gastroschisis have remained relatively stable.

Causation and risk factors The cause of gastroschisis is unknown but the main theory is that it results from disruption to the blood supply in early pregnancy. As a result, a number of influences upon the developing circulatory system of a fetus have been claimed as risk factors: maternal use of aspirin, recreational drug taking in early pregnancy, social disadvantage, smoking, poor diet and environmental factors. Links between some of these risk factors and young maternal age are well established.

Figure 3 Distribution of gastroschisis births and total births by mother’s age

<20

20–24

25–29

Known to be incomplete (e.g. where late confirmation of diagnosis).

Regular checks to ensure completeness of data (facilitated by close links with collaborating physicians).

30–34 Maternal age (years)

Accuracy

35–39 Gastroschisis cases All births

>=40 0%

10%

20%

30%

Proportion of births

Source: BINOCAR registers 1994–2004

40%

Figure 4 Prevalence of gastroschisis according to the mother’s age 30

20 years

20–24 years

25–29 years

30–34 years

35–39 years

40 years

Rate er 10 000 total irths

1994

1996

1998

2000

Year of delivery Source: BINOCAR registers 1994–2004

2002

2004

CMO ANNUAL REPORT 2004

4 Gastroschisis: a growing concern

The importance of accurate registers

The differences between the two systems are highlighted in Table 2. BINOCAR registers are reporting twice as many gastroschisis cases as NCAS, which highlights the high level of routine under-reporting of this condition. The under-reporting of all congenital anomalies in the areas not covered by a BINOCAR register is of major public health concern. Congenital anomaly registers not only help alert populations to problems of increasing prevalence in specific anomalies or syndromes, they also enable experts to carry out investigations into increasing trends and possible clusters. As the causes of many congenital anomalies are still unknown, continued monitoring of and investigation into their occurrence should be a priority for public health. Networks such as BINOCAR and EUROCAT provide an existing framework for such investigations and enable collaborative work to facilitate research into the causation of rare anomalies.

Since 1964, the National Congenital Anomaly System (NCAS) at the Office for National Statistics has monitored the numbers of congenital anomalies reported by health authorities. Registers have also been set up in some regions to collect cases of congenital anomalies. Sometimes their focus is pre-natal diagnosis and counselling, in others it is part of epidemiological studies. Registers collecting cases of specific anomalies such as Down’s syndrome and facial clefts have also been set up. All these registers are part of the British Isles Network of Congenital Anomalies Register (BINOCAR). BINOCAR was set up jointly, in 1996, by the Office for National Statistics and Dr David Stone at the Glasgow Register of Congenital Anomalies. The purpose of the network is to bring together all those working in the field of monitoring and reporting on congenital anomalies with the aim of improving the system.

Figure 5 United Kingdom and Republic of Ireland coverage of local congenital anomaly registers, 2004

Coverage by local registers Areas not covered by the local registers

The funding of such registers is not secure and many registers are forced to divert valuable time away from collecting, analysing and interpreting the data to lobbying for their continued existence. A template for the establishment of congenital anomaly registers is readily available with support provided from established registers. The provision of national funding for regional congenital anomaly registers would allow work to continue to safeguard the health and wellbeing of all mothers and infants across the whole of England.

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4 Gastroschisis: a growing concern

ACTION

RECOMMENDED

1 Research should be commissioned to establish the cause of gastroschisis and the reasons for the prevalence trends being seen.

The geographical coverage and reporting rigour of regional congenital anomaly registers should be increased and central core

funding should be made available to secure the long-term future of these precious national resources.

LEARNING HOW TO LEARN COMPLIANCE WITH PATIENT SAFETY ALERTS IN THE NHS

CMO ANNUAL REPORT 2004

5 Compliance with patient safety alerts in the NHS

KEY POINTS

Until recently, healthcare worldwide placed less focus on safety than other high-risk industries did.

Patient safety is now a key priority for the NHS and many other health services around the world.

The modern approach to improving safety not only concentrates on the provision of well-trained, conscientious staff but also on the strengthening of weak systems. In this way, while human error cannot be prevented, its impact can be reduced.

A major step towards improving patient safety is to ensure that, when patients are harmed, sources of risk are identified, solutions are implemented comprehensively and lessons are learned.

One way in which solutions are implemented in the NHS is through the issue of a patient safety alert.

Four recent examples of alerts were studied to assess compliance. It was found that: (a) compliance was slow and some deadlines were not met,

even though taking action could reduce the risk of a patientâ&#x20AC;&#x2122;s death; and (b) some NHS trusts reporting compliance were found, on independent inspection, to be non-compliant. 7

The NHS has not yet fully embraced the culture of patient safety.

Patient safety is now a key priority for the NHS and many other health services around the world.

In 2004, the airline industry was able to claim its safest year ever. No European or American airline had crashed in the previous three years. This major achievement in a previously high-risk, industry has been hard won. Air safety has been a focus for the airline industry for four decades. Lessons have been learned from the major disasters, reporting systems have been developed to analyse all incidents – both big and small – that could be a source of future risk, and a culture of safety has been actively and consistently promoted. Regular and sustained improvements have been made to reduce the risk of air travel for passengers and crew. In healthcare, the position is entirely different. It is only relatively recently that attention has been focused on the safety of patient care as an issue. Despite the relatively high level of risk associated with healthcare – roughly one in 10 patients admitted to hospital in developed countries suffers some form of medical error – systematic attempts to improve safety and the transformations in culture, attitude, leadership and working practices necessary to drive that improvement are only just beginning. This country was one of the first to give priority to tackling this problem. In 2000, I produced the first ever comprehensive report on patient safety in the UK. An organisation with a memory outlined the problem and set out a strategy to deal with

it. A second report, Building a safer NHS for patients, set out an implementation plan in detail. The National Patient Safety Agency was established to develop and maintain a reporting system for adverse events and ‘near misses’ so that they could be analysed, and the sources of risk identified and acted upon. One of the mechanisms for improving patient safety – though not the only one – is the seemingly simple process in which a national alert is sent to local NHS organisations, which they are then asked to act upon. Given the higher profile currently accorded to patient safety, this chapter reviews the alert system and the extent to which NHS hospitals have complied with it in a number of key risk areas.

Example 1 Safety of anaesthetic machines In November 2000, a 3-year-old girl died in the Accident and Emergency Department of Newham Hospital, London. She was mistakenly given pure nitrous oxide gas instead of oxygen. In the urgency of the moment – the need to resuscitate a seriously ill child – a doctor mistakenly administered nitrous oxide only. It was a classic human error in an already unsafe system. It need not have happened, had the anaesthetic machine been fitted with a safety guard or an alarm warning of the administration of a low level of oxygen.

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The then Medical Devices Agency (MDA) issued an alert in May 2001 (Anaesthetic Machines: Prevention of Hypoxic Gas Mixtures). This advised that all anaesthetic machines capable of delivering hypoxic (low oxygen level) gas mixtures must have a hypoxic guard fitted or must be fitted with an oxygen analyser providing audible alarms that warn of the delivery of hypoxic gas mixtures. Many older machines could not be fitted with a guard because they were not originally designed to accept one. Therefore, they were reliant on alarms as their safety feature. In practice, many NHS Trusts decided to replace the machines with new ones to overcome the difficulty. At the time, the Department of Health checked the number of such machines in the country and the number that had safety features. As a follow-up to the safety notice, in October 2001, the chief executive of the then Medical Devices Agency and I wrote jointly to chief executives of NHS Trusts and Regional Directors of Public Health asking them how the actions recommended in the safety notice had been implemented. The Regional Directors of Public Health, at my request, undertook a great deal of detailed work to emphasise the importance of early compliance. By July 2002, of the 5,843 anaesthetic machines in NHS hospitals in England, 186 had neither an oxygen analyser nor a hypoxic guard. However, of these, 47 had

had their ability to deliver hypoxic mixtures disabled, meaning that they could deliver oxygen or air only. All other anaesthetic machines in use in the NHS in England (5,657) complied with the safety notice by having at least one or other of the safety devices fitted. Many of the non-compliant machines were put out of service and NHS Trusts ordered new, compliant machines. All NHS Trusts with non-compliant machines gave assurances that these would be replaced or made compliant. By November 2002, all NHS Trusts reported (through the Regional Directors of Public Health) that they were compliant with the original patient safety alert. In the meantime, the Royal College of Anaesthetists recommended that trainee anaesthetists should not use machines without hypoxic guards. A subsequent survey, conducted through the Association of Anaesthetists of Great Britain and Ireland’s (AAGBI’s) network of Anaesthetic Equipment Officers, identified that 25 NHS Trusts were still using one or more older-style machines. While NHS Trusts had declared these compliant with the conditions of the original alert, there were concerns that these might still deliver a hypoxic gas mixture. In January 2005, after discussion with the various agencies concerned with safety and with the Association of Anaesthetists of Great Britain and Ireland (AAGBI), a further

5 Compliance with patient safety alerts in the NHS

TIMELINE

COMPLIANCE WITH SAFETY NOTICE ON OXYGEN DELIVERY BY ANAESTHETIC MACHINES NOVEMBER 2000 – 3-YEAR-OLD GIRL DIES AT NEWHAM HOSPITAL AFTER BEING GIVEN PURE NITROUS OXIDE GAS INSTEAD OF OXYGEN MAY 2001 – SAFETY NOTICE ISSUED TO THE NHS ON PREVENTION OF HYPOXIC GAS MIXTURES BEING DELIVERED BY ANAESTHETIC MACHINES OCTOBER 2001 – COMPLIANCE REPORTS REQUESTED FROM NHS TRUST CHIEF EXECUTIVES JULY 2002 – NATIONAL PICTURE SHOWS 5,657 ANAESTHETIC MACHINES ARE COMPLIANT AND, 186 ARE NOT COMPLIANT, 139 OF WHICH ARE STILL IN USE WITHOUT RISK-REDUCTION MODIFICATION NOVEMBER 2002 – NHS TRUSTS REPORT THAT ALL ANAESTHETIC MACHINES ARE COMPLIANT 2003 – ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN AND IRELAND SURVEY IDENTIFIES 25 NHS TRUSTS WITH OLDER– STYLE MACHINES JANUARY 2005 – NHS TRUSTS RECOMMENDED TO REPLACE THE FEW REMAINING OLDER-STYLE MACHINES

notice was issued requesting consideration of replacing these very few remaining olderstyle anaesthetic machines with modern versions that have anti-hypoxic mechanisms. Alternatively, the NHS organisations concerned were asked to consider whether the use of these machines was still essential, given the ongoing possible risks to patients. This was one of the first alerts sent out to the NHS since the increased attention that had been given to the subject of patient safety more generally. My report, An organisation with a memory, had been published and, in regular conference speeches to NHS audiences, I had championed the issue widely. Moreover, in my speeches I had often used the example of the child who died in Newham as an illustration of how patients could be put at risk and how safety could be improved. At first sight the speed of compliance with the alert appears slow: full compliance had still not been achieved 18 months after the alert was issued. Admittedly, many NHS Trusts were replacing old machines with new ones and this was a major undertaking across the country. Analysis in this case study also illustrates that there should be

more regular consultations with key stakeholders. The Association of Anaesthetists of Great Britain and Ireland and the Royal College of Anaesthetists, key professional bodies with expertise in this area, still had concerns about the safety of the residual older machines, and this perspective could have been built into the assessment of earlier visits.

Example 2 Compliance with intrathecal chemotherapy guidance A second example relates to the compliance with national guidance published on the safe administration of intrathecal (spinal) chemotherapy. This is a necessary treatment for some forms of cancer to keep the disease in remission. National concern was expressed when it was highlighted in my report, An organisation with a memory, that patients could be killed if the wrong drug is injected intrathecally, particularly a drug such as vincristine, which is commonly given intravenously as part of the same course of treatment. A target for elimination of this kind of fatal accident was set, but, in the interim, teenager Wayne Jowett was

CMO ANNUAL REPORT 2004

killed in Nottingham in very similar circumstances to earlier deaths. Progress in addressing this problem was reviewed in my 2002 Annual Report and drew attention to the production of national guidance on the safe administration of intrathecal chemotherapy, which was issued to the NHS in November 2001, based on the recommendations of the Toft report into the death of Wayne Jowett. This guidance was much stricter than anything previously published – for example, establishing and maintaining a register of named personnel who are certified as trained and competent to carry out intrathecal chemotherapy tasks. Progress has also been made with manufacturers to design and test connectors that will help prevent the wrong drug being injected and, should this prove possible, it will act as an additional safeguard. According to the guidance issued in November 2001, NHS Trusts were required to complete a checklist, confirming compliance, by the end of December 2001. By March 2002, 32 (21%) NHS Trusts remained non-compliant and it was Summer 2003 before full compliance was achieved. Compliance was achieved only by: • discussions between the hospitals

concerned and the Department of Health’s then performance management arm (the directorates of health and social care) • interventions by the nine Regional Directors of Public Health • direct intervention by myself as Chief Medical Officer • a warning by a health minister that chairs of non-compliant NHS Trust Boards would be personally held to account. Following feedback from peer review visits, revised guidance was issued in October 2003 for implementation by 30 November 2003. However, by the following summer (June 2004), 30 (21%) NHS Trusts were still considering or assessing it and, by the following autumn (November 2003), 17 (12%) NHS Trusts were still not able to report compliance. It took warning letters and telephone calls to chief executives of those NHS Trusts to achieve full reported compliance across the NHS by January 2005. A national cancer peer review programme started in November 2004 to assess, among other things, compliance with 50 intrathecal chemotherapy measures based on the revised guidance. Of the 19 NHS Trusts providing intrathecal chemotherapy services that had been reviewed by April 2005, nine

5 Compliance with patient safety alerts in the NHS

TIMELINE

COMPLIANCE WITH INTRATHECAL CHEMOTHERAPY GUIDANCE NOVEMBER 2001 – NEW GUIDANCE ISSUED CONTAINING RIGOROUS REQUIREMENTS FOR PATIENT SAFETY WITH COMPLIANCE SET FOR END DECEMBER 2001 MARCH 2002 – REVIEW OF SELF-ASSESSMENT RETURNS SHOWS 32 (21%) NHS TRUSTS NOT FULLY COMPLIANT JANUARY 2003 – REVIEW OF FURTHER SELFASSESSMENT RETURNS SHOWS 44 (34%) NHS TRUSTS NOT FULLY COMPLIANT MAY 2003 – EXTERNAL PEER REVIEW SHOWS 26 (18%) NHS TRUSTS NON-COMPLIANT JUNE 2003 – ALL NHS TRUSTS CONFIRM COMPLIANCE OCTOBER 2003 – REVISED GUIDANCE ISSUED JUNE 2004 – 30 (21%) NHS TRUSTS STILL ASSESSING THE NEW GUIDANCE OR HAVE NOT COMPLETED IMPLEMENTATION NOVEMBER 2004 – 17 (12%) NHS TRUSTS STILL NOT REPORTING COMPLIANCE NOVEMBER 2004 – GUIDANCE CONVERTED INTO 50 MEASURES AGAINST WHICH TRUSTS COULD BE PEER REVIEWED DECEMBER 2004 – 3 (2%) NHS TRUSTS NOT YET COMPLIANT JANUARY 2005 – ALL NHS TRUSTS REPORTING COMPLIANCE MAY 2005 – FURTHER EXTERNAL PEER REVIEW VISITS SHOW 9 OUT OF 19 NHS TRUSTS VISITED ARE NOT SATISFACTORILY COMPLIANT REMAINDER OF NHS TRUSTS PROVIDING INTRATHECAL CHEMOTHERAPY TO BE VISITED OVER THE NEXT 18 MONTHS

(47%) were non-compliant on inspection despite three of these having claimed compliance prior to the inspectorsâ&#x20AC;&#x2122; visits. These NHS Trusts are now either compliant or no longer providing an intrathecal chemotherapy service. So serious were some of the breaches that services were suspended. The peer review process will continue over the next 18 months. The performance of the remaining NHS Trusts, against the intrathecal chemotherapy standards, will need to be monitored extremely closely by the Department of Health and remedial action taken where necessary. It is difficult to imagine a higher profile patient incident in the NHS in England than the death of Wayne Jowett. It was used as a case study in the report, An organisation with a memory. I have used it extensively in conference speeches to illustrate how human error in a weak care system can cause a patientâ&#x20AC;&#x2122;s death. It was the subject of a major independent review (the Toft Report), which identified at least 40 system failures that led to Wayneâ&#x20AC;&#x2122;s death. The case was also the subject of international academic study, again because it was such a powerful tool to help health professionals and managers understand patient safety. Although a very rare event, a targeted challenge was established by the report, An organisation with a memory (later adopted by the Government), to eliminate this source of risk for the NHS. Intrathecal injection safety was the subject

of an award-winning training video. In spite of all this, and of the continuing risk of another tragic death in their hospitals, NHS Trusts took 19 months to comply with the original guidance and 18 months to comply with revised guidance and, worse still, after a first round of peer review visits, 47% of NHS Trusts were still not fully compliant with the latest up-to-date guidance. This case study reveals much about the safety culture of the NHS, which is clearly not yet focused or organised enough to reduce a potentially fatal risk to patients rapidly enough.

Example 3 Prevention of suicide by hanging from non-collapsible bed and shower curtain rails in mental health in-patient units In the report, An organisation with a memory, it was proposed that services should eliminate to zero, by 31 March 2002, the number of suicides among mental health inpatients by hanging from non-collapsible bed or shower curtain rails on wards. In preparing to achieve this target, in the year 2000, the then NHS regional offices consulted with local mental health services to draw up detailed action plans. The Department of Health agency, NHS Estates, was also involved in overseeing local progress in meeting this important objective. Individual action plans were analysed to

CMO ANNUAL REPORT 2004

ensure that they were on course to meet the target, and clarification was sought from mental health services where they had indicated delays in programmes or where compliance was dependent on funding not yet identified. Six NHS Trusts failed to meet the deadline of 31 March 2002, but by the end of May 2002, all NHS Trusts with mental health in-patient facilities reported full compliance. The programme of work to remove noncollapsible bed and shower curtain rails was centrally led and, given that it required installation of new equipment right across the country, was very well managed. Unrelated to this management activity, a national clinical audit of suicide and homicide involving mental health patients, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, subsequently identified that suicides by hanging from non-collapsible rails had not been completely eliminated. A further alert was therefore issued to the entire NHS in November 2004, reminding NHS Trusts providing mental health services of the requirement to remove non-collapsible bed or shower curtain rails. Four NHS Trusts appear to have either: a slower programme of replacement of these fittings, based on their own risk assessments, which have indicated that the risk of injury to patients from collapsible fittings outweighs the risk of suicide have no plans to remove non-collapsible

bed or shower curtain rails because of the concerns about the risk of injury to patients as outlined above. Each of these NHS Trusts will be visited by a national team who will assess the risks and will agree with the individual management teams the further action to be taken, including to: assess previous incidents of harm to patients or staff as a result of using rails as weapons and how high these risks are seek to establish that the wards in question with non-collapsible rails house only frail/dementia patients â&#x20AC;&#x201C; elderly patients may be capable of committing suicide by hanging establish what areas have been identified as low risk and why. This action is being pursued as a matter of urgency. What gives rise to concern in this example is the fact that some self-reports of compliance by NHS Trusts (albeit very small in number) proved unreliable when information came to light independently through a national confidential enquiry into suicide by people with mental illness. Nevertheless, there has been an encouraging fall in the number of in-patient suicides, from all causes, in England. The figure was 195 in 2000 when An organisation with a memory was published and was 156 in 2002 (the most recent year for which data are available), representing a fall of nearly 20%.

5 Compliance with patient safety alerts in the NHS

Example 4 Early experience with alerts issued through a new electronic Safety Alert Broadcast System A Safety Alert Broadcast System (SABS) was established following my recommendation to health ministers that a replacement for the paper-based alert system from multiple sources, and with no way of assessing compliance, was required. The new system is available to all health authorities, NHS Trusts and primary care organisations. The primary purpose of the system is to facilitate the issuing and dissemination of alerts, including cascading the information to all relevant organisations, and to allow monitoring of compliance with deadlines for completion of alerts. The Safety Alert Broadcast System allows for regular updating and monitoring of progress by those organisations that need to take action to comply with an alert. There are varieties of action states, ranging from ‘action required but not yet started’ to ‘action started but not complete’ and ‘action fully completed’. Over time, as the deadline approaches, it is expected that increasing numbers of NHS organisations will be able to confirm that action has been completed. Each safety alert is given a final deadline by which all

relevant organisations are expected to complete the required actions. An early experience of making use of the Safety Alert Broadcast System involved an alert issued about the use of oral methotrexate. Oral methotrexate is a safe and effective medication if taken at the right dose and with appropriate monitoring. The National Patient Safety Agency (NPSA) became aware of 137 patient safety incidents over the last 10 years in England due to problems when taking the medication. This included 25 patient deaths and 26 cases of serious harm. Two-thirds (67%) of these incidents involved prescribing the wrong frequency of dose of the tablets; 19% were due to a lack of or poor monitoring of therapy; and 7% were because of misidentification of the tablets by professionals or patients. In July 2004, the National Patient Safety Agency issued an alert to the NHS about oral methotrexate, highlighting safety problems and advising NHS organisations to: agree local action required provide patient information (with recommended core content) update prescribing and software programmes review purchasing.

Figure 1 Numbers of health organisations responding to oral methotrexate patient safety alert 600

500

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0 All responding organisations

Alert not applicable

Alert applicable – action required

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Figure 2 Reducing the harm caused by oral methotrexate: percentage of organisations achieving compliance with the patient safety alert over time

Percentage of organisations that have complied

100 90

Deadline: 245 days

80 70 60 50 40 30 20 10 0 80

100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 Days since alert issued

The National Patient Safety Agency received a number of queries from patient groups and clinicians about the patient information element of the alert. In order to address these concerns, an update was issued in November 2004. This emphasised that the recommended core content of patient information was to be used only in conjunction with existing guidance and patient information from authoritative sources. Analysis of the information held in the Safety Alert Broadcast System shows that there has been significant variation in the time taken by NHS Trusts and primary care organisations to achieve full completion of the actions required to reduce the harm from oral methotrexate. The alert and update issued in 2004 had a deadline for final completion of 31 March 2005. Figure 1 shows how many organisations were expected to respond to the original alert, where action was necessary and the number to which the alert was not applicable. The alert was applicable to 498

organisations, with action to be completed by 31 March 2005. The total time between the issue of the alert and the deadline for completion was 245 days. As Figure 2 shows, 20% of organisations had completed action within the first 80 days. This number rose steadily but slowly, so that by the deadline date some 45% of organisations had achieved full completion â&#x20AC;&#x201C; well short of the 100% required. More than 50 days beyond the deadline, the percentage of organisations reporting full completion of the actions had risen to only 54%. The fact that 46% of organisations that needed to take action had not been able to complete the action well beyond the deadline is a matter of some concern, particularly given the background of harm caused by the inappropriate use of oral methotrexate. Failure to meet the deadline does not mean that organisations have not taken any action, but it does show that significant numbers have been unable to complete the action for one reason or another. It also raises the question as to whether the deadline for completion was realistic and achievable.

5 Compliance with patient safety alerts in the NHS

Figure 3 Reducing the harm caused by oral methotrexate: percentage of health organisations within strategic health authority areas achieving compliance with the patient safety alert Strategic health authority NE London N and E Yorkshire & N Lincolnshire Essex SE London Bedfordshire & Herts W Midlands

Overall completion 54%

Analysis at strategic health authority (SHA) level also showed variable performance: the percentage of NHS organisations covered by each strategic health authority that complied by the deadline ranged from just 20% to 88% (Figure 3). In all, 16 out of 28 SHAs had compliance rates below the overall average of 54%. Comprehensive data are not yet available for the Safety Alert Broadcast System but early analysis suggests that differences in the ability of NHS organisations to comply with safety alert actions by deadlines are also apparent for many other alerts. The Safety Alert Broadcast System that I recommended to health ministers replaced the old system of multiple, paper-based returns, variable in format and emanating from different sources. Under the new system, all alerts arrive in a simple electronic mailbox in each NHS organisation. It is early days for this modernised system, but the evidence of slow and variable compliance is as apparent here as in the other three case studies (which initially used paper alerts). This suggests that the problems of compliance are at least partly with the current safety culture of the NHS rather than purely with the method of dissemination of information about risk to patients and how to reduce it.

Leicestershire, Northamptonshire & Rutland N Central London Birmingham & The Black Country NW London Cheshire & Merseyside Kent & Medway Northumberland, Tyne & Wear SW London Surrey & Sussex Hampshire & Isle of Wight Avon, Gloucestershire & Wiltshire Trent Co Durham & Tees Valley Cumbria and Lancashire S Yorkshire Thames Valley Shropshire & Staffordshire Dorset & Somerset Norfolk, Suffolk & Cambridgeshire SW Peninsula W Yorkshire Greater Manchester 0

Percentage complying

100

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5 Compliance with patient safety alerts in the NHS

ACTION

RECOMMENDED

Information on compliance with patient safety alerts by individual NHS organisations should be made public so that patients can be aware of servicesâ&#x20AC;&#x2122; performance.

The Healthcare Commission should place a special focus on NHS organisationsâ&#x20AC;&#x2122; compliance with safety alerts through Safety Alert Broadcast System.

Foundation Trusts, being the apparent elite of NHS hospitals, should show the highest levels of compliance with patient safety alerts and their performance should be noted by the regulator for this sector (Monitor).

A national group with a fixed-term of two years should review experience of all patient safety alerts, identify barriers to compliance and provide general guidance.

SPOTLIGHTING LOCAL HEALTH AND INITIATIVES

CMO ANNUAL REPORT 2004

Spotlighting local health and initiatives

Spotlighting local health and initiatives Improving the population’s health, by preventing disease or delaying its onset and by reducing health inequalities, is a national priority. The delivery of these goals, however, often depends on action at the local level. The Department of Health operates at both national and regional levels through the presence of teams in each regional government office. Each regional team is led by a Regional Director of Public Health, who works alongside senior officials from other government departments in the regional government offices. There are nine regional government offices across the country. The management structure of the NHS is organised into strategic health authorities (SHAs) that, together, provide coverage for the whole of England. Within each strategic health authority’s boundaries are between

five and 19 primary care trusts (PCTs). The primary care trusts receive funds allocated by the Government for the NHS. They plan and provide primary care services, public health services, commission hospital care in accordance with the needs of their populations and each has a public health team. In this section of the Report, each of the geographical areas covered by England’s nine public health regions highlight a local health problem or initiative. This section is not intended to provide a comprehensive review of the health of each region but aims to highlight specific issues, such as a striking finding drawn from analysis of health statistics or an interesting health intervention implemented by the public health teams in the region.

NORTH EAST Worklessness and health

Worklessness and ill-health are closely related. While unemployment and economic inactivity are associated with higher rates of poor health, mental illness and premature death, poor health can itself lead to difficulties in both securing and retaining employment. These two factors can become entwined, leading to a spiral of decline in disadvantaged populations. In turn, high levels of worklessness serve to put a brake on the economic regeneration that would help to solve the problem in the longer term. Levels of worklessness are high in the North East of England with a high proportion of the population claiming Incapacity Benefit. In fact, the percentage of the working age population claiming Incapacity Benefit is higher in the North East than in any other English region: there are presently around 160,000 Incapacity Benefit claimants in the North East, representing more than 10% of the working age population. Within the region, some areas have particularly high levels of Incapacity Benefit claimants. In Easington, 19% of working age

people claim Incapacity Benefit, and in five other areas (Sedgefield, Hartlepool, Wear Valley, Gateshead and Sunderland) levels are above 10%. Understanding and addressing this position will contribute significantly to economic regeneration in the North East, leading in turn to improvements in population health and a reduction in health inequality. Although it may be suggested that variation in the numbers of Incapacity Benefit claimants may relate to financial incentives and economic factors, the data shows that numbers are also closely related to measures of population health, as illustrated in Figure 1. The difference between people being unwell and in work – and those who are unwell and out of work – is often subtle and difficult to address. However, given the health problems underlying the majority of worklessness related to incapacity, initiatives to improve economic recovery by reducing worklessness are more likely to be successful if they include measures to address health needs. In the North East, public health teams have been actively engaged in the early stages of initiatives such as the Department for Work and Pensions’ Pathways to Work pilots. Reducing worklessness is also a key objective of the Northern Way approach to

regeneration, with particular emphasis on tackling individual health and employment

Progress since the 2003 Annual Report

Dental health variation in children The 2003 Annual Report highlighted wide variations in dental health among five yearolds in the North East region. For example, surveys had identified a more than threefold variation in the number of decayed, missing and filled teeth between Hartlepool (average 0.86 per child) and South West Durham (average 2.82 per child). These variations were attributed to water fluoridation and deprivation. Organisations in the region are supporting the Government’s fluoridation strategy. Since the 2003 Annual Report, the Department of Health has drafted – and Parliament has agreed – water fluoridation regulations, which came into force on 1 April 2005. These regulations set out the process which strategic health authorities must

CMO ANNUAL REPORT 2004

follow before they can require water companies to fluoridate water. These regulations will enable local primary care trusts to take action to address these inequalities.

Figure 1 Relationship between Incapacity Benefit and limiting long-term illness in the working-age population

12 orth ast Percentage claiming Incapacity Benefit

0 10

Percentage with limiting long-term illness egional

o ernment

ffices

Spotlighting local health and initiatives

LONDON The 2012 Olympic bid – a lasting health legacy

Current levels of physical activity in London are low. Londoners are less physically active than the average for England: over 65% of men, 75% of women, 33% of boys and 50% of girls are not sufficiently active for good health. London’s children and young people have higher levels of obesity than any other region in England. The 2012 London Olympic bid has created a unique and exciting opportunity to strengthen the existing public health agenda and promote greater levels of physical activity in the capital’s population and across the country. The bid strongly reinforces the relationship between regular exercise and better physical and mental health. Regular exercise can reduce the risk of obesity and illness in general, as well as diseases such as coronary heart disease, stroke and Type 2 diabetes. The first of several physical activity co-ordinators for the health authorities in London has now been appointed. This is a joint funding initiative between the NHS in London and Sport England (London region) and will help to make practical connections

on the ground across the relevant agencies. The Department of Health and the NHS are also supporting the Sport England target of increasing participation in sport and physical activity by an average of 1% per year. The many benefits to health of hosting the 2012 Olympic and Paralympic Games will not be confined to the six-week competition period alone. A Health Impact Assessment Study has clearly demonstrated potential longer-term health benefits of hosting the Games. A National Sports Medicine Centre, which would have been developed regardless of the outcome of the Olympic bid, emphasises rehabilitation, education and research. The centre will not only be used by the world’s top athletes but its use will also be extended to local NHS and primary care facilities, providing services for anyone who plays sport and supporting the goal of increasing physical activity. Hosting the Olympics will also boost the recently established medical specialty of sports and exercise medicine, supporting the number of doctors receiving

training in an area that is increasingly becoming an important focus in healthcare. There are also wider benefits for health. The building developments that will take place offer an opportunity for regeneration, skills development and healthy sustainable development projects. Public health in London – and around the country – has already benefited, from the bid alone, through the promotion of greater levels of physical activity in the high-profile Back the Bid campaign. The 2012 Olympic bid underpinned and promoted existing public health strategies aimed at encouraging physical exercise. By drawing attention to the importance of these strategies, the bid itself, and the fact that we are now hosting the Games, offers tremendous potential to increase their impact.

CMO ANNUAL REPORT 2004

Progress since the 2003 Annual Report

minorities The 2003 Annual Report drew attention to the 2.9 million residents in London from ethnic groups other than white British, focusing in particular on the importance of ethnic information in order to plan, commission and deliver accessible healthcare services. Progress has been made in two main areas. Data collection has been improved by meeting the requirements of the Race Relations Amendment Act. This has prompted more robust and complete ethnicity data across the public sector, increasing the proportion of in-patient data with complete ethnic coding. In addition, primary care trusts are using health equity audit to identify differences related to race and ethnicity in service access and uptake. For example, ethnicity data in smoking cessation services are being used to focus services more appropriately and to ensure that they are culturally competent. Secondly, the London Health Observatory, working for the Association of Public Health Observatories (APHO), is leading a national analysis of ethnicity and health in the regions, which will be available in August 2005.

Spotlighting local health and initiatives

EAST MIDLANDS

Progress since the 2003 Annual Report

Defusing the obesity time bomb

Controlling tuberculosis

In recent years, the prevalence of obesity among East Midlands’ women has been consistently 4% higher than England – 26% as opposed to 22%. The highest prevalence of female obesity is in households where the reference person is classified as social class V (unskilled manual). In the same period, the prevalence of obesity among men in the East Midlands (23%) was also comparatively high but was not significantly different from the figure for England (21%). Levels of health in the East Midlands are improving but there are wide variations across the region, with poor diet being a particular problem. The East Midlands’ diet is notably higher in sugar and fat than the rest of England. The challenges to diet facing the region are the same as those faced by the country as a whole. These include: increasing the consumption of fruit and vegetables reducing intakes of salt, added sugars and fat (total and saturated); and encouraging physical exercise.

two of which specifi of obesity acr firstly, to impr incr Midlands r White Paper, tackling obesity is a key priority for action. The region currently has 98% of schools signed up to the School Fruit and Vegetable Scheme. Through the Investment for Health strategy, a regional Food and Health Action Plan will be developed and published in autumn 2005. A regional physical activity plan, Active East Midlands, is already in place and regional food and health and physical activity networks are now established to drive forward the assault on obesity. A Regional Obesity Framework (currently under development) will bring together and link all action on obesity across the East Midlands, and will be delivered through a regional obesity task force. These measures will significantly tackle the threat to public health posed by rising levels of obesity.

The 2003 Annual Report focused on the high rates of tuberculosis (TB) in the region. The East Midlands has the third highest rate of TB notifications of the nine English regions, representing an increase of about 20% compared with 1999. Since the publication of last year’s Annual Report, health communities have increasingly recognised the importance of TB as a threat to public health and have invested in the improvement of disease prevention and treatment services. This work has been supported by an increase in human resources for TB services. For example, services in Leicestershire – a TB ‘hot spot’ – have benefited from an increase in staffing of around 30% over the last 12 months. There has also been an increase in staffing at the TB services in Northamptonshire from one post to two. There has also been an improvement in response times, for example: the TB service in Leicestershire has recently reviewed the way it operates and has set challenging new targets for accelerating its response times. As a result, patients are being referred more efficiently and treatment begins more quickly. Referral and treatment lead times are undergoing audit from 5 June 2005.

In addition, there have been improvements in the laboratory analysis of TB strains. Services across the East and West Midlands are working in collaboration on a project that uses molecular typing to identify specific strains of the TB bacterium. This technique helps specialists to identify the links between

CMO ANNUAL REPORT 2004

Spotlighting local health and initiatives

cases and enables them to target their contact-tracing activity more effectively. So far, the increased investment in resources – both human and financial – has paid off: TB incidence in the region has fallen from 12 cases per 100,000 population in 2002 to nine cases per 100,000 in 2003.

Whilst there is no room for complacency (provisional figures for 2004 show a rise to just under 10 cases per 100,000), the fact that these figures are the lowest for five years is encouraging.

Figure 1 Trends in female age-adjusted obesity prevalence (%): East Midlands and England 30

Figure 2 Trends in male age-adjusted obesity prevalence (%): East Midlands and England 25

25 20

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Source: Health Surveys for England 1994 to 2002 *Data calculated on three year moving average

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WEST MIDLANDS High levels of death in early life

A distinctive public health problem in the West Midlands is perinatal mortality (stillbirths and deaths in the first week of life) and infant mortality (deaths in the first year of life) with consistently higher than national rates. The West Midlands is showing increases in infant mortality against a downward national trend. There is a wide variation across the region with two local authorities having rates of infant mortality that are almost double the national rates. In 2003, there were 850 perinatal and infant deaths in the West Midlands, the vast majority (648) occurring before the first week of life. The region has the highest infant mortality rate, at 7.3 deaths per 1,000 live births (Figure 1), and the highest perinatal mortality rate, at 10.1 deaths per 1,000 total (live and stillbirths) (Figure 2), compared with rates for England of 5.3 and 8.5 respectively. Providing a sure foundation through healthy pregnancy and early childhood is vital to the well-being of both mother and child. Key specific public health interventions in this area include:

ensuring appr health advice increasing br r Overall, the W smoking in pr teenage pr variation acr Br national average. Although there ar actions that have been taken to tackle this health issue at a local level, further work is needed to better understand the other factors involved, such as the relationship between ethnicity and infant and perinatal mortality rates. In addition to local action, a regional health partnership has been formed which is overseeing regional delivery of key health priorities, of which reducing infant mortality is one. Later this year, the Regional Director of Public Health will produce a special report on health inequalities in the region with a focus on infant mortality. In conjunction with the West Midlands Perinatal Institute and the West Midlands Public Health Observatory, the report will explore premature birth, very low birthweight, breathing difficulties, teenage pregnancy and congenital anomalies.

Progress since the 2003 Annual Report

High levels of obesity in females The 2003 Annual Report reported that the West Midlands has the second highest level of obesity for the female population aged 16 to 64 years, a figure approaching 30% of the population. Work in the region to tackle the problem has been undertaken in several areas. A regional physical activity co-ordinator has been appointed by the West Midlands Public Health Group and by Sport England (West Midlands) to increase partnership working and to raise levels of physical activity in the region. The School Fruit and Vegetable Scheme, aimed at promoting healthy eating in local schools, has benefited from an increase in recruitment. A regional lifestyle survey, commissioned in 2005 and to be published in the autumn, will provide a more detailed account of obesity levels in the region, highlighting those areas where more targeted action is required. In addition, a short obesity report, published jointly by the Regional Public Health Group and the West Midlands Public Health Observatory summarises activity aimed at tackling obesity in the region and provides an analysis of the evidence supporting various interventions. An Obesity Training Fund has been allocated to the 14 spearhead primary care trusts in the region, and tenders invited for the remaining funds.

Spotlighting local health and initiatives

CMO ANNUAL REPORT 2004

Figure 1 Trends in infant mortality for West Midlands and England â&#x20AC;&#x201C; rates per 1,000 live births

Figure 2 Trends in perinatal mortality for West Midlands and England â&#x20AC;&#x201C; rates per 1,000 total births 12

Infant mortality

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n lan

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i lan

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e t

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NORTH WEST Alcohol: health, crime and violence

The North West region has among the highest levels of alcohol consumption in the country and experiences a disproportionately high health and judicial burden from alcohol misuse: deaths from chronic liver disease have almost doubled across England and Wales since 1993, and rates in the North West remain 40% higher than for the country as a whole. In 2002 alone, between 2,700 and 4,500 deaths in the region were alcohol related along with 46,000 to 66,000 hospital episodes. A range of causes contributes to these figures, with the majority of alcoholrelated deaths due to liver cirrhosis and specific cancers for which alcohol is a risk factor. However, the majority of hospital episodes result from fall injuries, alcoholic psychosis, alcohol dependence and abuse, or liver cirrhosis. The burden of alcohol use also falls on judicial services with an estimated 71,000 alcohol-related crimes committed in the region in 2002. The majority of these were violent crimes, affecting victims’ health and creating fear in communities.

As with many other public health issues, the burden of alcohol misuse is greatest in the region’s more deprived areas, which see higher levels of alcohol-related mortality and crime. In the worst affected local authority areas, alcohol-related deaths reduce overall average life expectancy by six months for men and over two months for women. Consequently, alcohol is a significant and increasing contributor to health inequalities across the North West and has been identified by the North West Public Health Observatory as an issue requiring further investigation.

concentrated in Manchester, Liverpool, Preston and Blackpool. The New Starter areas have overall levels of poverty not much greater than the regional average. However, they experience relatively poor life expectancy and high standardised mortality. On investigation, these findings relate closely to illegal drug and alcohol-attributable causes. Alcohol presents a problem to most public services and the solutions to escalating alcohol-related problems must therefore be multi-disciplinary. The public health team in the North West region is currently examining how the NHS and Home Office can pool

the ef North W new classification – ‘ areas (the super branches (Figur Progress since the 2003 Annual Report alcohol-r Typically, fi in the very poorest (typified by older residents). However which ar the North W

Deaths by drowning Last year’s Annual Report highlighted the high numbers of deaths by drowning in the North West: between 1998 and 2002, the numbers of deaths by drowning were higher than the England and Wales average risk of accidental drowning. The Ashton, Wigan and Leigh Primary Care Trust area was cited as having a particularly high risk of drowning – both accidental and self-harming.

Spotlighting local health and initiatives

CMO ANNUAL REPORT 2004

Figure 1 Hospitalised prevalence rate for alcohol-specific conditions: residents of the North West region, 1998–2002

00 00 00 00 00 00 00 00 100

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0 Blossoming Families

People with condition per 100,000

Progress on a collaborative study of deaths by drowning in the North West region has been delayed. However, the Centre for Public Health, at Liverpool’s John Moores University, will be undertaking this research on behalf of the public health team in the current financial year (2005/06). Preliminary analysis of the data collected on deaths by drowning has enabled the identification of regional trends which may be useful in the application of any preventative measures. For example, according to the data, accidental drownings are most likely to occur at weekends, whereas suicides are more likely on Mondays or Thursdays. In addition, work undertaken to map the numbers of deaths by drowning showed that residents of areas close to canals are most at risk. Further analysis also indicated a strong link between socio-economic status and risk of death by drowning: people living in the most deprived fifth of local residential neighbourhoods are nearly three times more likely to drown than persons living in the least deprived fifth. The higher death rates observed in the most deprived areas apply not only to suicides but also to accidental drownings.

EAST OF ENGLAND Healthier food vending machines in schools

Vending machines are common in secondary schools. They are very popular with pupils and, in many cases, serve as a useful source of income for schools. The problem is that vending machine food is often extremely high in fat, sugar and salt. The provision of these ‘unhealthy’ products to schoolchildren contradicts national healthy eating policy. In 2004, the public health team in the East of England region carried out a healthy vending machines project. This was one of eight projects comprising the Government’s Food in Schools programme, designed to help schools become ‘healthier’ by promoting good practice. Ten schools were chosen to reflect a diverse mixture of location, size, deprivation, gender mix and academic success. The schools already had vending machines selling fizzy drinks and confectionery (biscuits, sweets and chocolate). New refrigerated vending machines, stocked with healthier fresh foods and drinks were installed in the chosen schools. The healthier foods included sandwiches, using white

(typically fortified) or brown bread/rolls or tortilla wraps, fruit, pasta salads, yogurts, fruit juices, milk-based drinks (shakes/smoothies) and water. At the end of the pilot it was found that, despite initial mechanical and supply problems, and the somewhat hesitant acceptance by students, over time the vending machines could successfully be used to supply healthier food options. Key findings of the pr e: drinks wer

loss; losses were linked to either a lack of commitment from the school itself and/or high product waste which required greater levels of management by the caterer. The project ran from July 2003 to September 2004 and established that schoolchildren enjoy having a range of healthy drinks and food available through vending machines and that such machines can be a commercially sound addition to a school’s food service. However, critical success factors include the support of senior school management, caterers and pupils, which must be gained prior to the installation of ‘healthy’ vending machines, and the provision of vending machines must be part of a broader school food policy. The results of the project are now part of the Food in Schools Toolkit. The toolkit

by volume

Progress since the 2003 Annual Report although profi wer prepar fi br

Rising poly drug use The 2003 Annual Report focused on the region’s emerging problems relating to changes in the availability and use of crack cocaine. An observed increase in poly drug

Spotlighting local health and initiatives

CMO ANNUAL REPORT 2004

Figure 1 East of England: top five items sold in healthier vending machines

15,147

Number of items sold

use was attributed to the emergence of crack markets and more aggressive sales strategies which have made the drug more widely available in many of the regionâ&#x20AC;&#x2122;s major towns. Dealers in the region are using the traditional heroin networks to push the use of crack cocaine. This means that many crack cocaine users are using heroin as their primary drug and crack as a recreational drug. In response to the problem, and in its role as a member of the regional Strategic Partnership Group for Substance Misuse, the East of England Public Health Group has contributed to and supported a number of interventions. Interventions have included a series of training events organised with the National Treatment Agency regional team and the Government Office East drugs team. Taking place across the region, the training targeted a range of practitioners including specialist providers, public health, criminal justice and social and healthcare workers. Investment in local interventions has supported the implementation of the regional drug control strategy on the ground. For example, it has helped fund specialist training for criminal justice workers in Essex and Suffolk, outreach interventions in Bedfordshire and stimulant services in Luton. All local interventions have been further supported by the regional launch of public health materials focusing on harm-reduction strategies.

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SOUTH WEST Malignant mesothelioma: a cancer legacy

Malignant mesothelioma is a rare cancer usually arising in the pleura (lining of the lungs). During the 1960s, the link between asbestos exposure and mesothelioma was recognised and now more than 80% of cases of mesothelioma are believed to be caused by asbestos. In the 1970s, legislation was passed to protect workers and the public. However, because of the long latent period between exposure and disease development (30–40 years), the number of new cases continues to rise. The South West Public Health Observatory’s Cancer Intelligence Team undertook a study to predict when the number of cases would peak, at what level and where. They found that: between 1997 and 1999, the South West region, Hampshire and Isle of Wight had the second highest male mesothelioma death rate per million in Great Britain and the largest increase in male death rate from this cancer age-specific incidence rates have been highest in the 59–75 age group (20 per 100,000 in 1999) although the

incr 1999) the gr

the curr the South W W

Progress since the 2003 Annual Report

narr

a multi-agency response

been gr than males (four Statistical pr regr accor

cases per year – around 1.5 times the current level (Figure 1) the greatest risk of developing mesothelioma, according to birth cohort, will be for people born in the period 1925–1935.

The 2003 Annual Report highlighted the impact of crime on the health of older adults in the South West region. Since then, four strands of work have been developed to address this threat to public health. Work has been undertaken to develop a greater understanding of those who are most at risk of becoming victims of crime and suffering adverse health consequences. The potential for multi-agency work in identifying at-risk groups is also better understood. The examination of evidence supporting the effectiveness of preventive

Spotlighting local health and initiatives

CMO ANNUAL REPORT 2004

Figure 1 Predicted number of malignant mesothelioma cases in the South West region, Hampshire and the Isle of Wight 2000â&#x20AC;&#x201C;2049

Cases

interventions is under way. All findings from this work have been disseminated to the many agencies involved in the protection and support of older adults through regional, sub-regional and national conferences and workshops. Progress in these areas of work will be presented in a forthcoming South West Public Health Observatory publication. It has emerged that older, frail females living alone in neglected properties are most at risk. Although the adoption of a simple, multi-agency assessment process may be the most effective method of identifying such individuals, there remains widespread concern about the sharing of identifiable information on individuals between agencies. More work is under way to ensure that multiagency interventions continue to protect these vulnerable members of our society.

ases

a ases

YORKSHIRE AND HUMBER Bowel cancer: now seen more often among the affluent

The annual incidence of colorectal cancer in the Yorkshire and Humber region in 2002 was 59 per 100,000 population â&#x20AC;&#x201C; approximately 2,850 new diagnoses of the disease each year. In the north of England during the early 1990s, this form of cancer was more common among relatively deprived social groups: incidence rates were inversely related to socio-economic status. During the most recent 12-year time period considered, the overall rates of colorectal cancer have remained fairly constant in both men and women. There has, however, been a marked increase in the incidence of colorectal cancer in men of higher socio-economic groups. The clear inverse relationship to socio-economic status evident in 1991 is no longer apparent. Trends for women are less clear. Neighbouring regions are showing similar findings and further work is under way to discover the reason for these effects. The increased incidence of the disease in higher socio-economic groups could be due to changes in colorectal cancer risk factors

related to affluence (e.g. diet and exercise), but this seems unlikely. Alternatively, it may be that affluent men are being diagnosed

Progress since the 2003 Annual Report

Reducing fuel poverty The 2003 Annual Report identified fuel poverty as a significant threat to health in the Yorkshire and Humber region, noting that the area suffered the worst fuel poverty in the country. Since then, important changes have been made. A regional housing strategy, targeting fuel poverty as a priority, has now been developed and is being considered by ministers. The strategy includes a specific objective: to reduce the percentage of

housing with a Standard Assessment Procedure (SAP) rating* of 30 or under in 10 years to less than 1% or 2% in social and private housing respectively. This will ensure that the most vulnerable households are targeted with measures that will protect their health in the long term. Given the 2003/04 excess winter deaths index, which shows a level of 18.6% for the region compared with the 14% average for England, this is a critical objective. In addition, the Department of Health Regional Public Health Group has funded the establishment of a regional steering group to co-ordinate an affordable warmth action plan. Led by the Government Office and facilitated by National Energy Action, the plan will be developed throughout 2005. It will assess the current regional fuel poverty position, measure progress across the region, identify gaps and seek to co-ordinate and direct resources to areas of acute fuel poverty. * The SAP rating is a benchmark figure, between 1 and 120, for the energy performance of dwellings. The higher the number, the better the standard.

CMO ANNUAL REPORT 2004

Figure 1 Colorectal cancer incidence in the Yorkshire and Humber region: most deprived (Q5) vs most affluent (Q1) men and women*

Age-standardised rate per 100,000

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st depri ed st depri ed

*Q1 = most affluent 20% (ie quintile) of population Q5 = most deprived 20% (ie quintile) of population **Data calculated on a 3-year moving average

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1 1

Spotlighting local health and initiatives

treatment options are very limited and, for serious infections, drugs need to be given by injection they can cause serious infections such as blood poisoning, possibly because of delayed diagnosis death rates may be high and this is possibly related to treatment delays initial identification of a case or an outbreak is hampered because, although the most common site of infection is the

SOUTH EAST A surge in E.coli superbug infections

E.coli are common bacteria that normally live harmlessly in the gut, but at times can also cause health problems such as urinary tract infections and, more seriously, blood poisoning. Large increases in infections due to antibiotic-resistant strains of E.coli are occurring in the South East of England. These extended-spectrum‚ beta-lactamase (ESBL)-producing E.coli infections, many of which are community-acquired, have been identified elsewhere in the United Kingdom and are part of a growing worldwide problem. People at particular risk include older people and those with chronic diseases or with weakened immune systems. A national survey undertaken in 2004 by the Health Protection Agency (to be repeated in 2005), found a number of outbreaks due to ESBL-producing E.coli and also highlighted variations in laboratory methods, some of which were inadequate to identify these organisms. ESBL-producing coliforms pose particular problems because:

In addressing this serious problem in Southampton, infection control services adopted a proactive approach, reinforcing general infection control measures and amending antibiotic policies. General practitioners were encouraged to submit urine samples when patients did not respond rapidly to first-line treatment for urinary tract infections. Despite these measures – as Figure 1 illustrates – contr

organisms is incr The Health Pr T

Progress since the 2003 Annual Report

producing E.coli fi and found that:

Improving access to NHS dental care

ther particular war there wer 86% wer blood infections hospitalised and 29 (8%) of patients died; and the number of deaths decreased, probably due to increasing awareness of the problem among clinicians.

The 2003 Annual Report identified poor access to NHS dental care as a significant health problem in much of the South East: the region has the second lowest proportion of dental practices accepting patients for NHS treatment. Although access to NHS dental care remains a problem in many parts of the South East, particularly in Kent, improvements have been made in many areas. Additional Dental Access Centres have been opened, providing access to NHS dental care in areas where it had previously been limited.

Spotlighting local health and initiatives

CMO ANNUAL REPORT 2004

Figure 1 Confirmed cases of ESBL-producing E.coli infection in the Southampton ‘outbreak’

Sep

Cases of ESBL-producing E.coli infection

In addition, parts of the region have exceeded government targets for the recruitment of new dentists. Recruitment from abroad has also contributed to increased access. In the Isle of Wight, for example, there was previously no access to any dentist, NHS or private. Now there are five new dentists recruited from overseas. There is still much room for the improvement of children’s dental health in the region, especially in Southampton and Portsmouth. Southampton is the first and only city so far to approve fluoridation of the water supply, principally to reduce inequalities in dental health since the Water Act 2003 was passed and new regulations came into force on 1 April 2005.

ON THE STATE OF PUBLIC HEALTH

PROGRESS CHECK

Chief Medical Officer. On the state of the public health: annual report of the Chief Medical Officer of the Department of Health 2001. London: Department of Health; 2001.

Department of Health. National guidance on the safe administration of intrathecal chemotherapy. Leeds: Department of Health; 2001. (Health service circular: HSC 2001/022).

Chief Medical Officer. On the state of the public health: annual report of the Chief Medical Officer of the Department of Health 2002. London: Department of Health; 2003.

Department of Health. West Nile virus: A contingency plan to protect the public’s health. London: Department of Health; 2004.

Chief Medical Officer. On the state of the public health: annual report of the Chief Medical Officer 2003. London: Department of Health; 2004. Department of Health. Choosing health: making healthier choices easier. London: Department of Health; 2004 (Cm. 6374). Department of Health. Consultation on the smoke free elements of the Health Improvement and Protection Bill. London: Department of Health; 2005. Department of Health. Towards cleaner hospitals and lower rates of infections. London: Department of Health; 2004. Department of Health. Department of Health Mandatory Bacteraemia Surveillance Scheme: MRSA bacteraemia by NHS Trust [web page on the Internet]. No date [cited 2005 Jun 30]. Available from http://www.dh.gov.uk/assetRoot/04/10/55/18/ 04105518.pdf Department of Health. Stopping tuberculosis in England: an action plan from the Chief Medical Officer. London: Department of Health; 2004. Department of Health. UK Health Departments’ influenza pandemic contingency plan. London: Department of Health; 2005. The Foundation Programme Committee of the Academy of Medical Royal Colleges and the Department of Health. Curriculum for the foundation years in postgraduate education and training. London: Academy of Medical Royal Colleges; 2005. Smith J. The Shipman Inquiry: fifth report: safeguarding patients: lessons from the past – proposals for the future. London: The Stationery Office; 2004. Chairman: Dame Janet Smith. (Cm. 6394-II). World Health Organization. Avian influenza – fact sheet: avian influenza and the significance of its transmission to humans [web page on the Internet]. 2004 [cited 2005 Jun 30]. Available from http://www.who.int/csr/don/2004_01_15/en/

TOBACCO AND BORDERS: DEATH MADE CHEAPER

ASH. Budget 2005: tobacco tax submission. London: ASH; 2005. Cullum P, Pissarides C A. Government Economic Service working paper series, no 150: the demand for tobacco products in the UK. London: HM Treasury; 2004 Department of Health. More information on tobacco: factsheet. London: Department of Health; 2004.

Food Standards Agency. Salt – watch it. [homepage on the Internet]. 2004 [cited on 2005 Aug 4]. Available from: http://www.salt.gov.uk/

European Commission. Excise Duty Tables: part III manufactured tobacco. Brussels: European Commission; 2004.

Lader D. Smoking-related behaviour and attitudes 2003. London: Office for National Statistics; 2004.

HM Customs and Excise publications:

National African HIV Prevention Programme [webpage on the Internet]. 2005 [cited 2005 Jul 1]. Available from: http://www.nahip.org.uk/briefing_0205.htm National Clinical Assessment Authority. Annual report and summary financial statements 2003–4. London: NHS National Clinical Assessment Authority; 2004. National Institute for Clinical Excellence. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. London: National Institute for Clinical Excellence; 2004. National Institute for Clinical Excellence. Obesity: Profit in loss [web page on the Internet]. 2005 [cited 2005 Jul 1]. Available from:http://www.publichealth.nice.org.uk/ page.aspx?o=503295 Pennington Group. The Pennington Group report on the circumstances leading to the 1996 outbreak of infection with E.coli 0157 in central Scotland, the implications for food safety and the lessons to be learned. Edinburgh: The Stationery Office; 1997. Research Assessment Exercise 2008 [web page on the Internet]. 2005 [cited 2005 Jul 1]. Available from: http://www.rae.ac.uk Serious Hazards of Transfusion (SHOT) [homepage on the Internet]. No date [cited 2005 Jul 4]. Available from: http://www.shotuk.org/ Academic sub group (Walport Report) Report of the Academic Careers Sub-Committee of Modernising Medical Careers and the UK Clinical Research Collaboration March 2005 [webpage on the Internet]. 2005 [cited 2005 Jul 4]. Available from: http://www.mmc.nhs.uk /download_files/Medically-andDentally-Qualified-academic-staff-recommendationsReport.pdf Tugwell P. Campaign to revitalize academic medicine kicks off. BMJ 2004; 328: 597.

HM Customs and Excise. Measuring indirect tax fraud. London: HM Customs and Excise; 2001. HM Customs and Excise. Tackling indirect tax fraud: November 2001. London: The Stationery Office; 2001. HM Customs and Excise. Measuring indirect tax losses. London: HM Customs and Excise; 2002. HM Customs and Excise. Protecting indirect tax revenues: November 2002. London: HMSO; 2002. HM Customs and Excise. Measuring and tackling indirect tax losses: an update on the government’s strategic approach. London: HM Customs and Excise; 2003. HM Customs and Excise. Spring departmental report 2003. London: The Stationery Office; 2003. (Cm. 5924). HM Customs and Excise. Measuring and tackling indirect tax losses. HM Customs and Excise: London; 2004. HM Customs and Excise, HM Treasury. Tackling tobacco smuggling. London: The Stationery Office; 2000. House of Commons. Treasury Committee. Excise duty fraud: fourth report of session 2004-05. Session 2003-04. London: HMSO; 2005. (HC 126). Joossens L. Smuggling and cross-border shopping of tobacco products in the European Union: a report for the Health Education Authority. London: Health Education Authority; 1999. Twigg L, Moon G, Walker S. The smoking epidemic in England. London: Health Development Agency; 2004.

CMO ANNUAL REPORT 2004

IT TAKES YOUR BREATH AWAY: THE IMPACT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

A FRESH LOOK: REALIGNING FOOD PROCUREMENT IN THE PUBLIC SECTOR

Bowers S. COPD is not a death sentence. Lancet 2004; 364: 896.

Coote, A. Claiming the health dividend: unlocking the benefits of NHS spending. London: Kings Fund; 2002.

British Lung Foundation [web page on the Internet]. 2004 [cited 2005 Jun 29]. Available from www.lunguk.org

Department for Environment, Food and Rural Affairs. Public sector food procurement initiative [web page on the Internet]. 2003 [cited 2005 Jun 29]. Available from http:www.defra.gov.uk/farm/ sustain/procurement/index.htm.

British Thoracic Society [web page on the Internet]. No date [cited 2005 Jun 22]. Available from http://www.britthoracic.org.uk/iqs/sfa.list/cpti.32/press_releases British Thoracic Society. The burden of lung disease [web page on the Internet]. 2001 [cited 2005 Jun 29]. Available from http://www.brit-thoracic. org.uk/c2/uploads/BurdenofLungDisease.pdf

Department for Environment, Food and Rural Affairs. The strategy for sustainable farming and food: facing the future. London: Department for Environment, Food and Rural Affairs; 2002.

Calverley P, Walker P. Chronic obstructive pulmonary disease. Lancet 2004; 362: 1053-1061. Department of Health. Smoking kills: a White Paper on tobacco. London: The Stationery Office. 1998. (Cm. 4177)

Department for Environment, Food and Rural Affairs. National food survey 2000: annual report on food expenditure, consumption and nutrient intakes. London: The Stationery Office; 2001. http://www.defra.gov.uk/corporate/publications/pubcat/fo od.htm)]

Department of Health. Choosing Health: making healthier choices easier. London: Department of Health; 2004. (Cm. 6374).

Department of Health. National service framework for long-term conditions. Leeds: Department of Health; 2005.

Department of Health. Choosing a better diet: a food and health action plan. London: Department of Health; 2005.

Department of Health. Self care – a real choice. London: Department of Health; 2005. Guidelines on the management of COPD [web page on the Internet]. British Thoracic Society; 1997 [cited 2005 Jun 29]. Available from http://www.brit thoracic.org.uk /c2/uploads/ bts_20copd_20guidelines.pdf National Institute for Clinical Excellence. Chronic obstructive pulmonary disease: management of COPD in adults in primary and secondary care. London: National Institute for Clinical Excellence; 2004. (Clinical Guideline 12). Pauwels RA, Rabe KF. Burden and clinical features of COPD. Lancet 2004; 364: 613-620. Price D, Duerden M. Chronic obstructive pulmonary disease. BMJ 2003; 326: 1046-1047. The Royal College of Physicians and the British Thoracic Society, Anstey K, Lowe D, Michael Roberts C, Hosker H, editors. Report of the 2003 national COPD audit [web page on the Internet]. 2004 [cited 2005 Jun 29]. Available from http://www.rcplondon.ac.uk/college/ceeu/copd/nationalC OPDaudit2003report.pdf Wouters E. Management of severe COPD. Lancet 2004; 364: 883-895.

References

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NHS Estates, Department of Health, Hospital Caterers Association. Reducing food waste in the NHS. London: The Stationery Office; 2000. Spencer A. Recipe for Improvement. NHS Magazine 2001 (Feb); 2: 8–9. Sullivan, DH, Sun S, Walls, RC. Protein-energy undernutrition among elderly hospitalised patients: a prospective study. JAMA 1999; 281: 2013-2019. SUSTAIN, East Anglia Food Link. Good food on the public plate: a manual for sustainability in public sector food and catering. Watton: East Anglia Food Link; 2003. Traynor J, Walker A. People aged 65 and over: results of an independent study carried out on behalf of the Department of Health as part of the 2001 General Household Survey. London: The Stationery Office; 2003. Ward B, Lewis J. Plugging the leaks: making the most of every pound that enters your local economy. London: The New Economics Foundation; 2002.

LEARNING HOW TO LEARN: COMPLIANCE WITH PATIENT SAFETY ALERTS IN THE NHS

GASTROSCHISIS: A GROWING CONCERN

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CMO ANNUAL REPORT 2004

SPOTLIGHTING LOCAL HEALTH AND INITIATIVES

Beacon Dodsworth. P2 People & Places. [homepage on the Internet]. No date [cited 2005 Jul 1]. Available from http://www.p2peopleandplaces.co.uk/about.html Department for Education and Skills (DfES), Department of Health. Food in Schools Programme [homepage on the Internet]. No date [cited 2005 Jul 1]. Available from http://www.foodinschools.org/ Department of Health. Choosing Health: making healthier choices easier. London: Department of Health; 2004 (Cm. 6374). Department of Health. The Water Fluoridation (Consultation) Regulations 2004: consultation note. London: Department of Health; 2004. Department for Work and Pensions. Pathways to work: Helping people into employment. London: The Stationery Office; 2002. (Cm. 5690). East Midlands Regional Assemblyâ&#x20AC;&#x2122;s Public Health Task Group. Investment for Health [web page on the Internet]. 2003. [cited 2005 Jul 1]. Available from http://www.investmentforhealth. org.uk/index.asp London 2012 [homepage on the Internet]. 2005 [cited 2005 Jul 1]. Available from http://www.london2012.org/ London Health Observatory [homepage on the Internet]. No date [cited Jul 1 2005]. Available from http://www.lho.org.uk/ Office of the Deputy Prime Minister. Making it happen: the Northern Way [web page on the Internet]. 2004 [cited 2005 Jul 1]. Available from: http://www.odpm.gov.uk/stellent/groups/odpm_communities/ documents/page/odpm_comm_ 027362.hcsp Race Relations Act 1976. London: The Stationery Office; 1976.

References

Note: the people in the Tobacco Smuggling section are played by actors

ÂŠ Crown Copyright 2005 Produced by the Department of Health 269349 1p 5k July 2005 (BEM) The text of this document may be reproduced without formal permission or charge for personal or in-house use. First published July 2005 If you require further copies of this title please quote 269349 and contact: Department of Health Publications PO Box 777 London SE1 6XH Tel: 08701 555 455 Fax: 01623 724 524 Email: doh@prolog.uk.com 08700 102 870 â&#x20AC;&#x201C; Textphone (for minicom users) for the hard of hearing 8am to 6pm Monday to Friday. This report can also be made available in braille, audio-cassette tape, disk, large print and in other languages.