Your views: public health and prevention

The foundations of good health and wellbeing are laid at the start of life in pregnancy, childhood and adolescence.  The Marmot Review on health inequalities set out a framework for action that has at its centre the recognition that disadvantage starts before birth and accumulates throughout life.

This is reflected in the framework’s top two policy objectives:

  • starting well – giving every child the best start in life
  • developing well – enabling all children, young people and adults to maximize their capabilities and have control over their lives.

Children and young people are rightly a target for public health services.  The fact of their youth means there is time to prevent damaging behaviours and attitudes developing and time to help them establish good patterns of managing their health for the rest of their lives.  The development of the Children and Young People’s Health Outcomes Strategy provides us with an opportunity to help improve outcomes for children and young people through their own voice as well as the support and help of professionals and family so that they are equipped for life no matter what their background or family circumstances.

To help with this, we would like to hear from you on the following questions in relation to public health:

  • Where is the health service falling short for children and young people – what is our weakest link and what can we do to improve things to make sure it makes a real difference to the lives of children and young people?
  • With so many different parts of the health system in place, what do they need to focus on and improve to make sure they each work together to deliver the best possible health service for children and young people?
  • The NHS and Public Health Outcomes Frameworks propose key areas of focus: making sure everyone lives healthy lives for longer, addressing inequalities, enhancing quality of life for people with long term conditions, helping people recover from ill health or following an injury, ensuring people have a positive experience of care, treating and caring for people in a safe environment and protecting them from harm – are these the right priority areas in relation to children and young people’s health outcomes? Is there anything missing?
    See outcomes specific to children and young people in these frameworks
  • What should key health outcomes for children and young people include?

The Forum’s work on public health and prevention is led by Ann Hoskins and Barbara Hearn.

In Children and Young People’s Health Outcomes Forum | Tagged ,

22 Responses to Your views: public health and prevention

  1. Louise Hunt says:

    Hello! I would just like to point out that breastfeeding fits with both the NHS oucomes framework and the public health outcomes framework. Re the NHS outcomes framework; breastfeeding effects domains 1 ( reducing cot death), 3 and 4, especially reducing LRTI’s, but also when maternity services adopt UNICEF baby friendly care, care is more woman centred as part of this. As an example of this I would point out that BFI suggests a hands off approach to helping women learn to breast feed. One of the most common bad experiences women talk about after giving birth in a hospital is that staff grabbed their breasts. Breastfeeding then fits with both frameworks.
    I am particularly keen that breastfeeding is mentioned in the Childrens and Young Peoples Health Outcomes Framework because it effects children’s health before they are old enough to articulate this and has long term effects that can effect their childhood and learning. ( For example bottle fed babies have more ear infections which can effect their learning at school as well as their health at the time.). I would point out the effect on breastfeeding rates when a hospital becomes UNICEF BFI accredited. Breastfeeding initiation and continuation rates rise. This is not because women have been pressurised to breastfeed, but because the care they recieved has enabled them to fulfil their own breastfeeding goals. This is particularly true of those women from social groups traditionally less likely to breastfeed. Adopting policy that makes supporting women to breastfeed for as long as they wish reduces health inequalities.
    I spend a loarge amount of time voluntarily supporting other women to breastfeed for as long as they want. Peer support for breastfeeding increased community cohesion.
    Many thanks for your time in reading this.
    Louise Hunt.

  2. Pauline Edwards says:

    I am a specialist nurse for children in care and I am very concerned about where responsibilities for safeguarding and children in care will sit in the proposed restructuring of the NHS.
    I suspect that individual areas and organisations will be expected to make their own arrangments for where this responsiblity will lie. With future fragmentation of provider services and public health moving into local authoriites this is all very far from clear.
    The previous labour government had a firm committment to the health and wellbeing of children and families, including safeguarding and vulnerable children and young people. This group now seems to be less of a priority, with all eyes on the proposed reorganisations.
    There also seems to be a complete lack of clarity as to where named and designated roles for safeguarding and children in care will sit ie provider/commissioner, and this should be clarified as soon as possible
    Pauline Edwards

  3. Jo Leek says:

    As a School Nurse leading a team which supports the needs of children and young people attending Special Schools, I have two key comments:
    Firstly there is currently a huge emphasis on the health visitor service, with major investment in both training and improving the number of Health Visiting positions, but what is being done for school nursing? We await the final publication of the School Nursing Development Programme (potentially later this month) but have already been told it is highly unlikely there will be any investment in respect of staffing resources to implement this. Many school nursing teams across the country have lots of ideas and a belief that they have the potential to make a significant contribution to the health and wellbeing of school age children. However, current resources are stifling practice developments and many services are having to be delivered in reaction to crises rather than in the proactive approach they are trained to offer. The foundations of quality services in early childhood, which will hopefully be delivered through the investment in health visiting, need to continue through into later childhood and adolescence – children and families’ needs do not go away on school entry. There needs to be even greater recognition of the value of school nursing and move us well and truly away from the ‘nit-nurse’ image that appears so difficult to lose.
    Secondly in respect of supporting children with disabilities, would be interested to hear from others as to whether there is an increasing reduction in support being offered by charities / voluntary organisations. Having attended several multi-professional meetings recently it appears established avenues of support are either ceasing to exist; eligibility criteria becoming more complex or service provision being drastically reduced / changed to that previously offered. Many charities are not receiving the funding and grants which enable them to sustain the services they offer. This is further compounded by an even greater demand on services with rising numbers of children and young people with ever increasing complex needs surviving longer. This said the picture in children’s services is still better than that in adult services – young people with disabilites and complex needs are transferring across to adult services only to find a cull in all services, including those from health, taking place. There are pockets of effective working and improved outcomes for some children and young people but these need developing further enabling clear and easy pathways to be available to all. At the moment it often feels like we are working on a battleground with a ticking time bomb which will eventually explode as more and more parents and carers lose their resilience and go into ‘melt-down’.

  4. Pauline MacDonald says:

    I am an immunisation co-ordinator, and while I am very pleased that the PH outcomes framework includes immunisations I have concerns about the descriptors in the Technical specifications document.
    The denominators for the Hep B and BCG 3.3i and 3.3ii say ‘eligible population as defined in the hepatitis B/tuberculosis chapter of the Green Book within each reporting area’. This is not strictly true. Lots of persons are advised to have Hep B vaccine and BCG according to the Green Book, but these targeted immunisation programmes are for very specific persons as detailed in the CMO letters on the neonatal Hepatitis B programme and neonatal BCG programme.
    The Neonatal Hep B is currently effectively measured by COVER with the number of children born to Hep B positive mothers as the denominator.
    The neonatal programme is not measured well with only numbers collected by KC50. For areas where all babies are immunised the denominator is all babies, but many areas only target babies born into families from areas with high TB prevalence and the denominator is difficult to ascertain since it is dependent on ethnicity being accurately reported in data capture systems.
    Also the denominator for the Td/IPV booster 3.3xi says ‘number of children at each age 14 years up to 18 years resident within each reporting area’. This could mean that all the children aged 13-14, 14-15, 15-16, 16-17 and 17-18 are used as a total denominator but they only need to get this vaccine once between the ages of 13 and 18 years. There has always been a problem with this measure since KC50 only counts the numerator. In order to get uptake one single age group needs to be identified. Most school nurses give this vaccine in Year 10 but this can vary.
    HPV data is currently submitted onto ImmForm and is not submitted by resident population but by school population. If this is now to be done by resident population the historic data will be meaningless.
    In short I feel without some more explanation of the denominators organisations will measure different things and there will be seemingly huge improvement or huge drops in uptake compared to historical performance.

  5. Anne Donnelly says:

    I currently work within school health and the areas where I feel development is needed and where health care is falling short is:
    1. School nurse provision, resources and staffing
    2. 16-19 years provision

    Currently in practice I feel there is a concentration of efforts on health visiting and provisions for the pre-school child. Whilst I completely support the need for early years support and health visitor interventions, surely the same investment needs to be implemented into school health and adolescent health.
    Whilst staffing, resources and support is well up and running for health visitors, we are still keenly awaiting the School Nurse Development Programme, however again as previously mentioned it has also been hinted that in terms of resources and staffing we may continue to struggle. I assure you that ideas, passion and enthusiasm is plentiful in school nursing, however, in practice school nurses are under increasing pressure to stretch resources to the point of only assisting children and young people in crisis, rather than providing the health education and promotion which could prevent these crises. There is an increasing gap in services between early years (under 5) provision and school health services.
    School Health teams need to develop the ability to be proactive rather than reactive which we are forced to do at present due to staffing restraints.

    2. Secondly in terms of 16-19 years provision. I feel again this service is in need of development. As school nursing teams are struggling to react to the health needs of school aged children, young people aged 16-19 are being pushed aside and their health needs remain unsupported and not addressed.

    I think the first major area for development in all areas of school nursing is an investment in preventative, proactive health services, an increase in ability to work more autonomously for our communities and in addressing the health inequalities of our communities. This can only be achieved with an increase in staffing and more investment in school health services.

  6. Sheila Munks says:

    As a team leader for health Visiting and School nursing I am pleased that the long awaited document is finally out ‘getting it right for Children, young people and families’. However as expected there are no additional funds for School nursing and it feels as though the investment for the 0 – 4s( as in this area children start mainstream school at 4) is short sighted. It is not acceptable to in my world to withdraw services at this crucial age. School nurses have been underfunded for such a long time and the investment has been mimimal,We are currently not funding the specialist practitioner course for School nursing. This has been taken over by Health visiting to the detrement in my view of school nurses who at the moment feel that there is no career pathway for them unless they become health visitors.As the commissioning process gathers speed my fear and that of many of my colleagues is that children over 5 will be picked up only when they present as a ‘problem’., and that the investment will go to CAMHS service rather than early intervention through investment with School Nurses.PSHE has all but disapeared off the curriculem as schools become obessed with attainment levels and no recognition for the time and imput that school nurses spend delivering the Public Health messages which affect Public Health statistics. Where PSHE is done well uptake of services increases, and adolescents in particular report that their need are addressed.
    Surely the families need the support to follow them through as the child gains more independance and also has the added pressures from influences outside the home from peers, school, media etc.
    How can we do our job with one hand tied behing our backs?The Specialist practitioner Degree enables nurses to assess health needs, and equips them with the knowledge to make the changes. they come into the services ready to change the world but are then hit with a reality check and all to soon they appear to be disillusioned by commissioners targets and number crunching. Please, Please DOH I think the document says everything that school nurses and Health visitors have been saying for years but back it up with money in effect ‘put your money where your mouth is’ or don’t shoot us when nothing changes.We in the NHS embrace change but not for changes sake.
    I also manage a coupe of staff who work with young offenders. They are trying to do a terrific job with very vulnerable and marginalised young people who have chosen or strayed into crime. Many times the young people are the victims of horrendous crime and abuse. They are sometimes already parents themselves and the early intervention begins but is not sustained after 2 years.They also work with the young victims of crime and abuse but this is not seen as a priority and my be decommissioned. Why is it that we wonder where society is going.Why did young people riot last year? Maybe we should look at ourselves first and stop blaming others and start listening to young people and actually hear what they are saying then help them to do something about it.

    • Alix Patricia Cull says:

      I was resident school nurse 1958- 1968. funded by the education department. I was able to co-ordinate with teachers, parents, district M.O. and shcool doctor who visited once monthly to examine any pupils causing concern. The parents were on occasions invited to attend and discuss difficuies.
      I also {in private} had interviews with puils who had problems and help sort these out either with parents or with teachers.
      Two of the teachers and myself had a session with teenage girls who had put their queries in writing (ananymous) sothat we could find out w hat the general troubles were.
      Our emphasis was on the responsibilities of parenthood.
      Times have changed and I consider that there are too many teenage and unwated pregnancies. Funding for school nursingby the education authoritu might save funding from the number ofabortions and also from the problems which arise with the unwanted children of single mothers. Also savigs could be made from S.T.Ds.
      Back in that decade sex was not discussed with boys, but should be extended to boys now, as they have a responsiblity as well as the irls. Interpersonal relationships could also be included.

  7. Philip Insall says:

    Comments from Sustrans

    Sustrans works in the field of active travel, engaging with planning, transport and environmental sectors as well as public health to promote more walking and cycling. Our comments therefore relate to policy and practice around active travel, and the potential benefits in physical activity, road danger, air and noise pollution and social integration. We have not commented beyond this, although we suspect that similar arguments are valid in other areas of public health.

    In our view, public health policy documents often take a very medical and NHS-centric view of public health: they can overlook environmental and cultural determinants of people’s behaviour. It is noticeable that the public health area of this current conversation refers frequently to the health service, although public health will soon be based outside the NHS.

    The move of public health into local government offers a much enhanced opportunity for cross-sector partnership to influence health determinants such as local planning and transport policy and practice. There are already excellent local examples of public health exercising high-level strategic influence over transport strategies; in some cases public health jointly commissions with transport, for changes to the environment as well as behaviour change programmes.

    If public health teams are to fulfill the two policy objectives, that children should be able to start well and develop well, it will be essential that those children are born into an environment where healthy behaviours are the norm. Their parents should be able to incorporate physical activity into their daily lives, including active travel: as the four Chief Medical Officers say in Start Active, Stay Active, “for most people, the easiest and most acceptable forms of physical activity are those that can be incorporated into everyday life. Examples include walking or cycling instead of travelling by car, bus or train”. Traffic speeds and volumes should be low enough that the child can grow up with the freedom to make local journeys under their own steam, and to make full use of the street as public space for socialising and playing. This requires public health to engage from the most senior level with the sectors – such as planning, transport, regeneration and education – which actually take the decisions that shape the environment.

    It is also important that public health, the local authorities where it will now sit, and the NHS itself all play a much more active exemplary role. Walking and cycling access to official sites should always take priority over private motorised transport; estates, transport, human resources and other relevant disciplines should all identify explicit objectives in active travel promotion.

    The question was posed, where is the health service falling short for children and young people? One area of failure has been precisely this – strategies and operational plans in the NHS are still sometimes car-dominated. A good place to start would be for the NHS to get on and implement the relevant NICE guidance, and also the recommendations in the Take Action on Active Travel report by some 120 public health and other organisations.

    Regarding the outcome indicators themselves, we acknowledge that indicators such as child poverty and school absence are evidence of a wise, holistic approach, looking much wider than traditional health measurement. That said, we are disappointed that no indicator addresses children’s ability to choose active travel, and frankly astonished that there is no indicator even for children’s physical activity as a whole. It would be good to address that oversight – a physical activity indicator is needed for children, along with a measurement tool.

    Philip Insall, Health Director, Sustrans

  8. Isobel Duckworth says:

    I would like to see better uptake of Healthy Start vitamins for pregnant women and their babies/children from 6 months to 5 years. This supports the CMO recent guidance re Vit D and NICE guidance.

    Also support comments re breast feeding – we could do with an additional performance indicator at handover between midwife and Health visitor (10-14 days) current data reporting is at initiation and 6-8 weeks but the information is collected at handover and would be good to report at this point. Again a measure at 6 months might also be useful as WHO recommends breast feeding until 6 months.

  9. Alix Patricia Cull says:

    I would add to my previous comments that a school dentis should be included in the cae of the young population, as bad teeth can affect their generl health.

  10. Maggie South says:

    There is a danger that in the race to meet health outcomes we overlook the reasons why we are doing all this. The child or young person has to be at the centre. We need to ensure that where they live, learn and play is well resourced, supported and developed to ensure both universal and targeted health and wellbeing outcomes. I include in this the school as the setting where physical health and emotional wellbeing can be both promoted and encouraged to develop positively. Education has moved in to place where it seems only academic achievement is considered paramount. If we forget and ignore the whole person and we do not support processes that ensure happy, healthy children and young people then we will soon have a whole generation of “failures”. No-one, whether adult or child can perform to their potential if they are in an atmosphere which generates, pressure to attain academically and disregards all the other things we can achieve however small or seemingly unworthy.
    As a result of 12 years hard work by schools and local programmes there are a majority of schools which are Healthy Schools. These recognise the importance of health and wellbeing as the foundation on which success is built, they acknowledge the emotional health and wellbeing of both staff and pupils, they prepare children and young people for adult life through excellent and quality provision in PSHE and above all they have proved their status. It is not sustainable because there is no longer support from the Government for Healthy Schools. Many local programmes have gone. The legacy of local Healthy School Programmes still exists but not for much longer. We have a responsibility to our children and young people not to be short-sighted and to act now to reconsider the role of schools in health and wellbeing to ensure that outcomes for health are not just about preventing illness but also about developing whole, happy and competent adults who understand the benefits of keeping healthy.
    There is also an approaching dilemma. In April 2013 all Public Health departments will be the responsibility of local authorities. The same authorities that maintain schools. These bodies will have a strategic dilemma between the outcomes for health and the outcomes for education.

  11. Karen Thompson says:

    As a public health dietitian I would like to agree with many of the points already made.
    Improving public knowledge on the importance of Vitamin D in pregnancy and early years is important for maximising bone health. This should include Healthy Start for those who are eligible and the recommendation to buy supplementation for those who are not.
    Childhood obesity continues to be a high risk in our communities. Supporting communities to have easy access to healthy food both through oppotunities to grow it and well stocked local shops is important. Active travel is crucial along with clean and enticing green spaces to play.
    Opportuniites to learn to cook healthy and cheap meals that are fun and how to buy and use food leaving less waste.
    Including families in active play and healthy food choices is also essential.
    Lots of good work goes on but may not be well coordinated so staffing levels need to include time to meet, share and network productively so that new ideas are developed and duplication doesn’t occur.

  12. Beverly Davison says:

    Regarding Domain 4 – Ensure people have a positive experience of care…

    The ‘You’re Welcome’ workbook is a robust service improvement tool by which health service settings self-assess themselves against evidence based criteria. It is validated in both acute and community health settings. Aimed at improving the health service access and experience and subsequent health outcomes for young service users, its process is underpinned throughout by the involvement of young people in service design, monitoring and evaluation. It fits in so well into to Domain 4, I hope that DH will continue to raise its profile as an example of good practice and encourage healthcare commissioners and providers alike to advocate its implementation .

  13. Joint Committee on Vaccination and Immunisation says:

    I am writing on behalf of the Joint Committee on Vaccination and Immunisation. Accurate vaccination rates are one of the key health outcomes for children and young people. We foresee a need in the near future for an expansion of vaccination in both primary school children and amongst adolescents and young people. This is likely to involve both additional doses of existing vaccines and new vaccines.
    We need to be able to measure vaccine coverage in all children and adolescents using comparable geographical areas to those currently in use to allow comparisons over time. The current adolescent vaccinations are poorly recorded. It is unclear currently what the method of measuring vaccine coverage will be in the new public health architecture – having appropriate population denominators is critical. It is likely that information on how people in the adolescent years respond to these vaccines in terms of antibody will be important.
    The delivery of these vaccines is likely to lead to increased opportunities for health promotion with these young people and may require strengthening of school health services. We understand it is possible that schools may have the choice to opt out of health activities such as vaccination. We suggest that the establishment of closer working links between education and health to build on the success of the human papillomavirus vaccination programme would be valuable in ensuring young people are actively engaged in decisions about their health and in promoting prevention of illness in this group.

    Andrew J Hall
    Chairman JCVI on behalf of the committee

  14. Rosemary Molinari says:

    As school meal strategy adviser working with schools in promoting healthy school lunch since 2006, I would like to see greater importance and shared responsibility between the DfE and the DH in support the school food standards reform policy. This policy seems to be both undervalued and under estimated as a powerful healthy public policy. Its key strength is its capacity to influence head teacher discretion to act and improve the quality of school food and the dining experience. Children and young people when asked tell us time and time again that they want better school food and healthier dining environment with improve logistics that meets their needs. It’s time we listened to them. It also provides a meaningful performance indictor – that measures school meal take up as a measure of progress, delivering on outcomes for both childhood obesity and most important child poverty. The pending universal credit makes for a healthy school lunch increasingly important, and MUST be included in the community practitioner repertoire – taking school food beyond the school gate – making school food a shred responsibility supporting schools and families.

    .

  15. Heather Angilley says:

    Early intervention for children with coordination difficulties is vital for them to be able to access their environment and learn confidence in movement.
    Nurseries and schools can play a pivotal part in identifying these children and providing appropriate challenges. However, specialist skills possessed by therapists are not widely available in an advisory capacity. The payment of NHS treatments is by referrals so that preventative work on a consultative basis does not produce income for the NHS therefore is discouraged.
    The lack of communication between the departments of health and education is woeful and adversely affects services trying to work together.
    Evidence tells us that these children can grow to be disaffected at school, have low self esteem and more likely to be unemployed and abusers of drink and drugs. A low cost, joint initiative could improve the outcomes and reduce late referrals to the therapy services.

  16. Sarah Farmer says:

    I work in Oral Health Improvement and was delighted to see that reducing dental decay in 5 year olds has been selected as a public health outcome measure. I would question however why the outcome has been positioned in ‘NHS Public Health’ rather than as part of the wider health inequalities agenda, given the very close relationship between dental decay and social deprivation. I would agree that dental services have a key role to play in relation to providing child-friendly services, oral health promotion and preventative care such as Fluoride Varnish applications, however we also need to strengthen the involvement of early years services across the board. Oral Health Promotion, including fluoridation will be the responsibility of the Local Authority under the new NHS arrangements. The will be greater scope for example to introduce early years toothbrushing schemes in children’s centres and nurseries. We need to avoid oral health being seen as just the responsibility of dentists.

  17. Jo Jefferies says:

    Having just undertaken a health needs assessment regarding unintentional injuries in children and youg people I would like to comment on the Public Health Outcome 2.7 Hospital emegency admissions due to unintentional and deliberate injuries in under 18s. The data for this indicator is flawed, being heavily reliant on coding of external factors, the quality and completeness of which is variable and may reflect many zero length of stay admissions. Admissions may only reflect the most serious injuries sustained by children and as such, this indicator will give only partial information.

    Also the indicator combines unintentional and deliberate injuries which although related may require very different strategies to prevent. This combined indicator will not always be helpful for guiding local level strategy.

    I would like to see a clear focus on improving the quality of all accident and emergency data, as has been reccomended by RoSPA, the College of Emergency Medicine and others, so that robust information useful at a regional and local level can be produced.

    Jo Jefferies
    SpR Public Health
    NHS Berkshire West

  18. John Rees says:

    Bullet 1: Where is the health service falling short for children and young people – what is our weakest link and what can we do to improve things to make sure it makes a real difference to the lives of children and young people?

    NSCoPSE, the national association for advisors, consultants and inspectors of PSE is very concerned that the health service is falling short for children and young people. Health services will continue to fall even shorter in terms of health promotion and health improvement, due to policy changes which have significantly reduced opportunities to work with schools and other educational settings.

    We regard recent changes to health and educational policy as counter-productive to improving the health and wellbeing of children and young people. Recent policy and funding changes suggest that schools and colleges are no longer expected to deliver on, or even support, health outcomes for children and young people.

    The current and future health and well-being of children and young people is being jeapodised by failing to ensure their right to high-quality Personal, Social, Health & Economic education (PSHEe) and removing the expectations on schools to deliver effective health education.

    Schools are no longer expected to deliver on the outcomes of ‘Every Child Matters’ which was developed in response to the Climbe Report and as part of the UK implementation of the UN Convention on the Rights of the Child in1991. Although such origins may now seem historic, their importance and the relevance of their message remains undiminished which society ignores at our peril. ‘Care Guidance and Support’ are no longer inspected, under the new OFSTED framework and although this has, to an extent been superseded by judgements on ‘Behaviour and Safety, these is currently not being fully implemented to embed Public Health messages in schools or the curriculum.

    We recommend clearer guidance from DH and DfE as to how public health can be supported under OFSTED expectations such as ‘SMSC’ and ‘Behaviour & Safety’, both of which, if fully implemented, could make a significant contribution to health improvement. Our reading of many recent inspection reports, suggests that this is not happening.

    Cutting central funding for the National Healthy Schools Standard has significantly reduced local capacity and expertise to work between health and education. This has removed a crucial mechanism for Public Health to access schools and leverage the curriculum, but has also dismantled a unique national network to share expertise and good practice. We appreciate the need for local solutions for local problems but it seems extraordinary that health professionals in adjacent LAs have no mechanism to either contribute to national good practice or to operate within a structure of national communication. The potential for inefficiency, replication and ‘re-inventing the wheel – ineffectively, seems enormous and will waste precious resources.

    We regard the changes and cuts outlined above as retrograde and false economy, which, in the longer term will cost individuals, the NHS and health services significantly more than will be saved. Such policy changes will also fail to support educational improvement and reduce health improvement.

    We recommend reintroduction of a national scheme to support public health in education. As with ‘Healthy Schools’ this could be voluntary for schools, need not be a significant national expenditure but could prove cost-effective in health outcome. It would surely appear extraordinary to a visitor to the UK, that we have identified a range of health challenges but have no expectation, mechanism or coherent national strategy to teach health education. Failure to invest in wide-scale health education will eventually prove more expensive and relatively minor levels of investment in terms of national health and education budgets are needed to help reduce tooth decay, obesity, smoking prevalence and unintended pregnancy and to significantly addresses sexual, mental and physical health.

    As expertise is lost, and without a national coordinating body to support good practice, local responses are likely to be inefficient and consequently ineffective. Traditional ‘health terrorism’ such as showing images of advanced lung disease or sexually transmitted infections to shock (young) people into behaviour change are known to be ineffective or even counter productive, but to non-specialists may seem intuitively appropriate. Teachers, untrained in effective methodologies or ‘supported’ by well-meaning voluntary sector or youth workers, may inadvertently subject pupils to inappropriate or ineffective ‘education’. Faith or other groups, with particular views about abortion, homosexuality or contraception which are discriminatory, inaccurate, perverse or even illegal are already offering ‘advice’ to schools. Hard-pressed, untrained or gullible teachers, unsupported by local expertise or coordinated regional response, with access to a national framework of good practice are unlikely to be able to offer appropriate, cost-effective health education.

    We therefore urge this consultation to recommend the development of a national framework of expertise. Such a network could share coordinated, effective practice, support interested professionals, provide multiagency training and become a world-class repository for effective health education. This was, in part, provided by the national Teenage Pregnancy strategy and local coordinators. This strategy was, unfortunately always a misnomer in its support of wider sexual health and Public Health agendas. The cost of undiagnosed Chlamydia infection will be colossal to individuals and health budgets but even the establishment of a national network of sexual health coordinators, is likely to be contentious and fail to address a range of other Public Health issues. However, we believe that the development of a national network of health education specialists would be cost effective and could make a major contribution to health improvement and educational achievement.

    Scrapping the National PSHE CPD Programme for teachers, health and other professionals, has significantly reduced funding to train teachers to deliver the most sensitive and potentially contentious aspects of the curriculum. There is strong international and UK evidence to suggest that effective teaching of health education can positively impact on health outcomes and overall educational achievement. We suggest national funding to ensure that teachers receive adequate pre-service training and CPD. It is important to note that this is currently highly unlikely to be funded by schools themselves because of other priorities directed by Government educational policy and the consequently low status accorded to PSHEe.

    Failure to capitalize on the successes of the national sexual health and teenage pregnancy strategies, seems short-sighted. The UK and international evidence is clear that multi-agency collaboration, including local public health support involving schools and their wider communities contributes to health improvement and educational gain, cost benefit in terms of pro-social behaviours and reductions in young people who are NEET.

    There is strong evidence that theory-driven, evidence based health education can make a positive impact on positive health outcomes but also to achievement and individual attainment (e.g the APAUSE programme).

    The ‘RU Diferent’ research indicates a strong correlation between children not eating breakfast with depression. It seems extraordinary that new academies do not have to conform to agreed food standards. We suggest that this should be amended to ensure that children and young people are provided with healthy food in all state schools and academies, rather than have their diet manipulated by cost-cutting or profit-seeking providers.

    Consideration should also be given to an expectation that all Schools (and Academies), especially new-build, should have an appropriate designated health centre, and not just a ‘first aid room’ or space for poorly children.

    Parental surveys have constantly given a clear mandate to teach health education and young people have made regular and specific requests for, for example, improved teaching of sex and relationships education. These expectations should not go unheeded. We should not ignore examples of curriculum innovation from countries such as Hong Kong and Singapore, whose curriculum aims to achieve on 4 outcomes for children and young people, to enable them to become: Confident individuals, Self-directed learners, Active contributors and Concerned Citizens, and within which ‘wellbeing’ is a central theme. It may also be worth noting that such curricular provide PISA scores are significantly better than the UK.

    Opportunities to redeem the situation remain within the clarification from the current review of the national curriculum, recommendations from the DfE review of PSHE education, including updates on guidance for schools regarding drug, alcohol and tobacco education and sex and relationships education. As noted, above, clarification of OFSTED expectations of SMSC and ‘Behaviour & Safety’ would be welcome

    The inclusion of ‘Life Skills’ to develop Personal, Social Education should be regarded as a crucial component of education. Indeed, it should be unthinkable that a modern education system should fail to equip young people with the attitudes, skills and knowledge to be able to promote their health and wellbeing.

    Bullet 2: With so many different parts of the health system in place, what do they need to focus on and improve to make sure they each work together to deliver the best possible health service for children and young people?

    We are very concerned that the separation of Public Health from the NHS will mean that budgets for health promotion will no longer be recognized as a saving to health.

    For example, in a new building at Barnsley College, space has been allocated for a Health Centre, offering post-16 students immediate, on-site access. This is staffed by CASH, mental health, and other public health professionals. If some of these personnel are no longer part of the NHS, there is a potential that investment in health promotion is no longer directly recognized as a saving to acute services. The highly successful investment in Chlamydia screening, which has attracted significant numbers of young people, has undoubtedly saved money ‘down stream’. Young people accessing the Centre are able as a ‘one-stop-shop’ to access information and support on contraception, STIs, emotional concerns and drugs (e.g. quit smoking) advice. These services are available due to student demand but also as a result of proactive health information campaigns and the College recognize the importance of student wellbeing partly as their ‘duty of care’ and student’s improved ability to focus on coursework but also in terms of enhanced recruitment and improved attendance and retention.

    The very high rates of student access have been achieved without any reductions in the number of young people attending other health services in the town. This is therefore a net gain and consequential saving to the NHS treatment services. Separating health promotion from services is therefore potentially dislocates a successful, cost-effective service with attendant results on health and education.

    Bullet 3: The NHS and Public Health Outcomes Frameworks propose key areas of focus: making sure everyone lives healthy lives for longer, addressing inequalities, enhancing quality of life for people with long term conditions, helping people recover from ill health or following an injury, ensuring people have a positive experience of care, treating and caring for people in a safe environment and protecting them from harm – are these the right priority areas in relation to children and young people’s health outcomes? Is there anything missing?

    Health improvement cannot be simply about ‘mopping up problems’, we need to ‘turn off the tap’. There is strong evidence to suggest that school-based health education, when based on appropriate theory and supported by adequate investment, can make a significant contribution to improved health outcomes and educational attainment. We argue strongly therefore that health and education should collaborate for mutual advantage. There is very strong role for health professionals to work with teachers, not to replace good teaching but to add value and enhance the curriculum.

    Business has long recognized the importance of capturing market share early, and it is equally important that health education, contributing to learning and achievement across the curriculum, supports health and educational outcomes for children and young people. Early and sustained intervention, with access to the vast majority of young people, is essential.

    Patterns of good health (or indeed ill-health) are established early in childhood and need to be sustained and revisited. Early intervention is essential but just as many parents will teach children the rudiments of reading, literacy, speaking and listening, health education both to support public health outcomes and educational achievement, cannot be left to the vagaries of chance or parental whim. A spiral curriculum, teaching children correct names for body parts; the importance of personal hygiene; responsibility for self and that of others, fostering self–efficacy and emotional engagement with learning and the community, with the attendant communication, interpersonal and assertiveness techniques, should be taught as of right to contribute to personal and communal health but also to promote tolerance, respect and employability.

    Parents and educators, teaching about hand-washing or ‘catch it, bin it kill it’ may not always appreciate the contribution to reducing Chlamydia, HIV or other STIs. Such ‘building blocks’ are essential and the potential to contribute to improved academic success, if only by reducing absence, as well as contributing to health improvement, is clear.

    Health and educational professionals need to work collaboratively with parents, just as they do with the teaching of reading, numeracy or A-levels, but the health of communities and the consequential reductions in health costs is more than the sum of individual parts. There is a strong evidence base to support the notion of health behaviours being influenced by social norms. This has seen positive reductions in the number and serious injury resulting from car crashes; reduced numbers of people smoking and rates of teenage pregnancy. Such personal, social and health advantage (and reductions to remedial health spending) is achieved partly as a result of individuals acting in isolation, but can be significantly enhanced as a result of changes in group, or social attitudes. Some health promotion campaigns with adult audiences have shown positive change but it is even more effective if pro-social, pro-health, attitudes and understanding, supported by the necessary skills to make healthy choices, can be developed with children and young people.

    This argument demands therefore high-quality health education. It is unthinkable that schools, after 11 (or 13 years) of statutory education, should result in illiterate, innumerate children. Similarly, we should not tolerate schools, in an industrialized country in the twenty-first centaury, which fail to prepare and enable young citizens to promote and enhance their physical and emotional health and wellbeing. Children and young people have a right to such learning and for health professionals, educationalists and politicians; it is a social and economic imperative.

    Question 4: What should key health outcomes for children and young people include?

    We feel that this has been previous explained, in some detail, as the outcomes of Every Child Matters, which married health and educational outcomes:

    1. Being healthy – this outcome deals with the extent to which providers contribute to the development of healthy lifestyles in children. Evidence will include ways in which providers promote the following: physical, mental, emotional and sexual health; participation in sport and exercise; healthy eating and the drinking of water; the ability to recognise and combat personal stress; having self-esteem; and the avoidance of drug taking including smoking and alcohol. There should also be assessment of the extent to which appropriate support is available for both students and staff to help achieve these positive outcomes.
    2. Staying safe – this outcome is principally about the extent to which providers contribute to ensuring that ‘children’ stay safe from harm. Evidence includes complying with child protection legislation, undertaking CRB checks, protecting young people and vulnerable adults from bullying, harassment and other forms of maltreatment, discrimination, crime, anti-social behaviour, sexual exploitation, exposure to violence and other dangers. Ensuring that all relevant staff are appropriately trained.
    3. Enjoying and achieving – this outcome includes attending and enjoying education and training, and the extent to which learners make progress with regard to their learning and their personal development. Evidence to evaluate this includes arrangements to assess and monitor learners’ progress, support learners with poor attendance and behaviour, and meet the needs of potentially underachieving groups. Also relevant will be the extent and effectiveness of the ‘enrichment’ of provision by promoting social, cultural, sporting and recreational activities. Learners’ views about the degree to which they enjoy their ‘learning life’ are taken into account here.
    4. Making a positive contribution – this outcome includes the development of self-confidence and enterprising behaviour in learners, together with their understanding of rights and responsibilities, and their active participation in community life. Evidence includes measures to ensure understanding of rights and responsibilities, the extent to which learners are consulted about key decisions, and the provision of opportunities for learners to develop and lead provider and community activities. There should also be a focus on enabling young people to develop appropriate independent behaviour and to avoid engaging in antisocial behaviour.
    5. Achieving economic well-being – this outcome includes the effectiveness of the ways in which the provider prepares learners for the acquisition of the skills and knowledge needed for employment and for economically independent living. Evidence includes arrangements for developing self-confidence, enterprise and teamwork, the provision of good careers advice and training for financial competence, and the accessibility of opportunities for work experience and work-based learning.

    We appreciate that politically this may be hard to return to the but concepts of an entitlement to sufficient learning to enable children and young people to keep themselves physically and emotionally safe and to maximise their learning, health and wellbeing is essential.

    We argue, in the strongest possible terms, that the benefits and mutual advantage of health and education through good personal, social development (‘Life skills’ in many countries) should be recognized, funded and developed. This should be inspired by national Government, developed, interpreted and implemented locally as should be an integral of health and education policy and practice – for the mutual benefit and cost-saving of all.

    Schools have become remarkably adept at delivering what is assessed and expected. Such skills should be harnessed to train and support health and educational professionals to enable children and young people to become agents for positive change for health improvement, educational gain and social enhancement.

    Current policy from Health (DH) and Education (DfE), supported (or not) by OSFTED should be aligned to maximise the advantages and mutual benefits to both. We remains concerned that in many localities there will be a temporary period of disruption as public health teams return to LAs. There then remain many opportunities for shared benefit, but only if schools recognize the importance of their contribution to the mutual benefits health gain and educational improvement. Such recognition is unlikely to be achieved without direction or expectation.

    Health promotion, public health and clinical services cannot expect to deliver on their targets or cost-effective measures, in isolation. Schools, colleges and academies, under current expectations and inspection frameworks, are unlikely to prioritize adequate resources, necessary for health improvement.

    We believe strongly that the Government currently has a narrow window of opportunity, with changes to health policy, the curriculum review, DfE review of PSHEe and impending changes to inspection frameworks to make positive, decisive and cost-effective changes.

    NSCoPSE, as an organization would be delighted to contribute to such positive changes which could have significant benefit to health outcomes and costs, contribute strongly to learning and school improvement but is also nothing less than our children deserve.

    John Rees
    Vice Chair, NSCoPSE

  19. Sue Hinder says:

    Massively improve school dinners and consider giving breakfast to children in deprived areas. Schools are often serving rubbish and often there isn’t anything left for those on second sitting.

  20. Jillian Pitt says:

    Comments from The Food for Life Partnership

    Diet is an essential part of the wholelife course starting from birth.
    Yet many children are leaving education without the necessary skills and knowledge to make healthy food choices, or understand the implications of their choices. We believe that by not doing this we are not meeting the framework’s top two policy objectives at all.

    In the current climate, we believe that the Food for Life Partnership (FFLP) approach offers children and their families the chance to improve their overall health and well-being in being part of transforming school food cultures.

    FFLP provides an evidence based approach to changing habits at school, as well as family eating habits at home. Our evidence supports all six of the Marmot Review recommendations:

    1. Give every child the best start in life – FFLP schools show a 13% increase in free school meal take-up

    2.Enable all children, young people and adults to maximise their capabiliities and have control over their lives – FFLP gives both pupils and parents and carers access to practical food skills which in turn can priovide greater control over their food choices and diet. In addition twice as many primary schools received an Ofsted rating of Outstanding follwoing their participation in FFLP

    3. Create fair employment and good work for all – Independent research carried out by the New Economics Foundation found that £3 in social, economic and environmental value was created for every £1 invested in the Food for Life Catering Mark school menus

    4. Ensure a healthy standard of living for all – FFLP has the potential to close the gap for disadvantaged children in terms of their health and academic attainment (NFER, 2011)

    5. Create and develop healthy and sustainable places and communities – FFL Catering Mark Gold menus have up to 47% lower climate impact than standard school menus (Manchester University, 2010) and actively supports food growing.

    6. Strengthen the role and impact of ill-health prevention – FFLP evaluation shows a 28% increase in reported 5-a-day fruit and veg consumption by pupils and 45% for parents.

    In order to put public health at the heart of Government policy with respect to preventing ill-health, we want to see all Government departments working collaboratively to ensure a joined up approach to providing children with the best start in life, but also the ability to develop and have control over their wellbeing.

    With regards to health outcomes, much like Sustrans’s comment with relation to physical activity, we believe that it is essential that a diet related health outcome is included, along with a standard measurement tool.”

  21. Ashley Martin says:

     I am writing on behalf of the Royal Society for the Prevention of Accidents with specific comments on the questions raised above. RoSPA believes that Injury prevention is a key public health issue for children and young people today. Accidents involving children are a leading cause of childhood mortality in England.7 In England and Wales in 2009, 193 children aged 0-14 years died as a result of an accident.8 Across the UK, accidents are the principal cause of death up until age 39.

    Children under the age of five are one of the groups most vulnerable to home accidents. Deprivation also plays a role. Children of parents who are long-term unemployed or who have never worked are 13 times more likely to die as a result of unintentional injury and 37 times more likely to die from exposure to smoke, fire or flames than children of parents in higher managerial or professional occupations.

    Prevention is the key to ensuring that the toll of injuries and suffering is reduced among children and young people. Investing in prevention will also save the NHS and society money which can in turn be reinvested into other health services. However, in many areas of the country there is a significant disinvestment in injury prevention activities. There is also a lack of consistency nationwide. Within the new NHS and Public Health Framework it is imperative that a serious strategy is developed to ensure significant investment and development in the field of injury prevention. It is recognised that the current emphasis on decision making with regard to expenditure is for these decisions to be made at a local level. Whilst local autonomy is welcome and will no doubt lead to significant examples of local good practice it is essential that a strong national lead is given to ensure a consistent and effective approach across the country. Anything less will mean that the NHS and the new Public Health System continues to fall short for children and young people.

     There is a need to build consistency in to the delivery of services. Prevention services in particular are often threatened in times of reduced resources which means children and young families do not get consistent support within their local area or across the country. For example the Safe At Home National Home Safety Equipment Scheme, in addition to providing safety equipment for 66,000 families in disadvantaged areas across the country during 2009-11 also trained over 4000 staff working in children’s centres and other services, equipping them with the knowledge and expertise to reduce accidental injury among families they work with. The impact of this investment has been seriously undermined in many areas by the reduction in resources and loss of key staff since the national scheme came to an end in March 2011. Even areas with strong evidence based local schemes already in place before Safe At Home have seen a significant disinvestment since 2011 despite the significant effect that unintentional injuries has on children and young people in both the short and longer term. In order to maximize the impact of large investments of this kind, more thought needs to be given to the sustainability of these services and retention of trained staff so that their expertise can be used to help prevent unintentional injury in the longer term.

    The inclusion of “Hospital admissions caused by unintentional and deliberate injuries in under 18s” in the Public Health Outcomes Framework is welcome as long as these outcomes are not used within the NHS and Public Health as a “pick and mix” menu with the freedom to drop outcomes that may be more difficult to measure, manage or achieve. This outcome needs to be further refined by splitting the age groups so that age sensitive trends in injuries can be identified, and we need once and for all to develop a way of separating intentional from unintentional injuries as two very different approaches are required in terms of management and prevention.
    It will also be important to develop strong and credible data systems that can fully demonstrate the picture in relation to children’s accidents. This needs to cover A&E attendances as well as admissions and needs to very clearly define specific age groups and provide far better causal data than is currently available. The recent development of Injury Profiles by SWPHO is a major step in gathering and presenting relevant information in one place, but this tool can only be as useful as the quality of the data collected. There needs to be a very strong emphasis not just on the outcomes but the appropriate collection, management and dissemination of the data that can support work to achieve those outcomes.

    Ashley Martin
    Public Health Project Manager
    RoSPA
    31 May 2012

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