Hospitals in England are expected to perform a public health function for the communities they serve. Abraham George and colleagues explain how hospitals can increase their capacity to do so
In the North West, Stockport foundation trust and Wirral University Teaching Hospital foundation trust have well-established consultant-led public health departments, which offer placement opportunities for public health trainees, junior doctors and nurses.
Here, we describe how these departments’ public health work has contributed significantly to improved health and healthcare.
Health-promoting hospitals are advocated under the World Health Organisation’s 1986 Ottawa Charter for Health Promotion. They also appear in Choosing Health, which encourages health professionals to give advice on smoking, diet, exercise and other risk factors; to improve patient empowerment; and to foster links with primary care trusts, external agencies and other professional groups.
Developing a public health strategy
Since Wirral gained its health-promoting hospital status in 2006, it has been exploring how it can play a greater role in promoting health and well-being among staff, patients, visitors and the community of Wirral.
Its public health unit has helped bring managers and frontline staff together to map existing work and share ideas for development. Work is being undertaken with occupational health and other partners to explore how to promote a healthier lifestyle to staff. The trust is also developing its corporate citizenship agenda to increase its positive impact on the local community.
An evidence-based approach using epidemiological methods is central to changing clinical practice and clinical decision-making. Service audits and healthcare evaluation use a host of core public health skills, such as statistics, economic evaluation, critical appraisal, change management and project management.
Wirral is a first-wave site for this national programme in the North West and its public health unit has played a key part in its implementation. The aim of the programme is to drive up the quality of care and to reduce readmission, mortality, complications and lengths of stay by rewarding trusts for providing consistent, evidence-based, high-quality care.
Hip fracture audit
Hip fracture is a common but serious injury that mainly occurs in elderly people. Care is costly and often complex, involving different specialties and professions, particularly orthopaedics, physiotherapy and occupational therapy. Stockport’s public health unit currently leads the conduct and design of this unique audit, whose group membership has increased from two acute trusts in 2001 to 12 in 2007.
Surveillance and monitoring
Communicable and non-communicable disease surveillance is a core public health function. While rates of healthcare-associated infections are routinely monitored by microbiology, overall hospital mortality and morbidity rates also need to be monitored using specially and routinely collected data from internal and external sources.
Misdiagnosis or miscoding?
In 2008, Stockport’s public health unit carried out several studies to investigate possible excess mortality in patients with probable acute coronary syndromes.
The first study was a retrospective case note audit on patients with non-specific chest pain. The second was a short case note review in response to an alert from Dr Foster Intelligence concerning a higher than expected number of deaths among patients admitted with diagnoses of coronary atherosclerosis and other related diseases in 2007.
The results of the two studies raised concerns about ever-changing guidelines for diagnosis and management of cardiovascular and other chronic diseases. Deficiencies in training and documentation in patient case notes had led to coding errors and erroneous production of clinical indicators, which affected patient safety and quality and led to a potential loss of income to the trust.
As a result, a trust-wide effort was initiated to improve coding processes through improved joint working between coding staff and clinicians.
The implementation of National Institute for Health and Clinical Excellence guidance should be led by a suitable clinician, manager or public health practitioner focusing on key aspects such as:
disseminating guidance to key groups;
ensuring compliance with the core and developmental standards;
ensuring that effective audit and monitoring arrangements are in place;
ensuring that effective planning occurs.
Enhanced recovery after surgery
The enhanced recovery after surgery programme is about improving patient outcomes by speeding up recovery after surgery. This is achieved through patient education, peri-operative enhanced nutrition and early mobilisation.
Stockport’s public health unit was asked by the division of surgery to evaluate a pilot study investigating the feasibility and effectiveness of introducing the programme across different surgical specialties.
Once the evaluation is completed, analysis and comparison of outcomes will be made to inform change in surgical practice and guidelines.
NICE public health guidance
As the development of NICE public health guidance continues, acute trusts have to consider their role in the wider public health agenda. The unit at Wirral works with partners to ensure guidance is implemented. A monitoring tool has been developed and implemented which has been adopted by the local PCT and another trust. Recently, recommendations on maternal and child nutrition have been developed. These will be reflected in Wirral’s public health strategy.
Assessing local needs
A public health-led health needs assessment of the local community will make decision-making in secondary care service planning more objective and explore issues such as equity of access and quality, especially for vulnerable/deprived groups. This will ultimately reduce health inequalities.
Services for COPD patients
Chronic obstructive pulmonary disease encompasses a spectrum of respiratory diseases. It is responsible for a large proportion of hospital admissions during winter and is a major cause of mortality.
In 2007, Stockport’s public health unit and respiratory medicine department worked together to collect and analyse data on patterns of admissions, deaths, treatment compliance and performance over a 10-year period. They also collected staff opinions on the service’s quality and accessibility.
Results indicated that the trust’s performance on key outcome indicators was average. Nevertheless, there remained a perception among frontline staff that there was still room for improvement, especially for supportive community care for patients who did not live in Stockport.
Our conclusions and recommendations were discussed with senior managers to help us form better links with primary care and secure additional funding for service reconfiguration.