Current Scottish Executive policy provides an outstanding opportunity to improve health. Public Health with its emphasis on reducing health inequalities, is one of the Scottish Executive’s key cross-cutting programmes. As the driver of public health policy, the Executive needs to be able to call on authoritative advice from public health experts and needs a strong effective mechanism to carry through the various initiatives to improve the health of the public. This Review of the public health function is charged with reassessing the roles, relationships and locus of public health medicine and dentistry to ensure the optimal use of all available resources in the drive to safeguard and improve Scotland’s health.
The Review endorses the definition1 of public health as ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’, and takes the white papers Towards a Healthier Scotland and Designed to Care as its immediate policy context. We define the public health function (or endeavour) as ‘a robust, adequately resourced organisation that can secure and sustain the public health, addressing health policy issues at a population level and leading a co-ordinated effort to tackle underlying causes of poor health and disease’. Our recommendations are intended to:
THE PURPOSE AND NATURE OF PUBLIC HEALTH
Public health requires the mobilisation of local, national and international resources to secure the conditions in which people can be healthy. Public health practice requires a sound epidemiological approach and the ability to influence to achieve change. Key elements include:
Public health strategies must be underpinned by research, surveillance, intervention and evaluation. Emphasis must be placed on:
EPIDEMIOLOGY AND HEALTH INTELLIGENCE IN SCOTLAND
Scotland possesses extensive high-quality data systems that allow monitoring of health. Increasing linkage of health, disease and environmental data will monitor the effectiveness of the public health function, and of the organisations and individuals that contribute to it. Health Boards are encouraged to review their needs and arrangements for accessing ‘public health intelligence’ to enable them to function effectively as public health organisations.
Scotland’s epidemiologists must not work in isolation and their work should be focussed on long-term strategic aims. A national centre of excellence would co-ordinate (see below) and strengthen Scotland’s epidemiological research capacity, in addition to improving training and facilitating linkages. A strategic approach is required and further work is needed to release the potential of public health data resources and existing public health research aimed at improving our understanding of disease.
EDUCATION AND TRAINING IN PUBLIC HEALTH
The training of public health doctors and dentists must continue to meet the regulations laid down by professional registration and accreditation bodies. It should emphasise the core skills and attributes of public health, promote epidemiological expertise and a rigorous approach to problem solving, and foster flexible multidisciplinary practice.
The Master’s degree course in Public Health appears to be of varied quality and University Departments and specialist units should collaborate to produce a modular course that makes maximal use of Scotland’s expertise and resources. In-service training in Scotland would be best delivered by a single Training Scheme that exploits the best national and international resources, retains flexibility and is actively managed. A Public Health Institute for Scotland (see below) would help to develop high quality education and training. Appropriate skills training should also be available for non-specialists, including primary care clinicians and academic staff wishing to contribute to the public health function.
Enhanced management training should be available for public health specialists. Tailored training and continuing professional development (CPD) of aspiring and substantive Directors of Public Health (DsPH) is particularly important and Scotland should participate in the UK development of leadership courses and learning sets.
THE NATIONAL PUBLIC HEALTH INFRASTRUCTURE
The public health function in Scotland needs greater coherence and strong leadership. A national Public Health Institute would co-ordinate, facilitate and support the function and create an intellectual focus for health improvement. It would strengthen research and teaching links between academic departments, Health Boards and research units. The Institute’s development should be evolutionary, drawing on and developing the expertise of public health professionals employed throughout Scotland. The Institute could:
Managed public health networks (eg for remote and rural areas, health impact assessment, communicable disease control) would further strengthen the public health infrastructure. They could reduce duplication of effort, ensure cover for absent staff, and provide Boards with a greater range of expertise than is normally available. Commonality of health policy across Health Board areas would be encouraged, as would economies of scale in the provision of information, statistical support and other specialist input. Networks should be multi-professional and not constrained by existing geographical boundaries or barriers between disciplines.
THE REGIONAL LOCUS AND IDENTITY OF THE PUBLIC HEALTH FUNCTION
The Review holds strongly to the view that the public health function should have a single locus within a region. It recognises that the current arrangement whereby Scotland has fifteen Health Boards does not always lend itself to making the best use of scarce public health expertise. It does see the Health Board with its enhanced role as a "public health organisation" as the optimum locus, recognising that its resources will be deployed in partnership working with local authorities, NHS Trusts, Local Health Care Co-operatives (LHCCs) and others. Key tasks include the further development of the public health role of Boards, definition of their relationships with partner organisations (with clear shared health goals, objectives and expected outcomes), and clarification of the role of the DPH.
The profile of public health will be enhanced if partner organisations place great emphasis on population health improvement and show commitment to health improvement on the part of their senior officers and executives. The public health function needs a clear governance framework and must be widely perceived as holding within it an integrated multidisciplinary group of professionals who are keen to work with others to improve the public health. The core set of competencies possessed by public health professionals needs to be defined and the evidence-base for public health needs to be strengthened.
CONSULTANTS IN PUBLIC HEALTH MEDICINE AND DENTISTRY
Consultants in public health medicine and dentistry (CsPHM & CsDPH) are crucial to the public health function. They must have the necessary authority and support if they are to influence policy formulation and the allocation of expenditure on health-improving initiatives. They must be well-organised, accessible, able to exercise leadership and able to deploy their skills and expertise optimally. Their unique contribution derives from their experience of health services and clinical practice, specialist public health skills, broad-based vision of health improvement, political awareness, and attributes such as networking, communication and the ability to influence others.
The Review sees the following as core tasks for the public health function:
The Review sees the need for a more equitable distribution of consultant manpower when addressing public health priorities and has concerns about the breadth of remit and workload of some consultants. It underlines the need to avoid duplication of work by Health Boards. Given that CsPHM and CsDPH will remain a relatively scarce resource, they should work in multi-professional teams, undertaking only those functions that require their particular expertise and skill. This, in turn will allow them to strengthen their core competencies and maximise their professional development.
Current arrangements regard expenditure on public health departments as part of Health Board management costs. Although expenditure has to be managed, such capping can compromise the public health role of Boards and should be removed. Individual Boards should review their manpower needs in the light of the new public health agenda. While increasing demands on professionals may be offset by networking, we predict that this review will lead to a modest increase in the number of CsPHM and CsDPH. This work should be facilitated by the Scottish Executive Health Department and its Public Health Policy Unit (working with the appropriate professional organisations and taking account of other UK interests).
The Review notes with concern the low levels of dental public health staffing. We recommend that each mainland Health Board should have ready access to a minimum of 5 sessions per week of specialist CDPH advice, the overall provision equating to two consultants per million of the population. The Island Health Boards should continue to receive advice from their Chief Administrative Dental Officer.
KEY RELATIONSHIPS
Improved public health depends on effective relationships between the public, communities, Health Boards, local authorities, NHS Trusts, academic departments, voluntary organisations and Government. Local authorities have a particularly important contribution to make through education, social work, housing, environmental health, planning, building control, consumer and trading standards, cleansing services, leisure and recreation, libraries, parks, direct care and health promotion.
The public health agenda needs a high profile within local authorities; in turn, authorities require adequate public health input for their work with Boards. Community Planning, a process led by local authorities, allows all concerned to determine how collectively they can best promote the well-being of their communities. The development of Health Improvement Programmes (HIPs), a process led by Health Boards, now provides a major opportunity for Boards to work with partner organisations in the drive to improve public health.
The Review recommends that:
Public health professionals have a significant contribution to make to the work of NHS Trusts and LHCCs in improving health. This includes needs assessment, service planning and development, development of HIPs and Trust Implementation Plans (TIPs), work on clinical governance and clinical effectiveness, and the development of health improvement partnerships.
MULTIDISCIPLINARY PUBLIC HEALTH
The Review sees considerable scope for further involvement of nurses in the drive to improve public health and looks forward to the deliberations of the Chief Nursing Officer’s Review. Health promotion specialists are also essential to the public health function and need strong relationships with Health Board departments of public health, clear lines of accountability, a good evidence base and objective evaluation of their activity. Pharmacists also have an important role in health promotion, disease prevention and the provision of safe effective pharmaceutical care, while community-based health and social care professionals are well positioned to inform local needs assessment and promote healthy lifestyle messages and programmes. The Public Health Policy Unit should lead work to clarify the public health role of these professional groups.
While it is beyond the Review’s remit to make detailed proposals for professionals other than doctors and dentists, we see a pressing need to consider the size and composition of the public health workforce, with description of training needs, development, salary structures and career pathways for all professionals. The Chief Nursing Officer’s review is already considering nursing interests while collaboration between the UK Multidisciplinary Public Health Forum, the Royal Institute of Public Health and Hygiene and the Faculty of Public Health Medicine (FPHM) will describe standards for specialist public health practice.
The Review recognises the public health importance of a number of clinical services. There should be a well-defined relationship between departments of public health and clinical services with a population focus (eg child health, maternity, sexual health and community dental services). The need for excellent relationships with partner organisations, projects and communities should determine the location and development of such services.
THE DIRECTOR OF PUBLIC HEALTH
Towards a Healthier Scotland emphasises the role of the DPH as an agent of strategic change in delivering the public health agenda. The DPH role must evolve further if Directors and their teams are to respond effectively to the new public health agenda and provide region-wide leadership. The title ‘Director of Public Health and Health Policy’ would reflect this enhanced role. With the development of specialist training and accreditation, new cadres of professionals will be able to undertake many of the tasks currently undertaken by DsPH. However, we believe that accredited public health doctors with suitable experience and aptitude are optimally placed to act as DsPH.
The relationship between the Board General Manager and the DPH is crucial and the roles are complementary. Directors of Public Health in Scotland still carry the additional title of Chief Administrative Medical Officer (CAMO). We recommend that, with the necessary legislative and regulatory alterations, this title should be discarded. Many of the administrative tasks currently undertaken by DsPH could be delegated appropriately to others within the NHS.
The DPH Annual Report should drive and shape policy and public health activity. It should be an integral part of the planning process, an ‘annual plan’ as well as an annual report, and should be a central influence in the formulation of HIPs and Community Plans. In turn, it will be influenced by LHCC-based assessment of the needs of local populations. The Report should be linked with the Board’s performance framework and available for use in its annual review. The Report’s value would be increased if local authorities, Health Boards and NHS Trusts received and responded to it in public session. The Report could form a key component of clinical governance, serving as a measure of the department of public health’s function within the Health Board. We recommend that the DsPH lead further work on the future role and format of Annual Reports.
HEALTH BOARDS AS "PUBLIC HEALTH ORGANISATIONS"
Health Boards, as "public health organisations" working closely with local authorities and others, have the central role in protecting and improving population health at regional level. Our recommendation that Health Boards should be the locus for the regional public health function is grounded on the premise that health improvement is the raison d’être of Boards. This assumes that:
The Review notes the ongoing HIP process, the organisational development work being undertaken by NHS Management Executive, and plans to develop a performance management framework for the public health role of Health Boards. To assist this work we propose that the DPH Group and the General Managers’ Group be asked to collaborate in developing standards for the public health function within Health Boards.
COMMUNICABLE DISEASE AND ENVIRONMENTAL HEALTH
Health Boards must maintain a robust Communicable Diseases and Environmental Health (CD&EH) function. This involves proactive measures to control communicable disease and other environmental hazards; surveillance and action in response to surveillance reports; and reactive work, notably the handling of public health emergencies. We recommend that to be able to respond effectively to public health emergencies, each mainland Health Board should have at least:
The Review recommends that Health Boards review the joint arrangements for CD&EH with local authority partners (taking particular account of the adequacy of infection control in nursing and residential homes). We see great potential in networks as a means of optimising the CD&EH function and the use of scarce specialist EHO input, for example in food safety. We also see a major continuing role for the Scottish Centre for Infection and Environmental Health (SCIEH) in underpinning, strengthening and leading the development of Scotland’s CD&EH function.
QUALITY AND ACCOUNTABILITY
Accountability for improving population health rests with society at large as well as with public health professionals, organisations and stakeholders. "Public health governance" is the process by which governments and organisations are accountable for the continuous protection and improvement of the public’s health. The Review understands the difficulty of holding Health Boards accountable for meeting health targets for which they are not solely responsible. We do however believe that health targets should be explicitly set and monitored as part of the accountability process.
All public health professionals must participate in CPD that should meet agreed development needs made explicit in regularly updated personal development plans. There are some areas of CPD in which all practitioners should participate; notably the maintenance of core CD&EH skills for staff participating in on-call rotas.
The Review advocates a common structured approach to major public health issues. Scotland already has a strong Intercollegiate Guideline Network (SIGN) and we see great potential for collaboration with the FPHM in guideline production and dissemination. The proposed Public Health Institute for Scotland would have an important locus and managed public health networks will facilitate guideline implementation.
IMPLEMENTATION
The Review identifies key tasks to be undertaken at national and regional level if a robust public health function is to be secured and sustained. Developments are now required to: