CMO Annual Report 2005

CHIEF MEDICAL OFFICER ANNUAL REPORT 2005

Š Crown Copyright 2006

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Annual Report 2005 Main Features Waste Not, Want Not Learning to Fly Taking No Chances Raiding Public Health Budgets can Kill Planning for a Rising Tide

The Chief Medical Officer on the state of public health

CONTENTS

14 W ASTE NOT, WANT NOT

Reducing variation in clinical practice to deliver effective treatment equitably.

CMO ANNUAL REPORT 2005

02 ON THE STATE OF PUBLIC HEALTH 08 PROGRESS CHECK

0

Drawing parallels between aviation safety and patient safety.

32 TAKING NO CHANCES

Early recognition of warning signs can prevent kernicterus.

38 RAIDING PUBLIC HEALTH BUDGETS CAN KILL Protecting investment in health is not just important, it is essential to sustaining our health service.

46 PLANNING FOR A RISING TIDE

Being prepared for the flu pandemic.

54 SPOTLIGHTING REGIONAL HEALTH AND INITIATIVES 74 REFERENCES

CONTENTS

24 LEARNING TO FLY

0

ON THE STATE OF PUBLIC HEALTH

0 ON THE STATE OF PUBLIC HEALTH

I am now approaching my eighth anniversary in post as Chief Medical Officer for England and as the United Kingdom Government’s Chief Medical Adviser.

Internationally, the post is unique in the length of time it has been established and in its positioning, located as it is within government but independent, not political, in orientation.

I am 15th in a line of succession that dates back to 1855. Each of my predecessors has championed the need for action on the major health and healthcare problems of their day, often through the Chief Medical Officer’s Annual Reports.

CMO ANNUAL REPORT 2005

“I aim to serve the public by championing the need for action on the major health problems of the day and to act without fear or favour.”

0

In my Annual Reports so far, I have highlighted the requirement for action on the health challenges facing our country and the need to focus on the major issues in the delivery of healthcare in the 21st century. For example, in earlier Reports I addressed the dangers of the obesity ‘time bomb’, the serious problem of binge drinking, the ongoing and deeply worrying pattern of health inequalities (some parts of the country have levels of health comparable with those of the 1950s), and delays in identifying HIV infection, with the potential implications for the control of the disease in this country.

In particular, I have tried to keep the spotlight on the scourge of tobacco-related illness and death, which remains the most significant public health problem in our country.

In my Annual Reports, I have very actively championed the need to create legislation for smoke-free public places.

Despite initial hostility to my ideas, I was delighted by the overwhelming majority in favour of legislation to achieve this when the matter came before the House of Commons on 14 February 2006.

Many of the recommendations from my previous Annual Reports have been fully implemented, others partly, some hardly at all. In this year’s Report, I examine in detail progress in the areas for action in last year’s Report and showcase some of the developments stimulated by my other Annual Reports over the years.

The health year has been dominated by a small number of major issues. At the top of this list is the prospect of the first pandemic (worldwide epidemic) of influenza since 1968.

Such pandemics have occurred in natural cycles of between 10 and 40 years. The current serious outbreaks of avian (bird) influenza in wild birds and poultry in many parts of the world, with some human deaths, could be the spark that triggers a new human influenza pandemic, or it could arise in an entirely different way.

In October 2005, I launched the United Kingdom pandemic influenza plan, and since then a great deal of planning work, both within the NHS and across the whole of government, has taken place. Because of the public health importance of this topic, it forms one of the chapters in this year’s Annual Report.

CMO ANNUAL REPORT 2005

0 ON THE STATE OF PUBLIC HEALTH

A second health issue has attracted widespread public concern during the year: the financial deficits within the NHS. These have arisen despite high levels of resources allocated to the NHS. In his second report on the financing of the NHS, Securing Good Health for the Whole Population, published in February 2004, Sir Derek Wanless wrote of a ‘fully engaged scenario’ being necessary to sustain the viability of a publicly-funded NHS in the long term.

A major part of this scenario was a much higher priority being given to the prevention of disease and the promotion of health. As the NHS solves its financial problems, it is vital that the solutions do not involve the wholesale ‘raiding’ of public health budgets. The financial problems come at a time when the NHS is being reorganised, which has major implications for the public health system and for delivery of the goals set out in the public health White Paper, Choosing Health, that was published last year. I have addressed the importance of protecting the public health infrastructure and budgets in another chapter in this year’s Annual Report.

The last year was also an eventful one for health in Europe, as the United Kingdom held the European Union Presidency for the six months until the end of December 2005. The two health themes for our Presidency were health inequalities and patient safety. For both, international action is critical to tackle the issues effectively – whether this is the smuggling and illicit sale of tobacco, the promotion and marketing of food and alcohol to children and young people, or improving patient safety.

As well as significantly raising the profile and priority of the issues, through two major international summits and ground-breaking reports, we also left an important legacy. Commissioner Kyprianou’s welcome commitment to continued action through new pan-European groups – bringing together policy makers from all European Union member states – will be instrumental in ensuring sustained action on both health inequalities and patient safety.

I am delighted that we also had an influence on both European and global health policy, including the early priorities for the World Health Organization’s Framework

0

Convention on Tobacco Control, new European strategies on nutrition and alcohol, and the European Union information and knowledge system. Furthermore, concrete projects to support member states in developing national patient safety programmes and reporting and learning systems were instituted and significant progress was made to ensure safe professional practice and better information on health professionals who move across borders. I am pleased that the European Union bodies and member states, along with others such as the World Health Organization, have now taken on the mantle to drive forward these agendas, building on the interest raised during our Presidency.

Another major part of my work this year has been the review I was asked to undertake by the Secretary of State in response to the Fifth Report of the Shipman Inquiry.

This has been a massive undertaking involving comprehensive scrutiny of the purpose and effectiveness of medical regulation, an examination of the core functions of the General Medical Council, an exploration of mechanisms to assure the quality and safety of medical practice within health services, and the creation of a system of revalidation that will be fit for purpose. Dame Janet Smith, who chaired the Shipman Inquiry, was very critical in her report of many of the present arrangements and plans for the future.

My review was the first of medical regulation for 30 years, and the only one in 150 years to have looked at medical regulation together with relevant quality systems within healthcare services. I have delivered my report to Ministers.

I have again selected five main topics for attention in this year’s Annual Report, each with its own chapter.

In addition to pandemic influenza and the implications of organisational change and funding pressures for public health delivery, I address the topic of kernicterus, a rare but devastating disease affecting newborn babies. Kernicterus is potentially preventable but may be increasing in incidence.

A further chapter examines the processes operated within the airline industry and the culture of safety that is truly integral to the working lives of all those engaged in commercial aviation: the NHS has many lessons to learn from it.

0 ON THE STATE OF PUBLIC HEALTH

Sir Liam Donaldson Chief Medical Officer

CMO ANNUAL REPORT 2005

The first chapter of my 2005 Annual Report addresses a long-standing feature of health services in developed countries: the way in which healthcare interventions are applied with disturbing variability. Irrational variations in healthcare provision have been recognised since the 1930s, when J Alison Glover examined rates of tonsillectomy among children in the United Kingdom. Glover’s study led to a surge of international interest in the subject.

Inappropriate variation was found to be widespread and to occur in relation to an array of interventions.

Despite the creation of the National Health Service, improvements in medical education, the evolution of the concept of evidence-based medicine and everincreasing pressure on resources, marked discrepancies persist. In this chapter, I find myself echoing the words of the seventh Chief Medical Officer, over 80 years ago.

Inappropriate variation runs contrary to the moral contract agreed in 1948 between the NHS and the public – to provide care equitably. Furthermore, this pattern suggests waste and highlights potential problems in resource allocation and knowledge management.

In compiling this Report, I am grateful for the help of a number of colleagues within the Department of Health and the NHS. I am also deeply indebted to the family who shared with me their own shattering experience of kernicterus.

As in previous years, the opinions, conclusions and observations in the Report are my own.

I hope you find the Report of interest. The action that has been achieved as a result of my Annual Reports so far shows how important it is to keep the key public health challenges in the public eye and how vital it is to maintain a wide coalition of support and commitment to action.

Thank you to all who have helped in the past and I hope I will have your support again this year.

0

PROGRESS CHECK

health intervention for a generation.

I have long applied pressure to encourage the introduction of these robust measures through my Annual Reports, focusing on passive smoking (2002), the impact of smoking on the ageing of the skin (2003), the economic case for a smoking ban (2003) and tobacco and borders (2004). I am delighted that England will now follow the lead of other countries in this area. I look forward to the substantial health benefits that will accrue for the population over the coming years.

One regret is that Professor Sir Richard Doll, whose seminal work in the 1950s proved the link between smoking and lung cancer, did not live to witness this landmark. Sir Richard, a giant of 20th-century medicine, died in July 2005 at 92 years of age.

In this section, I report on the progress made on some of the key issues covered in my Annual Report for 2004. I also identify three areas from my previous Annual Reports where significant action has been taken over the last year.

0 PROGRESS CHECK

It would be difficult to note progress against the specific recommendations I made in previous Chief Medical Officer’s Annual Reports without first acknowledging the ongoing passage of the Health Bill through Parliament. On 14 February 2006, a clause was approved making provision to render all pubs, clubs and restaurants in England smoke-free.

The introduction of this provision and related measures, which is likely to take place during 2007, will constitute the most significant and beneficial public

CMO ANNUAL REPORT 2005

“The last 12 months will forever be remembered as the year we achieved progress towards historic smoke-free legislation.”

10

Tobacco and borders In my 2004 Annual Report, I highlighted the dramatic rise in recent years of tobacco products coming into the country having avoided national taxes and duties. This traffic costs the Exchequer £3 billion in lost revenue per annum and seriously undermines the effectiveness of tax increases in helping people to stop smoking. Furthermore, cheap tobacco – both smuggled and acquired legally at lower prices in Europe – tends to be consumed by the poorest people, exacerbating health inequalities.

I raised two areas of particular concern last year: first, that the Government’s smuggling strategy did not include hand-rolling tobacco; and second, the growing trade in counterfeit tobacco products. I was particularly pleased to see that in March 2006 Her Majesty’s Treasury and Her Majesty’s Revenue and Customs published New Responses to New Challenges: Reinforcing the Tackling Tobacco Control Strategy, which addressed these two major challenges.

A new target has been set to reduce the size of the illicit hand-rolling tobacco market in the United Kingdom by 1,200 tonnes (around 20%) by 2007/08. The Government also plans to work with tobacco manufacturers and overseas authorities to identify sites of counterfeit production throughout the world and disrupt, dismantle and prosecute where appropriate. Unfortunately, my call for a more challenging target for the reduction in the amount of smuggled tobacco has not been addressed by government. I hope this will be reviewed as part of the next round of the Comprehensive Spending Review, when government takes stock of its priorities and work programmes.

I am also disappointed that there has not yet been agreement on the European stage on an increase in the European Union minimum duty rate. Nor has there been any move to influence the European Commission to allow member states to reduce minimum limits for legal cross-border shopping to 200 cigarettes or 250 g of hand-rolling tobacco.

Finally, I welcome several other new measures announced by the Government in New Responses to New Challenges.

These include the allocation of 200 extra staff to fight the smuggling of hand-rolling

tobacco. I am also pleased that the Conference of the Parties to the World Health Organization Framework Convention on Tobacco Control agreed in February 2006 to produce a legally binding protocol that will address illicit trade. This offers the opportunity to spread good practice internationally.

Chronic obstructive pulmonary disease My 2004 Annual Report highlighted the increasing national burden posed by chronic obstructive pulmonary disease (COPD), a condition caused almost exclusively by smoking. COPD affects an estimated 3 million people and kills over 30,000 every year.

Apart from the passage of the Health Bill mentioned above, there have been other significant events. I called for the development of a National Service Framework for COPD, and last month Ministers approved this. An expert reference group is now being established to support the design and implementation of the framework, an important mechanism to drive quality improvement for this sometimes neglected group of patients.

My Report also called for consultant expansion programmes to be reviewed against the local need for respiratory physicians. As of September 2005, there were 608 consultants in respiratory medicine, an increase of just five consultants since September 2004. The Workforce Review Team highlighted this specialty in its annual recommendations to strategic health authorities. The number of five-year training places for specialist registrars in respiratory medicine has continued to rise, and this will deliver a significant expansion in the number of specialists within just a few years.

Finally, I highlighted the, at times, haphazard diagnosis of COPD and recommended that more primary care staff should be trained in the use of spirometry. The British Thoracic Society is now encouraging general practitioners and practice nurses to use spirometry, in line with this recommendation.

11 PROGRESS CHECK

also carried out pilot projects across the regions, identifying and successfully engaging with high-quality local suppliers of food for the public sector.

I also highlighted in my Annual Report the lack of awareness among these local suppliers of opportunities for working with the public sector. The new National Opportunities Portal website, launched in March 2006, will make local suppliers aware of forthcoming public sector tenders and supply opportunities.

My Report called for the £280 million investment in school meals to be used to ensure better quality and higher nutritional content, and for the Office for Standards in Education (Ofsted) to include nutrientbased standards in their inspections. Since September 2005, schools have been required to present to Ofsted their approach to food and healthy eating, as well as to provide evidence of the standard of their school lunches. Progress on the reform of school meals will be tracked by the Food Standards Agency.

The School Food Trust was established to support local authorities in making the transformation to providing healthy meals in schools. The Trust is developing proposals for nutritional standards for other types of school food and creating new qualifications and training for catering staff to equip them with the skills necessary to provide healthier meals. The new vocational qualification will help school cooks understand the components of a healthy meal, and how to make this an attractive choice for young people.

CMO ANNUAL REPORT 2005

Realigning food procurement in the public sector The public sector spends close to £2 billion on food and catering services, with the NHS being the largest public procurer of food in Europe. In my 2004 Annual Report, I called on the public sector to make better use of this tremendous purchasing power to improve the nation’s health and to promote a more sustainable food supply chain.

I am encouraged by the progress made on many of my recommendations.

I called on the Government to broaden its methodology for demonstrating value for money in procurement policy to include longer-term health benefits and sustainable development. Several government departments have now taken this on board.

I asked for the Food Standards Agency to use its review of nutritional standards in public institutions, including hospitals, prisons and care homes, as a basis for action. This review now includes the development of food-based guidance, as well as sample menus that meet nutritional recommendations and assist caterers in menu planning. The results are expected to be finalised in late 2006.

I also called on public sector food procurers to come together and agree more creative contract specifications for food and catering. In support of this work, the NHS Purchasing and Supply Agency is collaborating with other public sector purchasers, including the Ministry of Defence and Her Majesty’s Prison Service, to explore opportunities for coordinating a review of food specifications that take better account of the new nutritional requirements.

Last year’s Report highlighted the lack of awareness among buyers of the benefits of using a sustainable food supply. I recommended that the public sector increase its patronage of local high-quality food suppliers. A report from the Department of Trade and Industry provided evidence of cost savings and highlighted the benefits that small businesses can bring to the public sector market. Workshops and a toolkit aimed at public sector buyers, organised through the Public Sector Food Procurement Initiative (PSFPI), illustrated the benefits of sustainable purchasing. PSFPI has

12

Gastroschisis My 2004 Annual Report highlighted an increase in the prevalence of the structural congenital anomaly gastroschisis, particularly in babies born to younger mothers. With early surgery and specialist hospital care, more than 90% of affected babies survive.

Congenital anomaly registers are a vital public health tool, helping to alert populations to the increasing prevalence of specific anomalies. They also enable experts to carry out investigations into increasing trends and possible clusters.

In my Report, I drew attention to the difficulties with the two monitoring systems currently in operation – the National Congenital Anomaly System and the British Isles Network of Congenital Anomalies Register (Binocar). Full population coverage has still not been achieved, local registers are insufficiently funded, and their data are compromised by inconsistencies in reporting and by differences in coding.

I recommended that the geographical coverage and reporting rigour of regional congenital anomaly registers be increased.

I also recommended that central core funding be made available to secure the long-term future of regional congenital anomaly registers.

Early in 2006, a report was produced outlining current arrangements for the reporting of congenital anomalies, the cost implications of achieving full population coverage and options for its achievement.

The report and its recommendations are currently being considered.

My 2004 Annual Report also highlighted the need for a better understanding of the causes of gastroschisis and, in particular, of the current trends in prevalence.

Substantive action in relation to gastroschisis remains to be taken.

Compliance with patient safety alerts A major step towards improving patient safety is to ensure that sources of risk are identified and solutions are implemented comprehensively. One way of achieving this is by issuing patient safety alerts.

In my 2004 Annual Report, I drew attention to studies indicating that compliance with patient safety alerts in the NHS was poor.

In addition, some NHS Trusts that initially reported compliance were later found to be non-compliant.

I recommended that the Healthcare Commission should place a special focus on NHS organisations’ compliance with safety alerts. The Healthcare Commission has since introduced a new performance assessment system for all NHS Trusts, including Foundation Trusts, which includes evaluating how quickly hospitals respond and react to patient safety notices and alerts. The first results of this new assessment system will be published in autumn 2006.

I also called for a national group to review the results of all patient safety alerts to date, identifying barriers to compliance and offering general guidance.

This proposal is currently under consideration. In the meantime, a working group within the Department of Health looked at a random selection of patient safety alerts to try to identify potential barriers to compliance and the quality of the action taken. The University of York has recently been commissioned to continue this work. It is anticipated that they will report back on this by the end of April 2007.

OTHER NOTABLE DEVELOPMENTS ARISING FROM PREVIOUS ANNUAL REPORTS

CMO ANNUAL REPORT 2005

2003 annual report

Stroke RECOMMENDATION Wherever possible, people who have suffered a stroke should be managed in a dedicated specialist stroke unit.

HIV RECOMMENDATION The proportion of pregnant women screened for HIV infection should be raised from the current level of 80% to 100%.

UPDATE • All eligible NHS Trusts in England now have a dedicated stroke unit but only a minority of admitted stroke patients spend some or all of their time on that unit.

• A stroke policy team has been established and a national stroke strategy is now being developed.

UPDATE • 90% of pregnant women with HIV were diagnosed before delivery in 2004, reducing their risk of passing HIV to their unborn babies.

• 80% of men who have sex with men and attended genitourinary medicine clinics took up the offer of an HIV test.

• £300 million has been set aside to improve services for those with sexually transmitted diseases.

• Improving access to genitourinary medicine clinics is one of the top six priorities for the NHS in 2006.

Academic medicinE RECOMMENDATION The NHS, the university sector and those who fund research should do everything in their power to ensure that the UK Clinical Research Collaboration is a success.

UPDATE • An integrated academic training programme was launched in October 2005. The programme, designed in partnership with the UK Clinical Research Collaboration, provides 250 clinical academic fellowships and 100 clinical lectureships per annum.

13 PROGRESS CHECK

2001 annual report

14

WASTE NOT,WANT NOT

TWO Both under-use and over-use of medical interventions can be costly and expose patients to unnecessary risk.

THREE Variation that cannot be explained by the needs of patients may occur on the basis of geography (‘postcode prescribing’), on account of the preferences and habits of clinical decision makers, or due to other factors, such as the socioeconomic status of patients.

FOUR Variation is demonstrable in many areas of medical practice, including prescribing patterns, hysterectomy, treatment for people with coronary disease, and tonsillectomy among children.

FIVE Inappropriate variation may be a function of poor knowledge, the flawed application of the correct knowledge, a lack of resources, or the inappropriate allocation of extant resources.

SIX The efforts of the National Institute for Health and Clinical Excellence and Connecting for Health in the effective

dissemination of knowledge should be redoubled.

SEVEN Commissioners of health services should reaffirm their commitment to the NHS principle of equity, and techniques should be developed further to facilitate benchmarking of provision.

EIGHT The National Institute for Health and Clinical Excellence should be asked to issue guidance to the NHS on disinvestment, away from established interventions that are no longer appropriate or effective, or do not provide value for money.

Reducing variation in clinical practice TO deliver EFFECTIVE TREATMENT EQUITABLY

ONE Variation in the provision of specific health services may be appropriate but it can also suggest waste or inequity within the NHS.

15 WASTE NOT, WANT NOT

“Both under-use and over-use of treatments are rife in this and most other countries and are enemies of effective healthcare.”

CMO ANNUAL REPORT 2005

Reducing variation in clinical practice to deliver effective treatment equitably.

PROFESSOR ARCHIE COCHRANE

daily nhs activities

28,000

Sight tests

50,000

A&E attendances

124,000

Outpatient consultations

836,000

General practitioner consultations

1,948,000

16

Prescriptions issued

The doyen of evidence-based medicine, Professor Archie Cochrane (who died in 1988), was a medical student in London in the 1930s. There was a rally about the possibility of a National Health Service, and he decided to go. The official banner is said to have carried the slogan ‘All treatment must be free’.

Cochrane constructed his own, which read ‘All effective treatment must be free’.

With its strong underpinning ethos of equity, its ability to make systematic policies and its non-profit foundations, the NHS has a unique opportunity to address the fundamental causes of inappropriate variation in treatments and treatment rates. Cochrane’s celebrated vision of the 1930s, that ‘all effective treatment must be free’, is not yet fulfilled. More than many other healthcare systems, which also experience such variation, the NHS can solve this long-standing problem.

For almost 60 years, the National Health Service has been the mainstay of healthcare provision in England. By any standards, it is a large organisation, employing 1.4 million staff, and the diversity of the activities undertaken is huge.

Behind the numbers are the personal experiences of patients, for whom a consultation or operation may constitute a profound life event.

All citizens have the right to expect the same high standard of care and the same level of access to treatment and services. One of the founding principles of the NHS was that services should be equitable. This remains the case today, just as it was in 1948.

An equitable service is not one where the model of provision is inflexibly standardised across the country, where one general practice or district general hospital is a carbon copy of another.

Just as the health needs of individual patients differ, so too do those of local communities. In an equitable service, variety is permissible, indeed essential, to guarantee fair access to appropriate care.

Since the inception of the NHS, the range and complexity of available treatments has grown substantially, as has the public’s demand for medical care. The cost of healthcare has continued to rise, with the Department of Health’s total resource budget standing at over £75 billion for 2004/05. Financial resources are finite, the demands placed on them are very great, and ways are constantly being sought to ensure that limited resources can be made to go further.

Studies of the pattern of healthcare provision in North America, Britain and other developed countries from the mid-20th century onwards have consistently shown striking variations in clinical intervention rates between and within local services.

In the 1960s, analysis of records in one American state demonstrated a three- to

four-fold variation in rates of intervention for six common surgical procedures across 11 regions. Even more striking findings were made in a second state. This work was followed in 1973 by a study showing that the rate of surgical intervention in Canada was approximately 50% higher than that in England and Wales, even when adjusted for the different age and sex characteristics of the two populations.

The number of surgeons employed varied accordingly. There was no discernible difference in outcome (mortality) to suggest that one rate was any more appropriate than the other.

The way in which clinical decisions are made, the extent to which they depart from research evidence, and the factors that determine compliance with best practice have also been extensively studied by clinical and health service researchers.

Despite this, the solution to the problem of clinical practice variation has not been found, although there have been improvements in some fields. Efforts have been made within the NHS since at least the mid-1980s to promote so-called clinical effectiveness. The evidencebased medicine movement emerged in the early 1990s to try to close the gap between a clinical benefit established in research studies and its use at the bedside. Today, the potential flaws of individual research studies are more widely acknowledged, and the place of systematically-reviewed, patient-centred evidence, along with attention to its

Hip replacement VARIATIONS

574 hip joint and socket CMO ANNUAL REPORT 2005

combinations are currently used by the NHS for similar operations

17

Reducing variation in clinical practice TO deliver EFFECTIVE TREATMENT EQUITABLY

Although not easily quantifiable in financial terms, these problems lead to the waste of time and limited resources, poor outcomes of care, harm to patients and lost opportunities.

Each of these scenarios may have a number of root causes, which are not mutually exclusive: • poor knowledge on the part of the healthcare provider; • a discrepancy between what the healthcare provider knows should be done and what is done (a ‘knowing–doing’ gap); • insufficient resources, locally or generally, to allow appropriate practice; • inefficient or haphazard prioritisation.

Variation may not relate simply to the frequency with which an intervention is carried out but also to the methods employed. When a hip replacement is performed, both the head of the femur and the pelvic socket (into which it fits) are often replaced: in 2005, 574 different head and socket combinations were used in operations in England and Wales. It seems implausible that meaningful data about the optimal combination can be gathered, or that money can be saved through bulk purchase, when such a multitude of products and suppliers is used in this way.

WASTE NOT, WANT NOT

dissemination, is increasingly recognised.

The work of the National Institute for Health and Clinical Excellence, the creation of National Service Frameworks, the systematic work of the Cochrane Collaboration, and the production of guidelines by medical Royal Colleges and other professional bodies have all served to clarify best practice in relation to specific areas of clinical decision making.

Similar initiatives have been taken in many other countries, but the intractable nature of the problem is illustrated by the remarkable studies of Elizabeth McGlynn and her colleagues, who showed that only just over half of American patients received care fully appropriate to their needs. Indeed, the Committee on Quality of Health Care in America stated in 2001 that ‘health care today... routinely fails to deliver its potential benefits’. The problem is a universal one and, to date, its solution remains elusive.

Variation in the application of treatments, on a scale that cannot be explained by differing thresholds in patient need, is a frontier in the quality of healthcare that is yet to be conquered.

Where significant variation in service provision exists but is not readily explained (for example by the age structure of the population), one of a number of problems exists: • over-use of treatments of little therapeutic value; • under-use of treatments of proven effectiveness; • misuse of treatments.

FIGURE 1 MOST CHILDREN FROM AFFLUENT BACKGROUNDS IN THE 1930S HAD THEIR TONSILS TAKEN OUT

FIGURE 2 TODAY, CHILDREN FROM DEPRIVED BACKGROUNDS ARE MUCH MORE LIKELY TO HAVE THEIR TONSILS REMOVED THAN THOSE FROM PROFESSIONAL FAMILIES

450 TONSILLECTOMY RATE PER 100,000 CHILDREN

PERCENTAGE HAVING UNDERGONE TONSILLECTOMY AT AGE 15 YEARS

70 60 50 40 30 20 10 0 PRIVATE BOYS’ SCHOOLS (1933/34)

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PRIVATE GIRLS’ STATE SCHOOLS (ESTIMATE FOR 1936) SCHOOLS (1933/34)

Source: Glover JA. The incidence of tonsillectomy in school children. Proc R Soc Med 1938; 31:1219–36

Example 1: tonsillectomy The precise function of the tonsils (a collection of lymphoid tissue at the back of the mouth) remains unknown, although it is thought that they may play a role in developing the body’s defences against common inhaled germs. The tonsils of some people, particularly children, may appear enlarged and, on occasion, they can become infected or obstruct the airway and interfere with breathing patterns during sleep.

In the early 20th century, a vogue rapidly developed for surgically removing the tonsils. By the 1930s, it was thought that as many as 200,000 people were undergoing the procedure per annum in the United Kingdom (quadruple today’s rate). Some doctors at the time mistakenly felt that a wide variety of other conditions might benefit from the procedure, including scarlet fever, nephritis, bronchitis, asthma and middle ear infections. Tonsillectomy carried a risk, with estimates attributing 85 deaths or more per annum to post-operative complications such as bleeding. So alarming was the growth in tonsillectomies being carried out on children of elementary school age that my predecessor, Sir George Newman, was moved to highlight it in his Annual Report of 1923, cautioning against premature operative intervention.

‘It is incumbent on all Authorities and school medical officers to ensure that these operations are only undertaken

400 350

ENGLAND AVERAGE

300 250 200 150 100 50 0

LEAST DEPRIVED

MOST DEPRIVED

Source: Hospital Episode Statistics, England 2004/05

when absolutely necessary, and that they are properly and skilfully conducted... It is my duty to say explicitly that I have formed the definite opinion that due and necessary care has not always been taken in this matter.’

Sir George Newman, Chief Medical Officer, writing on tonsillectomy among children in his 1923 Annual Report

In 1936, a child in Bexhill was 27 times more likely to undergo tonsillectomy than one living in Birkenhead. Furthermore, there was a marked variation in operative rates by social class, with the children of the affluent three times more likely than average to undergo the operation (see Figure 1). In 1938, 83% of boys starting at Eton College were said to have already had their tonsils removed. A committee of the Medical Research Council observed that tonsillectomy was being carried out as a ‘routine prophylactic ritual for no particular reason and with no particular result’.

By the late 20th century, although tonsillectomy was less favoured by the medical profession and rates had fallen, it remained one of the most frequently performed procedures in England with approximately 50,000 per annum, around half of them in children. Serious postoperative bleeding now occurs in 1% of patients and, overall, the procedure is very much safer than previously. Over time, the acceptable indications for the operation have become more strictly defined.

Accepted indications for tonsillectomy • Frequent acute tonsillitis (where indication is known, 86% of procedures relate to tonsillitis) • Recurrent abscesses (quinsy) (2% of procedures relate to previous quinsy) • Obstructive sleep apnoea (10% of procedures relate to pharyngeal obstruction) Data on frequency taken from the National Prospective Tonsillectomy Audit

There continues to be a significant geographical variation and, remarkably, the relationship with social class seems to have been reversed. Now, children from affluent families are significantly less likely to undergo the procedure than those from deprived backgrounds (see Figure 2).

Such substantial variation in tonsillectomy rates between areas cannot be explained by the medical needs of patients, and the variation on the basis of social class also points to other explanations. The impact of recurrent throat infections in childhood is substantial, causing absence from school on the part of the child and from work on the part of caregivers. It is no surprise that the experience of such disruption goes on to colour a family’s view of the desirability, or otherwise, of tonsillectomy. Patients access tonsillectomy, under a specialist surgeon, through the wider healthcare system – historically school medical officers and now general practitioners. The referral behaviour of these clinicians, the habits of

FIGURE 3 OVER THE LAST FIVE YEARS, THE GROWTH IN INTERVENTIONS TO TREAT CORONARY ARTERY DISEASE HAS BEEN ENTIRELY IN ANGIOPLASTY RATHER THAN OPEN HEART SURGERY CORONARY ARTERY BYPASS GRAFTS ANGIOPLASTY

70,000

TOTAL 60,000

CMO ANNUAL REPORT 2005

NUMBER OF REVASCULARISATIONS

80,000

50,000 40,000 30,000 20,000 10,000

0 1999/ 2000

2000/01

2001/02

2002/03

2003/04

2004/05

YEAR

19

Source: Hospital Episode Statistics 1999/2000 to 2004/05

Example 2: coronary revascularisation A heart attack may occur when heart muscle fails to receive sufficient blood because of a narrowing in the coronary arteries. Such narrowing is due to the build-up of fatty cholesterol deposits within the vessel wall. In patients with symptomatic heart disease (angina or a previous heart attack) and in whom significant focal narrowing in the blood vessels is demonstrated by specialist investigation, a procedure to improve flow to the territory

FIGURE 4 THE GROWTH IN INTERVENTIONS TO TREAT CORONARY ARTERY DISEASE HAS VARIED IN DIFFERENT AREAS OF ENGLAND* 3,000

NUMBER OF REVASCULARISATIONS

2,500

2,000

1,500

1,000

500

0 2000/01

2001/02 2002/03 2003/04 CORONARY ARTERY BYPASS GRAFTS

2004/05

Source: Hospital Episode Statistics 2000/01 to 2004/05 * Each line on the graph represents a strategic health authority in England

2000/01 YEAR

2001/02

2002/03 2003/04 ANGIOPLASTY

2004/05

Reducing variation in clinical practice TO deliver EFFECTIVE TREATMENT EQUITABLY

procedure are more limited (and in an era of concern about the possible transmission of Creutzfeldt-Jakob disease through tonsillectomy), it is the affluent, better equipped with information and empowered to influence the decisions that concern them, who have been able to alter their pattern of healthcare more effectively.

If all children in England underwent tonsillectomy at the same rate as the top fifth in terms of affluence, around 8,000 operations could be avoided per annum and over ÂŁ6 million saved.

WASTE NOT, WANT NOT

the specialist surgeon and the interaction between doctors and caregivers dictate intervention rates.

Such a profound variation between social classes, and the dramatic reversal in the relationship that seemed to occur in the 1950s and 1960s, offers an important insight. When tonsillectomy was a procedure in the ascendancy, in fashion and approved of by the medical establishment, it was the affluent who had greatest access to it. Today, when the recognised indications for the

REVASCULARISATIONS PERFORMED NOW, AND REQUIRED WITH A PROJECTED NATIONAL RATE OF 1,900 PER MILLION POPULATION

FIGURE 5 THE NUMBER OF REVASCULARISATIONS CURRENTLY PERFORMED FALLS WELL SHORT OF THE LIKELY NEED FOR THE YEAR 2015 IN MANY PARTS OF ENGLAND

2,500

2,000

1,500

1,000 PROJECTED NATIONAL RATE OF 1,900 PER MILLION POPULATION

500

REVASCULARISATION RATE PER MILLION POPULATION – 2004/05

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

SOUTH WEST LONDON NORTH WEST LONDON THAMES VALLEY NORTH CENTRAL LONDON SOUTH EAST LONDON BEDFORDSHIRE & HERTFORDSHIRE SURREY & SUSSEX ESSEX HAMPSHIRE & ISLE OF WIGHT DORSET & SOMERSET AVON, GLOUCS & WILTS NORFOLK, SUFFOLK & CAMBS KENT & MEDWAY NORTH EAST LONDON

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

COVENTRY/WARKS LEICS, NORTHANTS & RUTLAND SOUTH WEST PENINSULA WEST YORKSHIRE NORTH & E YORKS & N LINCS BIRMINGHAM & BLACK COUNTRY TRENT CUMBRIA & LANCASHIRE SHROPSHIRE & STAFFORDSHIRE CHESHIRE & MERSEYSIDE GREATER MANCHESTER SOUTH YORKSHIRE NORTHUMBERLAND, TYNE & WEAR COUNTY DURHAM & TEES VALLEY

0 1

2

3

4

5

6

7

8

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

STRATEGIC HEALTH AUTHORITY (SEE LIST RIGHT)

Source: Hospital Episode Statistics 2004/05 and Department of Health Modelling Team

of the heart supplied by that vessel may be appropriate.

Twenty years ago, the only option for achieving such ‘revascularisation’ was a coronary artery bypass graft, a surgical operation in which blood vessels taken from other parts of the body are used to bypass diseased coronary segments. Open heart surgery is still necessary for some forms of coronary heart disease but there is now another option. A less invasive procedure known as angioplasty, whereby a balloon is inflated within the vessel in order to widen it, was first introduced in 1977. With the advent of stents (cylindrical meshes that hold open the vessel following dilatation), angioplasty has come to be regarded as a valid alternative to cardiac surgery for many (although not all) types of coronary heart disease.

Since publication of the National Service Framework for Coronary Heart Disease and the NHS Plan in 2000, the timely treatment of heart disease in England has been a focus of attention. Overall rates of revascularisation have increased dramatically (see Figure 3). However, activity has grown in some areas of the country at a very different rate to that in others (see Figure 4).

Variation in the rate of coronary revascularisation per se is to be expected.

The amount of coronary disease within given populations differs significantly according to the prevalence of the risk factors for atherosclerosis. The factors that have an impact at population level include an older age profile, higher rates of

smoking, higher levels of obesity or diabetes (influenced in turn by a population’s ethnic make-up), and a higher proportion of males in the population. Other factors, such as the extent to which a population uses health services, may have an indirect influence (by impacting on the identification and treatment, or otherwise, of high blood pressure).

Examining the crude rate of revascularisation in each area of the country is therefore misleading and unhelpful.

Rather, it is necessary to estimate a specific population’s need for revascularisation and then compare actual provision with that need. An equitable NHS will provide more revascularisation services to populations with a higher proportion of people with heart disease. In this respect, the NHS is not currently equitable.

In 2000, the National Service Framework for Coronary Heart Disease identified an appropriate national rate for revascularisation of 1,500 per million people per annum. Since then, rates of revascularisation (notably via angioplasty) have continued to rise throughout the developed world. One factor driving this rise is the vogue for immediate angioplasty as a treatment for heart attacks. Analysts have therefore identified several other potential national rates for the year 2015 – these are not targets, but rather modelled projections of need. One such figure, at the more conservative end of the spectrum, is a rate of 1,900 revascularisations per million people. By developing a model to assess the needs of local populations, it is possible

to estimate the different rates necessary in each locality in order to achieve this national headline figure. In this way, one can examine current provision against the likely requirements in 2015. Any mismatch, in either direction, can then be analysed (see Figure 5).

Some local health communities will be required to achieve very dramatic increases in the number of procedures performed in order to provide their population with an equitable level of service (see Figure 6).

FIGURE 6 THE INCREASE IN THE NUMBER OF REVASCULARISATIONS REQUIRED TO MEET THE ANTICIPATED NEED IN THE YEAR 2015 VARIES WIDELY ACROSS ENGLAND

STRATEGIC HEALTH AUTHORITY

20

3,000

GREATER MANCHESTER CHESHIRE & MERSEYSIDE COUNTY DURHAM & TEES VALLEY TRENT NORTHUMBERLAND, TYNE & WEAR SOUTH YORKSHIRE CUMBRIA & LANCASHIRE SHROPSHIRE & STAFFORDSHIRE AVON, GLOUCS & WILTS WEST YORKSHIRE NORTH & E YORKS & N LINCS LEICS, NORTHANTS & RUTLAND KENT & MEDWAY COVENTRY/WARKS HAMPSHIRE & ISLE OF WIGHT BIRMINGHAM & BLACK COUNTRY ESSEX NORFOLK, SUFFOLK & CAMBS NORTH CENTRAL LONDON DORSET & SOMERSET SOUTH EAST LONDON NORTH EAST LONDON BEDFORDSHIRE & HERTFORDSHIRE SURREY & SUSSEX

THAMES VALLEY SOUTH WEST LONDON SOUTH WEST PENINSULA NORTH WEST LONDON –600 –400 –200

0

200

400

600

800 1,000 1,200

REQUIRED CHANGE IN REVASCULARISATIONS PER MILLION POPULATION

Source: Hospital Episode Statistics and Department of Health Modelling Team

FIGURE 9 THE NUMBER OF HYSTERECTOMIES AMONGST WOMEN AGED 40–59 YEARS IN ENGLAND HAS BEEN FALLING

40,000

6

35,000 HYSTERECTOMIES PER YEAR

7

5 4 3 2 1

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30,000 25,000 20,000 15,000 10,000 5000

0 0

0 200

400

600

800

1,000

1,200

1997/98

1998/99

STATIN PRESCRIPTIONS PER 1,000 POPULATION PER YEAR

Source: Prevalence data from quality and outcomes framework 2004/05, prescription data from prescription pricing division of NHS business services authority

2001/02

2002/03

2003/04

2004/05

YEAR

21

Source: Hospital Episode Statistics 1997/98 to 2004/05

as to which patients should be offered statin therapy, based on their risk of a vascular event (heart attack or stroke) over the subsequent years. For some people, levels of risk are intermediate and statins can be purchased over the counter (although the prescription threshold has not been met).

One might expect that populations with a heavy burden of cardiovascular disease would demonstrate higher statin prescription rates. When prescription rates are compared with the crude premature death rate from coronary heart disease by strategic health authority, this relationship is apparent and has become stronger between 2002 and 2005.

However, hidden at this scale is the variation that occurs locally, between primary care trusts, in rates of statin prescription in relation to the needs of the local population. Some patients are not receiving the therapy that they ought to receive, whether through a lack of engagement with the local health service or through the fault of clinical decision makers or budget holders. When the burden of heart disease is determined by the returns of general practices (rather than by crude death rates), discrepancies persist. Access to evidence-based therapies to reduce the chances of further cardiovascular disease is not currently equitable (see Figure 7).

Example 4: hysterectomy in younger women Hysterectomy, the surgical removal of the womb, is an operation carried out

FIGURE 8 THE MEAN ANNUAL RATE OF HYSTERECTOMY VARIES MARKEDLY ACROSS ENGLAND NORTH CENTRAL LONDON NORTH WEST LONDON SOUTH WEST LONDON SOUTH WEST PENINSULA SURREY & SUSSEX THAMES VALLEY NORTH EAST LONDON BEDFORDSHIRE & HERTFORDSHIRE SOUTH EAST LONDON NORTH & E YORKS & N LINCS NORFOLK, SUFFOLK & CAMBS HAMPSHIRE & ISLE OF WIGHT AVON, GLOUCS & WILTS ESSEX ENGLAND LEICS, NORTHANTS & RUTLAND TRENT KENT & MEDWAY CHESHIRE & MERSEYSIDE CUMBRIA & LANCASHIRE WEST YORKSHIRE SOUTH YORKSHIRE NORTHUMBERLAND, TYNE & WEAR COVENTRY/WARKS GREATER MANCHESTER DORSET & SOMERSET COUNTY DURHAM & TEES VALLEY BIRMINGHAM & BLACK COUNTRY SHROPSHIRE & STAFFORDSHIRE 0

50 100 150 200 250 300

HYSTERECTOMY RATE PER 100,000 WOMEN PER YEAR

Source: Hospital Episode Statistics 1997/98 to 2004/05

for a number of indications, including excessively heavy vaginal bleeding (occurring in pre-menopausal women and accounting for nearly half of all hysterectomies) and suspicion of malignancy (largely in post-menopausal women). Hysterectomy is not a minor undertaking – associated with it are complications, hospital stays and costs.

Historically, rates of hysterectomy have varied geographically without apparent cause (see Figure 8).

Reducing variation in clinical practice TO deliver EFFECTIVE TREATMENT EQUITABLY

Example 3: statin prescription Patients identified as being at high risk of future coronary events, whether on account of their risk factors or by having a personal history of coronary disease, have an improved survival rate when they receive a number of different types of drug treatment.

Data from an ongoing national audit have demonstrated that a very high proportion of patients are now prescribed the relevant drugs when discharged from hospital after a heart attack. There are fewer data regarding those at risk but with no personal history of disease.

Statins reduce the level of cholesterol in the blood, a risk factor for further, or future, vascular disease. There are clear guidelines

2000/01

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Furthermore, there is notable variation across England in patient access to either surgery or angioplasty. In some parts of the country, patients having revascularisation are more than twice as likely to have it delivered through angioplasty as they would be in other areas.

Efforts to increase revascularisation capacity around the country focus predominantly on the further provision of angioplasty facilities. In the future, it will be important not only to observe capacity and whether crude clinical need is being met, but also to keep a check on the options available to patients as to how revascularisation is carried out (as, for some groups, bypass surgery may remain the more appropriate option).

1999/ 2000

STRATEGIC HEALTH AUTHORITY

PERCENTAGE OF POPULATION WITH CORONARY HEART DISEASE

FIGURE 7 THE PRESCRIPTION OF STATINS IN PRIMARY CARE TRUSTS GENERALLY RELATES TO THE BURDEN OF DISEASE BUT THERE ARE MANY NOTABLE OUTLIERS

FIGURE 10 THE PERCENTAGE REDUCTION BETWEEN 2000 AND 2005 IN HYSTERECTOMIES FOR 40 TO 59-YEAR-OLD WOMEN WITH EXCESSIVE MENSTRUAL BLEEDING VARIED WIDELY ACROSS ENGLAND

15% to 27% 27% to 39% 39% to 51% 51% to 64%

22

Source: Hospital Episode Statistics 1999/2000 and 2004/05

As early as the 1940s, it had become apparent that hysterectomy was not always undertaken for an appropriate reason. In a study of all hysterectomies undertaken at 35 hospitals in California over a year, the procedure was found not to be justified in approximately 40% of cases (the rates in the 35 hospitals ranged from 5% to 84%).

Today, hysterectomy is a common procedure, with almost 38,000 performed in England in 2004/05.

In the last decade, alternative treatments for heavy gynaecological bleeding have been developed and were favourably appraised by the National Institute for Health and Clinical Excellence in early 2003. It would therefore be expected that the numbers of hysterectomies carried out, particularly among younger women, should have fallen substantially following the introduction of this technology.

Hysterectomy rates have indeed declined, falling by 13% (for all indications) and 31% (for women aged between 40 and 59 years) between 2002/03 and 2004/05, continuing a trend that began in the late 1990s (see Figures 9 and 10). However, the rate of reduction has been variable across the country (and is unrelated to the baseline rate).

For women aged between 40 and 59 years with excessive menstrual bleeding, for whom alternative technologies are most appropriate, hysterectomy rates have fallen by as much as 64% in North Central London Strategic Health Authority but by as little as 15% in Northumberland, Tyne and Wear Strategic Health Authority.

Data again illustrate the variability in the baseline rate of hysterectomy around England, most likely as a result of clinicians’ habits rather than of differential need.

In addition, a variable uptake of new technologies can be demonstrated, reflecting differences in the use of resources and in the propensity of doctors and their patients to adopt innovative, evidencebased interventions.

If the average rate of hysterectomy in England could be reduced to that achieved in the 20% of the country with the lowest current rates, then 5,900 operations, costing £15 million, could be avoided per annum.

Although the costs of alternative treatments would need to be taken into account, financial savings would still be substantial.

Discussion Each example demonstrates that healthcare in the NHS is to some extent inequitable at present: the preference of clinicians, the socioeconomic status and empowerment of patients, and decisions regarding specific local resource allocation may influence clinical practice as much as the actual health needs of patients, the behaviour of any pathological process or the scientific evidence base.

As technology advances, the range of possible interventions continues to grow. With finite resources available for the provision of healthcare, it is important that effective therapies to relieve significant conditions are adopted and that ineffective interventions are abandoned. When carried out with transparency and objectivity,

priority setting is vital to the effective delivery of health services.

Doctors and other clinical decision makers represent a vital resource in the NHS. Through their training, they are well placed to put evidence (as applied to the individual patient in front of them) into practice and so enable the population to reap the benefits of medical advances.

Given the length and breadth of their training, doctors working as principals in general practice or as consultants in secondary care have often been regarded, both by themselves and by others, as independent and autonomous in their daily practice. These doctors have the experience to work without the supervision of others and to make complex and finely balanced decisions, but that is not to say that there is no place for guidelines and protocols to enable some standardisation of processes.

No person is wholly independent of others, or of the system in which they work.

Professional autonomy must not be used to mask inappropriate variations in the application of evidence to healthcare.

Inexplicable variability in the delivery of specific health interventions across the NHS suggests one of a number of problems: • inappropriate resource allocation; • poor spread of new knowledge to the consulting room, either through doctors, their patients or both; • appraisal decisions and processes that are insufficiently robust and less effective than they might be, either in their subject matter, conduct, dissemination or implementation.

ACTION RECOMMENDED

THREE In order to permit objective and transparent decision making by NHS commissioners, the National Institute for Health and Clinical Excellence should be asked to issue guidance in relation to disinvestment from established interventions that are of no proven value.

FOUR Further consideration should be given to the feasibility of varying tariff payments from commissioners to providers of care, according to the effectiveness (and likely appropriateness) of the procedure in question.

Reducing variation in clinical practice TO deliver EFFECTIVE TREATMENT EQUITABLY

TWo The National Institute for Health and Clinical Excellence should work to improve access to the information it produces for both

professionals and the public, assessing the needs and desires of different groups of clinicians and patients.

23 WASTE NOT, WANT NOT

ONE Attention should be paid to the active management of knowledge and to the roles that the National Library for Health and Connecting for Health can play in improving and systematising access to qualityassured information at the time and place of need.

CMO ANNUAL REPORT 2005

“Cochrane’s celebrated vision of the 1930s, that ‘all effective treatment must be free’, is not yet fulfilled.

More than many other healthcare systems, which also experience such variation, the NHS can solve this long-standing problem.”

24

LEARNING TO FLY Drawing parallels between aviation safety and patient safety.

Four Standard operating procedures are a powerful defence against errors and accidents causing harm in the

aviation industry. But this approach is counter-cultural in healthcare.

FIVE Solving safety problems requires engaging powerful leaders both locally and nationally. They need to have clear goals and take responsibility for making sure problems are promptly addressed and rectified, so that a culture of patient safety becomes ‘the way things are done around here’.

Drawing parallels between aviation safety and patient safety

TWO Properly focused incident analysis provides a unique insight into the strength of organisational processes and system defences to prevent harm to patients.

Three It is important to have committed and demonstrable leadership on safety, with targets, clear roles and responsibilities and proactive strategies for fixing safety problems and making safety everyone’s business.

25 LEARNING TO FLY

ONE Aviation has a much better record on safety than the healthcare industry and much can be learned from them.

CMO ANNUAL REPORT 2005

“Like the aviation industry, safety must be at the core of our health services if we are to improve patient care.”

The year 2004 was the safest ever for air travel: the number of airline fatalities worldwide was at the same level as in 1945.

This was despite the fact that the number of passengers had increased from 9 million to 1.8 billion per annum.

26 The aviation industry has an impressive safety record, which is getting better all the time. Such results have been achieved through a systematic and sustained focus on safety as a core part of business strategy for many decades.

The figures speak for themselves (see Figure 1). The year 2004 was the safest ever for air travel: the number of airline fatalities worldwide was at the same level as in 1945. This was despite the fact that the number of passengers had increased from 9 million to 1.8 billion per annum.

This has been achieved by a constant search for better and safer ways of designing, constructing and flying aeroplanes. Indeed, in the United States alone, if the accident rate today had remained the same as when jet transportation was introduced in the 1950s and early 1960s, there would be around 300 major airline accidents every year.

Looking to the future, the industry has set programmes in place now, which it is confident will lead to a further 25% reduction in aviation accidents and fatalities over the next few years.

These are compelling statistics.

They should inspire our own efforts in healthcare to continuously improve patient safety. Aviation has developed and implemented a range of valid reporting, analytical and investigative tools and approaches, which have been improved in

the light of experience. Such approaches identify sources and causes of risk in ways that lead to early preventive action and measurable improvement.

It is now six years since my report An Organisation with a Memory, which launched the patient safety programme within the NHS. In the report, I highlighted other high-risk industries that have a much better safety record than healthcare. Much can still be learned from them as healthcare grapples with the fundamental issues necessary to improve the safety of care for patients.

Recently, I chaired a small international meeting with safety experts from the aviation industry. Three important developments and areas in aviation safety emerged from this discussion.

There are, of course, important differences between flying passengers in an aeroplane and caring for sick patients, but there are major themes in common with the purpose of making the services safer.

Incident reporting: more than meets the eye?

There is a strong and proper belief that an important way to improve safety is to analyse, understand and learn from the things that go wrong.

The aviation industry has wellestablished, formal systems for safety incident reporting and risk analysis. Until recently, there has been relatively little research and knowledge on how reporting

systems actually operate once they are set up. In particular, the day-to-day practice of investigators in assessing incidents and using them to manage risks has not been well understood. Fascinating insights are provided by research recently undertaken by Dr Carl Macrae into how airline safety staff use and interact with information about risks to safe air travel.* Aviation and healthcare reporting systems share the challenge of making sense of the value of often brief, ‘minor incident’ reports, which, at first glance, may seem to have limited consequences.

These incident reports come from a wide range of operational areas and usually include events where something minor has not gone right or according to plan. The event may be a minor error for which someone has compensated or actively addressed the problem in time.

Such incident reports may appear to be of limited value as there is almost no adverse outcome or resulting harm. It is therefore difficult to discern whether the incident means the system is flawed or whether the system is actually working because it was only a minor incident that was picked up in a timely way.

This gives rise to the key challenge of how to define risk and safety, and, in the light of this, how to interpret incidents to identify new and emerging risks.

* Research currently being written up. Please contact Dr Carl Macrae for further details at: ESRC Centre for Analysis of Risk and Regulation, London School of Economics and Political Science; www.lse.ac.uk/depts/CARR

FIGURE 1 WORLDWIDE COMMERCIAL JET FLEET ACCIDENT RATE*

30

20

15

10

2000

1998

1996

1994

1992

1990

1988

1986

1984

1982

1980

1978

1976

1974

1972

1970

1968

1966

1964

1962

0

1960

5

CMO ANNUAL REPORT 2005

ACCIDENTS PER MILLION DEPARTURES

25

The National Audit Office reported in 2005 that ‘patient safety incidents cost the NHS an estimated £2 billion a year in extra bed days; in addition, hospitalacquired infections add a further £1 billion to these costs.’

YEAR

27

Source: Aviation Safety and Patient Safety Expert Meeting April 2006 *Excludes sabotage and military action

Lessons for healthcare The National Audit Office reported in 2005 that patient safety shortcomings cost the NHS at least £3 billion per annum. The National Patient Safety Agency was set up in 2001 to ensure that the NHS as a whole can systematically learn from errors and system failures.

To date, the Agency has accumulated almost a million incident reports.

Given the importance of incident reporting, both in terms of the burden of safety problems and the investment in

reporting being made by the NHS, the challenge now is to find effective ways of using such large data banks. Three main lessons emerge from the research findings in relation to the aviation industry.

Firstly, the need to develop further the analysis of incident reports in healthcare.

The focus must be on learning how organisational processes and system defences can be strengthened to prevent future harm to patients. We need to ask: ‘What does this incident tell us about the potential for minor mishaps to turn into major breakdowns in this hospital or health service?’

Secondly, the need for active involvement of individuals with clinical and operational experience in incident analysis, to better understand the practical organisational processes involved. A clinical culture must be built that understands the importance of these reports, not one that dismisses them as being of peripheral relevance to clinical services. Team-based training, such a successful approach in the aviation industry, is only beginning to emerge in clinical medicine and is not thought of in relation to patient safety.

In aviation, organisational processes are viewed as inherently practical, from entering data on the flight deck or repairing engines, right through to developing training regimes. We need detailed analysis of the practical work that provides effective safety defences in all healthcare settings. This is important because air safety incident analysts use incident reports not only to

Drawing parallels between aviation safety and patient safety

and the resilience of the organisational processes that surround them.

A focus on risk resilience leads air safety incident analysts to judgements of risk and safety that fall into three main categories: • acceptable risk resilience, which is as close an approximation to safety as they believe they can achieve in an area of the organisation; • reduced risk resilience, in which processes for dealing with risk are not as effective or extensive as they could be. For example, the systematic failure of a checking mechanism that was still backed up by a further routine check and an automated warning system; • degraded risk resilience, in which there are few or no systematic defences or organisational capacity to stop a slip or an error turning into something far worse.

This is a very serious situation where there is clear potential for the emergence of a major accident or serious harm.

LEARNING TO FLY

Traditionally, risk has been defined in terms of bad outcomes: harm and adverse consequences. In other words, a full-blown event which is clear, visible and obvious to everyone. In healthcare, safety is often defined in terms of the absence of adverse outcomes to patients.

This approach is now seen as over-simplistic. In safety-critical industries such as aviation and healthcare, potential catastrophe is never far away. Errors and system failures are not extraneous, unusual things that happen. They must be viewed as an inherent part of organisational life. Equipment will fail.

The human factor is critical, and professionals will make mistakes.

Patients will turn up out of sequence and at the wrong time. This is a normal part of a complex organisation.

In view of this, any minor incident can be a catastrophe if all the possible things that could go wrong come into play in one place, at one moment in time.

In aviation, a view of safety based on the concept of organisational ‘risk resilience’ has emerged. Macrae defines this as ‘the organisational capacity to protect operations from the potential of minor mishaps, fluctuations or anomalies developing into major organisational breakdowns’.

In other words, safety is resilience against minor incidents getting any worse.

Errors and failures are not necessarily the problem. The main concern is where those minor events can lead,

28 predict bad outcomes or classify particular errors and causal factors, but also to build a picture of the quality of current organisational processes and how well things are done in their organisation.

Thirdly, the need to develop more widely understood concepts of differing degrees of ‘risk resilience’, which are relevant to the unique circumstances of healthcare. We need to ask ourselves: ‘What do acceptable, reduced and degraded risk resilience look like in our healthcare service?’

Ramping up safety One of the most dangerous places in any airport is the area around the aircraft as it is being readied for flight. Known as the ‘ramp’, this is an area of intensive activity, often in a very short space of time, when baggage is unloaded and loaded, fresh supplies are brought onto the plane and refuelling occurs.

The parallel in healthcare is of busy clinical areas, particularly the emergency department and the operating theatre.

In the emergency department, patients need to be seen quickly, accurate diagnoses made and appropriate treatment and transfer undertaken.

During 2003, unsafe ramp areas were thought to have caused over 5,000 personal injuries to staff, including manual handling injuries, and damage amounting to several million pounds for just one major airline.

When attention was first paid to ramp

areas, apart from the risks of working with ground handling equipment, the problem of a weak culture of safety was identified.

Many staff placed priority on ‘getting the job over with’ rather than doing it safely.

It was not considered ‘cool’ to be too concerned with personal safety or that of colleagues. This same potential also exists in busy, stressful clinical areas where, for example, fracture management, drug treatment and other interventions may all happen simultaneously.

British Airways implemented a major ramp safety initiative at Heathrow Airport in 2003. This involved everyone with responsibility for problems in the safety culture that existed, including departmental heads, senior and middle management, their supervisors, team and crew leaders.

According to British Airways: ‘The overall aim of the programme is to reduce lost time, injuries, aircraft damage and vehicle damage and to enhance risk awareness on the ramp areas. It will also aim to improve communication of the safety message within all areas of the company.’

The combination of strategies that has been implemented includes: • transformational targets for improvement signed up to by the senior management team; • improving safety standards and ensuring compliance (e.g. ensuring maximum baggage weight compliance); • ramp safety visits twice a week by the

general manager to ‘walk the talk’ and promote safety; • a 24/7 general manager-level roster for attending serious and major incidents to ensure that formal investigation processes are undertaken; • automated vehicle control devices fitted to 700 vehicles to improve user traceability and ensure trained operation.

A further review identified continued problems with workforce behaviour and a lack of clarity over ownership of safety targets and priorities.

The response to this focused on the proactive management of risks before they led to injuries and accidents. Key staff, including managers, supervisors and team and crew leaders, were trained to readily observe safe and unsafe ramp behaviour.

The training also addressed ways in which they could deal with their observations in a constructive and non-threatening manner. This was particularly important because, as in many work situations, the seemingly simple act of giving positive and negative feedback to co-workers within the same work area was relatively rare.

Lessons for healthcare There are three obvious lessons for healthcare from the experiences of safety initiatives focusing on ramps around aircraft.

Firstly, the importance of assigning clear organisational roles and responsibilities for fixing safety problems. When I explored with experts why the ramp safety problem had been allowed to continue in an industry

CMO ANNUAL REPORT 2005

‘ One of my captains, who had a thing about the ramp, would go around and collect from the ramp nuts and bolts and screws and luggage labels and knives and forks. I used to take them along and empty them on the Chief Executive’s table at meetings and say “We have got to do something.”’

Captain Jock Lowe, Former chief Pilot, British Airways

29 products of a development process in which there is active participation from people within the organisation.

In healthcare, the story of the origins of the American Advanced Trauma Life Support (ATLS) programme shows the importance of such procedures. It is a hallmark of professionalism. It informs and trains junior surgeons and emergency department staff in the importance of a standardised approach to trauma.

Its aims are broad. If ATLS is followed correctly, and supported by adequate training, anyone from a rural doctor in a small hospital to a multidisciplinary trauma team in a major hospital should offer the same standard pathways of care.

Its origins are humble. In 1976, an orthopaedic surgeon crashed his plane in Nebraska. Tragically, his wife was killed and three of his four children suffered traumatic injuries. To further compound the situation, the care he received in the local hospital was disorganised and did not adhere to standard operating procedures. This disastrous event initiated the compilation of protocols for the safe treatment of such patients.

ATLS was first published in 1980, four years after the initial plane crash. It sets the international standard for trauma care and its study is an important part of becoming a member of the Royal College of Surgeons of England, which administers the programme in the United Kingdom.

There are other examples of good practice. The Resuscitation Council (UK)

Drawing parallels between aviation safety and patient safety

Standard operating procedures Individuals make mistakes. However, they are the final defence against system failures. This means that standard operating procedures – doing everything exactly the same way all the time – are a powerful part of the armoury of safety in the aviation industry.

Indeed, failure to follow standard operating procedures (SOPs) is a major contributing factor to aviation accidents.

SOPs function at both a general and a specific level. For example, despite aircraft being made by different manufacturers, like Boeing and Airbus, in the majority of cases each airline will have ensured similar procedures regardless of the make of the aeroplane.

Across airlines and internationally, in most cases, there is also standardisation of specific functions. The contact between the cabin crew and the flight crew highlights this very well. During take-off and landing, and sometimes in flight, a series of high-pitched sounds are often heard. These signal various communications from the flight crew to the cabin, for example when the plane is close to taking off or landing.

SOPs are not an object for discipline or blame. When things go wrong, it is not a matter of throwing the rulebook at someone and saying: ‘You didn’t follow what it says here.’ SOPs are inherently linked to the culture of an organisation.

In high-reliability organisations, they are

LEARNING TO FLY

with such an impressive safety record, I learned that it had never been properly focused on. Indeed, it was seen as the ‘cost of doing business’. In the first instance, impetus for action requires someone whose job lay with fixing the problems. The parallels with healthcare are striking, particularly on the value and importance of strong organisational and clinical ownership and leadership in addressing patient safety problems.

Secondly, the importance of multifaceted approaches to improving safety. The RAMPsafe initiative incorporates goal setting, standard setting, staff training, measurement of progress, visible and frequent senior management involvement and equipment design changes, to name but a few.

Thirdly, the value of not waiting for things to go wrong but rather actively seeking out risks and hazards before they cause harm. I remember on a recent visit to Johns Hopkins Hospital in Baltimore, Maryland, Dr Peter Pronovost telling me that an important part of the safety monitoring system in their hospital is to actively and systematically invite staff to identify the next thing that will harm patients in their work unit before it has actually happened.

This highlights another strength of the RAMPsafe initiative: emphasis being placed on equipping people with the tools to communicate information about risks and hazards effectively to their peers.

FIGURE 2 WORLD HEALTH ORGANIZATION PAIN LADDER: MOVING TOWARDS A STANDARD OPERATING PROCEDURE TO ENSURE SAFER CARE AND CONSISTENT STANDARDS FREEDOM FROM CANCER PAIN

3

OPIOID FOR MODERATE TO SEVERE PAIN +/- NON-OPIOID +/- ADJUVANT

PAIN PERSISTING OR INCREASING

2

OPIOID FOR MILD TO MODERATE PAIN +/- NON-OPIOID +/- ADJUVANT

PAIN PERSISTING OR INCREASING

1

NON-OPIOID +/- ADJUVANT

30 has recently updated the advanced life support procedures, which are invaluable to staff working in acute medicine.

Other, less acute specialties have also benefited greatly from standard operating procedures. Pain management should broadly follow a stepwise progression, ensuring that patients benefit as much as possible from less powerful analgesics before introducing opiate analgesia, which raises potential safety considerations (see Figure 2).

Lessons for healthcare In clinical practice, particularly medicine, a culture of ‘clinical autonomy’ has been the predominant tradition. So much so that when I was talking to a surgeon recently about standard operating procedures, he told me: ‘If you introduce that approach, it would be like working in a factory, not being a doctor.’ This view does not reflect the work being done in many clinical specialties, where they are beginning to understand the importance of SOPs, as the examples in this chapter demonstrate.

Standardising procedures in high-risk areas of clinical practice is not an assault on clinical freedom. It is compatible with high-quality clinical practice by highly trained, highly skilled professionals who continue to exercise judgement in most areas of their practice. This is an area where we can learn much from the airline industry.

Conclusions In healthcare, like aviation, errors and system failures should always necessitate action. At the end of every story of failure is a real person with a real story. The uniqueness of patients’ experiences is vital and must not be forgotten.

At its heart, the success of aviation safety has several key elements: • firstly, the importance of clear goal setting; • secondly, the importance of collecting data that are useful and used, so that everybody understands what is being looked for and the changes that need to occur; • thirdly, the importance of comprehensive and multifaceted approaches to risk management which focus on the important issues; • fourthly, the importance of building a strong safety culture that is owned by everyone in the organisation. I am struck by the definition of safety culture which suggests that it is ‘the way things are done around here... when no one is actually looking’; • fifthly, the importance of oversight, monitoring and clear accountabilities for action.

In conclusion, respected and influential doctors, nurses and healthcare leaders need to promote learning from errors, and lead by example.

ACTION RECOMMENDED

THREE Continual effort needs to be made to standardise clinical practice wherever there is opportunity to do so.

FOUR Powerful clinical leaders need to be engaged with patient safety and understand healthcare’s poor record.

FIVE Understanding the importance of patient safety should begin early in clinical practice and healthcare training curricula should focus strongly on this.

Drawing parallels between aviation safety and patient safety

TWO A culture of safety needs to be created within healthcare, similar to that in

aviation. Incident reporting and learning needs to occur routinely, and training needs to take place at all levels within healthcare to aid understanding of the importance of these measures.

31 LEARNING TO FLY

ONE The NHS should look to other high-risk industries for good examples of safety practice and then make reasonable comparisons with its own healthcare facilities.

CMO ANNUAL REPORT 2005

“We must learn from the successes of other industries and take the appropriate action; that way, we will save more lives.”

32

TAKING NO CHANCES Early recognition of warning signs can prevent kernicterus.

THREE There is no standardised national prevention scheme within England.

FIVE Not recognising the events that lead to kernicterus is a significant patient safety issue. six Better awareness by healthcare professionals and parents will reduce the problem.

SEVEN Parents are given insufficient information about jaundice and kernicterus on discharge from hospital, and the five bestselling books for new mothers give the subject little attention.

EIGHT More research is needed to establish whether screening to prevent kernicterus would be cost-effective.

NINE A national register would improve understanding of the disease.

Early recognition of warning signs can prevent Kernicterus

TWO It is largely preventable if early warning signs are recognised.

FOUR Kernicterus may be occurring more frequently because of earlier discharge of babies from hospital.

33 TAKING NO CHANCES

ONE Kernicterus is a serious disease of the brain, related to jaundice, which can occur in newborn babies. It usually results in severe disability (cerebral palsy) or death.

CMO ANNUAL REPORT 2005

“Knowing what to look for, and responding, can make the difference between life and death, or profound damage to the child.�

FIGURE 1 MORTALITY RATES WITHIN FOUR WEEKS OF BIRTH IN ENGLAND AND WALES

RATE PER 1,000 LIVE BIRTHS

12

10

8

6

4

2

0 1970

1975

1980

1985

1990

1995

2000

2005

YEAR

34

Source: Health Statistics Quarterly 27: 2004

Kernicterus is damage to the brain caused by the abnormal passage of the natural waste product bilirubin through the blood–brain barrier. This occurs when bilirubin is present at toxically high levels.

Bilirubin is produced in the body by the breakdown of red blood cells, which occurs more rapidly in newborn babies.

In adults, bilirubin is made water-soluble in the fully functioning liver and passes safely out of the body. In the newborn, it is normal for bilirubin levels to be elevated as the liver is relatively immature, and this causes varying degrees of jaundice, a yellow colouring of the skin and eyes.

This can be associated with normal breastfeeding or exacerbated by an increased number, or decreased lifespan, of red blood cells.

Jaundice is therefore a common occurrence in both premature (80%) and full-term (50%) newborns. It typically appears two to four days after birth and resolves itself one to two weeks later.

For the vast majority of cases, this is normal ‘physiological’ jaundice and no specific action is required.

Non-physiological (pathological) jaundice is more serious. Causes include blood group (rhesus or ABO) incompatibility, abnormal breakdown of red blood cells, infections, bruising related to delivery and rare metabolic disorders.

Bilirubin levels can continue to rise to toxic levels (severe hyperbilirubinaemia) and penetrate the brain (causing acute bilirubin encephalopathy). This may lead on to the permanent condition

kernicterus, which can cause long-term brain damage or death. Kernicterus literally means ‘yellow kern’. Kern refers to the brainstem nuclei, the part of the brain that is affected by the toxically high bilirubin.

INCIDENCE AND CONSEQUENCES OF KERNICTERUS Mortality rates amongst newborns in England and Wales have fallen dramatically in the last 35 years, in part due to general improvements in antenatal and postnatal care (see Figure 1). However, internationally kernicterus seems to be increasing.

The incidence of kernicterus in the United Kingdom is estimated to be 1 in 100,000 live births. In the two years up to May 2005, 14 cases were reported. Four of these babies died and six have long-term neurological and developmental problems.

A long-term consequence of kernicterus is cerebral palsy, but discolouration of the teeth and other problems may also feature.

Although the incidence of the disease is low as a proportion of total births, its impact on the child and family concerned is high. So too are the consequences of potential lifelong disability.

The 14 United Kingdom cases of kernicterus were studied by the British Paediatric Surveillance Unit. The condition was found to be more common in dark-skinned babies. It rarely appeared ‘out of the blue’ – other warning symptoms and signs, in addition to severe jaundice, were invariably present, including: impaired consciousness; abnormal

muscle tone; spasm in the head, neck and spine; and seizures.

In the British survey, other medical problems were also associated with the development of kernicterus. These included abnormal breakdown of red blood cells, dehydration, infection, and severe bruising related to delivery. Other studies have also indicated that male sex, prematurity, jaundice in the first 24 hours of life, previous siblings with jaundice and inadequate breastfeeding are all associated with developing toxically high levels of bilirubin.

Dehydration and inadequate breastfeeding are often linked, and severe jaundice is almost always associated with other problems. Pre-term babies may be at a reduced risk of kernicterus as they are often kept in hospital for a longer period of surveillance.

Early discharge from hospital Of the 14 cases of kernicterus identified, 10 were readmitted after leaving hospital.

The median age at initial discharge was between 24 and 48 hours. In recent years, increasingly early postnatal discharge of both full-term and near-term infants (see Figure 2) may have coincided with a more relaxed attitude to neonatal jaundice. It has been suggested in some countries that this may have contributed to the re-emergence of kernicterus.

In the past, kernicterus was strongly associated with blood group (rhesus) incompatibility, but this is now very rare due to better prevention of this condition.

Warning symptoms and signs

Associated problems

Cerebral palsy

Severe jaundice

Dehydration

Deafness

Impaired consciousness

Inadequate breastfeeding

Disturbed vision

Abnormal muscle tone

Infection

Feeding and speech difficulties

Spasm in the head, neck and spine Seizures

Severe bruising related to delivery

Stained teeth

Jaundice in the first 24 hours of life Previous siblings with jaundice Prematurity Abnormal breakdown of red blood cells

CMO ANNUAL REPORT 2005

Long-term IMPACT OF kernicterus

35

Olivia’s story • Olivia was born by vaginal delivery and weighed 3.7 kg.

• Her parents noticed her ‘gold-dust’ colour.

• Olivia and her mother were discharged eight hours after delivery.

• During the home visit the next day, the midwife noted jaundice and Olivia’s mother reported poor feeding.

No action was taken.

• The general practitioner visited the same day. During this time, Olivia was rolling over in an unusual way.

• The next day there was another visit from the midwife. Jaundice was noted again. No action was taken.

• The next day a different midwife visited, noted the jaundice and that Olivia was drowsy and not feeding. Olivia was readmitted to hospital and later to a specialist unit in another hospital.

• A toxically high blood bilirubin level was found and treatment started, but Olivia died the next day.

‘ Without prompt treatment, a build-up of bilirubin in the brain can lead to a condition called kernicterus. This can lead to brain damage or even death, so it is important that high levels of bilirubin are treated immediately.’

NHS DIRECT

Early recognition of warning signs can prevent Kernicterus

How is kernicterus treated?

Visual inspection is not a reliable way of assessing the severity of jaundice (especially in dark-skinned babies). It may need to be supplemented by measuring the bilirubin level in the blood. High levels of bilirubin and associated problems must be identified before severe jaundice sets in, as this can lead to kernicterus and irreversible brain damage. Treatment is initially with phototherapy but, in extreme

CASE STUDY

TAKING NO CHANCES

There is no standardised national prevention pathway or unified guidelines within the United Kingdom to prevent kernicterus. This is a significant patient safety challenge and is disturbing because, with greater awareness, this devastating condition could be, in part, preventable.

Sadly, the full extent and consequences of kernicterus (if the baby lives) are not usually established until the child is older.

Yet as long as they are treated, high levels of bilirubin (moderately severe hyperbilirubinaemia) do not necessarily cause long-term damage.

One family’s experience (see Olivia’s story) shows how a combination of factors can put a baby’s safety in jeopardy.

Baby Olivia died, but had she survived she would undoubtedly have been severely disabled. Analysis of the steps in her case shows that opportunities to make the diagnosis were not taken because of a lack of clinical awareness, delays in acting on clinically important signs, and a mistaken belief that her yellow complexion was related to Olivia’s ethnic minority origin.

FIGURE 2 LENGTH OF STAY FOLLOWING BIRTH (NHS DELIVERIES) IS GETTING SHORTER

PERCENTAGE IN EACH LENGTH OF STAY CATEGORY (SEE KEY)

100 90 80 70 60 50 40 30 20 10 0

KEY

36

1975

0–3 DAYS

1980

1985

1989

4–6 DAYS

1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99

7+ DAYS

1999/ 2000

2000/01 2001/02 2002/03 2003/04 2004/05

YEAR

Source: NHS Maternity Statistics, 1975 to 2004/05

cases, a full exchange transfusion of the baby’s blood may be necessary.

What action could be taken to prevent kernicterus?

In a safe, high-quality healthcare system kernicterus should not occur. Although rare in babies in this country, its impact in each individual case is potentially devastating. Kernicterus can be reduced further if the approach to its prevention is completely rethought. It tends to occur during the first week of life, when the infant has already been discharged from hospital. In America, the pilot kernicterus register has identified more than 120 cases of kernicterus in babies who had been discharged as normal from hospital.

Healthcare professionals in the community, and parents, must be made aware of the warning symptoms and signs and associated problems. They must then act quickly to seek specialist help.

Work is needed to develop a national standardised education programme.

Early discharge from hospital after an apparently uncomplicated delivery is good for mother and baby and allows them to be established in the home environment. However, it must be coupled with an awareness that early discharge occurs before jaundice has reached its peak and breastfeeding is properly established, which may leave some babies at risk of kernicterus.

This is especially true if they have other problems, such as dehydration. A robust

system needs to be in place to prevent kernicterus, but not so vigorous as to overinvestigate normal, physiological jaundice, keep patients in hospital unnecessarily and discourage breastfeeding.

In addition to better awareness in the community, pre-discharge risk assessment for developing kernicterus needs to take place systematically.

This should include clinical assessment and may comprise objective investigation.

Associated problems, such as dehydration and infection, will inevitably necessitate in-patient observation and measurement of bilirubin levels. However, there is currently a lack of evidence for routine screening of bilirubin blood levels to prevent kernicterus in England.

This requires further consideration.

In most parts of England, community midwives make regular visits to babies and their mothers after hospital discharge.

This should always ensure the early recognition and treatment of severe jaundice, as well as looking for other warning signs and associated problems. It also enables close surveillance of breastfeeding and appropriate action when it is failing.

The National Institute for Health and Clinical Excellence began to develop guidelines on postnatal care for healthcare professionals and parents in 2003, including guidance on jaundice. These are due to be published shortly. The central message of these guidelines is that surveillance of jaundice is vital and, if jaundice is

severe, or there are other problems, investigation should be carried out. They also strongly promote the importance of breastfeeding. Guidelines and sources of information like this are essential.

A telephone survey of 10 NHS Trusts revealed that 80% give no specific written information to parents on discharge about jaundice or kernicterus. In addition, a review of the five bestselling books for new mothers revealed limited information about jaundice or kernicterus.

Education of community healthcare professionals and parents about the risks associated with jaundice and the problems that may indicate the possibility of developing kernicterus is essential and cannot be overstated. Such babies must be urgently referred back to hospital: delay can be life-threatening or life-changing.

It is of the utmost importance to diagnose and treat diseases of the newborn swiftly and accurately. In the United Kingdom, we have a good track record of epidemiological surveillance of specific conditions. Establishing a registry for kernicterus would aid better quantification of the disease and foster better understanding of geographical incidence and long-term sequelae, allowing the development of a future patient safety strategy to reduce the incidence of this debilitating condition.

ACTION RECOMMENDED

FOUR Written information given to parents at the point of discharge from hospital after

birth should give explicit advice on the recognition and significance of jaundice and the warning signs of its complications.

FIVE Publishers of popular guides on pregnancy and childbirth should be encouraged to deal with jaundice and kernicterus in a way that fully informs parents of the risks.

Early recognition of warning signs can prevent Kernicterus

TWO The cost-effectiveness of a national screening blood test for bilirubin levels should be examined by the National Screening Committee.

THREE Education and training programmes for relevant healthcare professionals should raise levels of awareness and competence in the recognition and assessment of early neonatal jaundice.

37 TAKING NO CHANCES

ONE A national register of kernicterus should be established.

CMO ANNUAL REPORT 2005

“Through greater awareness by healthcare professionals and parents, and by thinking about screening, we could eradicate these tragedies.�

38

RAIDING PUBLIC HEALTH BUDGETS CAN KILL

TWO Expenditure on health improvement is failing to keep pace with the growth in NHS expenditure.

THREE There is a 20-fold variation in expenditure on health improvement by primary

care trusts, much more than could be accounted for by differential need.

expand senior staff numbers in line with other specialties.

FOUR At regional level, some variation in expenditure is related to evidence of population need, but half is not. Variations in senior staffing are unrelated to need.

SIX The lack of progress is more compatible with the Wanless ‘slow uptake’ scenario than with the ‘fully engaged’ scenario.

FIVE There is a relative deficit in public health capacity affecting the 48% of England’s population that lives in the Midlands and the North, which adds to the failure to

SEVEN Unless this situation is addressed, it will have significant implications in future for life expectancy, healthy years of life, demand for NHS services and premature deaths.

Protecting investment in health is not just important, it is essential to sustaining our health service

ONE Senior staff levels in public health are almost static, in contrast with the striking and consistent expansion in clinical specialties.

39 RAIDING PUBLIC HEALTH BUDGETS CAN KILL

“Striking local and regional differences in population health expenditure and infrastructure are causes of serious concern.”

CMO ANNUAL REPORT 2005

Protecting investment in health is not just important, it is essential to sustaining our health service.

FIGURE 1 NUMBER OF SENIOR PUBLIC HEALTH STAFF IN ENGLAND

1,000 900 800

NUMBER OF STAFF

700 600 500 400 300 200 100 0

1997

1998

1999

2000

2001

2002

2003

2004

2005

YEAR

40

Source: Health and Social Care Information Centre; Workforce Census 1997–2005

The delivery of improvements to the population’s health and the reduction of health inequalities depend not only on the actions of the NHS. Other sectors (notably local government, education services, neighbourhood renewal programmes and private enterprises) have a vitally important role to play.

At local level, the NHS can help to foster partnerships, coordinate initiatives, champion public health action and influence the agendas of other agencies.

Often a programme to improve health will be led from outside the health sector but with the local NHS as a participant. That said, the NHS has committed itself to a health-based philosophy, not one solely based on delivering care to patients. Moreover, the NHS is allocated a substantial budget to pursue its role in investing in measures that improve population health and reduce inequalities.

In talking extensively to public health professionals throughout the NHS over the past two years, the following points consistently emerge from their accounts: • E xpressed commitment to public health by many health bodies is not matched by concerted action.

• Public health budgets are regularly ‘raided’ to find funding to reduce hospital financial deficits or to meet productivity targets in clinical services.

• Valued small-scale local projects to improve health are often not sustained, losing funding and the skills that had been acquired over time.

Three features are unique to public health, and distinguish it sharply from clinical specialties.

Firstly, consultant and senior public health staff numbers have been broadly static for decades. Although the flowering of multidisciplinary public health since the late 1990s has brought welcome diversity and fresh blood, public health has yet to see the expansion that has become the norm in clinical fields. This has progressively diluted the public health voice among professional colleagues, and has inevitably impacted on the resilience of the function, hampering its ability to meet new requirements and develop in line with modern practice.

Secondly, service public health departments have, since 1974, been organised as part of the various management tiers of the NHS – districts, areas, regions, health authorities and primary care trusts.

Although helpful in integrating public health into the high-level function of these organisations, public health departments have been caught up in a great deal of reorganisation, with its attendant uncertainty and upheaval, consequent upon the various changes to management arrangements and configuration. Almost every time, the question has been posed: ‘What is

the role of public health?’ While helpful at times, this constant ‘navel gazing’ has ultimately eroded the focus and consistency of purpose of the public health function. A typical senior public health practitioner – say a director of public health – will have been obliged to apply for a new post, through abolition of their former one, more times than would be conceivable to a consultant physician or surgeon whose department remains largely unaffected by management reorganisation. Moreover, these changes have precipitated early retirement and loss of professional skills in an area of public services where experience and competence are often built up over many decades.

Thirdly, although improvements in population health are effective and valuable, the benefits are by nature both long term and not clearly related to individuals. Not only do the underlying changes that bring about better health take time to show their effects, they also help people who will never know, personally, that they have avoided illness or premature death which they would otherwise have suffered. In contrast, the plight of individuals already sick and in danger of complications or death is all too visible and immediate.

This understandable imbalance of perception pervades the allocation of resources between prevention and intervention at every level in the NHS, making it a struggle to identify scope to

FIGURE 2 SENIOR STAFF NUMBERS: PUBLIC HEALTH HAS REMAINED STATIC WHILE CLINICAL SPECIALTIES HAVE GROWN CLINICAL SPECIALTIES

140

130

120

110

100

90

1997

1998

1999

2000

2001

2002

2003

CMO ANNUAL REPORT 2005

PERCENTAGE OF 1997 VALUE

PUBLIC HEALTH

YEAR

Source: Department of Health Statistical Bulletin 2005/06; Hospital, Public Health Medicine and Community Health Services medical and dental staff in England, 1994–2004. Health and Social Care Information Centre; Workforce Census 1997–2003

totals for consultants and specialists, including directors and communicable disease posts, but excluding academic and other posts. On this basis, actual numbers in post had risen only to 637 by 2005, equivalent to less than half of the increase that should have been achieved by 1998. The level achieved in 2005 represents 12.7 per million population, only 12% above the 1988 level of 11.4 per million, and equivalent to about 30% of the recommended increase.

This pattern is particularly disappointing when compared with the significant and sustained consultant expansion achieved in every major clinical specialty group.

Staffing levels represent only a part of the picture. Programme budgeting is an initiative that requires PCTs to account for expenditure according to the clinical areas that it funds. The public health element of the programme budget is labelled category 21 (described as ‘healthy individuals’), which takes a broad view of public health including activity delivered in primary care and hospital services. Data are currently available only for 2003/04 and 2004/05.

In 2003/04, category 21 expenditure accounted for £993 million, 1.93% of the total £51 billion represented. In 2004/05, category 21 expenditure had risen by 7.7% to £1,069 million. Total expenditure accounted for in programme budgets, however, had risen by 13% to £58 billion.

The share of expenditure accounted for by category 21 therefore fell to 1.84%.

Protecting investment in health is not just important, it is essential to sustaining our health service

Overall position Overall, the number of senior public health staff (directors, consultants and specialists excluding academics) in England has been almost static since 1997, within 50 or so either side of a total of about 800 posts (see Figure 1).

The slight decline in 2002 coincides with the peak in setting up new primary care trusts (PCTs). The greater number of smaller, local PCTs should then have led to increased staff requirements in excess of the modest rise seen in 2003 and 2004, and the White Paper Choosing Health should have added further to the need for additional staffing.

The subsequent decline in 2005 actually observed is a very adverse trend.

In contrast, consultant numbers in medical and surgical specialties have risen markedly and consistently over this period. From 1997 to 2003, consultant numbers in clinical specialties increased by 35%; the equivalent increase for public health was 6% (see Figure 2).

Not one of the ten major clinical specialty groups showed less than 24% growth over this period, the largest increase being 49%. Nor has this position improved more recently: the Faculty of Public Health published a workforce survey in March 2006 showing a subsequent 7% decline in senior staff, including academics between 2003 and 2005. This survey also indicated an ageing senior public health workforce, with 45% aged 50 years and over.

Of those in consultant-level posts, almost 18% reported that they planned to leave the specialty within five years.

The last significant review of the public health function was carried out by a committee of inquiry, chaired by one of my predecessors, Sir Donald Acheson, and was published in 1988. At that time, Sir Donald’s committee identified 534 public health staff at consultant level and equivalent, corresponding to 11.4 per million population. The report recommended an increase by 1998 to 750 staff in post, estimated as equivalent to 15.8 per million population, a 40% increase which the report noted was in line with published government plans for general consultant expansion.

Because of changed definitions and the separation of commissioning from provision, it is not absolutely straightforward to assess achievement against these targets. However, the most obviously comparable figure is the Faculty of Public Health’s survey

RAIDING PUBLIC HEALTH BUDGETS CAN KILL

increase public health spending – and often difficult to sustain existing levels.

Whether it is a new and expensive drug for a life-threatening condition or a quicker treatment target, there will always be immediate and emotive demands for additional treatment services that inevitably exert pressure on decision makers to defer just a little further the equally necessary public health improvements.

41

FIGURE 3 EXPENDITURE ON POPULATION HEALTH IN PRIMARY CARE TRUSTS SHOWED 20-FOLD VARIATION IN 2004/05 8,000,000

CATEGORY 21 EXPENDITURE 2004/05 £ PER 100,000 POPULATION

7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 ENGLAND MEAN £2,173,843 PER 100,000 POPULATION 2,000,000 1,000,000 0 PRIMARY CARE TRUSTS

Source: Department of Health Programme Budgeting Data 2004/05

Although these data at national level are neither as robust nor as complete as they might be, the picture they present does nothing to dispel the significant concern generated by reports from the field.

Local variation Figure 3 shows 2004/05 programme budget category 21 expenditure per 100,000 population by individual primary care trust. The range is remarkable, from less than £400,000 in Newcastleunder-Lyme PCT to almost £8 million in Southwark PCT, a 20-fold variation.

The variation at strategic health authority level is also striking. Figure 4 shows the pattern in the percentage of total programme budget expenditure within category 21 among the 28 authorities in 2004/05. The range is from 1.22% in Norfolk, Suffolk and Cambridgeshire Strategic Health Authority to 2.87% in South East London Strategic Health Authority, a difference of a factor of 2.35.

At the level of aggregation represented by strategic health authorities, with populations ranging from 1.1 million to over 2.5 million, this illustrates a very large degree of difference in the priority accorded to this expenditure in different parts of the country.

There was no discernible relationship between category 21 spending and either spending on acute services or the incidence of budgetary overspends.

There is an association between higher population need and increased expenditure. Populations in the South East, South West and East of England with less deprivation and therefore better health tend to have lower levels of category 21 expenditure per 100,000 population. Conversely, populations in the North East and North West have high levels of deprivation and therefore poorer health, and tend to have higher levels of category 21 expenditure per 100,000 population.

While this pattern is encouraging, the association with deprivation accounts for only about half of the observed variation in expenditure between regional populations. Figure 5 shows the total gap between spending expected on the basis of population need and observed expenditure. London and the South East are clearly managing to spend significantly more than would be expected, by about £35 million and over £10 million respectively, while the West Midlands, East of England and East Midlands are each more than £10 million below the expected level.

The effects of differential spending of this magnitude are likely to be significant for the populations concerned.

There is no evidence of any relationship at all between senior staffing levels and population need. Figure 6 shows the total gap between actual senior staffing and that expected for

FIGURE 4 STRATEGIC HEALTH AUTHORITY EXPENDITURE ON POPULATION HEALTH IN 2004/05 SHOWED LARGE VARIATION

STRATEGIC HEALTH AUTHORITY

42

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

PERCENTAGE OF BUDGET SPENT ON POPULATION HEALTH 1. SOUTH EAST LONDON 2. SOUTH WEST LONDON 3. NORTHUMBERLAND, TYNE & WEAR 4. WEST YORKSHIRE 5. THAMES VALLEY 6. SOUTH YORKSHIRE 7. CHESHIRE & MERSEYSIDE 8. GREATER MANCHESTER 9. LEICS, NORTHANTS & RUTLAND 10. COUNTY DURHAM & TEES VALLEY 11. COVENTRY/WARKS 12. DORSET & SOMERSET 13. NORTH & E YORKS & N LINCS 14. AVON, GLOUCS & WILTS

15. HAMPSHIRE & ISLE OF WIGHT 16. CUMBRIA & LANCASHIRE 17. SURREY & SUSSEX 18. SHROPSHIRE & STAFFORDSHIRE 19. NORTH EAST LONDON 20. SOUTH WEST PENINSULA 21. BEDFORDSHIRE & HERTFORDSHIRE 22. KENT & MEDWAY 23. ESSEX 24. BIRMINGHAM & BLACK COUNTRY 25. TRENT 26. NORTH CENTRAL LONDON 27. NORTH WEST LONDON 28. NORFOLK, SUFFOLK & CAMBS

Source: Department of Health Programme Budgeting Data 2004/05

FIGURE 5 POPULATION HEALTH EXPENDITURE (2004/05) IN SOME REGIONS LOWER THAN EXPECTED ON THE BASIS OF NEED

FIGURE 6 THE NORTH AND MIDLANDS HAVE MAJOR PUBLIC HEALTH STAFFING SHORTFALLS AGAINST NEED

LONDON

LONDON SOUTH EAST SOUTH WEST

YORKSHIRE & THE HUMBER

EAST OF ENGLAND

NORTH EAST

NORTH EAST NORTH WEST

WEST MIDLANDS

EAST MIDLANDS

NORTH WEST

EAST OF ENGLAND

EAST MIDLANDS

WEST MIDLANDS –20

–10

0

10

YORKSHIRE & THE HUMBER 20

30

40

EXPENDITURE (£MILLION) BELOW/ABOVE THAT EXPECTED FROM NEED

Source: Department of Health Programme Budgeting Data 2004/05

–10

0

10

20

30

40

NUMBER OF SENIOR STAFF BELOW/ABOVE LEVEL EXPECTED FROM NEED

Source: Faculty of Public Health. The specialist public health workforce in the United Kingdom, 2006; Department of Health Programme Budgeting Data 2004/05

Conclusions Public health services are essential to protect and improve the health of the population as well as to reduce health inequalities. Nevertheless, they are vulnerable, in ways that clinical specialties are not, to lack of growth,

to the effects of repeated management reorganisation and to the compelling and emotive competition for resources from clinical services. There is strong anecdotal information from within the NHS which tells a consistent story for public health of poor morale, declining numbers and inadequate recruitment, and budgets being raided to solve financial deficits in the acute sector.

The evidence that is available does little to dispel this picture. Senior staffing levels have failed to rise appreciably, and lag far behind the striking and consistent consultant expansion achieved in all clinical specialty groups.

Programme budget data show a level of expenditure on public health falling as a proportion of total spending.

At local level, there are substantial variations in public health expenditure, too large to be explicable by differential need. At regional level, there is evidence that public health expenditure is partly related to population need, but there are still large residuals between expenditure expected on this basis and that which actually takes place. The pattern of senior public health staffing between regions is unrelated to population need, again with large residuals between expected and actual staffing levels. The net effect of this pattern is a maldistribution in public health capacity and expenditure, affecting the 48% of the population across the

Protecting investment in health is not just important, it is essential to sustaining our health service

scenario was essentially a continuation of existing trends, including achievement of current public health targets. The ‘slow uptake’ scenario modelled the effects of a levelling off in achievement at current levels, while the ‘fully engaged’ scenario envisaged by Wanless assumed health improvement comparable with the best being achieved internationally.

Integral to the modelling of these scenarios were the levels of resource increase in what the report broadly described as health promotion. It is clear that progress on this component is way off the ‘fully engaged’ scenario and, unless there is a dramatic change, actually looks much more like the ‘slow uptake’ scenario. The detailed modelling in the Wanless report summarised the difference in outcome between the two scenarios as 2.9 years of male life expectancy and 2.5 years of female life expectancy, and more ill health requiring an additional net NHS expenditure of £30 billion per year by 2022. On the basis of adult smoking alone, this will represent a failure to avert 50,000 premature deaths a year.

43 RAIDING PUBLIC HEALTH BUDGETS CAN KILL

each region (where expected numbers are derived from the spread of public health expenditure associated with health need). On this basis, London and the South East between them have 58 posts more than expected, 24% of the senior workforce. In contrast, Yorkshire and the Humber, the East Midlands, North West, West Midlands and North East have relative shortfalls of between 8 and 17 staff each, between 12% and 40% of the workforce.

These are striking differences.

The five disadvantaged regions – the North East, North West, Yorkshire and the Humber, East Midlands and West Midlands – cover a huge swathe of the middle and north of the country, encompassing 23.6 million people (48% of England’s population) and including the most deprived populations in the poorest health. Senior public health staffing for these populations in total is more than 20% below an equitable level. When coupled with the overall national picture of essentially no growth in senior public health posts, in stark contrast with what has been achieved in every major clinical specialty group, this is a depressing picture.

In 2004, the Government published the final Wanless report, Securing our Future Health, which set out three possible future scenarios with very different implications for future health and health services. The ‘solid progress’

–20

CMO ANNUAL REPORT 2005

SOUTH EAST SOUTH WEST

FigurE 7 THE PREDICTED EFFECTS OF THE WANLESS REPORT’S ‘SLOW UPTAKE’ SCENARIO COMPARED WITH THE ‘FULLY ENGAGED’ SCENARIO

2.5

YEARS Loss of increased life expectancy for women

2.9

YEARS Loss of increased life expectancy for men

50,000

Failure to avert premature deaths from smoking

44 middle and north of the country that shows the highest level of health need and would stand to benefit the most.

If, as a result, future population health trends follow the ‘slow uptake’ pattern set out in the Wanless report on population health (see Figure 7), this will have a significantly deleterious effect on the health of the public, including a loss of increased life expectancy and a failure to avert premature deaths.

The Government has made a major and unprecedented commitment to public health over the last eight years, including two White Papers, a major review of health inequalities, a cross-cutting spending review, the establishment of a Cabinet subcommittee and programmes of action right across government. Local government too has embraced the public health agenda in a sustained and imaginative way.

Given all this, it would be a tragedy if public health were to fall victim to the risks that have beset it in the past, most importantly that its budgets are siphoned off to help meet the heavy demand for resources in a constantly pressurised acute healthcare sector. There is both strong anecdotal and analytical evidence that this is already happening, despite the policy commitments that have been made to increase the emphasis on public health. This will cause great harm. It will fail to build the foundations

of a healthier population for the future.

It will undermine the strategy outlined in the Wanless report’s ‘fully engaged’ scenario to sustain a financially viable NHS by reducing demand for care. It will miss the opportunity to transform the NHS from a predominantly ‘healthcare’ service to a true ‘health’ service.

This situation has not been created by any person or group of people. It is the result of many disparate factors, but at its heart is a set of attitudes that emphasises short-term thinking, holds too dear the idea of the hospital bed and regards the prevention of premature death, disease and disability as an option not a duty.

It is time for things to change.

ACTION RECOMMENDED

THREE All NHS bodies should ensure that their public health capacity and capability is sufficient for their proper functioning.

Protecting investment in health is not just important, it is essential to sustaining our health service

TWO Health service commissioners should take steps to satisfy themselves that expenditure on public health reflects the needs of their population.

45 RAIDING PUBLIC HEALTH BUDGETS CAN KILL

ONE Consideration should be given to establishing a comprehensive review (the first in almost 20 years) into arrangements to improve and safeguard the health of the public.

CMO ANNUAL REPORT 2005

“Local commissioners’ decisions must be aligned to their population’s needs and they must see improving health and reducing inequalities as core to their role.”

46

PLANNING FOR A RISING TIDE Being prepared for the flu pandemic.

THREE Traditionally, most emergency planning activity is geared to sudden, short-lived and geographically contained events, producing several hundred casualties.

FIVE NHS decision making is increasingly devolved to a local level but this makes emergency planning more difficult to steer and coordinate.

SIX While vaccines and antivirals form an important defence, simple respiratory

hygiene will be significant. Home care will be the norm, and primary care and social services will be under much pressure.

SEVEN The NHS must now translate local strategic plans into actual operational capability to respond.

EIGHT During a pandemic, difficult ethical issues will arise. These issues ought to be considered on a national basis, in advance of a pandemic.

Being prepared for the Flu pandemic

TWO Major planning activity has taken place in this and many other countries.

FOUR Pandemic influenza will have an impact over a much wider area and period of time. The number of casualties will be higher by several orders of magnitude.

47 PLANNING FOR A RISING TIDE

ONE Influenza pandemics are a natural phenomenon and it is highly probable that there will be another.

CMO ANNUAL REPORT 2005

“When the influenza pandemic arrives, healthcare facilities will be under enormous pressure and will need to be targeted at those most in need.�

48 A pandemic (worldwide epidemic) of influenza occurs when a new strain of the influenza (flu) virus emerges to which people have no natural immunity. In these circumstances, hundreds of millions of people around the world can become ill with flu and a proportion will die from the complications of the disease, such as pneumonia.

Three documented pandemics of flu have occurred in the last century. The worst – often referred to as ‘Spanish’ flu – caused major international problems in 1918 and resulted in a great deal of serious illness and many deaths. Those that occurred in 1957 and 1968 were much less severe. Other pandemics have occurred earlier in history, but, as this was before infectious diseases were properly understood, little is known about them.

It is now 38 years since the last flu pandemic and, given that they are natural biological phenomena, it is highly probable that there will be another. I drew attention to the risks of a 21st-century flu pandemic in my 2002 report, Getting Ahead of the Curve. Since then, with the rapid international spread of H5N1 avian influenza, concern about the likelihood of a new pandemic has grown and major planning activity has taken place in this and many – if not most – other countries.

The United Kingdom’s Influenza Pandemic Contingency Plan was published in consultation form in March 2005 and reissued in October 2005, taking into account comments received. This is intended to be a dynamic document, continuously updated in the light of new information. That Plan and the United Kingdom’s subsequent preparations for a pandemic have since been commended by the World Health Organization.

The Department of Health leads the Government’s planning and preparation for the health impact of a pandemic of influenza. In addition to its responsibilities for the NHS in England, it has a wider role in directing and coordinating the United Kingdom’s health response, working closely with the Devolved Administrations. Almost every other major department is involved in some aspect of this cross-government planning activity, which is coordinated by the Cabinet Office’s Civil Contingency Secretariat. A ministerial committee of the Cabinet, chaired by the Secretary of State for Health, oversees the arrangements.

Although emergency planning has always been an integral part of the responsibilities of NHS ambulance services and hospital emergency departments, it became a much more mainstream activity for planners and policy makers in the early 1990s. The planning philosophy was built around the concept of a major incident, defined at that time as ‘an event that owing to the number and

severity of live casualties requires special arrangements by the health service’.

Today’s emergency plans are based on an ‘all hazards’ approach – focusing on dealing with the effects of any incident as well as its cause – so, whilst public health emergencies such as larger outbreaks of food-borne illness or environmentally transmitted infections (e.g. Legionnaires’ disease) present very different challenges, they form an equally important part of the overall agenda for health emergency preparedness.

In the past, NHS emergency plans have been implemented in response to a range of sudden casualty-producing events, the largest of which have involved 300 to 400 casualties. Typical of NHS activities in such circumstances are: the assessment and triage of casualties at the scene; paramedic support to the injured; clearance of patients with non-essential treatment needs from hospital beds; calling in off-duty staff; assessment of injured patients in accident and emergency departments of receiving hospitals; and surgical and other casualty treatment.

The long-term care of injured people with needs for specialist services, such as burns (for example after the Bradford stadium fire) or mental health problems, can result in enduring pressure on local services. The record of the NHS and the emergency services has been excellent, both in the immediate response to the event itself and in its aftermath.

CMO ANNUAL REPORT 2005

49

Being prepared for the Flu pandemic

• A pandemic is likely to result in much wider social, economic and logistical disruption on a national and international scale, which will hinder the delivery of services.

Decisions about the planning, funding and provision of healthcare in the NHS are increasingly being devolved to a local level, where the health needs of communities and neighbourhoods are best understood. In addition, there is much more diversity in the provision of care, with private sector health organisations and voluntary organisations competing with traditional NHS providers for contracts.

While devolved and diverse services can have real advantages in ensuring that they are sensitive to local circumstances, they are more difficult to steer and coordinate – key requirements in dealing with any kind of high-impact national emergency.

The exact hazard and risk posed by a new influenza strain to the human population cannot be predicted accurately until the strain has emerged.

Only then can its behaviour in the first human hosts, and its precise genetic make-up, be examined.

A number of assumptions and estimates therefore need to be used in planning for an influenza pandemic, and the Department of Health has undertaken and commissioned extensive mathematical modelling work to identify the likely impact of various scenarios on the population and their health services (see Figure 1).

PLANNING FOR A RISING TIDE

These responses were all made to incidents that unfolded rapidly from a particular point in time – so-called ‘big-bang’ events. They were all of substantial immediate impact and fairly time limited. There have rarely been circumstances in which NHS services have been swamped or unable to cope due to the scale of the emergency.

Moreover, such events last for a relatively short time and are usually geographically limited to one part of the country, allowing surrounding and more distant areas to either help deal with the excess demand or to carry on business as usual.

The circumstances of a pandemic influenza emergency would be in marked contrast.

• Although there would be a starting point for the emergency, it could emerge in several parts of the country at the same time.

• The affected people (‘casualties’) would present to the NHS over days, weeks and months, rather than minutes and hours.

• The sheer volume of patients requiring hospital care would be much higher, dwarfing the numbers from the largest ‘big-bang’ emergency.

• The demands on primary care services would be very high, in contrast to their relatively limited role in many ‘big-bang’ emergencies.

• Health and social care staff would be affected directly and may themselves be too ill to work.

The estimated impact of Pandemic Flu in the peak week in the average acute hospital ROUTINE BED STOCK

DEMAND IN PEAK WEEK OF PANDEMIC

800

The impact of the peak week of Pandemic flu in the average general practice

308

General beds

Additional patients each day who may benefit from admission

85

New clinical cases of pandemic influenza

19

21

Cases requiring face-to-face consultation

Critical care beds

Additional patients each day who may benefit from critical care

The modelling indicates that having taken two to four weeks to accumulate in the country of origin – currently most likely to be in the Far East – the first cases of a new strain of influenza could be transmitted internationally within a very short time.

People who are infected may travel in the time before symptoms develop and carry the infection across the world.

Pandemic influenza could arrive in the United Kingdom in as little as two to four weeks, or less, with a peak incidence of an epidemic in our country about 50 days later.

Good basic hygiene practices – reducing the spread of droplets containing the virus by coughing and sneezing into tissues, disposing of tissues carefully and washing hands frequently – are one important way to slow the spread of the disease. It is important that we all make these good practices part of our everyday lives now, so that when a pandemic comes they are second nature to us.

The two major medical countermeasures that could be used in an influenza pandemic are antiviral medicines and vaccines.

Antiviral medicines are unproven in a mass population outbreak of influenza, but in the more common seasonal influenza situation they have been shown to reduce the length of the attack for the individual affected by one or two days if given early (within 48 hours of symptoms developing).

They can also reduce the chance of complications and, particularly important

in slowing the spread of disease, make patients somewhat less infectious.

Modelling suggests that, to have maximum impact on reducing spread, they should be given within 12 hours of the onset of symptoms. The contingency plans in the United Kingdom and many other countries involve stockpiling the antiviral drug oseltamivir (Tamiflu). The Department of Health’s stockpile will be sufficient to treat all symptomatic patients at a 25% clinical attack rate. A higher attack rate – or any wasteful or inappropriate use of the medicine – will deplete the stockpile and international demand will make replenishment or resupply unlikely at the height of the pandemic.

A vaccine to combat the exact strain of virus causing an influenza pandemic cannot be manufactured until the new strain is identified. Even with the most modern scientific techniques, such a vaccine is unlikely to begin to be available for at least four to six months. This would almost certainly miss the first wave of pandemic influenza in this country.

Vaccine strategy is an important area that is being kept under active review.

The preparations being made at the present time in the NHS, the Department of Health and across government more widely are unprecedented.

50

77

2,000

16,000 14,000

1,500

12,000 10,000

1,000

8,000 6,000

500

4,000 2,000 0

0 1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

HOSPITALISATIONS, CRITICAL CARE ADMISSIONS AND DEATHS IN THE CATCHMENT AREA OF A LARGE PRIMARY CARE TRUST

18,000

WEEK CLINICAL CASES

GP CONSULATIONS

CRITICAL CARE ADMISSIONS

HOSPITALISATIONS

Assumptions: • Clinical attack rate 25% • Complication rate (and need to see a general practitioner) 25% • Hospitalisation rate (of all cases) 3.72% • Critical care required by 25% of those hospitalised • Death rate (of all cases) 0.37% • Catchment of average hospital 300,000 • Three full-time doctors (equivalent) in a typical general practice • Antivirals accessed and taken by all appropriate cases

DEATHS

51

THE BIG-BANG OR SUDDEN EMERGENCY (SUCH AS A FIRE, A TERRORIST-INITIATED EXPLOSION OR A MAJOR TRANSPORT ACCIDENT) PATIENT NUMBERS

USUALLY MODERATE BUT A SUDDEN SURGE. MAXIMUM CASUALTIES ARRIVE QUICKLY IN A SYSTEM FUNCTIONING WITHIN NORMAL LIMITS. STAFF NOT USUALLY ILL OR INCAPACITATED

ACROSS THE WHOLE SYSTEM, NOTABLY PRIMARY CARE HEAVILY INVOLVED FROM THE OUTSET

IMPACT ON HEALTH SERVICES

AMBULANCE SERVICE, EMERGENCY ROOMS, SURGERY, INTENSIVE CARE, BURNS, TRAUMA, AND LATER, REHABILITATION. CERTAIN KEY HOSPITAL-BASED SPECIALTIES PRINCIPALLY INVOLVED – PRIMARY CARE HARDLY AT ALL

SOCIAL CARE AND LOCAL AUTHORITIES

MAIN PARTNERS

POLICE AND FIRE SERVICES

PERVASIVE

ZONE OF RISK

USUALLY ISOLATED (THOUGH LARGE-SCALE BIOLOGICAL, CHEMICAL OR RADIATION-BASED INCIDENTS COULD BE AN EXCEPTION)

LOW (ALL LOCAL SYSTEMS IN SIMILAR SITUATION)

SCOPE FOR MUTUAL AID

HIGH (OTHER LOCAL SYSTEMS HAVE CAPACITY TO SUPPORT)

LIMITED BY LENGTH OF TIME OVER WHICH HEIGHTENED ACTIVITY NEEDS TO BE MAINTAINED, STAFF SICKNESS ABSENCE AND FAMILY CARE RESPONSIBILITIES

SCOPE FOR INCREASING AVAILABILITY OF WORKFORCE

HIGH. USUALLY MANY VOLUNTEERS AND SHORT DURATION OF HEIGHTENED ACTIVITY ASSIST SUPPLEMENTATION OF STAFFING

HIGH (RISK OF PERSONAL INFECTION)

OCCUPATIONAL RISK TO WORKFORCE

LOW (MINIMAL RISK OF PERSONAL INJURY FOLLOWING EXTRACTION FROM SCENE)

CONTINUOUS

DEBATE AND DISCUSSION

DURING AND IN AFTERMATH OF EVENT

SPREAD OVER LONG PERIODS (INCLUDING PRIOR TO OCCURRENCE OF ILLNESS AND DEATHS)

TIMING OF RESOURCE ALLOCATION

CONCENTRATED (LARGELY AROUND TIME OF INJURIES AND DEATHS)

INTERNAL (PLANNING PHASE CAN CREATE FALSE SENSE OF SECURITY)

PERCEIVED LOCUS OF CONTROL

EXTERNAL (HIGHLY-SPECIFIC PLANNING NOT FEASIBLE)

Being prepared for the Flu pandemic

POTENTIALLY VERY HIGH AND BUILDING TO A PEAK. MAXIMUM CASUALTIES ARRIVE IN AN ALREADY STRETCHED SYSTEM. STAFF MAY BE ILL OR INCAPACITATED

PLANNING FOR A RISING TIDE

The different characteristics of a rising tide threat AND a sudden emergency, and the different challenges posed to health services THE RISING TIDE THREAT (SUCH AS AN EMERGING INFECTIOUS DISEASE)

CMO ANNUAL REPORT 2005

CLINICAL CASES AND GP CONSULTATIONS IN THE CATCHMENT AREA OF A LARGE PRIMARY CARE TRUST

FIGURE 1 THE IMPACT OF PANDEMIC INFLUENZA ON A LARGE PRIMARY CARE TRUST (POPULATION 300,000) BASED ON A CLINICAL ATTACK RATE OF 25% AND A CASE FATALITY RATE OF 0.37%

52 NHS challenges The key elements of contingency planning relevant to the local NHS and its preparedness include the following: • Creating additional capacity and optimising its use: - in hospitals to deal with those who are likely to suffer the most serious complications – including specialist capacity for those with severe respiratory illness; - in primary care to provide initial assessment and treatment for the many thousands of sufferers who will need care outside hospital – the great majority of those affected; - in social care to support and maintain those who are ill in their residential settings.

• Continuing to provide essential healthcare services for those with emergency, chronic or other needs unrelated to flu over the course of the pandemic.

• Adopting measures designed to stop or slow the spread of infection and promote control.

• Providing clear and consistent public information and advice.

• Supplementing the healthcare workforce, deploying it flexibly and fully utilising individual potential and skills.

• Developing effective mechanisms to provide rapid access to antivirals and other essential drugs and equipment for those who need treatment, while maintaining adequate control and security arrangements to conserve

supplies and prevent waste.

• Maintaining those essential supplies and services required to allow the NHS to function.

• Sustaining the response over a period of 12 to 15 weeks or more.

• Recognising interdependencies by planning jointly and fully integrating plans with those of other partner agencies.

The potential threat posed by an influenza pandemic is far-reaching. While significant progress has already been made in preparing the United Kingdom in general, and the NHS in particular, for its likely emergence and impact, there is much still to be done. The NHS must now translate local strategic plans into an actual operational capability to respond. This will be all the more challenging in the context of the current NHS reorganisation, which must not be allowed to disrupt planning and practice.

A clear underpinning philosophy of care needs to be established for the NHS. When the influenza pandemic arrives in this country, many people will become ill. For the vast majority, the illness will be self-limiting and they will recover without complications. Others will develop chest infections or other problems which can easily be treated in primary care. A minority will develop more serious complications requiring hospitalisation. However, although the proportion needing hospital care will be small, the absolute numbers will be very large because so many people will catch influenza. Healthcare resources will

be limited and it will be essential that these are used only by those most in need. The underpinning philosophy must therefore be one of care at home wherever possible.

A key part of managing the response will be to ensure that the majority of patients manage themselves at home with suitable guidance on when and where to seek help. This will require a major programme to communicate with the public.

Building on the foundations of a home-care and self-care strategy, local NHS plans will need to work within a national framework, engaging existing services as far as possible and augmenting and adapting these where necessary. Planners must ensure that they make realistic assumptions about the resources likely to be available and that health and social care staff are involved closely in the planning process.

During a pandemic, difficult ethical decisions will have to be made. Who, for example, should have priority for drugs or vaccines if they are in short supply? On what basis should ‘critical care’ beds be allocated? Should NHS staff be expected to come to work to help others, even if this impacts on their caring for their own families? What are the implications of not sending someone to hospital if beds are at full capacity?

Questions such as these deserve careful and considered thought. They should be addressed nationally, by professionals and the public, in advance of a pandemic.

ACTION RECOMMENDED

TWO The new primary care trusts should give early attention to assessing their preparedness for pandemic influenza.

FOUR A national group should be established to explore the ethical issues affecting healthcare during a pandemic.

FIVE Efforts to make good respiratory hygiene and frequent handwashing part of everyone’s everyday life should begin now.

SIX Communications with the public on the health aspects of pandemic influenza should be built on the concept of home care, with advice on whether, when and how to seek help from health services.

Being prepared for the Flu pandemic

THREE The new strategic health authorities should give early attention to evaluating the preparedness of NHS organisations in their areas for pandemic influenza.

Plans should be tested regularly.

53 PLANNING FOR A RISING TIDE

ONE The NHS response to a pandemic of influenza should be based on home care. Local NHS plans should build on existing services, augmenting and adapting these where necessary.

CMO ANNUAL REPORT 2005

“The influenza pandemic will pose a unique challenge to NHS emergency planning in the modern era. Clear national policies and strong, wellrehearsed local plans will be the keys to mitigating its effects.”

54

SPOTLIGHTING REGIONAL HEALTH AND INITIATIVES CMO ANNUAL REPORT 2005

55 SPOTLIGHTING REGIONAL HEALTH AND INITIATIVES

“Around the country our teams are faced with major public health challenges.

Real progress is being made.”

NORTH EAST

Preventing deaths on the railway network

56 Between April 2002 and April 2005, there were 580 cases of suicide or suspected suicide on the national rail network; 13 of these occurred in the North East. This figure appears relatively small until the impact of one suicide on families, services and cost-efficiency is taken into consideration.

In addition to the impact of the event on the individual’s family and friends, each suicide is estimated to cause an average cumulative delay of 1,131 minutes on the national rail network, costing around £61,000. Furthermore, it can be a traumatic experience for railway employees who witness the event or deal with the aftermath, and those who have to inform the victim’s next of kin.

The Suicides and Open Verdicts on the Railway Network project was commissioned to investigate suicides on the railways and the consequences for individuals and organisations. Its report in 2003 recommended that rail operators consider the location and preponderance of deaths on open track when allocating resources for the prevention of suicides, and that more notices and key telephone numbers be displayed at strategic points indicating how confidential help could be obtained.

Research indicates that the introduction of these safety measures across the North East rail network could reduce the number of suicides. A joint initiative taken by Durham County Council and Derwentside Primary Care Trust introduced signs with helpline numbers at a suicide hot spot in the Derwentside area. South Tyneside Primary Care Trust joined forces with Nexus, the Tyne and Wear metro system, to draw attention to helplines on advertising hoardings.

Initial evidence from the Samaritans and NHS Direct suggests that calls to

helplines have followed from people seeing the signs and advertisements.

At stations with unusual geography, such as Durham (which leads onto a viaduct and is close to a mental health hospital), new physical barriers are being considered. Other possible measures to reduce the risk of suicide on the rail network include the use of CCTV systems, installing safety barriers at suicide sites and greater collaboration between local mental health services and the police in the sharing of information on those at greatest risk.

Rail companies in the North East will continue to work with the Rail Safety and Standards Board to implement the recommendations of the Suicides and Open Verdicts on the Railway Network report. As part of this work, they will continue piloting potential safety measures throughout the North East.

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

CMO ANNUAL REPORT 2005

57 Aim High Routeback encourages health professionals to refer patients to the initiative. The scheme has been integrated into patient exit strategies used by counsellors in general practice surgeries and staff in community mental health teams. The largest general practice in the district is sending out Aim High Routeback leaflets to its 15,000 patients, while libraries, community centres and public buildings also have leaflets explaining the scheme.

Aim High Routeback has received £1.6 million of funding support for the next two years from the regional development agency, One North East, as part of the agency’s Northern Way initiative.

SPOTLIGHTING REGIONAL HEALTH and initiatives

Action to help people on incapacity benefit The 2004 Chief Medical Officer’s Annual Report highlighted the large number of people claiming incapacity benefit in the North East. The region had the highest rate of claimants of all nine regions in England, rising to a peak at Easington, County Durham, where almost one in five working-age adults was claiming. The report described the participation of public health teams in developing initiatives aimed at helping people on incapacity benefit back into employment.

Aim High Routeback is the first of three pilots that will test new approaches to involving employers and the voluntary sector in adding to the Pathways to Work programme. Coordinated by Easington Primary Care Trust, it aims to complement the Jobcentre Plus Pathways to Work programme for incapacity benefit claimants that is being rolled out across the country. Other pilots are planned for Sunderland and Middlesbrough.

Potential candidates attend an assessment to establish the severity of their health problems and their job goals. Those who are suitable and consent to join the programme are offered individually tailored support to find employment. Since its launch in November 2005, the project has recruited over 80 people into the scheme and found jobs and training for more than 20.

LONDON

GOOD CUISINE, POOR NUTRITION

58 London has some of the finest restaurants in the world, yet poor nutrition contributes to 4,000 deaths a year in the region.

London also has one of the highest rates in England of obesity in children under 11 years old: 18.2% compared with 14.8% nationally (see Figure 1).

Poor diet is a major cause of preventable ill health and is much more common among lower socioeconomic groups, which tend to be concentrated in urban areas. The Healthy and Sustainable Food for London initiative is being implemented from 2006 to create a fairer, healthier and more sustainable food culture in the region.

Healthy and Sustainable Food for London’s approach considers the eight key stages of the food supply chain ‘from growing it to throwing it’ (see Figure 2).

Health impact assessments were performed for every stage of the food chain and identified key health considerations, for example nutrient content, labour standards, pesticide exposure, health and safety, antibiotic use and farmer welfare.

The 10-year strategy aims to have a healthy and sustainable food culture by 2016. Priority areas for action include: • supporting a strong food economy; • helping consumers make healthy choices in their diet;

• improving the sustainability of food purchasing in the public and private sectors; • developing stronger links between regional and national producers and the London market; • delivering healthy schools; • reducing food-related waste and litter.

To achieve this, a number of initiatives are being considered, including working with retailers to promote healthy eating, developing a directory on healthy eating and sustainable food, increasing the number of school farm visits, enhancing and promoting existing food labelling and establishing a pilot sustainable/healthy food reward card scheme in London.

Other initiatives by the Regional Public Health Group already support action in some of these areas. Through its regional leadership on the implementation of the Department of Health’s Choosing a Better Diet: A Food and Health Action Plan, the group has been working to make healthy diet choices easier. This includes coordinating the School Fruit and Vegetable Scheme, supporting 5 A DAY initiatives, disseminating the Food in Schools Toolkit and training Healthy Schools Coordinators. The group has also been promoting sustainable procurement under its remit to help the NHS in London fulfil its corporate responsibility by improving its catering operations.

FIGURE 1 THE PREVALENCE OF OBESITY IN CHILDREN VARIES ACROSS ENGLAND

PER CENT OBESE

15+% 13% to 14% 11% to 12% 10%

Source: Obesity among children under 11.

Joint Health Surveys Unit, National Centre for Social Research, 2005

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

CMO ANNUAL REPORT 2005

59

SUPPLY FACTORS

Stage 1 Primary production Stage 2 Processing and manufacturing Stage 3 Transport, storage and distribution Stage 4 Food retail

DEMAND FACTORS

Stage 5 Food purchasing Stage 6 Food preparation, storage and cooking Stage 7 Eating and consumption Stage 8 Disposal

Safeguarding the health legacy of the 2012 Olympics Since last year’s Chief Medical Officer’s Annual Report highlighted the health benefits of hosting the 2012 Olympic Games, the Games have been awarded to London. Much work has been carried out to ensure that the preparations – as well as the Games themselves – continue to strengthen the public health agenda and promote greater levels of physical activity in the region’s population and across the country.

In November 2005, a seminar focusing on the health benefits of hosting the Olympic Games identified four key health dividends: • Medical and health services will be established for the Olympic and Paralympic venues. This will include the Polyclinic, providing medical care for the Olympic family and spectators, emergency care, health surveillance, emergency planning and anti-doping programmes.

• Regeneration of north east London in preparation for 2012 will benefit the community and surrounding areas by leading to an increase in the availability of housing, employment and training opportunities. Adverse effects on the health of those people living in the communities surrounding the Olympic Park due to noise, pollution and increased traffic must be minimised.

• The White Paper, Choosing Health, identified increased levels of physical

activity as one of the key tools for improving the health of the UK population. Planning is under way to ensure that the Games add value to existing Choosing Health programmes, such as health trainers, the obesity social marketing campaign, and work in schools to increase participation in physical activity and support healthier lifestyles. The opportunities the Games provide will also be used to inform future programmes and have already been highlighted in Our Health, Our Care, Our Say with a pledge for a fitter Britain by 2012. A range of Games-specific projects are being developed. These include plans to promote the health of construction workers building the Olympic Park; ensure that healthy food options are available at the Olympic Park during the Games; ensure a smoke-free Games; address any potential impacts of sponsorship on health; and promote participation in wider (non sports-related) physical activity through the cultural Olympiad.

• The National Sports and Exercise Medicine Centre will provide an integrated centre of excellence in the diagnosis, treatment and rehabilitation of high-performance athletes.

A working group chaired by the Director of Medical Services for the British Olympic Association has been established to develop a detailed proposal for the facility.

SPOTLIGHTING REGIONAL HEALTH and initiatives

FIGURE 2 EIGHT STAGES IN the FOOD procurement CHAIN

EAST MIDLANDS

Syphilis: the return of a scourge of the past

60 Most people think that syphilis survives only in the pages of medical history books. Although the disease was virtually eradicated from the country in the 20th century, recent evidence suggests it is making a comeback. The East Midlands region has seen a much sharper increase in the number of syphilis infections in recent years than for other sexually transmitted diseases such as chlamydia, gonorrhoea and herpes (see Figure 1).

Although the number of cases regionally is relatively small, substantial localised outbreaks of syphilis have occurred in Nottinghamshire and Leicestershire (see Figure 2).

In Nottinghamshire, there were two new cases of syphilis in 2000, but by 2004 this figure had risen to 59. The number of cases dealt with at Nottingham City Hospital – the main genitourinary medicine clinic in the city – has more than doubled in the past two years. In 2003, the hospital treated 32 cases of syphilis.

This rose to 72 cases in the first 9 months of 2005.

Like the rest of the United Kingdom, the sharpest rise in the East Midlands has occurred in 25 to 44-year-olds. Those most at risk have more than one sexual partner, change partners frequently or have intercourse with sex workers.

In Leicester, 70 new cases have covered a range of age groups, ethnic

backgrounds and sexual preferences.

No single cause has been identified for the rise but emerging evidence suggests links to the city’s sex industry.

In Leicester, more women from Eastern Europe are working in the sex industry, predominantly in massage parlours. They are reported to take higher risks by providing unprotected sex.

Syphilis infection in the East Midlands represents a significant public health problem. If left untreated, syphilis can lead to paralysis and even death.

In pregnant women, the disease can cause miscarriage, stillbirth or foetal abnormalities. Effective antibiotic treatment can render patients non-infectious within two days.

One of the key challenges in syphilis control is diagnosis. Symptoms are often indistinguishable from those of other diseases and many people do not realise they are infected, unknowingly putting others at risk. In both Nottingham and Leicester, research has found that each new case of syphilis will be linked to a further one or two cases.

Several initiatives are under way as part of a regional drive to combat the problem. In Nottingham, a poster warning of the invasion of syphilis has been placed in many of the city’s bars and clubs, informing people that syphilis cases are on the increase.

In Leicester, a similar poster campaign highlights the increase in syphilis and informs people of the possible routes

of transmission, including oral and anal sex or genital contact. The posters, put up in the city’s gyms, pubs and massage parlours, recommend the use of condoms as a primary method of prevention.

Genitourinary medicine clinics are being carefully monitored for new cases and the Health Protection Agency is working closely with the Crime and Disorder Reduction Partnerships to develop further interventions.

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

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61

2000

2001

2002

2003

YEAR SELECTED DIAGNOSES GONORRHOEA CHLAMYDIA WARTS

2004

2.5 2.4 2.3 2.2 2.1 2.0 1.9 1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0

HERPES

SYPHILIS

Source: KC60 Statutory returns 2000–04 *Note the different scales: levels of syphilis are generally lower.

FIGURE 2 LARGE OUTBREAK OF SYPHILIS IN LEICESTERSHIRE AND NOTTINGHAMSHIRE RATE OF SYPHILIS PER 100,000 PEOPLE

12.0 10.0 8.0 6.0 4.0 2.0 0.0

2000

2001

2002 2003 YEAR

LEICESTERSHIRE DERBYSHIRE LINCOLNSHIRE

2004

2005

NORTHAMPTONSHIRE NOTTINGHAMSHIRE

Source: KC60 Statutory returns 2000–05

RATE OF SYPHILIS PER 100,000 PEOPLE

RATE OF SELECTED DIAGNOSES* PER 100,000 PEOPLE

200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0

ACTION ON OBESITY In my Annual Report for 2004, I drew attention to the high levels of obesity in the East Midlands, particularly among women.

At 26%, obesity among women has been consistently 4% higher than the national average. The region has been tackling this long-term health problem by reaching people in their homes and their places of work.

A multi-agency Regional Obesity Task Group developed an obesity framework for the East Midlands. The framework identifies key actions for the next 12 months, including addressing specific issues relating to black and minority ethnic communities, who are particularly vulnerable to obesity because of the loss of traditional diets.

The newly established Regional Food and Health Network and the Regional Physical Activity Network offer services addressing obesity issues, such as email alerts, chatroom participation and notice boards, which can be accessed at home or at work round the clock via the internet.

A regional audit will examine currently available support and advice services for overweight people. It will also identify the training needs of the wider public health workforce, including leisure centre staff, school nurses and food workers, to ensure they are properly prepared to help people consider their diet and activity levels, and to support them in maintaining a healthy lifestyle.

At the beginning of 2006, work began on the development of a Regional Food

and Health Action Plan. This identifies ways in which organisations can work towards improving the diet of families and children.

This was followed by the first ever regional school and food conference in the East Midlands.

If reductions in obesity levels are to be achieved and maintained, initiatives promoting healthy diets and physical activity at home must be matched by similar initiatives at work and school. Working Well in the East Midlands, which is currently being piloted in the region’s workplaces, offers programmes promoting healthy eating, physical activity, awareness of cholesterol and other key health indicators.

Additionally, nearly all schools in the region now participate in the School Fruit and Vegetable Scheme. This provides children with fruit and vegetables at school, and makes them more aware of the importance of a healthy diet.

SPOTLIGHTING REGIONAL HEALTH and initiatives

FIGURE 1 MAJOR INCREASE IN SYPHILIS INFECTIONS IN THE EAST MIDLANDS IN ONLY TWO YEARS

WEST MIDLANDS

HIGHEST WINTER DEATH TOLL IN ENGLAND

62

In winter 2004/05, there were nearly 20% more deaths in England than the average expected for a non-winter four-month period. In the West Midlands it was 21.6% – the highest in the country. The greatest increase was in older people; nearly a third more deaths occurred in people aged over 85 years during this period (see Figure 1).

Rapid drops in temperature are linked to sharp rises in the death rate during winter months, with an associated increase in circulatory problems and respiratory infections in older people, including influenza.

Vaccines against influenza and pneumococcal infections offer effective protection against these conditions.

Influenza vaccine uptake in England for 2004/05 was just above 71%. In the West Midlands, it ranged from 64.5% to 75.7% depending on the primary care trust, with the average at 70.5%. Uptake of the pneumococcal vaccine also needs to be increased. This immunisation programme was rolled out in a phased manner in 2003. By March 2005, only 26% of people over 65 in the West Midlands had been immunised.

Deaths caused by cold are avoidable.

A warm, damp-free place to live reduces stress due to cold, yet the Regional Housing Strategy found that in the West Midlands in 2005 around 39% of homes – 820,000 – did not meet the Decent Homes Standard. Of these homes, 620,000 were in the private sector.

Fuel poverty (where a household has to spend more than 10% of its disposable income on fuel) affects around 150,000 households in the West Midlands.

Around half of these are occupied by a person aged 60 years or over.

There are two principal schemes aimed at reducing fuel poverty. Health Through Warmth is a partnership scheme between npower and National Energy Action, a charity that helps low-income households with home insulation and heating. Launched in 2001, the scheme operates in Birmingham, Dudley and Wolverhampton. It has received 8,268 referrals and disbursed £4.4 million in grants. The scheme has also trained 3,755 staff from public sector and voluntary organisations to recognise the health effects of a cold home and provide benefits advice.

The Warm Front grant scheme, set up in June 2000, also provides help with insulation and heating. By April 2006, the scheme had helped over 162,000 homes in the region. The uptake of assistance has been greatest in the most deprived neighbourhoods (see Figure 2).

In spite of the various initiatives and interventions, excess winter mortality remains a public health threat in the West Midlands. More needs to be done to tackle the underlying causes of poor housing and material deprivation leading to fuel poverty.

FIGURE 1 MORE PEOPLE, PARTICULARLY OLDER PEOPLE, DIE IN WINTER THAN AT OTHER TIMES OF THE YEAR: THE DIFFERENCE IN THE WEST MIDLANDS IS THE GREATEST ENGLAND SOUTH WEST ENGLISH REGION

The average number of deaths during the winter months (December to March) is higher than the average during the non-winter months. This difference is known as the Excess Winter Death Index.

SOUTH EAST LONDON EAST OF ENGLAND WEST MIDLANDS EAST MIDLANDS YORKSHIRE & THE HUMBER NORTH WEST NORTH EAST 0.0

5.0

10.0 15.0 20.0 25.0 30.0 35.0

EXCESS WINTER DEATH INDEX AS A PERCENTAGE OF THE DEATHS OCCURRING OVER THE AVERAGE FOUR-MONTH PERIOD EXCESS WINTER DEATH INDEX (ALL AGES) EXCESS WINTER DEATH INDEX (85 YEARS+)

Source: Office for National Statistics 2006

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

FIGURE 2 THE MOST DEPRIVED AREAS IN THE WEST MIDLANDS ARE GETTING MOST SUPPORT FROM WARM FRONT

0.16 0.14

CMO ANNUAL REPORT 2005

PERCENTAGE OF HOUSEHOLDS HELPED BY A WARM FRONT GRANT SINCE 2000 (R=0.85)

0.18

0.12 0.10 0.08 0.06 0.04 0.02 0

0

0.1

0.2

0.3

0.4

0.5

0.6

PERCENTAGE OF THE LOCAL AUTHORITY’S POPULATION LIVING IN AREAS OF HIGH DEPRIVATION

63

Source: Data drawn from EAGA Partnership Limited and the Office for National Statistics

poor nutrition and teenage pregnancy.

It also recommended culturally sensitive efforts to encourage the initiation and continuation of breastfeeding, early antenatal booking, effective antenatal care and the provision of high-quality family support through children’s centres and children’s trusts.

A project investigating the causes of stillbirth and infant death in the region identified smoking in pregnancy, severe immaturity and congenital anomalies as major contributors to infant mortality.

Deaths associated with the slowing of foetal growth relatively late in pregnancy are potentially avoidable. Service providers are now advised to use the customised growth charts developed by the West Midlands Perinatal Institute to improve early recognition of growth restriction, helping ensure interventions are provided as soon as needed.

These initiatives are already making a difference. Recent figures from the West Midlands Perinatal Institute show that, for the first time, stillbirth rates in the West Midlands have fallen to the level of the national average.

SPOTLIGHTING REGIONAL HEALTH and initiatives

Reducing infant mortality In my 2004 Annual Report, I highlighted increases in infant mortality (deaths in the first year of life) in the West Midlands in contrast to a downward national trend.

Similarly, the rates of perinatal mortality (stillbirths and deaths in the first week of life) in the region were consistently higher than the national average. Two local authorities in the region – Birmingham and Stoke-on-Trent – had almost double the national rate of infant mortality.

Since then, a great deal of work has been undertaken to tackle the problem.

Birmingham set a target of reducing the rate of perinatal mortality by 20% over the next five years, focusing on three key interventions: early antenatal booking, continuity of antenatal care and the detection of intrauterine growth restriction.

Primary care trusts in Stoke-on-Trent, together with the local strategic partnership, undertook an assessment of adverse outcomes in maternity services in line with the National Service Framework for Children, Young People and Maternity Services. Priority actions include assessing the effectiveness of interventions, auditing practice, improving links with children’s centres and reviewing smoking cessation services for pregnant women.

A report on health inequalities highlighted the importance of tackling infant mortality in the region. Its recommendations emphasised the need to focus on reducing known risk factors including smoking in pregnancy,

64

WEST YORKSHIRE TYNE & WEAR MERSEYSIDE LANCASHIRE GREATER MANCHESTER

CHESHIRE DEVON NOTTINGHAMSHIRE CUMBRIA LONDON SOUTH YORKSHIRE

WEST SUSSEX WEST MIDLANDS ESSEX EAST SUSSEX CORNWALL CAMBRIDGESHIRE

+5.0

SUFFOLK DERBYSHIRE ROYAL BERKSHIRE WILTSHIRE HUMBERSIDE NORTHUMBERLAND BUCKINGHAMSHIRE HERTFORDSHIRE NORFOLK OXFORDSHIRE

+10.0

KENT SHROPSHIRE ISLE OF WIGHT WARWICKSHIRE DORSET BEDFORDSHIRE & LUTON GLOUCESTERSHIRE STAFFORDSHIRE CLEVELAND COUNTY DURHAM & DARLINGTON AVON HEREFORD & WORCESTER

FIGURE 1 IN MOST AREAS, INJURIES AS A RESULT OF DOMESTIC FIRES HAVE FALLEN IN RECENT YEARS

–10.0

LINCOLNSHIRE

SURREY NORTHAMPTONSHIRE HAMPSHIRE NORTH YORKSHIRE

-5.0

LEICESTERSHIRE

0.0 SOMERSET

PERCENTAGE CHANGE IN THE RATE OF DOMESTIC FIRE INJURIES IN THE POPULATION BETWEEN 2000/01 AND 2004/05

NORTH WEST

–15.0

Source: Best Value Performance Indicators for the Fire Services

In 2004, fire prevention in the home became a statutory requirement for fire and rescue services in England.

The position of trust and respect enjoyed by the services and their unique place in local communities makes them an important resource for the delivery of public health, beyond the reduction of fire-related injuries and deaths. Along with other fire services in the North West region, Merseyside Fire and Rescue Service (the performance of which is widely admired) has pioneered an approach that provides an example to communities everywhere of the potential impact fire services could have on the long-term health of the communities they serve.

In Merseyside, as in most areas, injuries as a result of domestic fires have fallen in recent years (see Figure 1).

Merseyside has led the way in initiating a Home Fire Risk Assessment Scheme, which aims to assess every home in the area and fit a free smoke alarm. These visits have presented unprecedented opportunities for improving the health of people in the region at the same time as protecting them from risk of fire.

Unintended benefits include the generation of a potentially powerful database on the local population’s smoking habits. Fire and rescue services were able to identify hard-to-reach groups at particular risk of

becoming victims of fire, in particular the elderly, those with addictions and people from ethnic minorities for whom English was not their first language.

An evaluation of the Home Fire Risk Assessment Scheme in Merseyside was commissioned to assess the impact of the scheme on injuries and deaths from fire.

It found a clear association between the introduction of the scheme and a decrease in the incidence of fires in the home and the number of fire-related injuries and fatalities.

In the course of these visits, the fire services are able to act as the eyes and ears of health and social services. They have introduced the Single Assessment Process, which identifies individuals with social and health issues such as psychiatric illness or those prone to falls, and refers them to the appropriate agency. The services work with older and vulnerable people, advising them on issues such as staying warm, eating well, and avoiding slips, trips and falls in the home. This helps them continue to live independently in their own homes.

Outside the home, fire services are using their position of trust and respect to promote public health in the local community. For example, the youth engagement scheme offered by Merseyside Fire and Rescue Service, ‘All Fired Up’, uses fire station gym equipment and the stations’ kitchens to develop healthy eating and exercise plans for young people who have been referred by their local general practitioner.

Other fire and rescue services in the region have also been innovative and have made significant contributions to public health.

Cheshire Fire and Rescue Service and Central Cheshire Primary Care Trust joined forces to increase the uptake of influenza vaccinations in people over 65 years of age. Utilising one of three mobile outreach fire stations – housed in a large mobile trailer unit – the scheme engaged with people who would not normally visit their general practitioner. Over 700 people were immunised and the fire service provided free smoke alarms and safety advice.

Lancashire Fire and Rescue Service is also assisting older people to lead independent lives. This scheme identifies ‘at-risk’ individuals who require social workers or health visitors to assess their needs. The fire service ensures that fire risks are identified and mitigated and that the appropriate agencies support individuals to continue to live independently within their own homes. An innovative pilot, Fire Safety Check Plus, brings together all these different agencies and has featured a number of ‘show and tell’ training sessions, where each agency learns about the role of others, so as to facilitate better signposting.

Collectively, North West fire and rescue services, working together with health agencies, have prevented deaths and injuries from fires and other emergencies and have helped improve the wider health of local communities.

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

CMO ANNUAL REPORT 2005

65

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1

SMALLEST IMPACT

22

LARGEST IMPACT

43

RANKING AMONGST ALL 43 AUTHORITIES IN THE REGION

RURAL LOCAL AUTHORITY WITHIN SHIRE COUNTY URBAN LOCAL AUTHORITY WITHIN SHIRE COUNTY METROPOLITAN LOCAL AUTHORITY WITHIN METROPOLITAN COUNTY

1. SYNTHETIC ESTIMATE OF BINGE DRINKING 2. ALCOHOL-SPECIFIC HOSPITAL ADMISSIONS – MALES 3. ALCOHOL-SPECIFIC HOSPITAL ADMISSIONS – FEMALES 4. ALCOHOL-RELATED HOSPITAL ADMISSIONS – MALES 5. ALCOHOL-RELATED HOSPITAL ADMISSIONS – FEMALES 6. ALCOHOL-RELATED MONTHS OF LIFE LOST – MALES 7. ALCOHOL-RELATED MONTHS OF LIFE LOST – FEMALES 8. ALCOHOL-RELATED RECORDED CRIME 9. ALCOHOL-RELATED VIOLENT OFFENCES 1 0. ALCOHOL-RELATED MORE SERIOUS VIOLENT OFFENCES 11. ALCOHOL-RELATED WOUNDING 12. ALCOHOL-RELATED LESS SERIOUS VIOLENT OFFENCES 13. ALCOHOL-RELATED ASSAULT ON A CONSTABLE 14. ALCOHOL-RELATED SEXUAL OFFENCES

Source: Regional Alcohol Indicators North West of England, NWPHO 2006

Alcohol, crime and health: breaking the cycle Last year’s Annual Report described the serious threat to public health posed by high levels of alcohol misuse in the region.

The mortality rate for chronic liver disease in the North West was 40% higher than the national average.

In recognition of the major burden posed by alcohol misuse on the region’s public services, the problem is now a priority across a range of sectors, including the health services and criminal justice services. A Regional Alcohol Strategy Group has been established to direct a research programme that will support local activity on alcohol harm reduction. New systems for routinely monitoring the impact of alcohol misuse and the progress made in reducing it have been developed.

The regional alcohol indicators, developed jointly by the Centre for Public Health and the North West Public Health Observatory, are the first output from these new systems. The data provided allow local authorities to examine the impact of alcohol on their area against its impact on other areas and to monitor any changes in the effects on services and residents.

Figure 2 highlights the alcohol profile of three different local authorities in the North West. It demonstrates the relatively low impact on one, more rural, area (within a shire county), modest effects in an urban local authority (within a shire county) and

the disproportionate impact of alcohol in one metropolitan local authority (within a metropolitan county).

Alcohol has been identified as one of four key themes in the Government Office North West Corporate Plan, and the Regional Alcohol Strategy Group will report quarterly on progress. The alcohol indicators will be used to support the negotiation and monitoring of Local Area Agreements and Local Delivery Plans.

SPOTLIGHTING REGIONAL HEALTH and initiatives

FIGURE 2 ALCOHOL CAUSES GREATER SOCIAL AND MEDICAL PROBLEMS IN METROPOLITAN AREAS

EAST OF ENGLAND

Improving the health and well-being of migrant workers and asylum seekers

66 Over recent years, there has been a steady increase in the number of migrant workers coming to the East of England.

Migrant workers are those with leave to stay in the country and permission to take up paid employment. It is estimated that between 50,000 and 80,000 migrant workers have come to the region within the last five years.

As well as a sizeable Portuguese population, large numbers of Eastern Europeans, particularly from Lithuania and Poland, have recently arrived to take up employment. In the sectors where migrants predominantly work – agriculture, construction, health provision, food processing, hotels and catering, cleaning and manufacturing – as many as one in three companies employ migrant workers.

The East of England Regional Public Health Group is working with other public sector organisations in the region to promote the health and well-being of migrant workers. Several measures have been implemented to improve the provision and accessibility of key services such as health, housing, education and childcare.

A constant issue raised by all agencies working to support the migrant worker population is communication. On arrival, most migrant workers are unaware of their rights and entitlements as citizens of

the European Union. To help address this problem, Southern Norfolk Primary Care Trust produced a booklet in Portuguese (the highest proportion of Portuguese migrants outside London is in East Anglia), which contains information on accessing various support agencies.

The booklet has been sent for distribution to employers with large numbers of Portuguese workers.

There are several other initiatives aimed at improving access to key support services for migrant workers.

• The smoking cessation service is working with employers to make services available at times convenient to migrants working difficult hours.

• Translation services within general practices, together with greater flexibility in booking appointments, are improving access to healthcare for migrant workers.

• Proactive management of oral health, such as the provision of information leaflets on dental hygiene, is helping to prevent problems.

• Laminated information cards are providing both patients and healthcare professionals with the information required to enable the treatment of minor illnesses at pharmacies.

• The development of special appointment cards enables general practitioners and pharmacy staff to more easily recognise individuals needing interpretation services.

• Medical labels printed in Portuguese are supplied for prescribed medication.

In Peterborough, illegal migrants seeking access to the labour markets of the East of England and failed asylum seekers are particularly vulnerable to social exclusion and isolation from essential services.

Many newly arrived asylum seekers have significant health needs. Since 2002, more than 2,000 asylum seekers from 43 nationalities have been dispersed to Peterborough. Some of their health problems include undiagnosed HIV and other sexually transmitted diseases, substance misuse, undiagnosed respiratory diseases, tuberculosis and mental health problems.

In Peterborough, a wide range of statutory and voluntary sector agencies offer support for new arrivals, including a designated general practitioner service working with a full list of asylum seekers and refugees. Resources at the service target mental health, including posttraumatic stress disorder. Projects have been set up to train sessional workers as ‘peer interactors’ in both sexual health and drug misuse.

Greater Peterborough Primary Care Partnership is a partner in New Link. This Home Office-backed initiative enables individuals to access information in a ‘onestop shop’ approach. The NHS walk-in centre provides outreach health advice, including registration with a general practitioner, to vulnerable and excluded groups including new arrivals.

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

CMO ANNUAL REPORT 2005

67 Of particular concern is the poor quality of the products supplied in vending machines at sports centres sharing sites with schools. A great deal of work is under way to help schools offer healthy choices to their pupils, but this may be undermined if the healthier options within schools are not matched with similar choices in vending machines accessible to pupils at sports and leisure centres.

SPOTLIGHTING REGIONAL HEALTH and initiatives

Providing healthy vending machines in schools Last year’s Chief Medical Officer’s Annual Report described the healthy vending machines project undertaken as part of the Government’s Food in Schools programme. Vending machines are very common in secondary schools. They provide a useful source of income for the schools but the products sold are often high in fat, sugar and salt. The project found that, over time, vending machines could successfully be changed to supply healthier food options.

The results of the healthy vending machines project are included in the Food in Schools Toolkit. This toolkit continues to be the main resource used by schools in changing the contents of their vending machines. The East of England Regional Public Health Group also supports schools by providing specific advice about how they can provide healthier products in their vending machines, and in those of sports centres based on school campuses.

In 2005, a regional survey of vending machines in the sports and leisure sector was carried out. A questionnaire sent to 532 sports and leisure centres in all six counties of the region received 180 responses. Results showed that 71 centres are on the same site as schools, but only 18 of these have at least one vending machine selling healthy food or snacks. Twenty-seven have at least one machine selling healthy drinks.

SOUTH WEST

Environmental surveillance system goes live

68 The environment is a major determinant of public health but our understanding of the relationship between the two is limited, particularly the cumulative effect and long-term impact of exposure to environmental hazards such as commercial chemicals.

To expand available data, increase understanding and improve responses to environmental events, the Health Protection Agency, in collaboration with the South West Regional Public Health Group, is piloting a new multi-agency environmental public health surveillance system.

Launched in July 2005, the webbased South West Environmental Surveillance System is designed to track the response to and consequences of acute and chronic environmental events.

Around 70,000 chemicals are in regular commercial use, and it is estimated that 600 new chemicals enter the market place each month. The evidence base for the short- and long-term effects of exposure to these agents is very limited, with adequate toxicology available for only 2% to 3%.

Over 70 local and regional agencies with a role in the management of and response to environmental events, such as local authorities, ambulance trusts and fire and rescue services, are participating.

The system has been designed to be simple, flexible, secure and interactive.

It provides all reporting agencies and primary care trusts with instant access to information. Each organisation can update the system with a new incident, or with additional information on a reported incident, by completing a standard form on the password-protected website.

As well as facilitating the reporting of incidents, the system has a comprehensive search facility, which the participants can access at any time. For example, at the point when an incident is first reported, participants can explore how similar incidents in the region were managed.

The Health Protection Agency South West has produced two reports on the system’s operation between October 2005 and March 2006. During this period, 71 incidents were reported across the South West – an average of 12 a month.

Key findings included the following: • Just under half (44%) of reported incidents involved actual exposure to hazardous substances, and were as diverse as an ammonia leak from a refrigeration plant and a domestic fuel oil leak.

• The majority of incidents concerned leaks and spills (52%).

• Almost a third of reported incidents occurred in residential locations.

• The main route of exposure was inhalation (54%).

• Thirty-six different agent types were recorded – the most common being products of combustion.

The Health Protection Agency South West will continue to analyse data provided by the system to identify trends in the types of incidents reported and key areas requiring further epidemiological investigation, training and prevention.

It has already been possible to link three incidents of refrigerant gas leaks in different parts of the region. Lessons from these incidents have been learned and action taken to prevent further occurrences.

The system has already begun to prompt change. One hazardous materials group is reviewing its alert and notification arrangements, and a fire service is reviewing its equipment and response process.

The project, co-funded by the South West Regional Public Health Group, is currently being evaluated for possible national roll-out later in the year.

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

CMO ANNUAL REPORT 2005

69

SOUTH GLOUCESTERSHIRE EASTLEIGH

UNITARY OR LOCAL AUTHORITY

SWINDON

ISLE OF WIGHT

NEW FOREST

HAVANT

CITY OF BRISTOL

SOUTHAMPTON

PORTSMOUTH

PLYMOUTH 0

50

100

150

200

250

NUMBER OF CASES OF MESOTHELIOMA (1989–2003) MALE

Source: SWPHO 2006

FEMALE

300

Predicting the burden of malignant mesothelioma Last year’s Chief Medical Officer’s Annual Report described work undertaken by the South West Public Health Observatory to predict the pattern of increase in cases of malignant mesothelioma across the South West, Hampshire and the Isle of Wight.

Mesothelioma arises most frequently in the outer lining of the lungs (pleura).

Approximately 8 out of 10 cases are caused by exposure to asbestos dust.

Mesothelioma has a long latency period and develops 15 to 30 years, or even up to 60 years after exposure.

Most people developing the disease are 60 years old or over.

The model predicted that the peak would occur between 2010 and 2015, at around 325 cases per annum, and that the greatest numbers would be in local authorities with a history of shipbuilding.

These data have been used to reassure local directors of public health that increases in cases are in line with predictions from the model, and in service planning to validate recent increased demand for chemotherapy and to predict future costs.

Over the past year, the South West Public Health Observatory has compared the latest registration data and has confirmed the validity of the model’s predictions. Working with regional officers of the Health and Safety Executive and the Trades Union Congress, the Observatory

has undertaken further investigation of geographical variations in numbers and male to female ratios of cases, and in occupation-related exposures, to gain a greater understanding of the epidemiology of mesothelioma within the South West.

Most notable is the striking difference in male to female ratios (see Figure 1) between Plymouth (25:1) and Portsmouth (9:1), Southampton (8:1) and Bristol (3:1).

Investigations to date suggest that, in Plymouth, males with mesothelioma predominantly worked in the shipyards, which provided on-site laundry services for workers’ clothing. This is in contrast to Portsmouth and Southampton, which also have a history of shipbuilding but did not provide on-site laundry services.

One hypothesis is that males without access to on-site laundry services brought their work clothing home, exposing their families to secondary contact. In Bristol, where shipbuilding is not a major activity, occupational exposure is predominantly among thermal engineers, plumbers and building maintenance workers.

Ongoing work is taking place to gain a better understanding of the occupationrelated causes of mesothelioma, some of which may not have been identified before.

SPOTLIGHTING REGIONAL HEALTH and initiatives

FIGURE 1 THE 10 UNITARY AND LOCAL AUTHORITIES IN THE SOUTH WEST, HAMPSHIRE AND ISLE OF WIGHT WITH THE HIGHEST NUMBER OF CASES OF MESOTHELIOMA OVER A 15-YEAR PERIOD

YORKSHIRE AND THE HUMBER

Poor dental health of children in Yorkshire and the Humber

70 Good oral health in childhood provides a platform for good oral health in adulthood and the prevention of problems in later life. Yet children in the Yorkshire and the Humber region are more likely than most to need a dentist.

A report from the British Association for the Study of Community Dentistry highlighted the fact that the region has the second highest level of decayed, missing or filled teeth (dmft) in England, with the more deprived areas tending to have higher levels of decay than more advantaged areas. The situation is of concern, as tooth decay is preventable.

Dental staff examined nearly 23,000 (40%) of the region’s 5-year-old children.

Results showed an average of 2.05 dmft per child compared with an England average of 1.5. In 16 of the region’s 34 primary care trusts, more than half of all 5-year-olds had experienced tooth decay. In four areas – Barnsley, Bradford City, North Kirklees and East Leeds – over 60% had some degree of decay. Across the region, those children who had some dental decay had an average of four affected teeth.

While levels of decay in North and East Yorkshire and Northern Lincolnshire Strategic Health Authority are close to the England average, West Yorkshire Strategic Health Authority has the highest average dmft in England, and South

Yorkshire has the fourth highest average (see Figure 1). Levels of dmft are higher than the England average in two-thirds of primary care trusts in the region.

This regional trend of high dmft continues with young people: in 2002/03, the Yorkshire and the Humber region had the highest level of mean dmft in 14-year-olds, with a mean dmft of 1.92 compared with 1.43 in England.

In general, the levels of decay in primary care trusts in more deprived areas were higher than in the more affluent areas, where children are more likely to have better diets, restrict sugar consumption and use fluoride toothpaste.

One effective method for preventing tooth decay is fluoridating water supplies.

Fluoride is naturally present in all water supplies and can be boosted to the optimal level for dental health of 1 part fluoride in 1 million parts of water (1.0 mg/litre). Levels of tooth decay are consistently lower in the West Midlands, where 70% of the population receives fluoridated water, compared with Yorkshire and the Humber. In the most income-deprived families in the West Midlands, 5-year-olds have an average of 1.1 dmft, similar to their counterparts in the most affluent families in Yorkshire and the Humber, where the average is 1.3.

The Department of Health issued guidance on fluoridation last year. Water companies must fluoridate their water supply if strategic health authorities ask them to, provided they can demonstrate

strong public support. Dental care services already undertake a range of oral health promotion programmes to reduce sugar consumption and improve oral hygiene in communities with the poorest oral health. With evidence showing the continued poor dental health of children in the Yorkshire and the Humber region, the new strategic health authority and primary care trusts will need to give serious consideration to the role that fluoridation might play, together with other preventive strategies, in improving dental health in the region.

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

Figure 1 THE DENTAL HEALTH OF 5-YEAR-OLD CHILDREN 2003/04

MEAN dmft OF ALL CHILDREN

PERCENTAGE OF CHILDREN WITH DENTAL DECAY (dmft>0)

MEAN dmft OF CHILDREN WITH DENTAL DECAY WHERE dmft>0

NORTH & E YORKS & N LINCS

1.40

38.2

3.67

SOUTH YORKSHIRE

2.05

49.4

4.16

WEST YORKSHIRE

2.51

55.4

4.53

ENGLAND

1.49

38.7

3.85

CMO ANNUAL REPORT 2005

STRATEGIC HEALTH AUTHORITY

71

Source: British Association for the Study of Community Dentistry survey

While not yet ready to report, the work will increase understanding of the reasons why inequalities in cancer rates occur and, it is hoped, will give an indication on how inequalities can be addressed – for example through improving access to screening services and targeted health promotions.

A national bowel cancer screening programme is currently being rolled out.

This is one of the first national bowel cancer screening programmes in Europe, and the first cancer screening programme in England to involve men as well as women. By 2009, when there will be full coverage across the country, around 3,000 bowel cancers a year should be detected.

Hull will be one of the first national sites for roll-out of this programme and the Northern and Yorkshire Cancer Registry and Information Service will be able to monitor the impact of this on cancer incidence rates and survival.

SPOTLIGHTING REGIONAL HEALTH and initiatives

Bowel cancer: now seen more often among the affluent There are approximately 2,850 new diagnoses of bowel cancer per annum in the Yorkshire and the Humber region – a rate that has stayed constant for the past 12 years. Last year’s Annual Report noted a marked increase in incidence in men in higher socioeconomic groups, which represented a reversal of previous trends. To try to understand precisely what is behind this changing pattern, statisticians at the Northern and Yorkshire Cancer Registry and Information Service are evaluating the latest incidence data and undertaking a more detailed analysis of other factors that could be affecting trends.

Researchers are looking at the agestandardised incidence rates of colorectal cancer by deprivation (based on the Index of Multiple Deprivation 2000 income score) across the North East, Yorkshire and the Humber, and East Midlands between 1991 and 2002 using three-year rolling averages. Deprivation quintiles have been standardised both locally and nationally for comparison. In addition to comparing deprived and affluent males and females, the researchers are investigating other factors such as position of the cancer in the bowel and how advanced the cancer is at diagnosis, as both can affect survival rates. This information may help when developing health promotion initiatives aimed at particular groups of men.

SOUTH EAST

FIGURE 1 LIFE EXPECTANCY IN WEST SUSSEX ELECTORAL WARDS WITH AND WITHOUT NURSING HOMES, BY RANK ORDER (1997–2001) 86

LIFE EXPECTANCY AT BIRTH (YEARS)

84 82 80 78 76 74 72 70

0

10

20

30

40

50

60

70

80

PERCENTILE OF RANK OF LIFE EXPECTANCY AT BIRTH ELECTORAL WARDS WITH NO NURSING HOME DEATHS ELECTORAL WARDS WITH NURSING HOME DEATHS

72

Source: Public Health Mortality File and Exeter

One of the ways to monitor progress towards the Government target of reducing health inequalities in England is to measure the extent of differences in life expectancy between areas. Research undertaken by the West Sussex Public Health Observatory on behalf of the South East Public Health Observatory examined the impact of the distribution of nursing homes on life expectancy rates in West Sussex at the level of electoral ward.

West Sussex is a relatively affluent part of the country with about 120 nursing homes. At the time of the 2001 census, there were approximately 2,900 people living in residential care establishments.

The research found that nursing home deaths have a very strong impact on life expectancy figures: those wards with nursing homes tended to have life expectancy figures approximately two years lower than similar wards without nursing homes. Overall, nursing home deaths can provide the explanation for nearly 40% of the variation in life expectancy between wards. Importantly, this effect is independent of deprivation (see Figure 1).

Geographic variations in life expectancy are the product of a wide range of underlying determinants of health.

In general the more deprived an area, the lower the life expectancy of its residents will be. A trend towards comparable life expectancy levels between areas may

indicate a more general reduction in differences in the level of deprivation.

If life expectancy is used to measure the progress being made towards reducing the extent of deprivation across the country, it is crucial that the causes of any differences other than deprivation are taken properly into account.

One of these could be the concentration of nursing homes within local areas. Older people living in nursing homes tend to be in poorer health than those not living in nursing homes. As these homes are unevenly distributed across the country, a higher death rate – and consequently lower life expectancy level – in one area could simply be the result of frail older people moving into that area, making up a larger proportion of the local population.

Deaths among nursing home residents are not easy to monitor. In order to ensure that life expectancy figures or similar deaths-based indicators for small areas across all parts of England are correctly interpreted, the information should be presented alongside data on the proportion of nursing home deaths in an area.

Similarly, indicators of the quality of social care services, such as the proportion of older people supported to live at home, may be adversely affected by the presence of nursing homes. Unless the influence of nursing homes is taken into account, there is the risk that resources may not be targeted at those local areas with the highest underlying levels of deprivation and health inequalities.

90

100

PROGRESS MADE SINCE THE 2004 ANNUAL REPORT

FIGURE 2 NUMBER OF EXTENDED-SPECTRUM BETA LACTAMASE (ESBL)-PRODUCING ISOLATES OF E. COLI IN SOUTHAMPTON BY CALENDAR MONTH 2003–05

80 70 60 50 40

SOURCE OF SPECIMEN FROM WHICH ISOLATES OBTAINED: TISSUE SWAB SPUTUM ASPIRATE BLOOD URINE OTHER

CMO ANNUAL REPORT 2005

30 20

OCT

NOV

JUL

SEP

JUN

AUG

APR

MAY

MAR

DEC JAN 2005 FEB

SEP

OCT

NOV

JUL

AUG

JUN

APR

MAY

MAR

DEC

JAN 2004 FEB

OCT

NOV

JUL

SEP

JUN

AUG

APR

MAY

0

MAR

10

JAN 2003 FEB

NUMBER OF ESBL-PRODUCING ISOLATES OF E. COLI IDENTIFIED

90

YEAR AND MONTH

73

Source: Health Protection Agency South East Regional Laboratory 2006

issued guidance on the diagnosis and control of ESBL-producing organisms in 2004. An enhanced surveillance system covering 16 laboratories in London and the South East for a two-month period established a case series of 680 ESBLproducing Enterobacteriaceae, of which about 150 were community acquired. A key finding was that the infection rate increased substantially with age. A case control study of community-acquired ESBL-producing E. coli was also set up in the South East and London. Interim analysis has shown a case fatality rate for community-acquired urinary tract infections of approximately 30%.

A mortality analysis is now in hand with the support of the Office for National Statistics and the Health Protection Agency’s Centre for Infection.

The outcome of these studies will be published as soon as possible to guide further epidemiological and microbiological investigations and interventions.

SPOTLIGHTING REGIONAL HEALTH and initiatives

Reducing E. coli infections in Southampton Last year’s Annual Report described an outbreak of extended-spectrum beta lactamase (ESBL)-producing Enterobacteriaceae coli around the Southampton area. The outbreak was due to a single strain of ESBL-producing E. coli, and was first recognised by the Southampton Health Protection Agency South East Regional Laboratory in 2003. The outbreak peaked in November 2004 (see Figure 2) but fell from 85 new acquisitions per month to around 12 over the subsequent year.

It is not clear why there has been such a significant reduction, though the Health Protection Agency is currently investigating this. Enhanced infection control measures and antibiotic policy changes have been introduced and are possible explanations. Despite the decrease in new acquisitions, cases of infection continue to occur, suggesting a persisting risk in colonised individuals.

The significance of this outbreak is that beta lactams are among the most widely used group of antibiotics throughout the world, and organisms that produce the ESBL enzyme, such as E. coli, Klebsiella and Enterobacter species, are very effective at inactivating these sorts of antibiotics. Antibiotic resistance to some non-beta lactams such as trimethoprim, fluoroquinolones and aminoglycosides is also seen. In response to this emerging problem, the Health Protection Agency

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CHIEF MEDICAL OFFICER ANNUAL REPORT 2005

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First published July 2006.

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Annual Report 2005 Main Features Waste Not, Want Not Learning to Fly Taking No Chances Raiding Public Health Budgets can Kill Planning for a Rising Tide

The Chief Medical Officer on the state of public health