Paediatrics and Public Health:
The start of a beautiful relationship?
If there’s anything I learnt from our recent deanery study day on Public Health, it’s that public health are really keen to talk to us; That and to always choose a rear facing seat on the train…
Public health is about improving and protecting the health of entire populations rather than individual patients. As a specialty, they have the tendency to look at the ‘bigger picture’ and maintain the foresight to achieve positive change over time rather than lurching from crisis to crisis as often appears to be the nature of modern day health care.
You can’t really argue against this philosophy and when I look at the big issues that frustrate me such as childhood obesity, it’s public health who
are leading the way in creating solutions. These solutions aren’t often speedy and as per most changes at a population level are inextricably linked with our archaic political system. As I (and a famous chap called Virchow) have said previously:
“Politics is nothing but medicine on a larger scale”
So I thought I’d share a little of what I’ve learnt about this valuable specialty and what we can do for each other to improve the health and wellbeing of our nations' children.
Notify Notify Notify…
I mentioned that the public health processes can be a little slow….Well, that’s usually correct except for one important area which they’re really very good at; preventing the spread of infectious diseases.
Why is this relevant to paediatricians in particular? Children are both susceptible too and the vectors for many infectious diseases due to their immature immune systems and impressive viral loads. If you’ve seen one child with meningococcal septicaemia, you really don’t want to see a second, and neither do they! In these situations the preventative measures can be time critical and they really want to hear from you as early as possible, even if the diagnosis isn’t laboratory confirmed.
Also did I mention it’s also your statutory duty to report notifiable diseases? No one’s going to hunt you down if you over-report and with regards to meningococcus they do ask you to identify whether it’s a possible, probable or confirmed case. After all we do see a lot of non-blanching rashes…
The duty to report applies to the following
Notifiable diseases (pre or post confirmation)- see list here.
Infection that could present significant harm to human health but is not a notifiable disease (e.g. chicken pox in a healthcare worker)
Contamination such as with chemicals or radiation in a manner which could present significant harm to human health
The majority of us probably fall into the category of chronic under notifiers particularly with regards to common paediatric presentations such as scarlet fever and bloody diarrhoea. I’m pretty sure I see at least one suspected case of these a week in the assessment unit. It’s worth remembering that bloody diarrhoea could be E.Coli 0157 and that such infections can still kill as we are tragically reminded by the South Wales E.Coli outbreak of 2005.
Injuries or ‘accidents’ are the leading cause of death in the under 45’s and the link between social inequality and childhood injuries is evident.
The term ‘accident’ is frequently discouraged by public health implying that these are random events that could therefore not have been prevented. If resources allowed, the case could be argued for these non intentional injuries to also be made notifiable so that lessons are learnt and preventative measures taken in the future.
Public Health helps to keep our children safe by providing the data and expert knowledge to drive through specific measures and legislation that protect children. The Child Safety Report Card is a system developed by the European Child Safety Alliance that allows us to measure national progress and set targets to reduce injury related death and disability amongst children and adolescents. Have a read about your countries’ efforts here.
Here are just a few of the evidence-based accident prevention measures that work:
Road Traffic Collisions
Our lifetime risk of a road traffic accent is 1 in 3 meaning that potentially the most dangerous thing you can do is drive your children to school or allow your teenage daughter to get into the car with her boyfriend
Graduated driving license schemes have been proven to be effective at reducing death and disability in young people in Australia, New Zealand and the US. The power to legislate this lies with Westminster. As it’s not a devolved power, the Welsh Government continue to pressurize on this issue
Rear facing baby seats and appropriate child restraints: Seat-belts are meant to go over your shoulder not round your neck! The law states that all children up to 150cm tall should be secured in a child restraint suitable for their height and weight whether that be a car seat or a booster sear and that it’s best to be rear facing as long as possible (even as an adult on public transport!)
Speed Limits- reducing the default speed limit from 30mph to 20mph would have a significant impact on pedestrian and cyclist safety reducing the need for expensive traffic calming measures and have benefits for our overall health. When the Wales Bill comes into power next year, the Welsh Government will have the power to make its own speed limits so watch this space
Go to www.brake.org.uk for further information on all the above
Recently branded as ‘baby-killers’, these brightly coloured attractive parcels are not only handy for the washing machine or dishwater but devishly attractive and potentially fatal to young children.
The ‘NOT FOR PLAY…KEEP THEM AWAY’ campaign in NHS Scotland was highly successfully in achieving positive change with 40% of those families interviewed installing cupboard latches and 60% making positive changes to the home safety environment- read more here
“Children Can’t Fly” is a New York based health education program developed in the 1970’s to help reduce child injury and death from window falls and involved the provision of free window guards to high risk families, reducing the number of reported falls by 50%
Public awareness was further raised following the death of singer Eric Clapton’s 4 year old son in a multi-storey window fall in 1991.
The list of potential dangers seemed endless ranging from children drinking nicotine filled e-cigarettes to suffocating on nappy sacks. It’s made be contemplate whether I’d want to bring a child into this danger filled world in the first place. Luckily, the Children in Wales organization in partnership with Public Health Wales have developed a child safety toolkit focusing on a different unintentional injury topic each month to help professionals (and extremely vigilant parents) understand what they can do to reduce the risk.
How many times do you give the ‘healthy lifestyle’ talk in clinic and feel like a school teacher telling off a naughty pupil? It makes us cringe interiorly, tends to cause our patients to switch off and is highly unlikely to be effective.
Health Promotion is a huge part of public health’s role and it’s a skill to be learnt, not a lecture at the end of a clinic consult. The latest buzz word is ‘MECC’ or ‘Making Every Contact Count’. This approach based on motivational interviewing techniques aims to create a system wide change across our NHS, empowering staff to support behaviour change and promote healthy lifestyles with the suggestion that no professional is exempt from this responsibility and even the smallest efforts made by many people can lead to the greatest changes.
These brief interventions are based on working with those patients ready to change their behaviours using a collaborative and patient centered approach. Most of us are fairly smug about our communication skills but it’s only when you break it down and read about motivational interviewing in detail that you appreciate the subtle differences.
I’m a big fan of the idea although a few hackles were raised at teaching about the proposal and how achievable it is in a busy acute paediatric setting when the technique relies so heavily on social contracting and follow up. As far as I can see; healthy parents make for healthy children and if we are able to influence health harming behaviours such as smoking and physical inactivity in any way, I’m game to give it a go.
Also, there’s evidence that motivational interviewing can improve glycaemic control in ‘naughty’ adolescent diabetic patients so surely it follows that it could be effective for other health harming behaviours in this age group…as long as we do it well enough. If you’d like further information on motivational interviewing techniques and MECC- go to http://mecc.publichealthnetwork.cymru/en/
Developing child health services
If you hate buzz words and live in Wales (like me), the worlds ‘Prudent Healthcare” are probably starting to annoy you a bit. Although the 4 principles are good (see below) the term seems to have become synonymous with efficiency savings rather than improving patient outcome.
Certainly reducing inappropriate variation in care through evidenced based approaches (including adequate staffing!) doesn’t always match with the views of the nation’s voters and it is not uncommon to see the usual line of placards as another district general closes its doors to make way for a well staffed centralized service. The standard expected for paediatric care continues to elevate as the RCPCH Facing the Future 2 report recommends a consultant review within 14 hours of admission for all children. As resources disappear before our eyes, the planning of children’s services is becoming increasingly fraught with difficulties. A nation-wide dose of pragmatism is certainly warranted.
That’s why it’s vitally important that all our child health screening programmes are ‘prudent’. It’s worth reading the “Transforming Young Lives across Wales” report which presents in detail both the child-centered and economic argument for investing in ‘The Early Years’ as well as reducing the underpinning social inequalities that lead to variation in child health.
The Healthy Child Wales programme was created following a collaboration between public health and a multitude of child health professionals to create a standardized screening and intervention programme for all children in Wales regardless of their social background or geographical location and focusing on 3 key areas.
Screening- Newborn check, blood spot, hearing, vision and child measurement programme
Immunization- As per UK schedule
Surveillance- Monitoring and supporting child development through key health visitor contacts
The Flying Start programme provides additional early years support further aimed at reducing the impact of inequality on child health and is targeted specifically at those geographical areas where deprivation is highest. This includes free quality part time child care, an enhanced health visiting service, parenting programmes and early language development resources. Although concerns have been raised about the ‘postcode’ nature of the additional support available, the reasons given were to reduce any associated stigma of accessing such services in these areas. Dr Heather Payne (Senior Medical Officer) for the Welsh Government introduced the concept of Proportionate Universalism;
“To reduce the steepness of the social gradient in health, actions must be universal but with a scale and intensity that is proportionate to the level of disadvantage”
To end our day of public health enlightenment, BTTB’s very own Smiti gave a talk on immunization. She is a mega massive pro vaccinator by the way (and quite rightly…) After all immunization along with clean water is the public health intervention that has had the greatest impact on world health.
I have never seen such vigilance in counseling about immunization (even in the middle of a night shift!!) Did you know that 1 in 11 deaths in pregnancy are caused by flu? Or that the pertussis vaccine has significantly reduced in effectiveness since being changed to the acellular form? Or even more exciting for us pro-vaccinators- the Hepatitis B vaccine is being introduced universally in the UK from 2017?
I think I’ll leave this one to the expert as I’m sure she’s got a pretty awesome article up her sleeve.
I guess the main thing I’ve learnt is that both we Paediatricians and our Public Health colleagues want the same thing and that’s to keep our world’s children healthy and happy. Between us we’ve probably got some pretty good ideas about how to do this… Maybe we just need to talk to each other a little more.
26th May 2017