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In the latest of a series of blogs about Prevention Programmes, a Consultant in Public Health and A&E Doctor for Barnsley Hospital NHS Foundation Trust and Barnsley Metropolitan Borough Council, discusses the role of hospitals in delivering preventative interventions and promoting healthy communities:
I want to reflect on the role of prevention in hospitals, on the clinical relevance of prevention and on whether prevention is the square peg and a hospital the round hole.
There are two broad areas of tension in my view:
The first tension is whether we can justify focusing on prevention in the healthcare setting when NHS resources are stretched and hospitals struggle to meet their headline targets. But for me prevention generates such a good return on investment that we should be doing it everywhere – paddling back upstream. However, this has long been true, and yet we haven’t generated proportionate investment so that doesn’t solve the puzzle.
How about the clinical and organisational relevance of prevention? An example is the benefit of implementing the Ottawa Model for Smoking Cessation in secondary care. The impact is quantifiable and starts from year one – around 400 lives saved and 800 readmissions avoided for a hospital the size of ours. And so the first tension quickly eases with similar cases for the other key risk factors emerging. We begin to build a case for the “P” of prevention shifting up the clinical alphabet – A (airway), B (breathing), C (circulation), D (disabling illness), P (prevention of future illness).
The second tension is how can we justify medicalising prevention and bringing it into the realms of hospitals when the biggest impact will always be achieved through other determinants such as economic, social or commercial?
This is where we must recognise opportunity. Through A&E and outpatient attendances, admissions and a large workforce, a hospital has a massive reach into a local population. Each interaction provides an opportunity to gather intelligence, inform Public Health and strengthen prevention.
An example is our high local rates of harm from alcohol in people under 18. Knowing that alcohol-related admissions in this age-group is also high gives us a target group with high need and vulnerability. It also gives us very ready access to in-depth intelligence and opportunity to intervene – go to the hospital, speak with this group and do some good Public Health. And so, the second tension begins to ease.
What is my solution? I think this agenda of prevention and Public Health in a hospital should develop hereon in, starting with three crucial components – simplicity, infrastructure, and the wider system for health.
The opportunities are massive and I hope prevention in the NHS Long Term Plan will be act one of many decades to come, but for now feasibility lies in simplicity. Stick to the big risk factors of tobacco, alcohol and obesity – activity and diet – and throw in some parity of esteem. Make space for holistic care that recognises a person’s mental and social health as interdependent with their physical. This will allow focus, effective implementation and a building of momentum.
To make any of this possible a hospital needs to strike the right balance of this being everyone’s business and investing in a dedicated prevention infrastructure. Depending on the size of the hospital, this needs a Public Health specialist, a prevention programme manager, specialist advisors per risk factor – an integrated stop smoking service and alcohol care team, etcetera – and some boots on the ground to support implementation in the hospital, reiterate the message and gather intelligence, or a Prevention and Healthy Lives Team.
Finally, to fulfil its new potential and old duty, a hospital needs to influence the local system for health in which it sits. A hospital should be an exemplar organisation and anchor institution that demonstrates the benefit of promoting health in its staff and through its wider influence, including through its purchasing and provision.
It should work more closely with local policy-makers to ensure economic and development plans consider health as an asset.
It should support its other health and social care partners to be driven by outcomes and reducing inequalities – starting with prevention and catching health upstream.
In short, a hospital should be a Public Health Institution … even more so than it already is.