Delivering
Impact 2015-2016
Image: Gates Foundation
Welcome to the 2015 review of activity at the Cambridge Institute of Public Health. Our mission is to generate knowledge and evidence to improve global public health, using our research, teaching and analysis to promote well-being, prevent disease and reduce health inequalities. Our membership draws together scientists, clinicians and public health professionals in Cambridge. Read more about our mission at: www.iph.cam.ac.uk
Primary Care Unit
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NIHR School for Public Health Research
Beh a n av i o Res d Hea ur ear l ch U th nit
Centre for Cancer Genetic Epidemiology
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ch ar th se al HR e e N I al R or H ic s ic n om ed Do en om in G B i nit and U G e r Clini o nt c al olo gy
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Director: Professor Carol Brayne
PH an E K d I no w n Te tell led am ig ge Ea enc st e
Contents Director’s update
4
Generating evidence for health
6
Department of Public Health and Primary Care
10
Primary care research Primary Care Unit
14
Behaviour and health
Research in population sciences and public health
Behaviour and Health Research Unit
16
Health services research Cambridge Centre for Health Services Research
Making research relevant
18
IHR School for Public Health Research at Cambridge
Applied health and social care research
Education and training for scientists, clinicians and public health professionals
19
CLAHRC East of England
20
Epidemiology in action MRC Epidemiology Unit and CEDAR
22
Statistics for health MRC Biostatistics Unit
Analysis of population health data and evidence
Health and nutrition research MRC Human Nutrition Research
24
Making the most of health innovations
26
PHG Foundation
Delivering health intelligence
28
Public Health England
Members
30
Governance
31 Department of Public Health and Primary Care, University of Cambridge MRC Epidemiology Unit, University of Cambridge Medical Research Council Units Health policy think tank Public Health England Units Cross departmental programmes at the Institute
Director’s update Professor Carol Brayne
The Institute is a robust partnership of Cambridge-based population health scientists, clinicians and analysts, working to generate evidence and knowledge to improve public health and well-being at local, regional and global levels. This review describes how our research, teaching and analysis delivers impact on health outcomes and highlights recent developments across some of our most exciting areas of work.
Global Public Health Fellowships Two new Global Public Health Fellowships, The Dennis and Mireille Gillings Global Public Health Fellowships, were launched in September 2015 and are a collaboration between the Cambridge Institute of Public Health and the Institut Pasteur. Designed to advance the next generation of public health leaders, the three year post-doctoral fellowships aim to instil financial acumen and business entrepreneurship against a backdrop of research excellence, all at a formative stage in the careers of young scientists. The fellowships are aligned with Drs Dennis and Mireille Gillings’ vision of developing leaders with skills to steer society through threats of pandemics, towards more healthy behaviours and healthy ageing. The research focus will be on two areas critical to sustainable global public health solutions: emerging infectious diseases and neuroscience, specifically autism. While the Institute has been producing scientific leaders in public health for decades, the Dennis and Mireille Gillings Global Public Health Fellowships present an exciting opportunity to establish an explicit link between scientific and business leadership and train future global public health leaders. 4
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Connecting public health researchers across Cambridge
Developing our policy capacity Delivering impact on public health – through our research and analysis – depends on how effectively we engage with the external stakeholders to whom our findings are relevant. In 2015-16 we are building up our capacity to connect with policymakers, learning from those of our groups who already have substantial interaction with policymakers in Whitehall and local government.
Dr Paula Frampton, PublicHealth@Cambridge
The PublicHealth@Cambridge Strategic Research Network is a multi-disciplinary community for public health research across Cambridge, hosted by the Cambridge Institute of Public Health. The Network connects more than 900 researchers from diverse disciplines engaged in public health and well-being related research, and also links to local public health practice and service delivery. The aim of the Network is to facilitate collaboration above and beyond that which can be enabled by the Cambridge Institute of Public Health.
Our appointment of Dr Rosalind Parkes-Ratanshi, our new Senior Lecturer in Public Health, whose post is supported by Public Health England, will help us to strengthen relationships with key policymakers. Our new policy engagement project, funded by the Higher Education Innovation Fund and steered by Professor Mike Kelly, Senior Visiting Fellow at the Primary Care Unit, will connect researchers whose work has substantial policy implications with selected policymakers at local, regional and national levels.
The Network receives core funding from the University Research Policy Committee and has just successfully been renewed for a further three years, with recognition of the effective internal and external links and successful collaborations established so far.
A vibrant environment for teaching and training The Institute sets out to educate and inspire public health leaders, scientists and practitioners through a comprehensive and substantial teaching and training programme.
Key recent highlights include: ––2015 Showcase event in June attended by 150 participants, enabling cross-disciplinary discussion and debate around key themes including sustainability, diet and health, and use of Big Data in public health research. The 2016 Showcase will include a focus on the political economy of public health;
Our specialist public health and primary care teaching is provided to the University of Cambridge’s medical students and our three Masters programmes draw on our unique pool of expertise. Over 100 PhD students are embedded in research teams within the Institute. We also train NHS Public Health Registrars and provide short courses for professionals on many topics including biostatistics, public health intelligence and epidemiology.
––Launch of the Evidence@Cambridge group – a 65 person strong network of researchers engaged in systematic reviews or other forms of evidence synthesis, providing a forum for collaboration and exchange of expertise across traditional Department and School boundaries;
All students benefit from our flagship Bradford Hill seminar series, which in 2015/16 features international speakers including Professor Mika Salminen, Director of the National Institute for Health and Welfare, Helsinki, Finland and Chair of the Global Health Security Agenda; and Dean Dariush Mozaffarian, Tufts University Friedman School of Nutrition Science & Policy.
––Upcoming workshop on the Efficacy of Public Health Policies, using standardised packaging of tobacco as an exemplar to examine evidence behind public policy from a legal and public health standpoint. To join the Network or search for funding opportunities or potential collaborative partners, see the website at www.publichealth.cam.ac.uk
Dr Julio Frenk, President at the University of Miami and former Dean of the Harvard TH Chan School of Public Health, will deliver the 2015 Public Health Annual Lecture 2015. 5
Generating evidence for health Department of Public Health and Primary Care Head: Professor John Danesh
The Department of Public Health and Primary Care includes several major research groups, such as the Cardiovascular Epidemiology Unit, the Cancer Genetic Epidemiology Unit, the Primary Care Research Unit, the Behaviour and Health Research Unit, and the Cambridge Centre for Health Services Research (some of which are described in separate sections below). The Department’s overarching goal is to generate evidence that will inform the prevention of premature death and disability, the promotion of health, and the formulation of evidence based health policy. Read more about Department news at: www.phpc.cam.ac.uk
Interface between epidemiology and clinical medicine Analysis of the 2.5 million-person Emerging Risk Factors Collaboration has informed international cardiovascular guidelines by showing that there is little incremental prediction provided by assessment of C-reactive protein (NEJM 2012), lipoproteins (JAMA 2012), glycated haemoglobin (JAMA 2014), or fatty acids (Ann Int Med 2014). Investigators in the Cardiovascular Epidemiology Unit have also helped confirm that inhibitors of the NPC1L1 protein, such as ezetimibe, are expected to lower cardiovascular risk (NEJM 2014), and identified triglyceride-rich pathways (Nature 2015) and pathways relating to both height and coronary disease as potential therapeutic targets (NEJM 2015).
Population-scale “multi-omics”
Big data for population health
In a major collaboration between the University of Cambridge and the Wellcome Trust Sanger Institute, cohort-wide whole genome sequencing (at a high depth) has commenced for the 50,000 blood donors in the INTERVAL study (PI: Professor Danesh). The objective is to lay foundations for new approaches to disease prevention by gaining novel insights into the genomic regulation of several thousand molecular phenotypes (eg, lipids, metabolites), linking this information with a variety of chronic disease outcomes. This work is being widened to proteomics in a major collaboration with Merck (co-PI: Dr Adam Butterworth). To enhance connectivity between epidemiology and biology, the Department appointed Dr Dirk Paul as Lecturer in Integrative Human Genomics in 2015.
In an analysis led by Dr Emanuele Di Angelantonio, Professor Simon Thompson and others in the Department involving 1.2 million participants in population cohorts that have recorded 135,000 deaths, it was shown that mortality associated with a history of diabetes, stroke, or myocardial infarction was similar for each condition (ERFC, JAMA, 2015). Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was about 15-20 years lower in people with cardiometabolic multimorbidity. To enhance leadership in data science, the Department established a Readership in Translational Genomics and Data Science in 2015 (currently under recruitment).
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Generating evidence for health Global health initiatives
New strategic partnerships
Dr Rajiv Chowdhury, Dr Di Angelantonio and others have expanded efforts in Bangladesh to study the relevance of arsenic exposure and other toxic metals to cardiovascular disease by enlarging the “BRAVE” case-control study of myocardial infarction to almost 15,000 participants. To study the determinants and consequences of anaemia across different age groups in Bangladesh, the same investigators have commenced a pilot study which aims to enrol 20,000 further participants through a household survey. Investigators in the Department are co-investigators in the new Multi-Ethnic New Zealand study of Acute Coronary Syndromes (MENZACS), which aims to identify the biological and other determinants of cardiometabolic conditions in people of Maori, Pacific Island, and other ethnicities at high-risk of such conditions.
In October 2015, the £4 million NIHR Blood and Transplant Research Unit in Donor Health and Genomics (Director: Professor Danesh) was launched. This initiative, which involves NHS Blood and Transplant and the Sanger Institute as strategic partners, aims to enhance the safety and efficiency of blood donation through basic and applied population health research. In another multi-department collaboration spanning population health, vascular biology, and functional genomics, the £3 million British Heart Foundation Cambridge Centre of Cardiovascular Excellence (Director: Professor Nick Morrell) was launched last year. As an extension of this interdisciplinary strategy, the University plans to create a major Heart and Lung Research Institute (to include cardiovascular epidemiology) immediately adjacent to the re-located Papworth Hospital, the UK’s largest cardiothoracic centre.
New research fellowships
The Department has also been closely involved in Cambridge’s engagement with the national Alan Turing Institute in Data Science. The Turing Institute was established in 2015 in partnership with the University of Cambridge (and four other universities in the UK) with the aim of harnessing computational and mathematical sciences to advance discovery and applied sciences (including population health and medicine), using largescale and diverse digital data.
In 2015 Homerton College, the largest college of the University, and the Department of Public Health and Primary Care jointly established four-year Junior Research Fellowships in the areas of cancer genomics and global health.
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Number of people with dementia in some Western European countries could be stabilising
Using epidemiology to guide policy to reduce health inequalities – an example from dementia research
Risk of dementia may be falling due to improved education and living conditions, and better prevention and treatment of vascular diseases, highlighting the need for policies to improve health across the lifecourse (Wu, Y et al, Lancet, 2015).
Impacting on policy is an important outcome from epidemiological research. Knowing how much of any particular disease or disorder exists in the population provides us with a sense of need for whole populations - not just for now, but also in the future.
“The suggested decrease in dementia occurrence coincides with improvements in protective factors such as education and living conditions and a general reduction in risk factors such as vascular diseases over recent decades. Policies which address determinants of health in earlier life stages and enhance cognitive reserve for populations may have the greatest long term impact on reduction of dementia risk at given ages in later life as well as on population health more generally.” Professor Carol Brayne
Dr Fiona Matthews, MRC Biostatistics Unit and Newcastle University
For dementia, there is a perceived level of under-diagnosis, particularly in the older population. Only epidemiological studies can provide a robust insight into the true level of dementia, without the biases that arise if we only look at who gets referred into which system, from primary care to specialist centres. We already know from many studies that a substantial proportion of dementia might be related to common risk factors for diseases (such as smoking, diet and physical activity). How changes in these factors over time impact on total dementia becomes therefore a question not just of scientific interest but major policy interest. The Cognitive Function and Ageing Studies have provided estimates on the prevalence of dementia across the country, using a large epidemiological investigation where all individuals have been assessed for the presence of the dementia syndrome. We found that the prevalence of dementia had decreased within the general population over time with continuing strong differences between men and women. There was still a strong age effect and dementia was also found to be more common in deprived communities. These findings should help policymakers to prioritise funding and case finding approaches. They indicate a focus on areas of the country with the greatest current numbers of people with dementia and also on those areas where risk factors across the lifecourse have profiles that confer higher risk of future dementia. UPDATE: Cambridge is the lead centre for a multi-institutional Doctoral Training Programme in Dementia funded by the Alzheimer’s Society. The Cognitive Function and Ageing Studies (CFAS) will provide a platform to support 4 PhD students based at CFAS centres in Cambridge, Newcastle, UEA and Exeter. All students will be using CFAS data and will visit each centre to learn key skills such as statistical analysis and epidemiological methods. 9
Primary care research All images: Dr Jon Ferdinand
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Primary Care Unit Professor Jonathan Mant
The Cambridge Primary Care Unit (PCU) works to reduce the burden of ill health: ––by identifying and targeting the behaviours that lead to chronic disease; ––by improving early detection of illness; ––by improving the delivery of health services in community settings; ––and by teaching medical students, clinicians, researchers and educators. We aim to deliver research and education at the highest international standards of excellence. Read more about the Unit’s research at: www.phpc.cam.ac.uk/pcu
NIHR School for Primary Care Research The Primary Care Unit re-joins the NIHR School for Primary Care Research in October 2015, which aims to increase the evidence base for primary care practice and train future leaders by providing multi-disciplinary training and career development opportunities.
“We hope to contribute to research in prevention and diagnosis, including for example, early detection of type 2 diabetes and novel and scalable interventions for smoking cessation using very brief face-to-face interventions and mobile technology.” “We hope to explore the effectiveness of approaches to improving the delivery of end of life care in the community – the NIHR School is well placed to access the data needed to make an important international contribution. We will also be able to develop and evaluate interventions to enhance the interaction between patients and practitioners and look at how that can improve the quality of care offered.”
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Primary care research Stroke research to address key issues for survivors
Clinical nursing Professor Christi Deaton Our developing research focuses on improving the provision of, and access to, rehabilitation for patients with heart failure and COPD, and supporting carers of patients with heart failure. Ongoing research focuses on variation in care and the role of specialist nurses for patients with non ST elevation myocardial infarction, and outcomes after stroke. The Clinical Nursing Research Group (CNRG) has obtained funding from the Cambridge Biomedical Research Centre and Addenbrooke’s Charitable Trust to support internal research fellowships for nurses, midwives and allied health professionals to develop doctoral and post-doctoral research fellowships. Four fellows have been funded for 2015-16.
A new £2 million NIHR funded research programme at the Primary Care Unit, in collaboration with the University of Leicester, aims to address two of the key issues that stroke survivors identify: a feeling of abandonment after discharge and a lack of information and knowledge about many aspects of stroke and stroke care.
Medical student education in Palliative and End of Life Care Dr Stephen Barclay
The team led by Professor Jonathan Mant is developing a new way for primary care services to work to enable them to meet the needs of stroke survivors after they have been discharged from specialist rehabilitation. This will include: improving communication between primary care and specialist services; structured review of patient needs; re-referral to specialist care where indicated; and a novel “Managing Life After Stroke” programme for stroke survivors and their carers.
Brief interventions for physical activity The teaching of Palliative Care in the Clinical School is led by a team within the Primary Care Unit, who have ensured considerable expansion of curricular time over recent years, and led the revision of a national curriculum document. Research has highlighted the positive changes in student attitudes during the clinical course and highlighted factors associated with the formation of anxiety and avoidance of dying patients amongst students (Barclay S, Journal of Pain and Symptom Management, 2014; Thiemann P, Journal of Pain and Symptom Management 2015).
Professor Stephen Sutton A comprehensive systematic review of brief interventions to increase physical activity showed that they are costeffective (British Journal of Sports Medicine, 2015). The use of pedometers and motivational interviews were the most cost-effective approaches. However, more research on the longer term costs and benefits of such interventions is needed. 12
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Decisions concerning nutrition and Breathlessness: developing hydration towards the end of life interventions Dr Stephen Barclay and Dr Gemma Clarke
Dr Morag Farquhar
Poor clinical decision-making concerning hydration towards the end of life was a major concern contributing to the withdrawal of the Liverpool Care Pathway for the Dying in 2013. The Palliative and End of Life Care Group have an established programme of work in this difficult area, with recent publications highlighting the challenges involved in decision-making in a local hospital (Knights D, British Journal of General Practice 2015; Clarke G, PLOS ONE 2013; Clarke G, Clinical Medicine 2014; Clarke G, BMC Medical Ethics 2015).
Cancer research at the Primary Care Unit Dr Fiona Walter The cancer group at the Unit has contributed to revised NICE guidelines for suspected cancer (2015) and delivered key findings on early diagnosis and patient preferences. As government in the UK increasingly turns to primary care to play a larger role in healthcare, the group is focused on how to equip doctors to tackle cancer effectively. We contributed to the Lancet Oncology Commission led by Greg Rubin, Professor of General Practice and Primary Care at Durham University.
A Breathlessness Intervention Service for patients with advanced disease which was co-developed and evaluated in a collaboration between the Primary Care Unit and clinicians at Addenbrooke’s Hospital was shown to be both clinically and cost-effective for patients with advanced cancer in a randomised controlled trial (Farquhar M, BMC Medicine 2014). Other services modelled on the intervention are now being established both within UK and internationally (Canada, Germany and Australia).
Looking ahead, new grants from the NIHR and charities (The Brain Tumour Charity, Macmillan Cancer Support) will support research including: a trial of a clinical decision support tool for oesophago-gastric cancer; exploration of barriers to early diagnosis of brain, upper gastrointestinal and prostate cancer; and to develop new models of care for cancer survivors.
The Living with Breathlessness study is identifying unmet support needs in patients with advanced COPD and their informal carers (family and friends who support them). The study team are working with national stakeholders to develop actionable responses to these findings. The Learning about Breathlessness study is developing an evidence-based educational intervention on breathlessness for informal carers of patients with breathlessness due to advanced COPD or cancer.
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Behaviour and health Behaviour and Health Research Unit Professor Theresa Marteau
The Behaviour and Health Research Unit (BHRU) is funded by the UK Department of Health to contribute evidence to national and international efforts to achieve sustained behaviour change to improve health outcomes and reduce health inequalities. We develop evidence on effective ways of changing four sets of behaviour – smoking, excessive consumption of food and alcohol, and physical inactivity. Read more about BHRU at: www.bhru.iph.cam.ac.uk
Size Matters A recent review on portion, package or tableware size, published in the Cochrane Database of Systematic Reviews, has generated the most conclusive evidence to date that people consistently consume more food and drink when offered larger-sized portions, packages or tableware (Hollands G, Cochrane Reviews 2015). The size of effect suggests that if sustained reductions in exposure to large sizes can be achieved across the whole diet this could reduce energy consumed each day by up to 16% among UK adults. Within a week of publication the Altmetric for this review placed it in the top 0.1% of all Cochrane Reviews (#3 of 6976), of all articles of a similar age and of all articles ever tracked. This review is informing current policy-making on obesity.
Why don’t poor men eat more fruit? Building on an earlier study of the food purchases of 25,000 British households, the Unit conducted a study to understand more about why, compared with less deprived households, those in more deprived households purchase a larger proportion of energy from less healthy foods and drinks and a smaller proportion from healthier foods and drinks. Focusing on fruit, there were no differences in self-reported liking but men from more deprived groups had a lower implicit (nonconscious) liking of fruit (Pechey, R Appetite, 2015). This suggests that interventions that increase availability or reduce the price of fruit will be unlikely to increase consumption in this group.
Evidence Matters for Public Acceptability Public acceptability influences policy action, but the most acceptable policies are not always the most effective. A discrete choice experiment was conducted to investigate the acceptability of different interventions to reduce alcohol consumption (increased price, reduced availability and advertising) and the effect of providing information on expected effectiveness (in reducing crimes and hospital admissions), using a UK general population sample of 1202 adults. Providing information on expected effectiveness increased acceptability (Pechey, R., Soc Sci Med 2014). Policy-makers struggling to mobilise support for hitherto unpopular but promising policies should consider giving greater prominence to their expected outcomes.
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INCREASES IN PORTION SIZES 1993 NOW STEAK AND KIDNEY PIE
SLICE OF WHITE BREAD
(short crust, individual)
CHICKEN CURRY WITH RICE (frozen)
(large loaf, medium thickness)
Portion distortion
1993 Weight: 160g Calories: 425kcal
Weight: 36g Calories: 85kcal
Weight: 260g Calories: 305kcal
Weight: 240g Calories: 640kcal
Weight: 40g Calories: 95kcal
Weight: 395g Calories: 460kcal
50% INCREASE
11% INCREASE
52% INCREASE
NOW
FROM THE BREAD ALONE, HAVING A SANDWICH FOR LUNCH EVERY DAY IS EQUAL TO 7,300 CALORIES A YEAR MORE NOW THAN IN 1993
GAINS IN WEIGHT IN ENGLAND
1993
53%OF ADULTS WERE OVERWEIGHT OR OBESE THE AVERAGE BMI WAS
25.8
2011
62%OF ADULTS WERE OVERWEIGHT OR OBESE THE AVERAGE BMI WAS
27.1
OVEREATING BY JUST 100 CALORIES A DAY CAN LEAD TO A 5kg (11lb) INCREASE IN WEIGHT IN A YEAR, WHICH IS 25kg
(NEARY 4 STONE) IN JUST 5 YEARS (SIMILAR TO A HEAVY SUITCASE)
CANCER AND WEIGHT STRONG EVIDENCE SHOWS THAT IF EVERYONE IN
THE UK WAS A HEALTHY WEIGHT THE FOLLOWING CANCER CASES COULD BE PREVENTED EVERY YEAR: BREAST
(POSTMENOPAUSAL)
OESOPHAGUS
16% (8,000 cases)
31% (2,600 cases)
GALLBLADDER
PANCREAS
16% (120 cases)
15% (1,300 cases)
KIDNEY
BOWEL
OVARY
WOMB
19% (1,900 cases)
4% (280 cases)
Image: World Cancer Research Fund
14% (6,000 cases)
38% (3,200 cases)
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––Over the past 20 years, portion sizes of some foods in the UK have increased significantly. At the same time, the number of people who are overweight or obese has also increased. Eating more than we need can lead to weight gain, which is a risk factor for several common cancers, including bowel and breast cancer. Choosing to eat smaller portions, avoiding processed foods and basing your diet on mostly plant foods can help you stay a healthy weight.
Health services research Cambridge Centre for Health Services Research Professors Martin Roland and Jon Sussex
The Cambridge Centre for Health Services Research (CCHSR) is a collaboration between the Health Services Research Group at the University of Cambridge and healthcare researchers at RAND Europe, co-directed by Professor Martin Roland at the University of Cambridge. The leadership of the RAND Europe team changed during the year with Ellen Nolte’s move to LSE, and we welcomed Jon Sussex from the Office of Health Economics as the new co-director of CCHSR. Read more about CCHSR at www.cchsr.iph.cam.ac.uk
Patient experience in cancer Yoryos Lyratozopoulos and colleagues active in ‘cancer health services research’ continued to deliver important findings, including the negative impact on patient experience arising from referral delays once patients subsequently diagnosed with cancer had seen their GP. This highlights the importance of public health and health care interventions in reducing delays in cancer diagnosis.
Developing capacity in health economics There are now 75 members of HealthEconomics@Cambridge, a network led by Dr Ed Wilson, which brings together people with an interest in health and economics from across the University and Cambridgeshire area, with a regular seminar series (http://talks.cam.ac.uk/show/index/53002). A report on the economic impact of the Cambridge bioscience cluster, prepared with Professor Peter Tyler from the Department of Land Economy and Cambridge Econometrics, demonstrated that Cambridge is the leading bioscience cluster in Europe, but also showed how the infrastructure in Cambridge is limiting future growth.
The Future Primary Care Workforce Martin Roland chaired a commission for Health Education England (HEE) which produced a report ‘The Future of Primary Care: Creating Teams for Tomorrow’. The report made clear recommendations for HEE, NHS England and the Department of Health, which, if implemented, could take general practice out of its constant feeling of crisis towards leading what could be one of the best health care systems in the world. In other work, members of CCHSR have continued to contribute to evaluations across the NHS and beyond, including the evaluations of the Macmillan Cancer Centre, telephone triage in primary care, the NHS ‘Innovation, Health and Wealth’ programme, and the Health Foundation’s ‘Q initiative’.
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Understanding patient feedback Dr Jenni Burt, CCHSR
This year saw the conclusion of the five year programme ‘Improve’ managed by Dr Jenni Burt, which aimed to get a better understanding of how patients use surveys to record their experiences, with a particular focus on ethnic minorities. The programme aimed to understand how primary care staffrespond to feedback and to find ways of engaging staffmore actively in the process of understanding feedback.
was found that South Asians used response scales in a different way to White British respondents. When viewing the same consultation in an experimental vignette study, South Asian respondents gave scores which were much higher than White British respondents. This suggests that the low scores given by South Asian patients in surveys such as the GP Patient Survey reflect care which is genuinely worse than that experienced by their White British counterparts.
The study found that patients readily criticised their care when reviewing consultations on video but were reluctant to be critical when completing a questionnaire after the consultation. When trained raters judged communication within a consultation to be poor, a substantial proportion of patients still rated the doctor as ‘good’ or ‘very good’. Absolute scores should be treated with some caution: they may present an over-optimistic view of the GP’s care, though relative scores can still be useful for comparing practices.
In both general practices and out of hours centres, this study found that staff in GP practices neither believed nor trusted patient surveys. Doctors expressed marked ambivalence in discussing their own individual survey results, with frequent negative comments about surveys alongside positive comments about the importance of patient feedback in monitoring and improving services. To try and engage staff more actively with patient feedback, an exploratory trial of real-time feedback (RTF) was conducted, using touchscreens in the waiting room. Staff and patients were broadly positive about their experience of using RTF and practices valued being able to include their own questions in the survey. However, few patients actually left their views and much more work needs to be done to find better ways of feeding patient experiences back to clinicians and practice staff.
One aim was to understand why Asian patients consistently provide low scores in patient surveys. Asian respondents to the GP Patient Survey tend to be registered in practices with low scores and that explains about half of the difference in reported experience between South Asian and White British patients. However, no evidence
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Making research relevant NIHR School for Public Health Research at Cambridge
Assessing the impact of Time Credits on health and well-being Dr Louise Lafortune, Cambridge Institute of Public Health
Professor Carol Brayne with Dr Louise Lafortune
The NIHR School for Public Health Research at the Cambridge Institute of Public Health (SPHR@Cam) aims to build practice and policy relevant evidence to improve population health and inequalities. Several of our projects have entered the phase of influencing public health practice and policy locally and nationally. Read more about NIHR SPHR at Cambridge at: www.iph.cam.ac.uk/nihr-sphr
Reducing obesity in young children Over the past few years, the focus of obesity prevention has shifted to preschool children due to the high prevalence of obesity at school entry and recognition that habits formed in early life could persist into adulthood. Dr Rajalakshmi Lakshman’s project on obesity consists of a series of four evidence reviews looking at the determinants of obesity related dietary and physical activity behaviours in young children (pre-school 0-6 years). Active engagement is now under way with public health policymakers to inform the design and content of suitable interventions pertaining to: intake of sugary drinks, intake of high calorie foods, fruit and vegetable consumption, and sedentary behaviours.
The Public Health Practitioner Evaluation Scheme (PHPES) enables people who are introducing innovative public health initiatives to work in partnership with the NIHR SPHR to conduct rigorous evaluations of their cost-effectiveness. The scheme is particularly focused on local public health initiatives, rather than projects that are part of national programmes. In collaboration with the Cambridgeshire County Council Community Engagement Team and SPICE, Dr Gemma Burgess (Department of Land Economy) and Dr Louise Lafortune are conducting an evaluation of the Time Credit programme in Wisbech. In the Time Credit model, people earn Time Credits by giving their time to local service and groups - one Time Credit is earned for each hour of time given. People can then ‘spend’ Time Credits to access events, training and leisure activities provided by public, community and private organisations. Time Credits are a unique tool to enable engagement with some of the most vulnerable members of the community and reduce social isolation. The evaluation, which runs from August 2015 to March 2017, aims to assess the impact of this model on health and social well-being.
Ageing well An integrated public health approach to optimise health in older age groups is being developed, bringing together risk prediction, evidence synthesis about current practice, evaluation of preventive interventions and population modelling. This programme is led from Cambridge and includes a cross-cutting Cognitive Health theme. The team conducted three scientific evidence reviews for the National Institute for Health and Care Excellence (NICE) to underpin the upcoming Public Health Guidance: “Disability, dementia and frailty in later life – mid-life approaches to prevent or delay the onset of these conditions”. 18
Applied health and social care research CLAHRC East of England Professor Peter Jones
Responding to Winterbourne View
NIHR CLAHRC East of England (CLAHRC EoE) is now in its second year of a five-year applied health and social care research programme. The research programme focuses on the needs of people with complex problems, who are often vulnerable, with multiple agencies involved in their care. The CLAHRC addresses the needs of young people, frail older people, those with dementia, those people with learning disabilities, and those with acquired brain injuries and mental ill health. Patient and public involvement (PPI) lies at the heart of the collaboration. Read more about the CLAHRC EoE at: www.clahrc-eoe.nihr.ac.uk/
This CLAHRC EoE study draws upon our previous research about community teams for people with learning disabilities following the scandal at Winterbourne View hospital in 2011, and has already led to changes within Cambridgeshire Learning Disability Partnership, including changes to multi-disciplinary team meetings and a process for agreeing placements.
Capacity building Capacity building in research is a key priority for CLARHC EoE. We have awarded 57 CLAHRC fellowships since 2011 (including 12 current and 45 former fellows). Our fellows, who come from a wide range of backgrounds including: Consultant Psychiatrists, NHS managers, Clinical Psychologists, Consultant Clinical Neuropsychologists, General Practitioners and Registered Nurses, work on projects that span our research themes. From autumn 2015, we are providing further opportunities for practitioners and early-career researchers by funding PhD students for each of our five research themes.
‘Never Events’ ‘Never events’ are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by the healthcare provider. Following a number of foreign object retentions, the CLAHRC EoE Patient Safety theme and Engineering Design Centre were asked to do a piece of work related to surgical guide wires at Addenbrooke’s Hospital in order to investigate ways to reduce the risk of the retention of guide wires used during the placement of central venous catheters – a procedure used routinely by anaesthetists. This work produced an estimate of the level of risk of further ‘never events’, identified a likely cause of retained guidewires, and proposed a range of possible solutions.
CLAHRC EoE is also the national lead for four recently funded Doctoral Training Centres in dementia care research. This programme aims to develop research leaders to build up the evidence base that underpins the provision of dementia care.
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Epidemiology in action MRC Epidemiology Unit and CEDAR Professor Nick Wareham
This year, the MRC Epidemiology Unit has successfully navigated its Quinquennial Review, securing funding for its core programmes from 2015-2020. The MRC Board recognised the Unit as a highly productive, strategically important and world leading centre of expertise for epidemiology, diabetes and associated metabolic disorders. The high quality of its scientific outputs were noted, together with a strong strategic vision, an excellent training environment and a comprehensive communications, public engagement and knowledge exchange programme. Together with the Unit-led Centre for Diet and Activity Research (CEDAR), researchers are making important contributions to the development of public health practice and policy – from the development of interactive tools to support healthy neighbourhoods to Prof Nick Wareham’s invitation to give expert testimony to the House of Commons Health Committee.
The Unit continues to develop its research across its wide portfolio, with particular areas of focus for the future including: ––An expansion of the dietary public health portfolio as part of CEDAR, in order to build a greater understanding of the influence and impact dietary behaviours to inform public policy and industry action. ––Development of ‘big data’ research, including the InterConnect initiative on gene-environment interaction in diabetes and obesity, and collaborations with UK Biobank, which holds data on around half a million participants from across the country. ––Contributing to the prevention and control of non-communicable disease in low and middle income countries, in partnership with the Wellcome Trust Cambridge Centre for Global Health Research.
Research Highlights Read more about our news at www.mrc-epid.cam.ac.uk/news
Growth and development
Prevention and diabetes
Research using UK Biobank data has revealed that the timing of puberty has wide-ranging impacts on health in later life. The timing of puberty varies significantly between individuals, with the normal onset of puberty ranging from 8 to 13 in girls and from 9 to 14 in boys. Analysis of data from nearly half a million participants found that those in the earliest or latest 20% to go through puberty had higher risks for late life disease when compared to those in the middle 20%. The age at which both men and women begin puberty is associated with 48 different health conditions, from diabetes to depression (Day, FR et al, Scientific Reports, 2015).
Early detection and treatment of type 2 diabetes may reduce heart disease and mortality. Combining data from the ADDITION-Europe study with a computer simulation model of diabetes progression allowed researchers to estimate the impact of screening followed by treatment, compared to no screening. The model predicted that for people with undiagnosed type 2 diabetes, screening would be associated with a 29% reduction in relative risk of a cardiovascular disease event over the next 10 years compared with a delay of six years in diagnosis and treatment. The comparable change in all-cause mortality was 20% relative risk.
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www.iph.cam.ac.uk Physical activity
In another study, a meta-analysis of 17 observational studies indicated that regular consumption of sugar sweetened drinks is positively associated with type 2 diabetes, independent of obesity status.
Lack of exercise may be responsible for twice as many deaths as obesity, according to an analysis of more than 300,000 participants in the EPIC study. The research found that while physical inactivity may contribute to an increased body mass index (BMI), the association between physical inactivity and mortality is independent of an individual’s BMI. The researchers estimated that for inactive people, doing exercise equivalent to just a 20 minute brisk walk each day could reduce relative risk of premature death by between 16-30% (Ekelund, U et al, AJCN, 2015).
The authors estimated that, over a 10 year period in the UK, about 79,000 cases of type 2 diabetes could be attributed to consumption of sugar sweetened beverages (Imamura, F et al, BMJ, 2015). Data from the EPICNorfolk study, meanwhile, found that drinking water or unsweetened tea or coffee in place of one sugary drink per day can reduce the risk of developing diabetes (O’Connor, L et al, Diabetologia, 2015). And EPIC-InterAct data showed that the consumption of dietary fibre is associated with a reduced risk of developing diabetes (The InterAct Consortium, Diabetologia, 2015).
Each hour per day spent watching TV, using the internet or playing computer games during Year 10 is associated with poorer grades at GCSE at age 16. Researchers also found that pupils doing an extra hour of daily homework and reading performed significantly better than their peers. CEDAR researchers found that each hour per day of time spent in front of the TV or online at age 14.5 years was associated with 9.3 fewer GCSE points at age 16 years – the equivalent, for example, to two grades in one subject or one grade in each of two subjects (Corder, K et al, IJBNPA, 2015).
Diet and global health CEDAR research using data from Norfolk revealed that the number of takeaway food outlets has risen substantially over the past two decades, with a large increase seen in areas of socioeconomic disadvantage. And novel use of national UK data by CEDAR has shown a growing gap between the prices of more and less healthy foods between 2002 and 2012, with healthy foods in 2012 being three times more expensive per calorie than less healthy foods (Jones, NRV et al, PLOSE ONE, 2014).
Encouraging people to switch from driving to work to walking, cycling or using public transport could help reduce the level of obesity in the population. CEDAR research from the University of East Anglia showed that switching from car commuting to active travel or public transport was associated with a reduction in body mass index (BMI), even over a relatively short time period of two years (Martin, A et al, J Epidemiol Community Health, 2015). However, CEDAR analysis of the 2001 and 2011 Census data revealed that growing cycling levels have not been accompanied by greater age and gender diversity. In places where cycling to work has risen, cycle commuting has remained a disproportionately male activity, and has become even more skewed towards younger age groups. New strategies may be needed therefore to help more women and older people take up cycling (Aldred, R et al, Transport Reviews, 2015).
Across the world, diet quality has declined, but with major differences across regions. The Global Burden of Diseases Nutrition and Chronic Diseases Expert Group reviewed dietary surveys that represented almost 90 percent of the world’s adult population, looking at trends from 1990 to 2010. Even as consumption of healthier foods has increased in many countries, unhealthy foods have outpaced this growth, especially in middle income countries (Imamura, F et al, The Lancet Global Health, 2015). Greater adherence with a diet rich in vegetables, low fat dairy and whole grains would not only be good for health, but also for the planet. The Dietary Approaches to Stop Hypertension (DASH) diet is a proven way to prevent and control hypertension and other chronic disease – and new analysis has shown that this diet is also associated with lower emissions of climate-changing greenhouse gases (Monsivais, P et al, AJCN, 2015).
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Statistics for health MRC Biostatistics Unit Professor Sylvia Richardson
“Statistics is applicable in all aspects of medicine, epidemiology and public health. Statistics should be the base for designing clinical trials, as well as evaluating the effectiveness of public policies,” Sylvia Richardson, Director of the MRC BSU in Cambridge.
The MRC Biostatistics Unit (BSU) is one of the largest groups of biostatisticians in Europe, and a major centre for research, training and knowledge transfer, with the mission: ‘to advance biomedical science by maintaining an international leading centre for the development, application and dissemination of statistical methods’.
in 2006-2010 (193/1970 opioid-related deaths) to 6.3% (76/1212) during 2011-2013. In the light of these results from Scotland and the N-ALIVE’s own data, the N-ALIVE pilot Trial ceased randomizing in 15 English prisons on 8th December 2014 and offered naloxone-on-release to its already randomized but not-yet-released prisoners.
Current and recent research on evidence synthesis, policy evaluation, new models and trial designs, and association between genetic information in health, has had direct impact and influence on clinical practice and public health.
A model free way of escalating doses in a dual agent phase I trial The future of drug development in oncology is increasingly to use multiple drugs in combination. This necessitates research in how to design phase I trials to find the maximum tolerated dose combination. There is an increasing need to find a trial design that has solid statistical operating characteristics, but yet is also easy to understand and use.
Read more news from the Unit at: www.mrc-bsu.cam.ac.uk
Policy breakthrough in drug-related deaths research Professor Sheila Bird’s research team at BSU was first to quantify the high risk of drug-related death soon after prison-release, now internationally recognised; and more recently in the 4 weeks after hospital-discharge. Naloxone, the opiate agonist, is used by paramedics to reverse heroin overdoses. Could take-home naloxone be a solution?
Dr Adrian Mander’s research programme has developed a new design that seeks to be simple. The design has the acronym PIPE which stands for the Product of Independent beta Probabilities dose Escalation, and uses statistical distributions in order to identify different toxicity contours over the possible drug combinations. The calculations are relatively simple and can be carried out using Excel, making it more accessible to trialists.
In 2012, randomization began in the prison-based N-ALIVE pilot trial to find out if naloxone-on-release could reduce overdose deaths soon after release from prison. The N-ALIVE trial did not randomize in Scottish prisons because take-home naloxone was made a funded public health policy in Scotland from 2011. Professor Bird’s advice was accepted that the primary outcome for Scotland’s National Naloxone Policy should be comparison of the proportion of opioid-related deaths that had a 4-week antecedent of prison-release. The proportion fell dramatically from 9.8%
The method was published early this year (Statistics in Medicine, 2015) and has already attracted interest from various clinical trials units and the pharmaceutical industry. Statisticians in Roche Pharmaceuticals have now translated the R-code for the design into a public web application, available soon.
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www.iph.cam.ac.uk Relaxing the independent censoring assumption in the Cox proportional hazards model using multiple imputation The Cox proportional hazards regression model is widely used to model time to event data; in 2014, Nature reported that “Cox 1972” is the 24th most cited research paper of all time. However the standard method for fitting this model requires the “independent censoring assumption”, that individuals lost to follow-up have similar survival to those remaining. Dr Ian White’s research programme has developed a new way to relax this assumption, using easily interpreted sensitivity parameters, which describe the departure from independent censoring. The new method was applied to data from a HIV trial in Tanzania, where the population of interest was nonpregnant women, so women who became pregnant during the trial were censored at their pregnancy times. Here, the independent censoring assumption is implausible, because the event of interest (HIV infection) and censoring (where due to pregnancy) share a common cause of unprotected sexual intercourse. This study showed that of three apparent predictors of HIV infection (age, alcohol consumption, mobility), only age could robustly be inferred to be a useful predictor. This method is widely applicable for sensitivity analyses.
Stratified medicine BSU provides statistical expertise in stratified medicine, longitudinal modelling, clinical trials design, statistical genomics and subject-matter knowledge. June 2015 saw the official start of the MRC-funded MASTERPLANS Consortium in Systemic Lupus Erythematosus (SLE), involving BSU scientists Professor Vern Farewell, Dr Brian Tom and Dr Li Su. Its vision is to significantly improve clinical outcomes in SLE by increasing remission/low disease activity response rates to therapy through a stratified approach that relies on better understanding of key pathways and prognostic biomarkers. This adds to existing substantial portfolio of publicprivate partnerships in stratified medicine, which includes rheumatoid arthritis (RA-MAP Consortium), one of the most common auto-immune diseases in the world. 23
Health and nutrition research MRC Human Nutrition Research MRC Human Nutrition Research conducts nutrition research and surveillance to improve the health of the population, with a focus on cardiometabolic risk and obesity, musculo-skeletal health, intestinal function and nutritional vulnerabilities. Find out more at: www.mrc-hnr.cam.ac.uk
Nutrition and Bone Health
Nutrition Surveys and Studies
Professor Ann Prentice
Polly Page
Adolescence and skeletal health A 12 year follow-up of an RCT showed that calcium supplementation prepuberty in Gambian adolescent boys advanced the pubertal growth spurt, resulting in shorter stature but no lasting effect on bone mineral or bone size in young adulthood (J Clin Endocrinol Metab 2014:99:2169-3176). Lifecourse data from the MRC National Survey of Health and Development demonstrated the influence of adolescence growth patterns on skeletal health at age 60-64 years (J Bone Miner Res 2015: 29 123-133). These studies add to our previous research showing the importance of longitudinal and lifecourse studies to identify determinants of bone health in adolescence and later life.
Vitamin D requirements in pregnancy and old age As consortium partners in two UK-based RCTs of vitamin D supplementation on bone health in pregnancy (MAVIDOS, led by MRC Lifecourse Epidemiology Unit, Southampton) and old age (VDOP, led by the University of Newcastle) we finalised the sample collection and analysis to determine the supplement effect on vitamin D status and related biochemistry. These trials will provide robust evidence on whether there is a need for vitamin D supplementation in these vulnerable groups.
Iron deficiency and phosphate metabolism Studies in Gambian children have demonstrated an unexpected link between poor iron status and raised fibroblast factor-23, a key hormone involved in phosphate regulation that has been implicated in the aetiology of non-vitamin D deficiency rickets in our previous studies (Endocrine Connections 3:1-10). This shows that iron status needs to be considered in disorders of phosphate metabolism.
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The National Diet and Nutrition Survey Rolling Programme (NDNS RP) is the only source of reliable data on nutritional intake and status for the UK population. As scientific lead, we have coauthored four government reports presenting headline results from Years 1 to 4, 2008-2012 (combined results) for the UK overall, Scotland, Northern Ireland, and on blood folate results. At our laboratories we have also developed the international goldstandard mass-spectrometric research method for measurement of serum folate, thus bringing the UK in line with recommendations of the 2008 international expert workshop that blood folate analysis in the UK should move to research methods selected as providing the most accurate quantitation possible.
www.iph.cam.ac.uk
Maternal and Child Nutrition Group: Research grant success Dr Sophie Moore
Creating brain function for age reference curves: in collaboration with Professor Clare Elwell (UCL). A prospective infant cohort study of functional neuro-imaging, growth, behavioural and sociodemographic measures in UK (Cambridge) and Gambian infants from birth to 24 months of age has been funded by the Bill and Melinda Gates Foundation, led by Dr Sophie Moore in collaboration with Professor Clare Elwell (UCL), Dr Sarah Lloyd Fox (Birkbeck), Dr Topun Austin (Evelyn Perinatal Imaging Centre, Addenbrooke’s) and the MRC Unit The Gambia. The acquired data will be the first longitudinal dataset of functional neuroimaging from birth and matched between two diverse population groups. The choice of the functional neuroimaging paradigms has been specifically designed to gather data on a range of cognitive domains and functional connectivity, and enable the calculation of brain function-for-age reference curves. These curves will be used to establish typical and atypical trajectories of neurocognitive development in UK and Gambian infants. The impact of faltering early growth on neurodevelopmental trajectories will be assessed within the Gambian cohort. The results generated by this project will enable the identification of critical windows for developmental delay and guide future proof of concept interventions to protect the at risk brain and reduce long term neurological deficit.
Metabolic and lipodomic applications Dr Jules Griffin, Lipid Profiling and Signalling Group
Lipodomics - the large-scale study of pathways and networks of cellular lipids in biological systems – is a fast expanding field within systems biology. One of the major advantages of measuring metabolites including lipids – the intermediates and products of metabolism - is that they are influenced both by disease and diet. Thus, for diseases where diet has a profound impact such as cardiovascular disease and type 2 diabetes, one can use an individual’s metabolic profile to understand how the environment, and in particular diet, interacts with disease risk. While metabolomic and lipidomic tools have been demonstrated to provide novel insight in small intervention studies, there is a significant analytical challenge to taking these tools to the epidemiological scale. This past year the Lipid Profiling and Signalling group led by Dr Jules Griffin have seen their method development in metabolomics come to fruition in terms of application to population science. In conjunction with the MRC Epidemiology Unit and the Department of Public Health and Primary Care, using Gas chromatography to measure the fatty acid content of phospholipids, we have analysed over 40,000 individuals in the EPIC Interact, EPIC Heart and EPIC CVD sub-cohorts of EPIC, providing insight into how diet interacts with risk of developing type 2 diabetes and cardiovascular disease. However, such approaches ignore the exact molecules these fatty acids are associated with, and to address this we have used direct infusion high resolution mass spectrometry to directly profile intact lipids in blood plasma, applying this approach to the Fenland (Wareham and colleagues) and PROMIS (Danesh and colleagues) cohorts. This has identified triacylglycerols with shorter, more saturated fatty acids as being associated with fatty liver disease and increased risk of type 2 diabetes. This analysis can be performed in less than 3 minutes and is ideal for large epidemiology studies. In addition, we added a new metabolomic analysis pipeline to our epidemiological toolkit with the adoption of the Biocrates p180 plate technology. Applying this to the Fenland cohort we have analysed over 11,500 individuals for 180 metabolites that cover core metabolism, including amino acids, sugars, phospholipids and TCA cycle intermediates.
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Making the most of health innovations PHG Foundation Dr Hilary Burton
As a multidisciplinary policy unit with a strong grounding in public health, the PHG Foundation’s mission is to help policy and decision-makers deliver the benefits of genomics and life sciences for every citizen. In the rapidly evolving world of healthcare, our strategic priority is to support the development and delivery of effective, sustainable and more personalised healthcare. We aim to do this by grasping the potential of new technologies; thinking differently about healthcare; and shaping the policy debate. Read more about the Foundation’s work at: www.phgfoundation.org
Using genomics to improve infectious disease control
examining their potential impact on health services, including financial implications. Our expanding health economics function is also contributing to various BRC projects with the evaluation of clinical genome sequencing in different health service contexts.
Infectious diseases are an ever-present health burden, thought to cost £30 billion each year in England alone. Genome sequencing can potentially improve detection and management by allowing faster and more precise characterisation of pathogens (viruses and bacteria) that cause disease than traditional methods, and is already being used to investigate outbreaks and healthcare associated infections. A major programme of research under the auspices of the Cambridge Biomedical Research Centre (BRC) has allowed us to examine this potential.
Understanding all the barriers and drivers for effective translation from research into practice is crucial to deliver patient benefit from scientific innovations. Our BRC work on infectious diseases is further supported by ethnographic research examining case studies on clinical genome sequencing (to investigate outbreaks of MRSA, Legionnaires’ disease and tuberculosis), with a view to developing a novel methodology of translation. We are also examining the engagement of children in research, and of women in the Pregnancy Outcome Prediction Study.
Our strategic review of the microbiological and public health applications of genomics, Pathogen Genomics Into Practice, identifies the steps needed for effective and equitable national use. It includes a policy roadmap for Public Health England, NHS England and the Department of Health, outlining actions needed for service implementation and delivery of pathogen genomics in the short term, and subsequent innovation and expansion.
Optimising healthcare genomics Making the most of genomics is an ongoing theme. Our report Realising Genomics in Clinical Practice highlighted important ethical, legal, social and practical issues and made policy recommendations to maximise benefits and minimise potential harms for patients. We have been developing standards for effective data sharing in partnership with the Association for Clinical Genetic Science. The complementary Clinical Genome Analysis project has seen us work closely with experts to explain this complex clinical tool for wider audiences, including challenges to successfully embedding within health services.
Supporting informed policy development and clinical translation With a new focus on public affairs, we have set up and provide the secretariat for a new All Party Parliamentary Group on the application of innovative bioscience and technology in healthcare, which is chaired by Lord Norman Warner and Jo Churchill MP. We continue to provide guidance on new technologies for policy-makers,
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www.iph.cam.ac.uk Our pioneering Mainstreaming Genomics work, aimed at growing excellence within different medical specialties, has gained further impetus with the formation of a collaborative working group with the Royal College of Physicians and the Health Education England genomics programme and release of a collection of new resources for different medical specialities. Focusing on the 100,000 Genomes Project itself, we are leading the Clinical Evaluation and Implementation sub-domain of the Genomics England Clinical Interpretation Partnership (GECIP) domain. For this, we shall be working with research leaders to learn crucial lessons about the effective implementation of genomics within clinical services, including our development and analysis of novel health economics approaches to assessing their costs and benefits.
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Delivering health intelligence Public Health England Drs John Battersby, Sian Evans, and Julian Flowers
Public Health England (PHE) is the executive agency, sponsored by the Department of Health, to protect and improve the nation’s health and well-being, and reduce health inequalities.
Regional Knowledge and Intelligence
Health Wales and before that Director of Public Health in Suffolk, Professor Bradley will be undertaking this national role in PHE from the Cambridge base. Other changes in 2014/15 included the appointment of Dr Julian Flowers as PHE’s Head of Public Health Data Science. Dr John Battersby is now PHE’s lead for training and workforce development in health knowledge and intelligence. He will have a particular focus on developing the 1,000 or so knowledge and intelligence staff across PHE and local government, ensuring that they are ready to grasp the challenges of new advances in information management and analysis. Dr Sian Evans continues to lead PHE’s local Knowledge and Intelligence service in the East of England.
PHE’s regional Knowledge and Intelligence Team (KIT East) is based at the Cambridge Institute of Public Health. It provides Information and insight from data to improve health. Keep up to date with our health intelligence work at: fingertips.phe.org.uk
New leadership 2014/15 saw the appointment of Professor Peter Bradley as PHE’s Director of Knowledge and Intelligence. Formerly Executive Director of Public Health Development at Public
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www.iph.cam.ac.uk Fingertips data platform
specialist training for analysts as well as a pilot workshop evaluation in public health, to be provided by Dr Louise Lafortune, from the School for Public Health Research team at the Institute.
There has been further development of the national Fingertips data platform which now provides monthly updates of health indicators supporting 20 different health profiles. The award-winning Longer Lives platform has also expanded and now includes data on premature mortality, diabetes, high blood pressure, alcohol and drugs and NHS Health Checks. There are plans to further improve and streamline the indicator production process in 2015/16.
Update on analytical work Analytical work completed during the year, under the leadership of Head of Information, Vittoria Polito, has included a deep dive review of the rate of mortality due to communicable disease, investigation following concerns of possible cancer clusters, monitoring of flu and hospital activity over the winter period and support for the national campaign on breathlessness. Work is underway to refresh the modelled catchment populations for acute hospital trusts and to analyse the most common operative hospital procedures to support healthcare commissioning.
East of England awards The East of England Intelligent Working Awards demonstrated the wide range of ways PHE national data products are being used locally. The award, which was open to anyone outside of PHE working in the East of England area, called for examples of how PHE knowledge and intelligence products and resources were being used to change practice and improve health locally. First prize winner was Wayne Thompson and the team at Luton Borough Council whose entry ‘r u down with the kidz’ described the use of a range of PHE data tools in the development of local school health profiles.
Individual responses to Ebola crisis Members of the local team have been supporting PHE’s international response to the Ebola outbreak in West Africa. Laura Philpott, from the East of England National Drug Treatment Monitoring Service, worked in the National Incident Centre in the UK. Julia Yelloly, from the local knowledge and intelligence team, travelled to Sierra Leone to work in one of the three PHE laboratories established there.
Sharing good practice Providing local support in the use and interpretation of nationally produced data tools and products is a key role. 2014/15 saw the strengthening of the knowledge transfer function within the local knowledge and intelligence service. Helen Knowles, former Head of Population Health with Bedford and Central Bedfordshire Council, was appointed as Principal Knowledge Transfer Facilitator to lead on providing local input into the development of national products as well as working with local users of the resources. 2015/16 has seen the launch of the East of England data tools and user forum to review and share good practice in using data tools.
Learning Disability The Learning Disabilities Health Intelligence network undertook two national surveys of local authority and health service care, one of services for people with learning disabilities (Glover, G., Joint Learning Disabilities Health and Social Care Self-Assessment Framework 2014), the other of services for people with autism. In addition to this we published a major study of the use of psychotropic medication in people with learning disabilities (Glover, G. PHE Gateway number: 2015105). This demonstrated disturbingly high levels of the use of antipsychotic medication in the absence of appropriate clinical indications. This work has led to the setting up of an NHS England Call to Action led by the Chief Pharmacist Keith Ridge to address this problem.
It is important that the public health workforce have the core knowledge and skills needed to be able to understand and act on health data and the KIT East provide a range of learning opportunities to develop these skills. The foundation level training in health intelligence for non-analysts has recently been revised and relaunched as a one day course. Plans are also underway to provide more
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Members Department of Public Health and Primary Care, University of Cambridge (John Danesh)
Medical Research Council Units
––Behaviour and Health Research Unit (Theresa Marteau)
––MRC Human Nutrition Research Unit (Ann Prentice)
––MRC Biostatistics Unit (Sylvia Richardson)
Health policy think tank
––Cambridge Centre for Health Services Research (Martin Roland, Jon Sussex)
––PHG Foundation (Hilary Burton)
––Cardiovascular Epidemiology Unit (John Danesh)
Public Health England Units
––Centre for Cancer Genetic Epidemiology (Doug Easton, Paul Pharoah)
––East of England Field Epidemiology Unit (Mark Reacher) ––The National Cancer Registration Service Eastern Office (Jem Rashbass)
––Clinical Gerontology Unit (Kay-Tee Khaw) ––NIHR Biomedical Research Unit in Donor Health and Genomics (John Danesh)
––PHE Knowledge and Intelligence Team East (Julian Flowers)
––Nursing Research Group (Christi Deaton)
Cross departmental programmes at the Institute
––Primary Care Unit (Jonathan Mant) ––Public Health, Ageing and the Brain (Carol Brayne)
MRC Epidemiology Unit, University of Cambridge (Nick Wareham)
––Cambridge Biomedical Resource Centre – Evaluation and Implementation Theme (Carol Brayne, Hilary Burton, Martin Roland)
––UKCRC Centre for Diet and Activity Research (Nick Wareham)
––Cambridge Biomedical Resource Centre – Population Science Theme (John Danesh, Nick Wareham) ––NIHR CLAHRC East of England (Carol Brayne, Peter Jones) ––NIHR School for Public Health Research (Cambridge hub: Carol Brayne)
Publication date: October 2015 Edited by: Lucy Lloyd Designed by: Dip Creative 30
Governance
www.iph.cam.ac.uk
The Cambridge Institute of Public Health is an institution within the Faculty of Clinical Medicine at the University of Cambridge.
Director The Director is the administrative head of the Institute, responsible for the direction of public health study and research here. Professor Carol Brayne was reappointed in 2012 for a second five year term.
Executive Committee The Institute is steered by the Executive Committee Professor Carol Brayne, Director of Cambridge Institute of Public Health
Dr Paula Frampton, PublicHealth@ Cambridge Network Coordinator
Professor Theresa Marteau, Director of Behaviour and Health Research Unit
Dr Hilary Burton, Director of PHG Foundation
Dr Christine Hill, Deputy Director CLAHRC East of England
Professor John Danesh, Head of the Department of Public Health and Primary Care
Mr Keith Hoddy, Business & Operations Manager
Professor Ann Prentice, Director & Head of the Nutrition and Bone Health Group
Professor Douglas Easton, Director of the Centre for Cancer Genetic Epidemiology Dr Julian Flowers, Director of the Eastern Knowledge and Intelligence Team, Public Health England
Professor Kay-Tee Khaw, Professor of Clinical Gerontology Ms Lucy Lloyd, Communications Manager Professor Jonathan Mant, Head of the Primary Care Unit
Dr Mark Reacher, Consultant Epidemiologist, Eastern Field Epidemiology Unit, Public Health England Professor Sylvia Richardson, Director of the MRC Biostatistics Unit Professor Martin Roland, Professor of Health Services Research Professor Nick Wareham, Director of the MRC Epidemiology Unit
Committee of Management The Committee was inaugurated in 2014 to promote research and teaching in the field of public health. Professor Carol Brayne, Director of Cambridge Institute of Public Health Dr Caroline Edmonds, Secretary to the School of Clinical Medicine, University of Cambridge Professor Bernie Hannigan, Director of Research & Development, Public Health England Professor Peter Jones, Deputy Head, School of Clinical Medicine, University of Cambridge
Professor Stefan Scholtes, Dennis Gillings Professor of Health Management, University of Cambridge Judge Business School Professor Pim van Gool, Professor of Neurology at the Academic Medical Centre (AMC), University of Amsterdam Professor Cyrus Cooper, Director of the MRC Lifecourse Epidemiology Unit, University of Southampton
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Ms Sue Dunkerton, Director of the Knowledge Transfer Network, Innovate UK Dr Tony Jewell, Chair of Wales for Africa Health Links Network, Former CMO Wales Dr Catherine Goodall, Interim Centre Director, Public Health England Dr Liz Robin, Director of Public Health, Cambridgeshire County Council
Our overarching mission is to improve the public’s health, using our research, teaching and analysis to promote well-being, prevent disease and reduce health inequalities. For more information about any aspect of our work, please get in touch:
Cambridge Institute of Public Health University of Cambridge School of Clinical Medicine Forvie Site Cambridge Biomedical Campus Cambridge CB2 0SR 01223 330300 www.iph.cam.ac.uk @InstPubHealth