Summary of entire public health syllabus for Cambridge Medical School in three pages.

1. Health protection entails the disciplines and services that protect
members of the society from INFECTIOUS DISEASES or
ENVITONMENTAL THREATS to their health, such as radiation,
chemicals, contamination of resources, dangers at the workplace,
industrial accidents, natural disasters and terrorist acts. It aims to
control threats by developing national, local or individual policies for
vaccinations, isolation PROCEDURES or emergency protocols
and carries out SURVEILLANCE of health threats, in order to allow
rapid response in case of an outbreak.
• STAGES
Gather information regarding the health threat (ID and quantify) => implement
measures (prevention, treatment, control, education, short or long term) =>
monitor / carry out surveillance.
• COMMUNICABLE DISEASES
Infectious diseases declining in Western world while non-infectious/chronic
conditions are increasing. New challenges: Pandemics, nosocomial infections,
Abx resistance, new diseases (CJD, SARS, influenza strains)
• TARGETING INFECTIOUS DISEASES
MODE: direct – indirect – droplet; need to know
MECHANISM: target agent – reservoir – transmission - infection – treatment –
treatment resistance
AIM OF INTERVENTION: containment – eradication
• VACCINATIONS
WHEN TO VACCINATE: high spread, high burden, high incidence/prevalence,
high complications, good vaccine, good process, cheap, rest similar to WHO
criteria for screening.
WHOM TO VACCINATE: population vs. targeted
TYPES OF VACCINES: live, attenuated, killed, inactivated, toxoid, subunit,
passive (Ig)
REQU. VACCINATION PROPORTION: to prevent spread
RVP = 1 – 1 / R0
R0 = number of 2* infections caused by single case
1/R0 = 1* cases needed to cause one 2* infection
RVP = remaining people need vaccination to break chain
Know UK vaccination schedule.
• SURVEILLANCE. Ongoing systematic collection, collation and analysis of
risk factors, incidence, distribution, morbidity and mortality of diseases of public
interest in order to take appropriate quick action.
METHODS: real time evaluation, surveys, representative samples, reporting
(voluntary vs. mandatory)
OUTBREAK INVESTIGATION: (outbreak = disease occurrence > expected)
Descriptive study, then analytical study to ID cause
Members of outbreak control team: environmental health officer, microbiologist,
consultant in health protection/communicable disease (head), consultant
epidemiologist, treating physicians (GP, hospital), spokes person, secretariate,
infection control nurse, food standards agency representative, regional repre-
sentative,
• ENVIROMENTAL THREATS
Source => pathways => receptor => effects / aim is : break chain!
METHODS: evacuation, decontamination, legislation, safety measures
• DISASTER CONTROL
Disaster = disruption of functioning of a community with detrimental
consequences for humans, the environment, the economy and the resources.
Emergency = threat to human welfare and environment or security
METHODS: prevention, preparation for the case of failed prevention, enabling
the response, enabling the recovery
A health needs assessment is an objective and systematic analysis of the health issues
facing a population leading to agreed priorities and resource allocation that will improve
health and reduce inequalities. Action is taken where measures have a high / the highest
impact, where changes are acceptable and can be integrated into current practice and are
feasible in terms of resource implications.
WHAT IS HEALTH NEED?
• A medical service that is wanted or required as patient/society would benefit from it.
Health needs are complex to define objectively and depend on who formulates their
need. Considering health needs, remember that health is more than just absence of illness,
healthcare comprises more than just treatment.
• HEALTH = physical, social and emotional well-being of an individual, group or community,
not just absence disease. Ability to function normally within society
• HEALTH NEEDS: health definition plus education, social services, housing,
environment, social policies
• HEALTHCARE NEEDS: treatment, prevention, diagnosis, continuing care, rehabilitation,
palliative care
• BRADSHAW’s types of NEED:
Expressed (by action), normative (expert-defined), comparative, felt (subjective)
(Need DOES.NOT.EQUAL demand DOES.NOT.EQU. Supply - Health need DOES.NOT.EQUAL healthcare need
Individual need DOES.NOT.EQUAL societal need - Patient’s need DOES.NOT.EQUAL clinician’s opinion of it)
WHO CARRIES OUT THE HNA
• Commissioning organisations, e.g. PCTs, ID need, define priorities (demand) and
purchasing/procurement of supply
• “Joint strategic needs assessment” by local governments for health and social care
HOW TO PERFORM HNA
• PROCESS: Gather information/analyse data, plan and prioritise (ID services required),
allocate resources and involve stakeholders (fairly/maximise equity), assess efficiency
• METHODOLOGY
1. COMPARATIVE NEEDS ASSESSMENT: Define population of interest and collect data,
e.g. routine data (see under “Health Status”). Compare local statistics to other areas,
compare local variables to set standards.
2. CORPORATE NEEDS ASSESSMENT: Involvement of other agencies – professionals,
local governments, voluntary sector, the public, communities, stakeholders via surveys,
citizen’s juries or appraisals.
3. EPIDEMIOLOGIAL NEEDS ASSESSMENT: Quantify particular health needs and relate
to the current services available, quantify their effectivity
=> able to prioritise health needs and decide on reallocation of resources keeping in mind:
• PRIORITIES
What would have highest gain/IMPACT?
Is implementation into services possible? CHANGEABILITY
Are changes ACCEPTABLE?
Is it feasible? Consider RESOURCE IMPLICATIONS
Involve all interested/affected/useful parties.
• Study designs – 1* research, 2* research, study hierarchies
• Critical appraisal of research papers (mainly 2*)
• Evidence-based medicine –use of current best evidence to inform decisions and
procedures and attempting to integrate individual expertise in order to improve
outcome.
WHAT IS PUBLIC HEALTH ?
Health improvement comprises PREVENTATIVE measures
and strategies for health promotion with the goal of improving
population health, at an individual or POPULATION level.
Prevention is facilitated by targeting individual behaviour in
order to avoid contraction or manifestation of a disease or
limit its outcome. Health promotion targets the entire
population through education, legislation, community
development and public policy regarding the prerequisites of
health.
How to improve the health outcomes by health services and
ensure processes are up to date.
• What is QUALITY: Subjective to patients, docs, managers
MAXWELL: accessibility, effectiveness, efficiency,
acceptability, equity
NHS: clinical effectiveness, patient safety and experience
• What is a PROBLEM in the health service:
Underuse, misuse, overuse, errors.
• How to perform an EVALUATION:
DONABEDIAN’s elements: structure, process, outputs
(results), outcome (long term)
• STRATEGIES FOR IMPROVEMENT:
** Regulations/standards (minimum)
NHS, GMC, NICE, QCC
** Improving best practice (beyond min)
Audit cycle: define, monitor, ID divergence, change
practice, evaluate change
The audit checks what is supposed to be done is done.
** Financial strategies
** System-level approaches
Clinical governance (corporate strategies), lean (best value
for patient), six sigma (aim for smallest error), root cause
analysis (learn from mistakes)
STANDARD
PROVISION
IMPLE
MENTA
TION
MONITORING
CLINICAL GOVERNANCE is a systematic approach
to improving quality of care in the NHS.
The QUALITY CARE COMMISSION is the public body of the
department of health (since 2009) ton monitor the NHS.
• LEVELS: Macro (% of all resources), Meso (distribution of
budget), micro (decisions between patients)
• DECISION MAKERS: clinicians up to Dept. of Health (government)
• FRAMEWORK FOR PRIORITISATION:
ID service in question
Assess: need, quality, economic evaluation
Decide on changes
Implement changes
Evaluate results
Re-prioritise
• ECONOMIC EVALUATION:
* Costs: direct, indirect, opportunity, marginal, incremental
* Cost-utility (quality and quantity)
QUALITY ADJUSTED LIFE YEARS = QALYS
Qualitative = % of full health
Quantitative = life expectancy
Measure of disease burden or number of years in full
health gained by particular intervention. => comparison
* Cost-effectiveness (quantity)
* Cost-benefit (more subjective)
* STRATEGIES FOR RATIONING
Exclusion (some get nothing), dilution (all get less), delay
(have to wait), termination (processes shorter)
• Policy refers to the decisions of governments which are not always evidence
based but also take political and cultural considerations into account.
MODELS
• WALT-GILSON model for policy analysis
Context of policy: situation, structure, culture, environment, professionalism
Process/implementation: top-down, bottom-up
Content
Implementors
• Other models: rational/sequential (like audit or prioritisation), incrementalist: carry
out small steps in agreement with groups of competing interest
CONCERNS
• Cost, efficacy, efficiency, effectiveness, quality of care, access, equity, patient-
centered care, information management, workforce development
PRIORITIES
• Improving LE, best start for children, employment, standard of living, sustainability,
disease prevention, addressing inequalities, disease prevention
STRATEGIES
• Market incentives (financial incentives, choice, including independent sector,
liberalisation)
• Structural reorganisations: top-down, bottom-up, Care Quality Commission, NICE
• Whole systems approach, inter-dependency of agencies with central vision and
avoiding duplication
• Specific to public health policy: BIOETHICS LADDER describing level of
intervention, aim at lowest effective level by enabling choice, guiding by default,
incentives, restriction, disincentives, elimination
• Management skills (mainly managing change)
• Leadership skills
• Prioritisation skills, see above
• Decision-making skills
INDIVIDUAL LEVEL
• Disease prevention:
1* = avoid contraction
Address risk factors: lifestyle,
environment, genes, exposure
2* = prevent outbreak/manifestation
Address knowledge, behaviour,
individual/population health
3* = prevent complications
Provide education, care, accessibility,
address co-morbidities
• Factors to change behaviour: will,
belief in possibility and outcome,
knowledge
• Stages of behavioural change: pre-
contemplation, contemplation,
action, maintenance, relapse
• Methods of targeting the individual:
Mass media campaigns, social
marketing, legislation, nudging
(indirect / +ve reinforcements)
POPULATION LEVEL
Main routes
• Education
Schools, professionals, authoriarian,
client-led
• Legislation
Law, taxes, regulations, pricing
• Communities
Empowerment, support groups,
school initiatives
• Public policy
Provide baseline
• Private sector
• Advocacy action
UN, organisations, professional
groups, unions, individuals
OTTAWA CHARTER
for health promotion 1986
• Public policy
• Supportive environments
• Strengthening communities
• Improving health services
• Developing knowledge and skills
SCREENING
Systematic testing of a defined sub-group for risk factors or signs of an illness in its
pre-symptomatic stage with the aim of prevention or reduction in morbidity/
mortality. Action will be taken in those individuals more likely to be helped than
harmed by further investigation or treatment.
• Advantages: reduced morbidity, reduced mortality, economic benefit
• Disadvantages: false reassurance, unnecessary psychological harm, costs,
treatment side-effects; opportunity costs, requires high coverage, difficult to put in
place, plan and implement, evaluate.
• WHO CRITERIA
** 4. reg. test: available, acceptable, inexpensive, valid (predictive value,
sensitivity, specificity), continuous
** 3 reg. disease: important condition, known progression, identifiable early stage
** 4 reg. treatment: available, acceptable, adequate cost, know how/whom to treat
** 4 reg. screening process: program of known effectiveness, benefits > harms,
cost justified within budget, adequately resourced
• UK PROGRAMMES
PREGNANT (FBC, infectious diseases, urine, foetus), BABIES/CHILDREN
(Guthrie=hypothyroidism, Pku, CF, Sickle, MCAPD; Babycheck=hips, heart,eyes;
hearing test, growth charts, vision checks), ADULTS (Cervical CA, Breast CA,
Colorectal CA, AAA, sight-threatening retinopathy in diabetics). Note: prostate CA is
voluntary as PSA bad test, lung CA CXR not sensitive enough and risk of radiation,
cost.
• PREVENTION PARADOX Most cases identified from population at low/moderate
risk, the minority of cases come from the righ risk population.
The health status of a population is determined by carrying out a study/survey named
“HEALTH PROFILE”, in which the mortality, morbidity and other factors affecting
health and disease in the population of interest (including determinants and
inequalities) are statistically/stystematically analysed.
At obtained from
• Statistical organisations (national surveys), hospitals (hospital episode statistics
HES), 1* care
• Public health organisations, e.g. notif. disease data, specialist disease registers
• Ideally also some subjective data from population itself regarding their needs
• NOTE: Finangle’s law of dynamic negatives. And time lags until data available.
MORTALITY
• Crude death rate = deaths /100k per year (age is confounder)
• Directly standardised death rate DSR = mortality rate of the population of
interest if it had the same age-distribution as the population of interest, obtained
by multiplying the crude death rate of each age group with proportion of the
standard population of that group, then summed up. Can divide by standard
population death rate to see difference.
• Indirect standardised mortality ratio SMR = don’t have age-specific data for
population of interest. Apply age-specific death rates of standard population to
population of interest an calculate total number of expected deaths, relate to
actually observed deaths.
• Proportional mortality = disease deaths/y : tot. deaths*100
• Perinatal mortality = (still births + deaths < 1w)/ total births
• Neonatal mortality rate = deaths in 28d / 1000 live births
• Post-neonatal m.r. = deaths 28d-1y / live births
• Maternity m.r. = maternal deaths / live births
• Infant mortality rate = deaths < 1 / live births
• Under five m.r. = deaths < 5 / live births per year x 1000
• Life expectancy LE
• Years of life lost YLL = sum all years lost <75 / population
• QALYs
MORBIDITY
• Information from notifiable diseases, hospital episode statistics HES, 1* care data,
disease registers, national surveys or censuses, surveillance and reporting, local
government data, commercially available data, office of national statistics, WHO
global observatory, Joint Strategic Needs Assessment by UK local governments
• QALYS => see under prioritisation
• INEQUALITIES, e.g. slope index of inequality SII = gap between best and worst
deciles
DATA
• How good is data? Completion, categorisation/coding/consistency, accuracy,
• Discrimination in terms of age, sex, time, location, population?
• Children
• Women
• Adults
• Ageing
• Statistics – inferring trends from large amounts of data
• Demography – analysing the size, structure and distributions of populations.
• Epidemiology – statistical analysis of the risk factors, incidence, morbidity and
mortality of diseases as well as the determinants of health and the control of
disease.
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Policy'Public Health efforts aim to
advise the government on:
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Scien1fic'Methods' Research'Methods' Execu1ve'Skills'
Public Health is the science of promoting health, preventing disease and premature death of a population by systematic efforts of
society, communities or individuals, usually in the presence of limited financial resources. It covers three key areas (but overlapping):