East London and City Alliance & Queen Mary, University of London

1. East London and City Alliance &Queen Mary, University of London PUBLIC HEALTH RESEARCH FORUM Wednesday 8th September 2010

2. What is Public Health? Public health is concerned with improving the health of the population, rather than treating the diseases of individual patients. “The science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society“ Donald Acheson

3. Public Health Research at Barts and the London School of Medicine and Dentistry Wolfson Institute of Preventative Medicine Charterhouse Square-West Smithfield RAE 2008- 2nd of 21 in quality of research in UK Centre for Health Sciences Whitechapel RAE 2008-4th of 23 in quality of research in UK

4. Examples of our previous success in public health Supplementation of flour with folic acid (Vitamin B9) to prevent spina bifida -adopted in 33 countries The polypill- a statin, 3 blood pressure lowering drugs, folic acid and aspirin - should reduce cardiovascular disease in over 55’s by 80% Cervical cancer-detection of the virus which causes the disease as a lab test Cervarix-cervical cancer vaccine-should reduce disease by 70%-all 12 year old girls

5. So what do we do now in public health? (Some examples) Cancer screening in the east end and internationally Vitamin D, TB and asthma in the east end The effect of the low emission zone on airway health in children Noise pollution and childhood achievement Transcultural mental health Hepatitis C in the immigrant community

6. Vitamin D-needed for strong bones, immune system etc 90% of Vitamin D made by ourselves in the skin by sunlight 50% of UK population Vitamin D deficient

7. Our Aim We want to do world-class research in Public Health! To do that you need world-class researchers

8. Continuing investment in Public Health Khalid Khan- Maternal Public Health and Epidemiology Trish Greenhalgh- Healthcare Innovation and Policy High profile appointment in Public Health (Jan 2011) Seif Shaheen-Respiratory Epidemiology Creation of a Public Health and Primary Care Clinical Academic Unit in Barts and the London NHS Trust

10. Our aim is to transform public health in the region from an area of social disadvantage and poor health outcomes to one of excellence • 5.8 million people receive health services from our partners • 10% of the UK population, 10% of the NHS budget • 12% of the births in the UK occur in our HIEC • 1 Academic Health Science centre & 8 Universities • 23 NHS providers including 6 mental health trusts • 17 Primary care trust & local boroughs Who we are Coordination & Facilitation to ensure that the right people are round the table to solve the problem, and then to implement the solution Evaluation of innovations to ensure continued quality of patient care and efficient use of resource Dissemination of best practice across the region so that inequalities do not occur What we do

11. Our 5.8million people have a lot in common when compared to the England Average: • Life expectancy for men is significantly worse • We have a high proportion of over 65s in poor health • We have a high number of early deaths due to heart disease and stroke Data source: Health Observatory London profile 2009

12. Data Source: Health Observatory East of England 2009

14. Focus 2010-2011 Theme PREVENTION Cardiovascular Disease LONG TERM CONDITIONS Chronic Obstructive Pulmonary Disease ACUTE CARE Maternity Goal • Identify 12000 people with Familial Hypercholesteria • Prevent primary CVD events 1.Lead the way in NIV 2. Self management & rescue packs 3. Effectiveness of short burst oxygen 4. GP regsters & COPD • Treat low risk women as low risk • Reduce C-section rate Outcome Patient: Equitable access, care closer to home, responsive service System: more for less, workforce fit for purpose, collaborative ethos, pathway redesign, internal experts HIEC: knowledge of success & failure to be learned from and then applied, informal and formal networks of innovators

16. Establishing a NE London Health Academy Report by Neil Goodwin CBE

17. Context Health4NEL NECLES HIEC UCL Partners Future of Homerton/Newham/WXH Economic Environment NHS White Paper QIPP

18. Need Strong vision and leadership Service transformation – inter-organisational and across systems Stronger emphasis on prevention and positive lifestyle changes Cost-effective development of flexible, adaptable and responsive workforce

19. Why? Smaller group would ease collaborative activity and agreement (eg on pathways) Tackle significant local challenges – major capital investments for BLT and BHRT Turn H4NEL to practical reality Improve linkage between commissioned workforce transformation and NEL offering by HEis and others

20. Why? Stimulate collaboration between HEIs playing to their strengths and needs of NE London Relationship building intra- and inter-sector Leadership Forum towards collaboration with GP Commissioners, LAs, Private Sector, 3rd sector Coherent NE London responser to national and local initiatives Create a reputation for excellence

21. The Service View Dr Ian Basnett Director of Public Health ELCA

22. Context “Equity & Excellence”: Liberating the NHS DH largely Public Health focused Independent NHS Commissioning Board No SHA or PCTs GP Consortia National Public Health Service PH into Boroughs, but collaboration 22

23. Ourpopulation Index of multiple deprivation Concentrated deprivation- Hackney second, Tower Hamlets third and Newham sixth most deprived boroughs in the UK Over half the population is from an minority ethnic background - 38% in City and Hackney, 60% in Newham A young population- 32% <20yrs; largest group (circa 35%) is 20 -39 yr olds Significant number of children living in families dependant upon benefits45.7% in Tower Hamlets (8.4% Richmond) Rapid population growth - 773,000 residents 2010/11 – more than 869,000 by 2021 Population Growth 2006 – 2026 (source GLA)

24. Tackling unacceptable health inequalities Life expectancy– Men 75.3 years in Tower Hamlets (83.7 in Kensington) women 79.8 years in Newham (lowest in London) Deaths from all causes per 100,000 population – 714 in Tower Hamlets; 381 in Kensington More than 3,000 people with severe long-term mental health conditions in City and Hackney, a prevalence of 1.2 per cent; 0.9 per cent in London, 0.7 per cent nationally But: All PCTs on track to narrow life expectancy gap – only 13 spearheads on track of both male and female out of 70 Infant mortality decreasing Better management of long-term conditions

25. Things that worry us • Population growth, mobility, funding allocation • Determinants, poverty, etc • Lifestyle • Better commissioning, evidence, cost-effectiveness and impact • Prioritisation

26. Things that worry us - cont • Improve health service delivery • Evaluation • Big killers, Ca, CVD, COPD • For all these inequalities 26

27. Research • Population sciences, migration, social sciences • Behaviour change, psychology & trials • Evidence and health economics • Disease specific questions 27

28. 1 year survival from breast cancer, by PCT 2003-5

29. Conclusion Significant joint research Remain significant opportunities for synergy NHS and service public health faces unprecedented change Perhaps more important to develop joint CAU public health

30. Primary Care Research and East London Public Health Chris Griffiths

32. Three projects - work in progress: • HIV screening in primary care • Vitamin D supplementation trials • Impact of Low Emission Zone

34. Can screening for HIV using • rapid tests in general • practice identify: • More HIV • HIV at earlier stage?

37. Anonymity: ‘With a GP nobody knows, so you could be sick for anything. It could be a headache, it could be flu, it could be anything, so they don’t know. So I think it’s good if the GP has it.’

38. Less Stress: ‘I don’t think that much can take away the stress of possibly testing positive for HIV, but I think that if you can close the gap between giving the initial sample and getting the result, it certainly would alleviate a lot of anxiety.’

39. Study design: Cluster randomisation of general practices 45 Hackney practices Randomisation Intervention practices trained to screen for HIV Control practices with usual care

40. Outcomes Primary – number of patients diagnosed with HIV Number of HIV tests done in health checks Secondary: Early diagnosis – CD4 count >200 cells/mm3 Cost effectiveness of screening vs usual care

41. Hyppönen et al. Am J Clin Nutr 2007;85:860-8. Serum 25(OH)D (nmol/l) Miller et al. Brit Med J 1971;1:475-9 Influenza case rates/100,000 Vitamin D deficiency and epidemic influenza

42. Vitamin D: immunomodulator ↑ Cathelicidin LL-37 ↑ Human neutrophil peptide 4 ↑ Lipocalin 2 ↑ IL-10 ↓ IL-8 ↓ MMP-1, -7, -9 ↑ TIMP-1 Antimicrobial Anti-inflammatory

43. OViD Optimising Vitamin D Status in London

44. Hypothesis Vitamin D supplementation will reduce the incidence of infection-triggered acute respiratory illness in Patients with asthma Patients with COPD Nursing home residents Nursing home staff

45. OVID: phase 1:Cross-sectional study of vit D status Asthma COPD NH Residents & staff

46. OVID: phase 2:Three RCTs of vit D supplementation Intervention: 6x2monthly 3mg oral vit D Outcomes: Acute respiratory infection Inflammatory mediators QOL Health care use Mortality Sub studies: Sputum induction – resp pathogens + infl mediators Response to vaccination Asthma RCT n=240 COPD RCT n=240 NH Residents & staff cluster RCT n=1000 + 1000

47. OVID: phase 3:Focus group studies of attitudes Asthma RCT COPD RCT NH Residents & staff cluster RCT

48. OVID: phase 4:Meta-analysis & economic modelling Asthma RCT COPD RCT NH Residents & staff cluster RCT

49. OVID: phase 5:Public health policy & recommendations Asthma RCT Policy COPD RCT NH Residents & staff cluster RCT

50. Cross Sectional Analysis of Children’s Respiratory Health in London Following the Introduction of the Low Emission Zone