Today’s Guest Blogger is Andrew Attfield, Associate Director for Public Health at Barts Health NHS Trust. Andrew attended our seminar on making early action a principle of public policy and we were intrigued by what he had to say about early action and health. For more on early action at The Young Foundation, you can listen to the podcast of the seminar, Stop Hitting the Snooze Button, or read Reducing Crime: The Case for Preventative Investment.
Watching BBC’s new drama “Ripper Street” the other night (rather gory, but still compelling in a steam punk kind of way) I noticed that the story line started with an epidemic. As Whitechapel residents keeled over next to a hand pump, a cleric announced the return of “King Cholera”. The pump loomed threatening throughout the episode, although the culprit turned out to be a larcenous baker, poisoning flour. Clearly the writers of this episode were aware of the pioneering work of the physician John Snow, who lived in 19th Century London. Snow famously mapped an outbreak of Cholera in his neighbourhood and demonstrated that those struck down by the disease had used water from a particular pump.  Based on his evidence, the parish council then removed its handle. This was a huge step forward in improved sanitation and clean water. You can still see the pump and commemorative plaque in Broadwick Street in Soho. 
I mention this as a classic case of preventative public health, and listening to David Robinson from Community Links speak on the Early Action Taskforce at the Young Foundation, I was struck by the parallels with the work that the Taskforce are undertaking. David spoke on how this work was majoring on persuading government that investing in early intervention improves outcomes and saves money. “Prevent today to save tomorrow” as the report says.
A point well made by David was that early action does not always need a long run in to demonstrate a return on investment. I think this is demonstrated by a couple of examples from the Public Health programme at Barts Health NHS Trust.  Barts Health is a new organisation formed from Barts and the London, Newham University and Whipps Cross University NHS Trusts and is the largest NHS Trust in the country. The new Trust runs six hospitals across East London, running acute, specialist and (in Tower Hamlets) community health. Because of its wide scope and geography, its Board has committed to a preventative approach by establishing a public health programme. We only started work in October 2012, but have already decided to work on three themes – making every patient contact count for health promotion, improving staff health and well being, and acting on the wider determinants of health as an employer and local environment.
My first example comes from the first theme. If you are asked to attend a pre-operative assessment you will be asked if you smoke. The clinicians need to know this for the operation. However if patients said they did smoke, we did not always ask the follow up questions – did they want to give up and would they like support in doing so. This a process we are now implementing, as we know that giving up smoking prior to an operation aids its success rate and speeds up recovery time. Of course giving up permanently is the best outcome of all, and given that a medical procedure is imminent, this is a good time to pass this message on to a patient. My second example relates to the second theme. Dr Stephen Boorman’s report on NHS Health and Wellbeing demonstrated that strong links between low rates of sickness among NHS staff not only with reduced costs and more engaged staff, but with better mortality rates, reduced infection rates and improved patient satisfaction. You might describe these examples as “no brainers”. They are clearly good for all concerned and save money from the word go. Aside from improved clinical outcomes, the results include reduced number of procedures, reduced prescription costs, fewer complaints and reduced agency costs. They are also low cost interventions with a strong evidence base and can be regarded as early action, in action.
Where early action becomes harder to sell in where the time gap between investment and return is much longer – for example in improving parenting and reduced youth offending – or where problems are complex and multi-factorial. Most health problems can be attributed to preventable issues such as poor lifestyle and/or wellbeing linked to low income and status. The third theme of our public health approach tries to maximise the impact of Barts Health by putting employment on the agenda for our communities (for example employing more local people) or improving our local environment (for example by reducing car use), but we know we are only one piece in the jigsaw of solutions. This where I think that stronger local partnerships would help. Local partnerships are more likely to stick to the ten year plans being proposed by the Early Action Task Force than ones set at a national level, and are less likely to be upended by frequent political change. Local government, the NHS, social housing landlords and the voluntary sector have the required local awareness of the issues faced by their populations. Of course setting targets around improving employment levels, reducing child poverty, improving air quality and increasing community cohesion is far from easy, but these are the factors needed to remove the handle from the pump generating poor health. The alternative is poorly functioning populations suffering from a range of long term conditions, such as Type 2 Diabetes, or poor mental health, and increased unequal and divisive health outcomes.
Can we really afford not to prevent?
1. “Ghost Map” by Stephen Johnson 2006 (Allen Lane) tells the story.
2. In addition to knowledge of John Snow, I wonder if the writers of “Ripper Street” where aware of another Doctor, Dr Alimantado, the reggae DJ who featured the Poison Flour track on the classic 1970s “Best Dressed Chicken in Town” album .
3. Changing Lives: Our Public Health Vision (Barts Health NHS Trust 2012). Please request a copy if interested.