PCPH eMagazine Spring 2022

Spring 2022 Department of Primary Care & Public Health

Spring 2022 We are now entering a new phase of the Covid-19 pandemic with testing for most people in England being cut back and Covid-19 control measures ending. We are very proud of the contribution that members of the department and the NIHR ARC team have made over the last two years in supporting the local, national and international response to Covid-19; and in the way in which they modified their teaching programmes to make use of online learning. We hope that we can now gradually move back to delivering our academic activities in a more normal fashion, with more people returning to work in the department. As this newsletter shows, we have continued to be very innovative and productive in our work despite the challenges brought by Professor Azeem Majeed the pandemic. Head of Department of Primary Care and Public Health Imperial College London Follow Prof Majeed on Twitter We welcome feedback on the ARCHIVE PRIVACY NOTICE newsletter and are taking submissions for future issues. Email your news, events, achievements and stories to us. [email protected] PCPH eMagazine is produced by Subscribe Unsubscribe Javier Gallego Mehrosa Memood Copyright © 2021 Department of Primary Care & Public Health, Imperial College London

Photo by Ian Schneider on Unsplash GENERAL PRACTICE IN ENGLAND: THE CURRENT CRISIS, OPPORTUNITIES AND CHALLENGES General practice or family medicine has historically been lauded as the “jewel in the crown” of the English National Health Service (NHS). General practice, at the heart of primary care, has continued to contribute to the high ranking of the NHS in international comparisons and evidence from several decades of research has shown that general practice in the UK has improved the nation’s health. Furthermore, it has provided equitable, cost-effective, and accessible care for all with the flexibility to adapt rapidly to a changing society and political climates, such as during the COVID-19 pandemic when there was rapid implementation of remote consultation models. However, this much-admired public sector service has recently come under unprecedented political and media spotlight instigated by the pressures of the current pandemic on the NHS. This coupled with collapsing morale among general practitioners (GPs), a shrinking GP workforce, inexorable demands, increasing workload, and decreasing real-terms per capita funding have caused many to sound alarm on a general practice in “crisis”. In this article published in the Journal of Ambulatory Care Management, we describe the evolving nature of general practice and the current crisis, as well as potential solutions and opportunities going forward.

NEW COURSES FROM WHO COLLABORATING CENTRE The Public Health Academy and the WHO Collaborating Centre have developed a course for the Kingdom of Saudi Arabia Public Health Authority which is fully active and operational. As part of this project, the WHO Collaborating Centre developed and delivered seven innovative, interactive courses jointly with colleagues from WHO Geneva, Europe and EMR. We have now completed the seven-week, Disease Burden and Health Planning training course, targeting Public Health Practitioners from KSA. These training attracted large number of applicants from around the world, and each course was delivered over 3 weeks with a maximum of 20 trainees to allow for quality of the interactive parts of the course. As interest has continued to grow, the Centre is preparing to deliver these courses on a regular basis and expand the portfolio with new training in both virtual and hybrid settings now that restrictions from COVID-19 are being lifted. INTERDISCIPLINARY DOCTORAL PHD PROJECT FOR GLOBAL HEALTH EDUCATION An exciting PhD project (funded by London Interdisciplinary Social Sciences Doctoral Training Partnership) is being hosted by the School of Public Health (SPH) to work together with the Undergraduate Public Health team: the PhD student will be working with the Global Health BSc course to examine the value of the innovative partnership between an academic institution and civil society organisation in curriculum co-design and co-delivery of global health education. The project is supervised by Dr Mariam Sbaiti (PCPH), Prof Helen Ward (DIDE) and Dr Chris Willott (King’s College London) and starts in October 2022. COLLEGE EDI SEED FUND MONEY AWARDED TO UG PUBLIC HEALTH EDUCATION TEAM The UGPH team have won funding from the College-wide Equality, Diversity and Inclusion seed fund to incorporate the voice of people with lived experience of social exclusion into undergraduate medicine teaching. Led by clinical teaching fellows Dr Florence Mutlow and Dr Hannah Wright, the team will work alongside interested students and experts by experience, through the organisation ‘Expert Focus’ to develop video content. The project will improve students’ exposure to and understanding of challenges faced by people experiencing exclusion. The online learning materials (to launch in July 2022) will encourage students to consider how as clinicians, they can address such inequities in their future practice.

WHO SEMINAR ON STUDENT RECENT UPDATES FROM THE INITIATIVES DURING THE COVID-19 MEDICAL EDUCATION INNOVATION PANDEMIC & RESEARCH TEAM (MEDIC) Our undergraduate primary care It has been a busy few months for the education courses now provide several MEdIC team. We were sad to say goodbye curricular opportunities for students to to Bethany Golding (our Community work in partnership with local schools and Collaborations Lead) who has taken up a communities to address healthcare new role with NHS England. We wish her priorities. every success in the new role and look forward to new collaborations with her in The WHO invited Dr Arti Maini and this new capacity. Imperial students Shahmeer Mohammed, Lauren Wheeler, Ailin Anto and Arunima The MEdIC team submitted five abstracts Basu to present examples of this work at a to the Madingley SAPC Conference in WHO webinar in January 2022 on January 2022 on a variety of topics ‘Student-led initiatives addressing including: the integration of digital health community health during the COVID-19 in the medical curriculum, the remote pandemic’. implementation of a widening access program and a new study looking at Initiatives discussed included the i-Explore belonging, authenticity and wellbeing in Social Accountability in Action module medical students. We were delighted to where second year students work closely hear that Dr Angelica Sharma, an with faculty and local schoolteachers to Academic Foundation doctor in our team, design and facilitate engaging after-school won the SAPC Early Career Research Prize sessions for secondary school pupils on for her presentation focussing on digital topics related to COVID-19. Also discussed health. was an example of a Community Action Project undertaken by year 3 medical We have had several publications recently students in partnership with their GP including: a paper focussing on the need practice and local community for digital health to be better integrated stakeholders that promoted COVID-19 into the medical curriculum, a practical vaccination in care home staff. These paper discussing how paediatricians can initiatives and the presentation itself were identify and address food insecurity and further supported by a number of the an opinion paper discussing the team including Dr Neha Ahuja, Dr Sheila importance of taking a relational Uppal, Ms Bethany Golding, Dr Josh Gaon approach in medical education. and Dr Dominique Forrest. The presentation was very well received and The MEdIC team has also submitted a generated much discussion, inspiring total of 14 abstracts across the upcoming webinar participants globally about what ASME (Association for the Study of can be achieved and learned by students, Medical Education) and AMEE faculty and local communities working (International Association For Medical together. Education) conferences this year. WATCH THE WEBINAR



Photo by Nadine Marfurt on Unsplash On 24 February 2022, the UK government removed the legal requirement for people in England to self- isolate after a positive covid-19 test result, with the other UK nations also easing restrictions. In doing so, the UK is acting ahead of many of its international peers to embark on a “vaccines only” strategy, hoping that existing immunity in the population will allow a “return to normal.” This view is in sharp contrast to public opinion. In a recent poll by market research company YouGov, only 17% of respondents thought that ending mandatory self- isolation was appropriate.

The removal of legal restrictions We remain in the middle of a global makes the people of England part of pandemic caused by a novel an experiment in which much pathogen and complicated by the remains uncertain. This is repeated emergence of new acknowledged by chief government variants. Policy decisions to manage advisers Chris Whitty and Patrick new outbreaks rely on robust and Vallance, who accompanied Boris timely data—the alpha, delta, and Johnson’s announcement with a omicron variants all became warning that rates of covid-19 dominant in the UK within weeks of infection and hospital admission the first reported cases. Although remain high. Of equal concern, the omicron is associated with a government’s announcement also significantly lower risk of hospital introduced plans to scale back two admission and death than previous crucial pillars of the UK’s covid-19 variants, the government’s Scientific surveillance: the Office for National Advisory Group for Emergencies Statistics’ (ONS) covid-19 infection (SAGE) acknowledges that this may survey and daily reporting of data be the exception rather than the on the UK Health Security Agency rule, emphasising the need for (UKHSA) covid-19 dashboard. ongoing vigilance to detect future When, and to what extent, these variants. important resources will be scaled back remains unclear. From 1 April 2022, when universal free covid tests are withdrawn The ONS survey is a world leading leaving only limited testing in place, example of random population most SARS-Co-V infections in sampling to estimate covid-19 England will remain undetected and prevalence over time. The UKHSA unreported. Our ability to track the dashboard has been a vital resource emergence of new variants or for the public, clinicians, journalists, trends in the incidence of infection and researchers, allowing them to and disease will become more identify local trends as well as reliant on robust, cross-sectional providing national data. The surveys such as the ONS survey. dashboard received up to 19 million Scaling back the survey, as hits a week in September 2021. proposed, risks missing emerging Data to understand and promptly variants or concerning rises in respond to covid-19 outbreaks are prevalence that could herald the essential for public health and the need for further restrictions; NHS, as well as for the wider public. moreover, the survey cannot

provide accurate and timely local health conditions. The public health data, as currently provided by the implications of immunity waning UKHSA dashboard. The detrimental over time remain uncertain. As we effects of delayed action are now move into a period of largely abundantly clear, and we must not optional (and paid for) testing and fall behind at this critical moment voluntary self-isolation, it is crucial when the UK’s pandemic is that people have easy access gradually coming under control. information to guide their actions and help minimise covid-19 risks to In announcing the latest relaxation themselves and their families. of restrictions, the prime minister asked the public to take individual The UK has been a world leader in responsibility for their actions, yet the routine surveillance of covid-19 informed decisions are reliant on and the transparent reporting of the availability and accessibility of covid-19 data. Scaling back vital information. Throughout the data systems prematurely is a false pandemic people have relied on economy and may need to be regional reporting of covid-19 cases reversed to manage future waves of on government dashboards and in infection. The UK has the resources news media, and they will continue and infrastructure to continue to need such accessible information existing surveillance, which has for the foreseeable future. clearly identifiable benefits. We need to sustain our existing While most people have received surveillance capabilities until we are two or more doses of a covid-19 certain that the pandemic is over in vaccine, almost 10% of adults in the UK, which won’t be until covid- England have not received a single 19 is controlled globally. dose and around 30% have not had a booster. Many others remain at Jonathan Clarke, Thomas Beaney, high risk of disease despite Azeem Majeed vaccination because of underlying A version of this article was first published in the British Medical Journal. FURTHER READING Covid-19: Implications of ending the legal requirement to self-isolate for employers and people who are clinically vulnerable Isolation for people with Covid-19 in England: Follow the guidance carefully

Dr Jamie Smyth GMPH student and Speciality Registrar in Acute Medicine Advances in communication and transportation technology over the last century have permitted entry to hitherto inaccessible regions of the globe. Whilst in some ways these breakthroughs have benefitted the global economy through international trade and development, they have allowed the world’s more illicit industries to benefit also. With the wider market provided by globalisation comes increased demand for all products and services, including slavery.

Image via rawpixel

With over 40 million globally, modern slavery is thriving in today’s interconnected world.1 Defined as “the recruitment, movement, harbouring or receiving of children, women or men through the use of force, coercion, abuse of vulnerability, deception or other means for the purpose of exploitation”, modern slavery is an umbrella term that encompasses several crimes.1 These include human trafficking, forced labour, and forced marriage. Victims are often kept in inhospitable conditions and exposed to violence and abuse. Consequently, they experience both physical and mental health disorders making modern slavery a public health issue in addition to a humanitarian crisis.1 Although most of the world’s current slavery burden lies within low- and middle-income countries (Figure 1), the existence of slavery within the global north cannot be overlooked.2 As per the Office of National Statistics’ 2020 report.3, the clandestine nature of the crime makes it difficult to accurately estimate the scale of modern slavery within the United Kingdom, making previous estimates issued by the Home Office and other groups less reliable.

Nevertheless, most recent estimates put the number of people living in slavery within the United Kingdom at more than 100,000 people.4,5 Efforts made by the UK, such as the Modern Slavery Act 2015.6, have been praised by both Walk Free.5 and the Council of Europe’s Group of Experts on Action against Trafficking in Human Beings.7. However, obstacles persist in the identification, rescue, and support of victims, and these serve to be exacerbated by events such as Brexit and the COVID19 pandemic. This commentary aims to briefly review and identify weaknesses in the existing governmental approach to tackling modern slavery, before recommending ways in which this approach could be strengthened in future. Due to the publication’s word limit, the focus on globalisation, and the multitude of crimes covered by the term modern slavery, this article will specifically focus on labour exploitation within the UK.

CURRENT GOVERNMENTAL APPROACH AND LIMITATIONS Historically, the UK has adhered to regional events of July 2020, wherein Boohoo Group international mandates such as the 2005 PLC’s Leicester based factories were found to Council of Europe Convention on Action be promoting unsafe and exploitative labour against Trafficking in Human Beings and practices, one would argue that the UK possessed no national legislation of its own. Government’s approach to regulation of business without imposing financial penalties Published in 2015, the Modern Slavery Act doesn’t go far enough. As per the 2021 report (MSA) represented the first national policy in published by the Council of Europe’s Group of the world to explicitly address modern Experts on Action against Trafficking in slavery.8 This legislation created a new anti- Human Beings.7 (GRETA), 40% of eligible slavery commissioner role, established new companies do not comply with section 54. In law enforcement tools for the investigation January 2021, the UK government agreed to and prosecution of slavers, and provided introduce sanctions for companies who fail to additional support for victims. Furthermore, comply, however, these sanctions have not through section 54, the MSA demanded been utilised. unprecedented transparency from large companies regarding their actions to reduce In addition to the example limitations the existence of slavery within their supply highlighted above, since its publication in chains. 2015, the UK government has made movements in a direction that undermines This demand for transparency requires all the MSA further. As of January 2021, the UK companies trading within the UK with a left the European Union. This meant that financial turnover of over 36 million to many previous European employment and produce annual reports on supply chains and migration laws ceased to apply. Academics their actions to reduce slavery within them. and charity leaders raised concerns prior to This policy in specific was deemed ground- Brexit that this may increase the likelihood of breaking at the time of publication and labour exploitation within the UK9,10. alongside the remainder of the MSA, held the Furthermore, the proposed 2021 Nationality potential to reduce slavery both within the UK and Borders Bill raises concerns regarding and internationally. intended management of migrants and asylum seekers.11 Despite this pioneering approach, the current governmental approach hasn’t been without Regarding the COVID19 pandemic, in its limitations. Despite requiring large December 2021, the UK government listed the businesses to publish information on their Malaysian company Supermax as an approved actions to reduces slavery within their supply supplier of PPE, despite accusations of chains, only a minority of UK companies exploitative labour practices in its factories.12 comply due to a lack of enforceable sanctions. These same allegations lead to Canada and As a result, companies can ignore rules the United States banning imports from without consequence. Given the recent Supermax earlier in the year. Recommendations Additional actions will be required to address the previously highlighted shortcomings within the MSA and the current UK governmental approach to exploitative labour practices. We have summarised these recommendations within Table 1.



Conclusions survivors, nongovernmental organisations, and international bodies. While the UK is taking positive steps towards curbing exploitative labour practices within its The United Kingdom was considered a front- borders and addressing the existing runner in the fight against modern slavery and shortcomings of the MSA, we argue that these labour exploitation through its publication of actions are in name only, with little being the 2015 Modern Slavery Act. To retain this done to hold businesses to account. status, additional actions need to be taken to meet the new challenges of Brexit, COVID19, Consequently, the UK Government runs the and the desire of businesses to maximise risk of being seen to be tough on slavery in profits at the expense of worker’s rights. name only, losing credibility with victims, References 1. Such E, Laurent C, Jaipaul R, Salway S. Modern slavery and public health: a rapid evidence assessment and an emergent public health approach. Public Health [Internet]. 2020 [cited 12 January 2022];180:168-179. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0033350619303385?via%3Dihub 2. Walk Free. Estimated prevalence of modern slavery by country [Internet]. 2018 [cited 13 January 2022]. Available from: https://www.globalslaveryindex.org/2018/findings/global-findings/ 3. Office for National Statistics. Modern slavery in the UK: March 2020 [Internet]. Office for National Statistics; 2020. Available from: https: //www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/modernslaveryintheuk/march2020 4. Home Office. 2020 UK Annual Report on Modern Slavery [Internet]. London: HM Government; 2022. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/927111/FINAL- _2020_Modern_Slavery_Report_14-10-20.pdf 5. United Kingdom | Global Slavery Index [Internet]. Globalslaveryindex.org. 2018 [cited 12 January 2022]. Available from: https://www.globalslaveryindex.org/2018/findings/country-studies/unitedkingdom/ 6. Modern Slavery Act 2015 [Internet]. GOV.UK. 2022 [cited 12 January 2022]. Available from: https://www.gov.uk/government/collections/modern-slavery-bill 7. Third evaluation round: Access to justice and effective remedies for victims of trafficking in human beings [Internet]. Strasbourg: Secretariat of the Council of Europe Convention on Action against Trafficking in Human Beings; 2022. Available from: https://rm.coe.int/greta-third-evalution-reporton-the-united-kingdom/1680a43b36 8. Broad R, Turnbull N. From Human Trafficking to Modern Slavery: The Development of Anti-Trafficking Policy in the UK. European Journal on Criminal Policy and Research [Internet]. 2018 [cited 13 January 2022];25(2):119-133. Available from: https://link.springer.com/article/10.1007/s10610-018-9375-4#Abs1 9. French S. Between globalisation and Brexit: Migration, pay and the road to modern slavery in the UK hospitality industry. Research in Hospitality Management [Internet]. 2018 [cited 14 January 2022];8(1):23-32. Available from: https://www.ajol.info/index.php/rhm/article/view/176707 10. Focus on Labour Exploitation & the Labour Exploitation Advisory Group. Lost in Transition: Brexit & Labour Exploitation [Internet]. 2017. Available from: https://www.labourexploitation.org/publications/lost-transition-brexit-labour- exploitation 11. Focus on Labour Exploitation. Anti-Slavery Sector's CEO Letter to MPs on the Nationality and Borders Bill [Internet]. 2022. Available from: https://www.labourexploitation.org/publications/antislavery-sectors-ceo-letter-mps-nationality-and- borders-bill 12. Bengtsen P. UK faces legal action for approving firm accused of using forced labour as PPE supplier. The Guardian [Internet]. 2022 [cited 14 January 2022];. Available from: https://www.theguardian.com/global- development/2022/jan/06/uk-faces-legal-action-forapproving-firm-accused-of-using-forced-labour-as-ppe-supplier 13. UN Human Rights Council. United Kingdom Nationality and Borders Bill undermines rights of victims of trafficking and modern slavery, UN experts say [Internet]. 2022. Available from: https://reliefweb.int/report/united-kingdom-great- britain-and-northern-ireland/united-kingdomnationality-and-borders-bill 14. “Directive 2011/36/EU of the European Parliament and of the Council of 5 April 2011 on preventing and combating trafficking in human beings and protecting its victims, and replacing Council Framework Decision 2002/629/JHA,” EUR-Lex. 15 April 2011. Available from: https://eurlex.europa.eu/eli/dir/2011/36/oj.

Image by Foundry Co from Pixabay



The Innovation and Evaluation Theme at NIHR ARC NWL are transforming the face of primary care delivery by piloting a Community Healthcare Worker model in Northwest London with the aim of rolling it out across the country.

A TRIED AND TESTED MODEL There is nothing ‘new’ about the CHW model. Devised in Brazil in the 1990s, and called the Family Health Strategy, there are over 250,000 CHWs making it the largest primary care system in the world. Described as ‘the ears and eyes of the GP in the community’, CHWs in Brazil are full time members of the local primary care team and they focus on a defined location, usually 200 households, keeping in regular contact with the residents. By visiting households at least once a month the delivery of primary care becomes truly local and embedded into everyday life. ‘SMALL INTERVENTIONS AT SCALE’ Dr Matt Harris, Innovation and Evaluation Theme Lead, worked with CHWs as a GP in Brazil (1999-2003), and on his return to the UK he was struck that we have lost a proactive approach to primary care, as he describes: “The key to the Brazilian model is that by the CHWs knowing all their families really well, small household interventions at scale have led to a huge impact on the whole population. In Brazil they have seen a decline in cardiovascular disease mortality of 34% in areas that have full implementation of the Family Health Strategy (Rasella et al BMJ 2014).” PROVIDING COMPREHENSIVE INTEGRATED SUPPORT This hyperlocal approach leverages the advantages of recruiting from the local community providing improved local employment opportunities. The added benefit of this is that the CHWs are familiar with the surroundings, the challenges the residents face, and are a consistent familiar face that helps to build trust and rapport. Churchill Gardens, a large social housing Maureen Katusabe have been recruited as estate in the Pimlico area of Westminster, the four CHWs and are working within the London is the trial location for the use of area to assess needs, health promotion, CHWs in the UK. Asma Monir, Nahima aid with navigation of support services Begum, Comfort Idowu-Fearon and and to triage and make referrals.





“When we come and knock on the door and sit with you, we see the whole person and the environment they live in. We become that bridge builder.” Comfort Idowu-Fearon, Community Health Worker for Churchill Gardens Above: Community Health Worker Asma Monir is a familiar friendly face ASSERTIVE OUTREACH MAKES A BIG DIFFERENCE Seemingly small early interventions are having a big impact already as demonstrated by these case studies. Case Study: Building trust and crimes. He had been wrongfully relationships imprisoned for 8 years in the country A CHW called a resident to book an which he fled from to seek asylum in the appointment, however he was reluctant UK, where he now lived in a studio flat, to book but eventually was persuaded to feeling trapped and isolated. Social meet the CHW in an open green space in exclusion and past trauma led to him the estate behind his house. During their being suicidal, which the CHW was able to meeting the resident informed the CHW elicit. that he is a victim of torture and war The CHW got the GP on board who was able to help the resident and prevent harm coming to the resident. Dr Neogi reflects: “One of them [CHW] brought to me a patient who was suicidal, who hadn’t presented to us, so obviously we then dealt with that patient, and got them the care they need. I would have never known. This person could have been a statistic. So, it does have huge value”. The CHW is regularly calling the resident on a weekly basis, which is appreciated, and the CHW feels he is becoming more amenable to accepting therapy and seeing the potential for things to get better.

Case Study: Personalised screening to worry about cervical cancer. Being advice Muslim herself the CHW was able to One of the CHW discovered early on in speak to the resident and clarify that the pilot that some Muslim women cervical screening is free, important and declined cervical screening because in the relevant for all women regardless of countries they came from this service marital status and get her to have the needs to be paid for. There was also a cervical screening done. belief that married women did not need “We are definitely getting more appointments for smears, and I’m sure this is all Asma’s work, from people of different ethnic minorities, which never used to happen. They were the hard-core patients, it was difficult to get them in. Actual hard numbers we don’t yet have but I think we will see that.” Dr Neogi SUSTAINABILITY AND SCALING When applied health and care research is most effective it improves service delivery by making it more efficient. Research conducted alongside newly implemented practices give a platform to generate further evidence on the impact. The cyclical process of continual improvement is demonstrated by pilot of Community Healthcare Worker (CHW) model. As the pilot continues it will produce more data as it intensifies the integration with existing services. A final report due mid next year (2022) will provide insights into the opportunities and challenges of spreading and scaling the model in other parts of the UK. Dr Cornelia Junghans, GP in Westminster and Implementation Lead for the pilot, said: “Although the pilot is only in its early stages of implementation, we are already seeing some significant impact on residents’ health and wellbeing and signs of scaling into other localities. Other boroughs in NW London are already planning to adopt this assertive, proactive outreach approach and two regions (Bridgewater, and Calderdale) have already commissioned it for their residents.” At a time when health services are stretched by demand, and Primary Care in particular is put under extra pressure the need for new ways of working is significant. The need to build capacity through innovative preventive public health and social care model, implemented and reviewed with high quality research methods, has never been more important. The CHW pilot in Northwest London is doing just that. DISCOVER MORE ABOUT THE COMMUNITY HEALTH WORKER MODEL Hear more about the development and implementation of the community health worker model and lessons learned for other areas around the UK interested to develop similar services in this webinar: Building Back Primary Care & PH Webinar #5: Community Health Worker model



(INTERACT) STUDY

The UK Government published the first Loneliness Strategy in 2018 and has since installed a ‘Loneliness Minister’ to get people talking about the problem. Since the early days of 2020, national lockdowns, social distancing measures & remote working have put a bright spotlight on loneliness – one of society’s rising problems that governments can no longer overlook. Loneliness & social isolation are significant opportunity for “in person” encounters. determinants of health & quality of life. They are strongly associated with People can experience different levels of psychological disorders, cardiovascular social isolation & loneliness over their disease & are even a risk factor for the lifetime, moving in & out of these states exacerbation of early mortality. For the as their personal circumstances change. last few decades, increasing urbanisation However, due to physical distancing & over-reliance on technology has led to measures & travel restrictions during the ‘atomisation’ of society – think online COVID, feelings of loneliness have games, virtual reality, chat rooms, AI increased, negatively impacting public chatbots & the recently publicised mental health & wellbeing. Will these Metaverse. There is also an increasing rising problems of society be the bane of number of services which can be accessed the 5th industrial revolution & a defining online including shopping & healthcare feature of 21st century living? Where is which decreases the need and this all going? MEASURING LONELINESS dwelling (post-code), it would make it possible to produce a ‘heat map’ to The Office for National Statistics (ONS) highlight the areas where people are created a guide which describes the feeling the most loneliness. Heat maps measures included in the national like this have been produced for the UK, indicator & recommended by the UK but to really understand what is going on, Government’s Loneliness Strategy. The we need more accurate heat maps that core measures used are the UCLA three can be used to drive decision making. This item scale & the single item question will only be possible by working closely ‘How often do you feel lonely’. These four with local councils & NHS primary care questions don’t take long to complete, & organisations. when linked to data like respondent age, gender, employment status & place of support individuals who are feeling socially isolated or who may be suffering BUILDING A PICTURE in silence. The study is a collaboration between the School of Public Health, Imperial SCARU launched the Measuring Hammersmith & Fulham Council, NIHR Loneliness (INTERACT) study, which aims to map loneliness at borough & city level to highlight the scale of the issue & help decision makers consider new ways to

ARC Northwest London, Imperial College The success of the study depends on London Healthcare NHS Trust & Professor collaborative working between partners Pamela Qualter (Study Co-Investigator, to engage with thousands of residents University of Manchester). It aims to using ethically approved study collect data from thousands of community information, including access to a brief dwelling individuals aged 16 years or over online survey which is available in various to produce a visual snapshot of loneliness languages. The results from the study will & social isolation across the capital & for help us in answering several key research other parts of the UK. The study team will questions to better understand whether reach out to thousands of residents & the patterns we observe from measuring encourage them to complete a brief loneliness directly are similar to those online survey. This will help build a clearer derived from ONS data using known picture of how loneliness affects people at predictors of loneliness (unemployment the borough & city level, & across regions. status, living alone & other factors). The findings will also support evidence-based This project is different in that it involves commissioning decisions to inform collaborative working between local meaningful approaches to tackle this councils, voluntary sector organisations rising problem of society which could and NHS (including general practices) to affect people from all walks of life. For engage with a wide segment of society. example, support services can use this Since there is no ‘one-size-fits-all’ information to consider what approach to tackle loneliness, we hope interventions could be offered based on that collaborative working between local the area in which people live, their authority, voluntary sector & NHS communities, the setting (school or care organisations would result in a heat map home). This could include mobilising with sufficient density to inform already existing community assets (such meaningful place-based asset-based as pharmacists, volunteer organisations & community development initiatives to support groups) & targeted interventions raise awareness & positively impact the (befriending schemes, organised coffee mental health & wellbeing of members of mornings & walks in the park) to support the community. people in need or who may be suffering in silence. THE WAY AHEAD Health Organisation is keen that Social isolation & loneliness are governments work harder at tackling this increasingly being recognised as a priority rising problem in society. Please help raise public health problem. During the course awareness of our study by disseminating of the UN Decade of Healthy Ageing the link to this brief online survey. Anyone (2021-2030), the Demographic Change & in the UK who is 16 years or over can Healthy Ageing Unit will be addressing choose to take part in the survey which social isolation & loneliness as one of the can be accessed in various languages. themes that cuts across the four main action areas of the Decade. The World Dr Austen El-Osta is Director of the Self-Care Academic Research Unit (SCARU) & Primary Care Research Manager at the School of Public Health.

Photo by Samuel Austin on Unsplash

NEW FUNDING TO BUILD MENTAL HEALTH RESEARCH CAPACITY AND CAPABILITY

The NIHR ARC Northwest London Multimorbidity and Mental Health Theme have learned that their bid to uplift the infrastructure capacity and capability for mental health research with the NIHR ARC NWL (£750K) was supported by the National Institute for Health Research (NIHR). Led by Principal Investigator Dasha Nicholls (Multimorbidity & Mental Health Theme), Shamini Gnani (Population Health Theme) and Dougal Hargreaves (Child Health Theme) the work, which has now started, has three priority objectives for building sustainable infrastructure. SUPPORT FOR YOUNG PEOPLE Dasha commented: “Whilst some great mental health research is happening in Northwest London, our capacity to conduct research has been limited. This funding will provide new opportunities to implement good support and treatment for young people around their mental health, both in prevention and to help those already in need. The pandemic has highlighted how vital it is that access to such care is possible for all those who need it.” Initially, they will develop a collaborative network (WP1) within the NWL Integrated Care System (ICS) and convene stakeholder workshops to co- develop the children and young people’s mental health dashboard within Whole Systems Integrated Care (WSIC) (WP2). Using these data, they will co- develop with schools a plan to assess need for and uptake of targeted interventions for children and young people in greatest need (WP3), with the explicit aim of tackling inequalities in outcomes, experience and access, and to inform and educate about evidence-based approaches to mental wellbeing. WORKING IN PARTNERSHIP Partners will include the NIHR Clinical Research Network, Imperial’s School of Public Health, Division of Psychiatry, Mohn Centre for Child Health and Wellbeing, Centre for Paediatrics and Child Health; Central and Northwest London NHS Foundation Trust and West London NHS Trust providers of secondary care mental health services; ICHP, NWL ICS, Primary Care Networks (PCNs), Young Healthwatch and Community Organisations.

Image by Emphyrio from Pixabay

The Eastern Mediterranean and Middle East (EMME) region has rapid population growth, large differences in socio- economic levels between developed and developing countries, migration, increased water demand, and ecosystems degradation. The region is experiencing a significant warming trend with longer and warmer summers, increased frequency and severity of heat waves, and a drier climate. Our paper in the Climate Change journal discusses the impact of climate change on infectious diseases in the region. While climate change plays an climate change already impacts the important role in contributing to health of vulnerable populations in political instability in the region the EMME and will have a greater through displacement of people, impact in future years, risk food insecurity, and increased assessment and timely design and violence, it also increases the risks implementation of health of vector-, water-, and food-borne preparedness and adaptation diseases. Poorer and less educated strategies are essential. people, young children and the elderly, migrants, and those with Joint national and cross-border long-term health problems are at infectious diseases management highest risk. A result of the systems for more effective inequalities among EMME countries preparedness and prevention are is an inconsistency in the availability needed, supported by interventions of reliable evidence about the that improve the environment. impacts on infectious diseases. Without such cooperation and effective interventions, climate To help address this gap, a search of change will lead to an increasing the literature was conducted as a morbidity and mortality in the basis for related recommended EMME from infectious diseases, responses and suggested actions for with a higher risk for the most preparedness and prevention. Since vulnerable populations.

Photo by Damir Spanic on Unsplash

WORLDWIDE EXPERIENCE OF HOMOZYGOUS FAMILIAL HYPERCHOLESTEROLAEMIA: RETROSPECTIVE COHORT STUDY New article published in The Lancet 2022 by the Homozygous Familial Hypercholesterolaemia International Clinical Collaborators (HICC) with the contribution/support of the FHSC team at PCPH, SPH, ICL. Homozygous Familial Hypercholesterolaemia (HoFH) is a rare genetic disease affecting 1 in 300K in the general population, which affects LDL-cholesterol clearance with very high LDL- cholesterol levels since birth, and puts individuals with this condition at very high risk of cardiovascular disease with cardiovascular disease events occurring within the first decades of life. This article reported that overall, 751 patients were White, 121 (23%) were patients from 38 countries were Asian, and 68 (13%) were Black or included, with 565 (75%) reporting mixed race. The major manifestations biallelic pathogenic variants. The of ASCVD or aortic stenosis were median age of diagnosis was 12·0 already present in 65 (9%) of patients years (IQR 5·5–27·0) years. Of the 751 at diagnosis of HoFH. Globally, pre- patients, 389 (52%) were female and treatment LDL cholesterol levels were 362 (48%) were male. Race was 14·7 mmol/L (IQR 11·6–18·4). Among reported for 527 patients; 338 (64%) patients with detailed therapeutic

information, 491 (92%) of 534 received This paper leveraged a call for a rare statins, 342 (64%) of 534 received disease awareness day in February by ezetimibe, and 243 (39%) of 621 FH Europe patient organisation. On the received lipoprotein apheresis. On- occasion of Rare Disease Day 2022, FH treatment LDL cholesterol levels were Europe hosted a special webinar on lower in high-income countries (3·93 Monday, 28th Feb in collaboration mmol/L, IQR 2·6–5·8) versus non-high- with the EAS. The topic of the event, income countries (9·3 mmol/L, 6·7– titled Leaving no-one behind: creating 12·7), with greater use of three or a better future together for all people more lipid-lowering therapies (LLT; living with rare and severe FH, was high-income 66% vs non-high-income inspired by the latest events in the 24%) and consequently more patients international FH advocacy space. That attaining guideline-recommended LDL included the High-level Technical cholesterol goals (high-income 21% vs Meeting on FH child screening, the non-high-income 3%). A first major recent findings published in The adverse cardiovascular event occurred Lancet, and the results from the a decade earlier in non-high-income metanalysis shared in the European countries, at a median age of 24·5 Journal of Preventive Cardiology. The years (IQR 17·0–34·5) versus 37·0 years event brought together a multi- (29·0–49·0) in high-income countries perspective panel representing the (adjusted hazard ratio 1·64, 95% CI voice of scientists and clinicians, 1·13–2·38). people living with HoFH as well as caregivers, international advocates and This recent article concluded that on policy influencers. The focus of the the largest international cohort of discussion was the need to build on HoFH patients and highlights global the recent scientific learnings to disparities between high vs non-high- positively influence the national and income countries (e.g., lower the European health policies, the role frequency of combination lipid- of patients’ organisations, scientists lowering therapy, genetic testing etc.) and clinicians in order to improve lives that result in clinically significant of HoFH patients. Amongst other differences in care and health experts, Prof. Kausik Ray of ICCP, PCPH outcomes. HoFH patients require early was on the panel and gave a talk diagnosis and treatment within the regarding the data published in this first decade of life, with more intensive article in The Lancet. The event lipid lowering therapy. As the greatest attracted 250 registrants, with 120 live global burden resides in less affluent participants. It was live streamed on worldly regions, critical reappraisal of Facebook, Zoom with simultaneous health-care policy and funding is translation (German, Italian, French). required at a global level to improve health outcomes for HoFH patients. Read more directly in The Lancet article.

Photo by Kelly Sikkema on Unsplash



WHO seminar on student initiatives during the COVID-19 pandemic Our undergraduate primary care education courses now provide several curricular opportunities for students to work in partnership with local schools and communities to address healthcare priorities. The WHO invited Dr Arti Maini and undertaken by year 3 medical Imperial students Shahmeer students in partnership with their Mohammed, Lauren Wheeler, Ailin GP practice and local community Anto and Arunima Basu to present stakeholders that promoted COVID- examples of this work at a WHO 19 vaccination in care home staff. webinar in January on ‘Student-led These initiatives and the initiatives addressing community presentation itself were further health during the COVID-19 supported by several members of pandemic’. the team including Dr Neha Ahuja, Dr Sheila Uppal, Ms Bethany Initiatives discussed included the i- Golding, Dr Josh Gaon and Dr Explore Social Accountability in Dominique Forrest. The Action module where second year presentation was very well received students work closely with faculty and generated much discussion, and local schoolteachers to design inspiring webinar participants and facilitate engaging after-school globally about what can be achieved sessions for secondary school pupils and learned by students, faculty and on topics related to COVID-19. Also local communities working discussed were examples of a together. Community Action Project Watch the webinar

ERADICATING YOUTH INITIATION TO WIN THE WAR AGAINST TOBACCO: A STAGED APPROACH TOWARDS A COMPREHENSIVE TOBACCO FREE GENERATION POLICY By Charlene Lee GMPH student and Director of Network Development, Tan Tock Seng Hospital Eliminating youth tobacco initiation has been widely acknowledged as a key step towards ending the global tobacco epidemic, which claims over 8 million lives each year. While the WHO Framework Convention on Tobacco Control and MPOWER strategies have seen success, prevalence of youth tobacco use remains in the double digits. Moreover, the recent steep rise in Electronic Nicotine Delivery Systems (ENDS) use among youth, coupled with gaps in ENDS regulation in many countries, could significantly derail progress if left unchecked.

Photo by Luka Malic on Unsplash

Photo by Maatla Seetelo on Unsplash

In a bid to address the drivers of youth initiation, and with an end goal of winning the war against tobacco, we propose a staged approach towards a comprehensive tobacco-free generation (TFG) policy – starting with an increased minimum legal tobacco age of 25 and an expanded scope that restricts both sale and use, and covers all tobacco products including ENDS; and culminating in a full-fledged national, ultimately global, TFG policy. Over the long term, this protects not only our youth, but all our future generations from the poisonous clutches of tobacco that have held us for far too long. Eight million lives are lost to tobacco each Additionally, Electronic Nicotine Delivery year1. Of the more than one billion adult Systems (ENDS) are emerging as a serious tobacco users globally, over 60% initiated threat. While available data is insufficient by age 20, and over 80% by 25.2. While to estimate global youth ENDS use, in 37 most express intentions to quit, less than of the 87 countries where such data is 10% succeed2. A critical first step to collected, youth ENDS use already curbing the global tobacco epidemic then, exceeds cigarette use1 (Figure 1). Yet over is to thwart tobacco initiation before 25. 80 countries still have no regulations addressing ENDS1. Such governance gaps The 2005 WHO Framework Convention on leave the door open for youth initiation to Tobacco Control (FCTC) has 182 parties3 persist. In this paper, we explore the striving to implement the MPOWER4 drivers of youth initiation and potential measures built on its principles. Over policy measures to address them. 2005-2020, global prevalence of tobacco Combining these, we then propose a use among youths aged 15-24 reduced staged approach to first eliminate youth from 18.7% to 14.2%5. However, it initiation, and ultimately phase out remains far from ideal; even among 13- to tobacco use. Finally, we discuss the 15-year-olds prevalence is 10%5. This success factors and potential challenges of suggests the need for supplementary our proposal. measures to overcome this plateau6. FIGURE 1 Prevalence of Youth Cigarette and E-Cigarette Smoking1. Top 15 Countries by Ratio of E-Cigarette to Cigarette Prevalence

ADDRESSING THE DRIVERS OF YOUTH INITIATION The key stimuli for youth tobacco faded, making unlawful initiation an initiation are the desire to look grown-up unattractive course of action10. and peer influence7. A minimum legal age (MLA) of 18 or 21 hence exerts a perverse Besides peers, tobacco use by parents and appealing effect to youths, particularly elder siblings have also been linked to teenagers, by portraying smoking as a greater odds of youth initiation11. This “rite-of-passage” to adulthood7,8. Within calls for measures addressing multi- social circles, youths above the MLA who generational tobacco use. The Tobacco- purchase tobacco products often offer Free Generation (TFG) concept proposes a them to younger peers7. Moreover, most ban on the sale and/or use of tobacco countries apply the MLA only on the sale, products for anyone born on/after a not use, of tobacco products9. There is certain date7,8. It addresses youth therefore both motive and opportunity initiation by first removing the perceived for youths to experiment. Increasing the association between tobacco and MLA to 25 years, and covering both sale adulthood, then gradually widening the and use, could stem initiation in the age gap and social links between youths under-25 group. It is less likely for and pre-TFG populations7,8. Over time, it teenagers to share a social circle with creates tobacco free older peers and over-25s; while for 20- to 24-year-olds, siblings, and later parents, eventually the allure of appearing older may have phasing out tobacco use for entire populations. PROPOSAL Riding on the tried-and-tested MPOWER construct, we propose to add a comprehensive TFG measure to the repository of policies, with staged achievement level indicators as illustrated in Table 1. Three key features define this proposal: 1. It covers all tobacco products, including ENDS; 2. An MLA of at least 25 years is proposed for both sale and use of tobacco; 3. For short-term visitors to countries with full TFG measures, a 25- yearold MLA on tobacco use is acceptable in place of the cut-off date of birth. International travel is commonplace in today’s globalised world, but we fully expect countries to implement TFG at different rates. This approach controls the economic impact from loss in tourism revenue by allowing countries to continue receiving visitors who bring their own personal supply, subject to taxes. Setting the MLA at 25 years, not younger, limits the social influence of such visitors on resident youths.

Photo by Toan Nguyen on Unsplash

TABLE 1 Tobacco-Free Generation (TFG) Measure: Implementation of TFG Policy *Tobacco products includes all smoked, smokeless and electronic delivery products SUCCESS FACTORS TFG should be implemented nationally. Balanga City, Philippines, which actualised TFG in 2016, is battling legal action by the Philippines Tobacco Industry claiming violation of the national Tobacco Regulation Act12. Brookline, Massachusetts enacted TFG in 2021, but faces lawsuits from retailers displeased about losing customers to out-of-town competitors13. These issues would not have surfaced under a nationwide policy. TFG scope should be comprehensive, keeping up with the array of emerging products the industry may develop. An incomplete TFG plan, such as New Zealand’s which covers only cigarettes when its youth ENDS use is double that of cigarettes1,14, may simply shift the problem from one product to another. CHALLENGES Critics may argue that a 25-year-old MLA contradicts the legal age of majority10. However, this is strongly backed by disproportionately high initiation rates before 252, and evidence from the US where increasing the MLA from 18 to 21 led to a notable decline in smoking among youths aged 18-2015. TFG may be challenged on the basis of denial of adult choice and discrimination by birthdate7,13. However, the high rates of youth initiation and subsequent quit attempts during adulthood suggest this is more akin to “child choice, adult addiction”7,p.i25. Plus, could withholding a harmful, addictive substance to protect the basic right to good health really amount to discrimination? Given the novelty of the TFG concept and limited implementations to date, prior evidence of effectiveness is lacking. However, similarly sweeping measures proved successful in

eradicating opium use in the early 20th century7. Besides, after half a century of battling against tobacco, perhaps more controversial measures could be warranted. CONCLUSION Addressing youth initiation is a critical step in curbing the global tobacco epidemic. While the FCTC and MPOWER measures have been successful, progress is plateauing and threatened by rising ENDS use. A staged approach to a comprehensive TFG policy offers a viable solution to eliminate tobacco use in youths to begin with, and eventually in entire populations. The staging provides a roadmap for stepwise implementation towards full- fledged TFG, adaptable to countries at different phases of tobacco control. More importantly, it provides a universal shared vision which all countries can strive towards, to protect our future generations, and to finally win this war against tobacco. REFERENCES 1. World Health Organization. WHO report on the global tobacco epidemic 2021: addressing new and emerging products. Geneva; 2021. 2. Reitsma MB, Flor LS, Mullany EC, Gupta V, Hay SI, Gakidou E. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990- 2019. The Lancet Public Health. 2021;6(7):e472-e81. 3. World Health Organization. Parties to the WHO Framework Convention on Tobacco Control: World Health Organization; 2022 [cited 2022 7 Jan]. Available from: https://www.who.int/fctc/cop/en/. 4. World Health Organization. MPOWER Geneva: World Health Organization; 2021 [cited 2021 15 Dec]. Available from: https://www.who.int/initiatives/mpower. 5. World Health Organization. WHO global report on trends in prevalence of tobacco use 2000-2025, fourth edition. Geneva; 2021. 6. Saw Swee Hock School of Public Health (National University of Singapore). Event Report on Public Health Thought Leadership Dialogue and Panel Discussion, 'Challenges to Current and Future Tobacco Control' (Wednesday, 6 March 2019). Singapore; 2019. 7. Berrick AJ. The tobacco-free generation proposal. Tobacco Control. 2013;22(suppl 1):i22-i6. 8. Khoo D, Chiam Y, Ng P, Berrick AJ, Koong HN. Phasingout tobacco: proposal to deny access to tobacco for those born from 2000. Tobacco Control. 2010;19(5):355-60. 9. European Union Agency for Fundamental Rights. Purchasing and consuming tobacco: European Union Agency for Fundamental Rights; 2018 [cited 2022 11 Jan]. Available from: https://fra.europa.eu/en/content/purchasing-andconsuming-tobacco. 10. Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington (DC): National Academies Press; 2015. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310401/. 11. Gilman SE, Rende R, Boergers J, Abrams DB, Buka SL, Clark MA, et al. Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. Pediatrics. 2009;123(2):e274-e81. 12. de Leon K, Sarita JT. The Philippines: Pioneering the Tobacco Endgame [Internet]: BMJ Publishing Group. 2020. [cited 2022]. Available from: https://blogs.bmj.com/tc/2020/01/13/the-philippinespioneering-the- tobacco-endgame/. 13. Ducharme J. How One Massachusetts Town Could Shape the Future of Tobacco: TIME; 2021 [cited 2022 9 Jan]. Available from: https://time.com/6126252/brooklinetobacco-free-generation-law/. 14. Menon P. New Zealand's smoking ban overlooks worry about growing youth vaping: Reuters; 2021 [cited 2022 8 Jan]. Available from: https://www.reuters.com/world/asiapacific/new-zealands-smoking-ban- overlooks-worryabout-growing-youth-vaping-2021-12-10/. 15. Bryan C, Hansen B, McNichols D, Sabia JJ. Do State Tobacco 21 Laws Work? National Bureau of Economic Research Working Paper Series [Internet]. 2020 [cited 2022 12 Jan]; No. 28173

MEET OUR FELLOWS This is a story from NIHR ARC Northwest London Fellows Tina Prendeville and Susan Barry about how our Improvement Leader Fellowship allowed them to explore new ways of working for midwives in obstetric units. Using quality improvement methodology and stakeholder engagement, the duo built meaningful connections with opinion leaders in their field and successfully piloted the Partnerships in Midwifery Study (PIMS).



WHO ARE THEY? Tina (pictured left) is a Senior Research Midwife within the Women’s Health Research Centre, Imperial College London, and Imperial College Healthcare NHS Trust. Since her role as a NIHR Research Champion in Northwest London, Tina has gone on to work in reproductive health research, supporting foetal medicine studies to detect problems in pregnancy. In 2020, she completed her MSc in Genomic Medicine at Imperial College London. Susan (pictured right) is a Consultant Midwife at Imperial College Healthcare NHS Trust and has an MSc in Midwifery from University College Dublin. She is committed to the continuous development and support of midwives to deliver high quality maternity care. PATIENT SAFETY OUTCOMES AND HEALTHCARE WORKER WELLBEING ARE INTRINSICALLY LINKED Demanding working environments together with minimal support from colleagues can result in workplace stress that often negatively impacts on patient safety. Nationally, midwives are concerned about staffing levels, the quality of care they can deliver, and concerningly, over 50 per cent are considering leaving the workforce. With this is mind, we worked as a Midwifery Study (PIMS) is a new duo to develop and test a concept way of working, building on the which proposes establishing a work and standards established in partnership between two midwives. one-to-one care in labour, one That is, a ‘shift partner’ to midwife to one woman or birthing collaborate with during a shift in the person. In this case, however, it obstetric unit or labour ward requires two midwives to two setting. The Partnerships in women or birthing people. “Our primary objective for our improvement project was to enhance the working experience of midwives, resulting in improvement of overall care for women and babies by reducing stress, improving retention, and the professional perception of midwives.” Tina Prendeville