Towards a Healthier Scotland :8

Towards a Healthier Scotland - A White Paper on Health

"Local councils are powerful allies of the NHS in collaborative action to improve health and tackle inequalities."

Chapter 6 Putting the Jigsaw Together

Role of Government

75. Individual health decisions are influenced by what people feel, hear and read and are usually taken well away from official channels or agencies. An inclusive approach is needed, recognising that the media and the settings of daily life - schools, workplaces, GP surgeries, leisure places - are important sources of information and motivation. In communities where health is generally poor and where other anxieties exist, health agencies must work alongside local community organisations. Health education and promotion may have little effect unless housing, employment, drug or community safety issues are also addressed, and levels of confidence and hope are lifted. Strong, healthy and safe communities - a key objective for this Government - are most likely to flourish where goals are shared, views are respected and people are part of new initiatives. Every part of the community has a contribution to make to better health. The challenge is to foster a healthy climate and ensure that local programmes are effectively co-ordinated.

76. The Government will provide clear leadership in the drive for improved health, working in close collaboration with the NHS, COSLA, the CBI, the STUC, the Health and Safety Commission, the proposed new Food Standards Agency and the voluntary sector. Steps are already in train locally and nationally to secure broad cross-cutting approaches which address local needs and reflect community views, transcend traditional service boundaries and focus on tackling inequality.

77. Worthwhile individual initiatives will have value added if they are part of a coherent programme with defined aims and outcomes, a theme echoed in many responses to the Green Paper. The Government fully recognise the need for national co-ordination of all initiatives with potential health benefits.

Action

A Public Health Strategy Group, led by the Minister for Health and drawn from all Scottish Office Departments, will ensure the integration of policies and initiatives with health implications within The Scottish Office, and encourage the use of Health Impact Assessment.

Role of the NHS

78. For the NHS in Scotland, the Priorities and Planning Guidance for 1999/2002, issued in September, 1998, has given fresh focus to its work. The Guidance re-emphasises that the prime aim of the NHS is to improve health, underlines the strategic imperative of tackling inequalities, and stresses the vital importance of securing the health of our children and young people.

79. To ensure that NHS resources are focused appropriately, the Minister for Health has established a wide-ranging independent review of the way in which health resources are shared out across Scotland. The review, due to report in June, 1999 and led by Professor Sir John Arbuthnott of Strathclyde University, is examining, among other factors, the effect of social deprivation on health need in the geographical allocation of resources.

80. Health boards, as public health organisations, are responsible for protecting and improving the health of their resident populations. The Government expect a lead from boards in achieving, throughout Scotland, the objectives for better health set out in this White Paper. As better health will come partly from social, environmental and economic improvement, this is not a job for boards alone. We look to them to work in concert with other parts of the NHS, local authorities and other public agencies, employers and trades unions, voluntary organisations and other local groups. Their role will be to champion, give a strategic lead, lead on some measures, support on others, and monitor health improvement across the piece.

81. We expect early local agreements between boards and local authorities which recognise the strong input both have to health improvement and which set out how local progress towards White Paper objectives will be made and monitored. We look to boards and local authorities to engage with other local partners and foresee that existing planning mechanisms, notably Health Improvement Programmes linked to Community Plans, will form the basis of this work. The new Ministerial Group on health, discussed in paragraphs 124 and 125, will ask to see regular evidence of effective local structures and progress.

82. In enabling boards to fulfil their role as public health organisations, Directors of Public Health and their colleagues in public health medicine have a critical role:

acting as a focal point when identifying needs, and planning and monitoring health improvement
influencing the development of healthy public policy with partner agencies and the strategic shaping of services utilising, amongst other things, Director of Public Health Annual Reports
using their role as designated medical officers in local authorities to strengthen links and to help ensure that health improvement is a key element of their plans
informing and influencing the management of healthcare to ensure that care is of the highest standard
strengthening initiatives within communities which help those with special needs to improve their health.

83. Health promotion specialists based in boards, NHS Trusts or locality teams have the expertise to guide the development of health promotion strategies, promote programmes in which communities take action to improve their own health, and evaluate the impact of such initiatives. There is also increasing recognition of the scope to enhance the role of nurses in the drive for improved public health and community development. In particular, health visitors, school nurses and practice nurses can draw upon the experience of local people in contributing to community responses to Government initiatives, such as healthy living centres and New Community Schools.

84. The key mechanism for identifying and addressing health needs in each health board area, urban and rural, is the annual Health Improvement Programme (HIP). In addition, boards continue to work with local authorities to co-ordinate the planning and implementation of health-related services and Government initiatives to tackle inequalities, such as Social Inclusion Partnerships.

85. Boards lead the HIP process in collaboration with NHS Trusts, clinicians, local authorities and others. HIPs cover all aspects of NHS activity which involve service development, disease prevention and health promotion. They ensure that the twin aims of health gain and reduced inequality permeate all parts of the NHS and provide a mechanism to harness and target resources to achieve the objectives of this White Paper. The NHS Management Executive is preparing guidance to help the Service respond to these challenges and will use its performance management processes to ensure that targets and agreed outcomes are achieved.

86. The Priorities and Planning Guidance for the NHS in Scotland for 1999/2002 states that each HIP should set out:

proposals to protect the public health, including emergency planning, and, in collaboration with local authorities, measures to safeguard the public health from communicable disease, including food-borne disease
proposals to promote health
proposals to analyse and tackle health inequalities
proposed service changes and development
plans to deliver waiting list targets
a programme to improve clinical effectiveness
plans to measure lifestyle changes in the short-term, and health gain in the medium-to-long term.

87. All parts of the NHS are expected to contribute to this agenda. It applies just as much to the acute sector where, for example, replacing the hip of an older person makes a substantial contribution to health gain, as to those services specifically related to health promotion and the prevention of ill-health. Primary care services have a key role in health improvement, the potential of which will be enhanced by the advent of Primary Care Trusts (PCTs) on 1 April, 1999. This change, coupled with the new working arrangements that are flowing from the White Paper, Designed to Care, will foster an environment in which staff from different disciplines can work together in the community to improve health and reduce health inequalities. With their combined local knowledge, skills and resources, PCTs with their local healthcare co-operatives and individual practices will be powerful agents for change in areas such as service delivery, screening, immunisation and health promotion.

88. Given its lead role in health improvement, the NHS must itself set an example by adopting policies to promote positive health and well-being in all settings and activities. HEBS has been piloting a framework with NHS partners to ensure that health promotion is an integral and sustainable part of healthcare, service delivery and organisational development. This framework will be implemented widely from 1999 onwards.

Review of Public Health Function

89. An expanded vision for improvement in public health requires that key professional resources are "fit for purpose". The Review of the Public Health Function, established by the Chief Medical Officer, aims to ensure that public health professionals are in the best position not only to safeguard health but also to champion, inform and measure health improvements and involve key stakeholders. An important facet of the Review is the need to optimise collaboration between academics, research scientists and NHS public health specialists in the assimilation of Government policies and research initiatives to improve health.

Action

Health boards will lead and promote health promotion and improvement throughout their services and are charged with demonstrating clear reductions in health inequalities.
Scotland's Chief Nursing Officer will initiate a review of the contribution made by nurses to improving the public's health, focusing especially on the role of the health visitor, the school nurse and the practice nurse.
Boards will support other agencies, such as Councils, which are working to improve health and quality of life, through focused initiatives that address life circumstances.
A review of the public health function is being led by the Chief Medical Officer to establish a framework in which the contribution of public health medicine can be maximised. The review will report in 1999.

Role of Local Government

90. The Green Paper highlighted the special influence that local authorities exert on health by virtue of their role in housing, social work, education, police services, transport, planning, health and safety enforcement, environmental health, leisure and recreation and economic and community development. They take the lead in Social Inclusion Partnerships, which are taking forward the regeneration and social inclusion agenda at local level. Crucially, they also have the leading role in community planning. Local councils are, therefore, powerful allies of the NHS in collaborative action to improve health and tackle inequalities and the combination of HIPs and Community Plans will be a potent instrument for ensuring a cohesive approach to health improvement, especially in disadvantaged areas. It will be imperative that there is close liaison between health boards and councils in the preparation of HIPs and Community Plans to ensure full synchronisation.

91. The Green Paper consultation revealed widespread support for proposals which would assist local authorities in maximising their contribution to improving health. Principal among these proposals was Government funding for a public health post in COSLA. The key role of the post holder will be to consult local authorities in drawing up good practice guidance and advice on health improvement.

92. The response to the Green Paper provided little support for the proposal that Directors of Public Health should sit on key local government committees. However, there was a welcome for closer working between boards and councils at senior level so as to provide a health perspective in policy development and decision-making. For example, COSLA recommended that Directors of Public Health should meet with Chief Executives of councils on a regular basis or be part of the Chief Executive's management team. The Convention also suggested that Directors of Public Health be sent papers of all relevant council committees, with the facility to comment, if desired. We strongly endorse these suggestions which will make for strengthened co-operation at local level. The Government have no wish to be prescriptive in setting a framework for such collaboration. It will be for health boards and councils to agree, in consultation, as appropriate, with voluntary and other organisations, local arrangements which ensure optimum partnership working.

93. We also fully support the establishment of posts funded jointly by health boards and local authorities to develop partnership activity, joint initiatives and a more strategic approach to health improvement. The practical value of such jointly funded posts has already been demonstrated in areas such as Grampian and Inverclyde.

94. Partnership working will be an area in which the Ministerial Group on health, discussed in paragraphs 124 and 125, will take a particular interest.

Action

The Government are proceeding to establish the public health post in COSLA.

Health Information for the Public

95. Informed choice favours healthy choice. Being informed means having access to the right amount of information at the right time, information which may be supplemented by discussion with a health care professional. It is important to emphasise that all health care professionals can contribute to this process: for example, pharmacists are in constant contact with the public and are well placed to provide health education and advice on health problems. And the NHS freephone helpline provides health information, counselling and general support to the public.

96. The Government appreciate that the Internet now offers easy access to comprehensive health information ( and other health-related data such as that on occupational health matters) in addition to that provided by traditional vehicles such as newspapers, magazines, radio and television. HEBSWeb (www.hebs.scot.nhs.uk) and the NHS Scottish Health On the Web (SHOW) (www.show.scot.nhs.uk) contain vast amounts of information and are already used extensively by health professionals and increasing numbers of the general public. In addition, HEBS has introduced, under the HEBSWeb umbrella, a virtual health centre and a cyberschool and is currently working to add a research centre and a learning centre. These developments illustrate the vast potential of information technology which the Government wish to see further utilised in promoting public health in Scotland. The Government are committed, therefore, to increasing public access to health information on the Internet and to exploiting the potential of emerging technologies such as digital television.

97. Many local services, drawn from the NHS, voluntary sector and other agencies, also offer help and advice for healthy living. While some of the 3,500 support groups concerned with specific aspects of health in Scotland already make user-friendly information available on web sites, there is a need to improve access to such information.

Action

The Government will continue to support ways of making health and lifestyle information readily available, including the extension of the NHS helpline, at both national and local levels, and through the use of digital television to provide Internet facilities.
The Government will offer a facility on Scottish Health on the Web to help local interests to make their material widely available.

Health Impact Assessment

98. Health Impact Assessment (HIA) is a method of evaluating the likely effects of policies, initiatives and activities on health at a population level and helping to develop recommendations to maximise health gain and minimise health risks. It offers a framework within which to consider, and influence, the broad determinants of health. Given the Government's determination to place health at the centre of planning and decision-making at national and local level, HIA is seen as an essential step when formulating policy at both levels. As emphasised in the Acheson Report, it is important that policies likely to have an impact on health should also be assessed in terms of their likely impact on health inequalities. Guidance is needed to maximise the utility of the HIA approach without making it unduly complex.

Action

The Government will fund the Scottish Needs Assessment Programme to develop standard guidance on Health Impact Assessment using current work in pilot areas such as the urban regeneration partnerships and aspects of urban transport policy.
The Public Health Strategy Group led by the Minister for Health will promote the widespread use of Health Impact Assessment when formulating Government policies.
Policy development and analysis will be strengthened further by the creation of a Professorship in Health Promotion Policy, to be launched with funding from HEBS in 1999.

Healthy Living Centres

99. The Green Paper described the Government's plans for a Lottery-financed network of healthy living centres which will improve health and well-being, with particular reference to those with the worst health who are living in deprived communities.

100. Partnership between the public and private sectors, voluntary agencies and the community concerned will be a cornerstone of the initiative. The projects will not have to follow traditional lifestyle behaviour models and can address wider social, economic and environmental influences on health. The initiative offers real potential for innovation and imagination and - for those who suffer disadvantage - an opportunity to improve health in their own area. As indicated earlier, Scotland will receive �34.5m of Lottery funding through the New Opportunities Fund for healthy living centre projects. Applications were invited in January, 1999.

Action

A separate advisory panel for Scotland will help the New Opportunities Fund assess bids to establish Scottish healthy living centres.

Health Promoting Schools

101. The Government recognise the concept of the health promoting school as important in ensuring not only that health education is integral to the curriculum but also that school ethos, policies, services and extra-curricular activities foster mental, physical and social well-being and healthy development. The concept is central to the New Community Schools initiative.

Action

Working with COSLA and the Scottish Consultative Council on the Curriculum, HEBS will establish a specialist unit to develop further health education and health promotion in schools.

Protecting and Promoting Health at Work

102. A Health and Safety Executive (HSE) survey published in 1995 on Self Reported Work Related Illness showed that, proportionately, more people in Scotland than elsewhere in the UK reported illnesses caused or worsened by work. It is important for Scotland's economy and for its workforce that employers protect and promote the health of their employees over and above their statutory obligations. The Green Paper consultation revealed widespread agreement regarding the potential of the workplace to protect, promote and maintain good health. Employers, trades unions and staff associations should be supported in developing a commitment to formulate good policies and implement good practice for health and safety at work. HEBS has a significant role to play in this activity.

103. An occupational health strategy is being prepared by the HSE, after wide consultation, to help shape the contribution of work to health in the UK, including Scotland, for the next 10 years. In the shorter term, the Health and Safety Commission, through its Occupational Health Advisory Committee, is considering ways of improving access to occupational health support and advice in Britain, particularly for people who work in small businesses. Recommendations will be made later this year.

104. Industry can also work for health by supporting community development and regeneration through job creation, helping to tackle social exclusion and by reducing pollution.

105. Scotland's Health at Work (SHAW) was established as a national accreditation initiative in 1996 to encourage all businesses in Scotland to participate in a voluntary award scheme which would stimulate employers to provide healthy workplaces. The Scottish Office, the CBI, the STUC, the NHS, HEBS and COSLA are among the Award's promoters. The response to this initiative has been good - to date over 350 organisations have joined with higher coverage in prospect.

Action

Workplace health promotion and occupational health support, with particular emphasis on small and medium- sized businesses, will be stepped up by appropriate agencies, notably HEBS and the Health and Safety Executive.
A long-term occupational health strategy is being prepared by the Health and Safety Executive, after consultation.
A publicity drive will be launched to secure wider coverage for SHAW, with a particular focus on small and medium-sized enterprises.
The Scottish Office will join other employers in applying for SHAW accreditation, and will encourage others to do so.

Communicable Diseases

106. Immunisation remains the single most effective measure that can be taken against communicable disease. New vaccines will be added to immunisation programmes once they have a safe and proven track record but much still needs to be done to ensure the full uptake of existing vaccines and to guard against any complacency which could allow the re-emergence of diseases such as tuberculosis and measles. New guidance has been issued on the threat now being posed by tuberculosis, while initiatives are being developed to counter the inappropriate use of antibiotics. Public health legislation is now being reviewed to ensure a strong framework within which to tackle communicable diseases and other public health emergencies. Following this review, public health legislation in the new Parliament will help strengthen Scotland's hand in dealing with outbreaks of communicable disease.

107. Scotland has not experienced the pandemic of HIV infection and AIDS that might once have been predicted and significant improvements in treatment have postponed the onset of symptomatic disease and progression to AIDS in HIV-infected patients. However, any complacency is dispelled by the fact that 1997 saw more new cases of HIV infection than any other year since 1987. The Government have established, therefore, an expert group to review HIV health promotion strategy, taking account of recent developments, notably the emergence of new drug therapies that can counter progression to AIDS.

108. Environmental health and public health are inextricably linked. Along with other public health professionals, Environmental Health Officers play a key role in protecting the public health not only in areas mentioned in Chapter 3, but also in matters such as food safety, as demonstrated in recent high profile incidents.

Action

The current review of public health legislation will clarify the role of Directors of Public Health and colleagues when dealing with outbreaks of communicable disease and other public health emergencies.
The expert group to review HIV health promotion strategy will report in summer, 1999.

Food Safety

109. Food safety is a key factor in public health. The Government are determined to re-establish consumer confidence in the safety of our food. In all of this, the new Food Standards Agency will have a pivotal role. Its main aim will be the protection of public health in relation to food, and it will be involved in all aspects of food safety from "the farm to the fork". On nutritional issues, it will work closely with HEBS which will retain its present responsibility for the promotion of a healthy diet. The draft Food Standards Bill was published for consultation on 27 January, 1999 and will be introduced to Parliament as soon as the necessary legislative time can be secured.

110. Considerable strides to improve food safety have also been made in advance of the Food Standards Agency. The Government have accepted all the recommendations of the Pennington Group which examined the events surrounding the 1996 Central Scotland outbreak of E coli 0157 food poisoning and identified the lessons to be learned. The recommendations have either been implemented or are currently being actively progressed. Increased funding amounting to �2.6m per annum has been made available to local authorities for increased hygiene enforcement activity and to allow them to assist food businesses to set in place improved hygiene systems.

Action

Guidance on the control of outbreaks of food-borne and water-borne diseases has just been revised by an expert group, taking account of the response to consultation and the Determination following the Fatal Accident Inquiry into the Central Scotland outbreak of E coli 0157 food poisoning. This guidance will be published shortly.