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York Health and Wellbeing Board |
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Health and Wellbeing Board |
17 November 2021 |
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Report of the Director of Public Health |
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Health Protection Assurance report
1. Summary
This report provides an update on health protection responsibilities within City of York Council and builds on the report from July 2018.
Health and Wellbeing Boards are required to be informed and assured that the health protection arrangements meet the needs of the local population.
2. Background
The scope of health protection is wide ranging. The system responsibilities for Health Protection changed on 1 October 2021 and these are outlined in Annex 1.
The scale of work undertaken by local government to prevent and manage threats to health will be driven by the health risks in the Local Authority area and includes:
· National programmes for vaccination and immunisation
· National programmes for screening, including those for antenatal and newborn; cancer (bowel, breast and cervical); diabetic eye screening and abdominal aortic aneurism screening
· Management of environmental hazards including those relating to air pollution and food
· Health emergency preparedness and response, including management of incidents relating to communicable disease (e.g. COVID-19) and chemical, biological, radiological and nuclear hazards
· Infection prevention and control in health and social care community settings
· Other measures for the prevention, treatment and control of the management of communicable disease as appropriate and in response to specific incidents.
Main/Key Issues to be considered
3. Sexual Health.
The two PHOF (Public Health Outcomes Framework) indicators for sexual health are Chlamydia detection rate and late diagnosis of HIV. For both these indicators York is worse than the England average. HIV England 43.1%, Yorkshire and Humber 51.3%, York 57.9% of HIV cases which are diagnosed late. Chlamydia rate per 100,000 population; England average 1420, Yorkshire & Humber 1498, York 1107.
The commissioned sexual health service continues to try to reverse this trend taking lessons learned and examples of good practice from national and local services.
In the last year the Chlamydia Care Pathway tool has been implemented in line with Public Health England guidance (PHE) to support comprehensive case management. This has 4 main areas of Increasing testing uptake, detecting infections, treatment and partner notification and management.
This year PHE (as was) has undertaken an evidence review of the National Chlamydia Screening Programme (NCSP) and has recommended some changes to the programme based on input from national and international experts and consultation with stakeholders and service users. Our commissioned providers – YorSexualHealth- will support these changes locally.
Comparing data from January to June 2019 and the same period in 2020 there was a 30% reduction in tests for chlamydia, gonorrhoea and syphilis and a 35% reduction in HIV at SHSs.
Between January and April 2020, the reduction in chlamydia testing was greater among specialist SHSs (85%) than in non-specialist SHSs (56%), largely due to the higher proportion of internet-delivered tests offered
Data taken from[1]PHE report.
4. Late HIV diagnosis.
It is worth noting that the data is over a 3 year period for the late HIV diagnosis. Due to the low number of cases, data swings hugely year on year.
Sexually Transmitted Infections (STI) detection rates in York (excluding Chlamydia 15-24 year olds) have improved and are better in York than the England and Regional average (Eng. 619, Y&H 419 and York 378 /100,000 population in 2020). Although late diagnosis of HIV remains a concern in York, this is reflected across the region.
There are fewer HIV diagnosis in Men who have Sex with Men (MSM), possibly due to the take up of Pre-Exposure Prophylaxis treatment (PrEP), as more MSM are using PrEP there are fewer cases in those that see themselves at risk and test regularly.
Late diagnosis of HIV is now mainly seen in individuals who would not be in a clinically higher risk population although recent PreP Impact Trials show that some groups share vulnerabilities which increases their risk of HIV and amplifies their need for, and access to, PrEP. Societal experience or complex environments may make it difficult to negotiate sex (such as housing insecurity, poverty, gender-based violence) or access services due to stigma or transphobia. The trial also recognised that there is an inequity in PrEP uptake in women, trans, non-binary, BAME and heterosexual men. Regional work is planned to look at how these inequalities can be addressed
5. The COVID effect.
There is strong evidence that the COVID-19 pandemic response, including social and physical distancing measures, led to a re-prioritisation and disruption in provision of, and patient access to, sexual health services. Several studies have that indicated during the pandemic there was a significant disruption to services and re-deployment of staff. There have also been reports of disruption to supplies of laboratory consumables due to increased demand which have impacted on testing service capacity.
It is likely there has been some reduction in infections and service need following compliance with social distancing measures, resulting in fewer opportunities for travelling and meeting sexual partners and reduced risk of exposure suggests there was a decline in risky behaviours during this period that may have contributed to the fall in diagnoses.
6. Immunisations and Vaccinations.
The table below shows the PHOF immunisation and Vaccination data where York is not in line with England or Y&H rates.
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PHOF Indicator |
England |
Yorkshire and the Humber |
York |
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MMR 2 doses (5 years). Target >95% (2019/20) |
86.8 |
89.8 |
89.5 |
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Flu primary school aged vaccination (2019) |
60.4 |
60.8 |
55.0 |
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HPV Vaccinations – 2 doses (13/14 years) female. Target >90% (2019/20) |
64.7 |
71.9 |
53.0 |
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Flu vaccinations for at risk individuals. Target >75% (2019/20) |
44.9 |
45.0 |
44.3 |
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Shingles Vaccination (71 years). Target >60% (2018/19) |
49.1 |
51.4 |
47.7 |
· MMR2 – By five years of age York is above the regional and national average for MMR1 with an uptake of 96%. However MMR2 still remains stubbornly below the national target, this may be due to a number of factors including parents not seeing the value of two vaccinations and delay in MMR1 uptake.
· Primary age flu – Provisional monthly data for Primary age Flu (September 2020 to 31 January 2021) indicated that this has risen to 74.9 in York whilst remaining fairly static for both the regional and England average.
· HPV – Human Papilloma Virus. Covid impact on school closures, pupils not being in school when the team attended, together with schools reluctance to have visiting teams in school have all had an impact on uptake. Work continues to mitigate against the low up take with a programme of catch up clinics and this has been further supported by a more favourable response from schools.
· Flu vaccination for at risk individuals. All local authorities across the Yorkshire and Humber Region and the England average were below the national target for this cohort. These again were the individual who were shielding as part of the COVID outbreak measures and this may have had an impact on this cohort.
· Shingles. The Shingles vaccination programme was affected severely due to the target group also being those who were shielding during the COVID-19 pandemic and not wanting to attend GP surgery.
7. Influenza.
The 2020/2021 influenza vaccination was the biggest vaccination programme ever, aiming to offer protection to as many eligible people as possible during the coronavirus (COVID-19) pandemic.
As a result of non-pharmaceutical interventions in place for COVID-19 (such as mask-wearing, physical and social distancing, and restricted international travel) influenza activity levels were extremely low globally in 2020 to 2021. A lower level of population immunity against influenza is expected in 2021 to 2022. In the situation where social mixing and social contact return towards pre-pandemic norms, it is expected that winter 2021 to 2022 will be the first winter in the UK when seasonal influenza virus (and other respiratory viruses) will co-circulate alongside COVID-19.
Seasonal influenza and COVID-19 viruses have the potential to add substantially to the winter pressures usually faced by the NHS, particularly if infection waves from both viruses coincide. The timing and magnitude of potential influenza and COVID-19 infection waves for winter 2021 to 2022 are currently unknown, but mathematical modelling indicates the 2021 to 2022 influenza season in the UK could be up to 50% larger than typically seen and it is also possible that the 2021 to 2022 influenza season will begin earlier than usual.
Influenza vaccination is therefore an important priority this coming autumn to reduce morbidity and mortality associated with influenza, and to reduce hospitalisations during a time when the NHS and social care may also be managing winter outbreaks of COVID-19.
8. Flu by group
The national influenza immunisation programme aims to provide direct protection to those who are at higher risk of influenza associated morbidity and mortality. Groups eligible for influenza vaccination are based on the advice of the Joint Committee on Vaccination and Immunisation (JCVI) and include older people, pregnant women, and those with certain underlying medical conditions.
Since 2013, influenza vaccination has been offered to children in a phased roll-out to provide both individual protection to the children themselves and reduce transmission across all age groups to protect vulnerable members of the population.
The expanded influenza vaccination programme that was introduced last year will continue in 2021 to 2022 as we are likely to see both influenza and COVID-19 in circulation. This means that the following additional cohorts will be included:
· 50 to 64 year olds will continue this year to protect this age group, as hospitalisation from COVID-19 also increases from the age of 50 years onwards.
· all those from years 7 to year 11 will be offered vaccination.
Details those eligible for NHS Influenza vaccination in 2021/2022 is outlined in Annex 2.
The table below gives the number of individuals who are eligible for a free flu vaccination, the numbers vaccinated and the percentage for Vale of York CCG in 2020.
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Cohort Name |
Count of Individuals |
Vaccinated |
% Vaccinated/Individuals |
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0 to 15 at risk |
1,655 |
1,148 |
69.37% |
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16 to 17 at risk |
483 |
257 |
53.21% |
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18 to 64 at risk |
31,691 |
19,996 |
63.10% |
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2-3 year olds |
6,531 |
4,563 |
69.87% |
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50 - 64 year olds |
72,749 |
36,389 |
50.02% |
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65 + at risk |
34,552 |
30,603 |
88.57% |
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65 + not at risk |
38,172 |
30,764 |
80.59% |
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NHS and social care Worker |
8,585 |
1,809 |
21.07% |
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Other - 0 to 17 |
691 |
691 |
100.00% |
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Other - 18 to 49 |
7,286 |
7,286 |
100.00% |
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Other - 50 to 64 before 1st Dec |
0 |
0 |
0.00% |
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Pregnant women |
1,516 |
249 |
16.42% |
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School age children reception to year 7 |
29,605 |
20,324 |
68.65% |
9. COVID-19
In January 2019 York saw the first case of COVID-19 in the country, since then the councils statutory Public Health functions have been developed around an Outbreak Management Plan and the establishment of an Outbreak Management Advisory Board (OMAB). The membership of the board is wide ranging and includes members of staff from within CYC and associated partners from statutory, private and voluntary sectors.
OMAB ensures that the statutory bodies are able to make informed decisions throughout the pandemic by building on good practice, identifying and supporting the resolution of any barriers and making the most of any opportunities that may arise including outbreak management, Test and Trace and supporting effective communication.
10. Overview of COVID response in York.
The numbers of COVID cases per 100,000 population changes daily and is available on York Open data. This platform also shows vaccination rates:
Vaccinations for People aged 16+ (1st and 2nd dose)
• As at 20.10.21 a total of 153,290 CYC residents aged 16+ have had the first dose of the vaccine. This represents 86% of the estimated (16+) population of York (ONS 2020)
• As at 20.10.21 a total of 143,988 CYC residents aged 16+ have had both doses of the vaccine. This represents 80.8% of the estimated (16+) population of York (ONS 2020).
Vaccinations for People aged 12-15 (1st dose only)
• As at 20.10.21 a total of 873 CYC residents aged 12-15 have had the first dose of the vaccine. This represents 10.4% of the estimated (12-15) population of York (ONS 2020)
11. Health Care Acquired Infections (HCAI’s)
To support the management and prevention of Health Care Acquired infections (HCAIs) a multi-disciplinary partnership group, chaired by Public Health meets regularly to:
· Through a multi-agency approach, manage Healthcare Associated Infection (HCAI) across the healthcare system aimed at the consistent reduction of all HCAI in the population of the Vale of York.
· Ensure that lessons for preventing future HCAI are learned from the review of current and previous cases.
· Ensure the lessons are shared across all sectors of healthcare
· Ensure completion of identified actions to implement the learning from these reviews.
Notification, outbreaks and deaths associated with Clostridium difficile (C.Diff or C.Difficile or CDI) and methicillin-resistant Staphylococcus aureus (MRSA) are all investigated in line with the CCG Serious Incident policy via a Root Cause Analysis (RCA) or Post Incident report (PIR). The group makes recommendations for improvement, disseminates and demonstrates the learning for these investigations by illustrating common root causes, themes and trends.
The group examines antibiotic prescribing across primary and secondary care and makes recommendations to improve practice in line with prescribing guidelines.
12. Oral Health
PHOF data shows that York, compared with England average has poorer access to dental services (England 94.7% successful access, York 92.5%). York has a slightly better outcome for visible dental decay in 5 year olds in comparison to the England average (England 23.4%, York 18.9%)
Oral diseases are the most prevalent non-communicable diseases (NCD) which cause mortality and disability worldwide. During the pandemic the severity of the impact of NCD is associated with the severity and positive rates of COVID-19 indicating that prevention and control of NCD are integral parts to the COVID response, NCDs are predicted to rise due to the prioritisation of COVID[2].
A global ban on elective dental procedures during the pandemic has had a strong impact on public oral health and oral health quality of life.[3] The impact of this is a deterioration of health promoting behaviours especially in the lower socio-economic groups where financial impacts of COVID has resulted in people not seeking dental treatments. Therefore public health and partners are working on oral health promotion messages to encourage good dental hygiene and care.
CYC Public Health chair the Oral Health Improvement Advisory Group (OHAIG) which is a multi agency meeting bringing together a wide range of partners and stakeholders to look at interventions and actions to promote the reduction in oral disease and dental decay.
13. Screening:
The NHS provides five national screening programmes for adults: abdominal aortic aneurysm (AAA), diabetic eye, Bowel cancer, breast cancer and cervical cancer. The COVID-19 pandemic and subsequent lock downs resulted in all programmes being significantly affected as they were temporally suspended during the early stages of the pandemic. Other factors which affected uptake was the inability or unwillingness of invitees to take part due to shielding, anxiety regarding overburdening the NHS and fear of the COVID virus.
Work is taking place to encourage people to come forward for screening and to assure people that the NHS, who deliver the screening programmes, is ‘open for business’. CYC public health work with partners to target communications for those screening programmes where targets are not being met.
Some comparative data for screening programmes is not available over the period of the pandemic.
· AAA – Abdominal Aortic Aneurysm. In England, screening for AAA is offered to men during the year they turn 65. Men aged 65 or over are most at risk of getting AAAs. For North Yorkshire and the Humber the percentage screened was 92.8% in 2020/21.
· Breast - Routine breast screening was paused on 24th March 2020 due to the coronavirus (Covid19) pandemic. Throughout the pandemic the service continued to see high risk women and women that had positive screen results. Routine screening in the North Yorkshire and York restarted in August 2020. Unfortunately local service data is not available due to the impact of the pandemic on screening services.
· Bowel - NHS bowel cancer screening programme is available to everyone aged 60 or over. In 2021 the programme expanded to include 56 year olds. The data is collected via CCG on the proportion of men and women aged 60 to 74 who when invited to participate in bowel cancer screening do so. For Vale of York CCG this is 77.1%. This is above the performance threshold of 60%.
· Cervical – All women and people with a cervix aged 25 to 64 are invited to screening by letter. Data is recorded by CCG area and in two cohorts with the acceptable level of those screened adequately set at 80%. In Vale of York CCG women aged 25 to 49 reached 71.4% and women aged 50 to 64, 77.1%.
· Diabetic Eye - Diabetic eye screening is a test to check for eye problems caused by diabetes. People aged 12 or over and have diabetes are invited via letter to have their eyes checked annually. The North Yorkshire Screening service covers York and achieves a 78.7% attendance rate which exceeds the acceptable performance threshold of 75%.
14. Infection, Prevention and Control (IPC).
The Public Health team in CYC work with the CCG via a section 75 agreement for the provision of community and Primary care IPC. IPC for secondary care is the responsibility of York Hospitals Foundation NHS Trust and is delivered in house.
15. What we do well in York?
Health Protection encompasses a wider range of topics and agencies to ensure risks to the population are minimised, Partnership working is evident throughout with all those involved working to a common goal. This has been recognised in the recent Covid peer review attached as appendix A.
Working at regional level via the Screening and Immunisation Oversight Group (SIOG) and at a local level via Screening and Immunisation Team, working with CCG and multi-agency working for reduction of HCAI and anti-microbial stewardship.
In York there have been good levels of vaccination up take and the local covid response to care homes, school and business has been exceptional
Governance for Health Protection in York is well established, strong and robust. This was further strengthened throughout the pandemic as the Director of Public Health established the COVID Advisory Board and a multi- disciplinary Outbreak Management Group to respond to the pandemic locally, implementing government guidelines and responding to local need.
Wider governance of health protection sits with the York and North Yorkshire Health Protection Board (HPB) which is chaired by York Director of Public Health and has multi agency attendance to give assurance that measures are in place from the local authority and partner agencies to reduce the risk of harm to our population.
To complement this a York specific Health Protection Group has been established, led by the Nurse Consultant in Public Health, this group takes its strategic lead from the HPB providing practical and operational support to ensure the health protection arrangements within the City are robust.
16. Consultation
The writing of this report has included input from Emergency Preparedness Manager, Public Protection and Business Intelligence from CYC. Data on screening and Immunisation programmes has been provided by Screening and Immunisation Co-ordinator from Yorkshire and the Humber NHS England/Improvement.
17. Options
The Health and Wellbeing Board are asked to accept this report as an accurate representation of health protection assurance in CYC, noting the risks and implications detailed within.
18. Analysis
COVID-19 continues to be a major Public Health concern as the country moves into its first winter where COVID and seasonal flu will add further pressures on to the NHS. The spread of the more transmissible Delta variant drove a rapid growth in COVID-19 cases in England and these continue to rise to a point where we now have significantly more cases than this time last year.
Without the non-pharmaceutical measures that reduced transmission in 2019/20 (e.g. face coverings, social distancing, and lockdown measures) it is likely that influenza infections will continue to increase.
Recovery plan to resume and catch up on the back log of Immunisation and Screening continues at a pace with the introduction of measures to keep staff and patients safe.
The number of organisations reporting recruitment difficulties has increased for many employers, including the NHS as the King’s Fund report indicated[4]. Loss of skilled workers will have an impact on hospitals, community health provision, HCV drivers and the supplies of goods and medicines.
19. Strategic/Operational Plans
Good Health and Wellbeing for our population is a consistent theme that runs through all of our Strategic and Operational Plans. Public Health have been supporting communities, colleagues and partners throughout the pandemic to create resilient, well informed staff and citizens. From changing how our mandated services operated to ensure that access for our most vulnerable residents was maintained, to ensuring that testing, contact tracing and COVID vaccinations were accessible to all. The council plan acknowledges these responses to the pandemic and outlines how we will build back stronger, healthier and fairer to ensure York remains resilient to the on-going pandemic.
To support the response to the pandemic the Director of Public Health established a COVID Outbreak Management Advisory Board and a multi- disciplinary Outbreak Management Group to respond to the pandemic locally, implementing government guidelines.
20. Implications
There are no specialist implications from this report.
21. Risk Management
The immediate Health Protection priority is to continue to fight the COVID-19 pandemic. There is still a risk of new novel viruses and variants and these pose the most serious risk to global recovery. Building on the infrastructure developed for COVID there is still the need to tackle and prevent other infectious diseases and external health threats as we move into the ‘contain’ phase of the pandemic.
The pandemic exposed stark inequalities in our society and city. Understanding and influencing the wide range of factors that determine health outcomes and impacts on the most disadvantaged and tackling these remain a priority for Public Health in York.
Future funding of commissioned services remains a concern. Sexually transmitted infections (STIs) and unplanned pregnancy are amongst the most important contributors to poor health, particularly in the most deprived neighbourhoods. A recent study indicated that in the UK the proportion of unplanned pregnancies almost doubled during the pandemic[5].
Major service transformations have taken place locally in the face of significant cuts to the budget and further innovations and efficiencies are now limited without an increase in spending. The Long Acting Reversible Contraception (LARC) contract held with are CCG partners is a particular cause for concern as the demand for LARC increases post-pandemic and lack of resource within the contract to make the service a viable commissioned service.
Staffing capacity is a concern across the health economy, and this is particularly seen in sexual health and IPC clinical staff. Qualified clinicians with these specialist skills are a valuable resource and are in short supply affecting the delivery of these services.
City of York Councils Emergency Planning Team works with the North Yorkshire Local Resilience Forum and blue light services to manage and respond to major incidents and emergencies, this includes (but not limited to): terrorist threats, flooding and pollution.
22. Recommendations
The Health and Wellbeing Board are asked to receive the report.
Contact Details
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Report Authors: Philippa Press Public Health Specialist Practitioner Advanced
Anita Dobson Nurse Consultant in Public Health
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Chief Officer responsible for the report: Sharon Stoltz Director of Public Health
Approved: 05.11.2021
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Wards Affected: All
Annexes:
Annex 1: Location of PHE functions from 1 October 2021
Annex 2: Those eligible for NHS influenza vaccination in 2021 to 2022
Appendix A: LGA Outbreak Management Peer Challenge