THE PURPOSE OF PUBLIC HEALTH
Health protection, promotion and improvement
The Review fully endorses the definition2 of public health as "the science and art of preventing disease, prolonging life and promoting health and wellbeing through the organised efforts of society". Essentially, public health is the process of mobilising local, national and international resources to ensure the conditions in which people can be healthy.4
The spirit of the definition captures the "essential elements"5 needed for modern public health:
A population perspective that attempts to secure "the greatest health improvement for the greatest number of people" particularly by addressing the needs of those individuals and groups who experience the worst health;
An emphasis on collective responsibility for health protection and improvement, and disease prevention;
The key role of the state;
A concern for the underlying socio-economic determinants of health as well as with individual health-related behaviour, and disease;
A multidisciplinary approach which incorporates quantitative and qualitative methods;
Partnership with the populations served.
Major public health strategies seek to prevent disease, premature death, illness and disability; promote health; improve medical care; and promote health-enhancing behaviour. These approaches use the techniques of research, surveillance, intervention and evaluation, with an emphasis on:
legal and fiscal measures to protect and promote health;
partnerships for health;
policies and strategies that create opportunities for better health;
securing the effectiveness of medical care;
the preventive aspects of medical care, such as immunisation and screening;
communicable disease and environmental health control;
health education and behaviour modification.
This broad view of public health recognises the interplay between the many determinants of health (Figure 1) and acknowledges that major health problems cannot be solved by medical care alone. It derives from international health promotion work underway since the mid 1970s 6 and the proposal of the World Health Organisation (WHO) for "Health for All by the Year 2000", a vision that was developed by the World Health Assembly in 1977 and launched at the Alma Ata Conference in 1978. It is motivated by concerns about inequalities in health, poverty and environmental issues and clearly moves away from a narrow definition of health focused on individual risks and an "absence of disease". It acknowledges that individual health-related behaviour is often influenced by life circumstances and, in turn, that an individual’s state of health or ill health has an important influence on their life circumstances. Likewise, specific diseases, including coronary heart disease, stroke, mental illness, and cancer are the net result of a variety of factors operating throughout an individual’s lifetime.
Figure 17
Figure 1
This inclusive view of health implies that a major focus for action is the forging of appropriate linkages between public health sciences and policy making, linkage which will be emphasised repeatedly in this Review.
The Review endorses the recent recommendations of the WHO in Europe8 which provide the following aims for public health professionals. To:
Influence the development of healthy public policies and strategies and manage their implementation;
Produce a strong knowledge base for health founded on robust health information systems and high quality epidemiological and interventional research;
Provide an epidemiological analysis of the population’s health, its determinants and health needs, identifying important inequalities in health;
Lead and manage programmes of research and development with implementation of effective and sustainable disease prevention, health protection and health promotion;
Integrate the delivery of high quality health care into a population perspective, focusing on the equity of health care provision and evaluation of outcomes, and assessing the extent to which important health needs are met;
Promote programmes and activities focused on health gain;
Provide strong leadership based on a clear vision and drive;
Positively influence the development of healthy communities;
Promote partnerships based upon a co-ordinated approach that addresses all the factors determining the public’s health;
Ensure good value for money in improving population health.
The UK was a signatory to the adoption in May 1998 of the WHO policy Health for all in the 21st Century which updates the vision of Health for all. The box below summarises the main elements of the HEALTH21 policy for the European Region of WHO.
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Elements of the HEALTH21 policy for the European Region of WHO (1998) One goal:
Two main aims:
Three basic values:
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The Review endorses the ‘Health for All’ approach. Implementation of the White Papers Designed to Care and Towards a Healthier Scotland, together with the further development of the public health function should go a long way to delivering this policy in Scotland.
Towards a Healthier Scotland (box) sets out the public health agenda while Designed to Care establishes a framework for a revitalised National Health Service in which health improvement and the prevention of illness are priorities. The Acute Services Review (1998) is also relevant with its emphasis on quality, multi-professional working and service configuration. Other relevant developments include the national Mental Health Framework, the findings of the Royal Commission on long term care, and the forthcoming national review of learning disabilities.
"Towards a Healthier Scotland" – Key themes
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Scotland’s poor health record and the development of healthy public policy
Scotland’s health is poor when compared with the rest of the United Kingdom and Western Europe. Far too many people die too young from diseases that can be prevented. Far too many suffer ill health, often for much of their lives. Scotland also has some of the worst oral health in the United Kingdom,9 a high proportion of smokers, and relatively poor nutrition. There are huge differences in life expectancy between the least and most deprived in our society. Good health brings with it a feeling of well being and allows us to "be the best we can"; it opens the door to opportunity and enables us to enjoy life to the full. Ill health translates into a huge burden of misery and lost potential for individuals, families, communities and for Scotland as a whole.
The health of the public is determined by the ways in which society acts to prevent disease, prolong life, and protect, promote and improve health and well being. A few examples give a sense of the enormous span of activity needed to protect and promote the public’s health:
development of immunisation and screening programmes;
provision of clean water;
development of comprehensive health care available and accessible to all;
health education to raise awareness of important risks to health and action to reduce risk;
action to create a safer and healthier environment with increased access to leisure and exercise facilities;
promotion of healthy eating and work to ensure food safety.
The public health effort depends crucially upon concerted action to tackle the underlying causes of ill health, and not just their effects. Hence the importance of the recent shift in government policy to acknowledge that social, economic and environmental factors are crucial determinants of health, ill health and disease, and that there are unacceptable inequalities in health. This new political climate encourages scrutiny of the potential adverse health effects of all national and local policies, with reduction of risk to acceptable levels being seen as a priority objective. It also offers the opportunity to ensure that where possible, policies impact positively on population health, and contribute to the narrowing of health inequalities.
The potential benefits afforded by such "healthy public policy" are huge. Prevention of disease and the promotion of good health is not the preserve of the NHS or public health professionals but is bound up in policy development across the entire economic and social spectrum. For example, there is now explicit recognition that unemployment, poverty, isolation/loneliness and social exclusion, poor housing and a polluted environment all have adverse effects on health. That health is worst where people are poorest and most deprived confirms the influence life circumstances have on well being. It follows that policies that reduce inequalities in society, improve the income of the poorest, result in employment for the most disadvantaged, with better housing, effective social networks, improved education and a cleaner environment will have significant health benefits.
The corollary is that central and local government, the NHS and a wide range of other bodies, public and private, voluntary and community-based, all have a contribution to make to better health. To realise this aim of improved health, public health professionals must embrace the broader perspective of healthy public policy and the social and economic context in which public health initiatives can flourish. At the local level, public health professionals must have the necessary legitimacy, authority and support to influence policy formulation and the allocation of expenditure on health improving initiatives. In turn there must be increasing openness about the process of policy making and increasing availability of the evidence that informs decision-making. These professionals must be accountable for the quality of public health practice that informs policy development and implementation, with organisations accountable for decisions that impact on the public’s health.
In addition to public health and NHS policy, a wide range of policy initiatives from Scottish Executive departments provides important vehicles for health improvement (box). The Executive has created a climate which encourages major stakeholders to work together in a coherent, co-ordinated and sustained way.
Scottish Executive initiatives providing vehicles for health improvement
Social Inclusion
Sustainable Development
Welfare to Work Initiatives (including the New Deal)
Families with Children, including expansion of family centres and a childcare strategy
Better education opportunities, including New Community Schools
Integrated Transport Policy
Tackling the Social Causes of Crime
Better Housing
Food Standards Agency
Local authorities can make a major contribution by developing policies with a positive health impact across their range of functions and by ensuring that community plans take health needs into account. The NHS in turn delivers population health programmes, promotes health in local communities, and provides high quality services. As major employers, local government and the NHS have significant opportunities to improve the health of their workforce. Voluntary organisations can often provide services in a way that public authorities cannot, while community organisations can stimulate and motivate the communities they serve. Business and commerce can put a great deal back into the communities on which they draw, while the media can wield a positive influence by frank but responsible reporting. Individuals, too, must assume responsibility, insofar as they are able, for their own health and well being and that of others.
Community Planning provides a framework within which the range of government initiatives, including those concerned with health improvement, can achieve maximum benefit. Led by local authorities, Community Planning aims to:
improve the services provided by local authorities and their public sector partners through closer, more co-ordinated working;
provide a process through which local authorities and their public sector partners, in consultation with the voluntary sector, the private sector, and the community, can agree both a strategic vision for their area and the action to be taken by each partner in pursuit of that vision, and;
provide an opportunity for local authorities and their public sector partners to hear the views of individuals and communities, define needs and assess how they can best be addressed.
The Review sees the development of Community Plans as complementary to the Health Improvement Programmes (HIPs) which are now such a central feature of the public health activity of Health Boards. Community planning allows the various agencies concerned to come together to consider how they can best promote the health and well-being of their communities in a climate of mutual understanding and co-operation. It also fosters community involvement in the public health agenda, and the LHCCs in the new Primary Care Trusts are well placed to facilitate such involvement. The Community Plan should have a time horizon that is long enough to achieve real change and should define success measures and key milestones so that progress can be monitored.
Strengths, weaknesses, opportunities and threats to the public health function
Many submissions to the Review identified strengths and weaknesses of the existing public health function in Scotland. The key points are reproduced here, emphasising that the Steering Group does not attach equal weight to them.
Strengths:
Presence of an expert public health work force committed to a broad inclusive vision of public health;
Established training programmes and career pathways for public health doctors and dentists;
Established national public health bodies (the Public Health Policy Unit , ISD, SCIEH and HEBS);
Established academic public health and dental public health departments;
Good relationships between dental public health consultants in the service and academic dental public health;
Excellent health and health service databases, including Cancer Registry, emerging primary care data and linked datasets;
Good working relationships between dental public health and public health;
Increasing electronic availability of data and other forms of information;
Close working relationships between some public health practitioners and some local authority departments, particularly Environmental Health Departments;
Developing national and local multi-agency partnerships and health improvement initiatives;
Networks in which public health professionals share expertise and undertake joint work in areas such as Communicable Diseases and Environmental Health (CD&EH) and needs assessment;
Involvement of public health practitioners in the development and evaluation of health and health care programmes.
Weaknesses:
Workload exceeds the capacity of the employed, trained public health workforce, raising the need to appraise manpower, assign tasks appropriately and avoid duplication of activity;
Lack of overall co-ordination/integration of the public health function;
Lack of an appropriate identity, profile and visibility for public health at both national and local level.
Failure to understand or value the work of public health professionals can undermine their effectiveness and generate a defensive culture;
Lack of appropriate focus (some respondents felt that the public health function has been focused on operational issues and the activities of public health doctors, rather than the broader vision of public health);
Shortage of some technical skills (such as needs assessment, analysis and interpretation of information, critical appraisal) and implementation skills;
Limited number of eligible applicants;
Sub-optimal working arrangements with local authorities (manifest, for example, in lack of consistency of local community plans and health plans);
Inadequacy of health (as opposed to health service) information systems and surveillance systems for communicable and non-communicable disease;
Difficulty in accessing public health evidence promptly and in a useable form;
Duplication of activity, particularly in marshalling epidemiological information and evidence of effectiveness of health programmes;
Limited partnership between academic and service public health departments;
Difficulty in maintaining a "critical mass" of expertise to deliver safe, high quality services, particularly in small Health Boards;
Variability of support when responding to public health emergencies, particularly in smaller Health Board areas;
Problems in respect of the CD&EH function including lack of clear organisation in some Health Boards, inadequate epidemiological investigation of some outbreaks and sub-optimal training of professionals involved in on-call duties;
Professional isolation of those working in smaller Boards and remote from major centres;
Difficulty in securing funding for joint initiatives (and in particular medium- to long-term funding) from appropriate sources;
Limited pooling of resources and expertise between Health Boards and between the NHS and other agencies;
Opportunities:
A new national policy for public health improvement with emphasis on tackling the determinants of ill health;
The availability of a public health workforce wishing to exploit the full potential of a new national health policy;
Recognition of the presence and potential of multiple vehicles for health improvement in the NHS, local and central government, the community and the private and voluntary sectors;
New emphasis on the role of Health Boards as public health organisations with defined Health Improvement Programmes;
A new requirement on local authorities to produce Community Plans informed by the needs of communities;
The scope for new ways of working jointly with local authorities and other agencies on issues related to the environment and health (e.g. transport and air pollution, energy use, housing and the health of vulnerable groups).
The growing number of links with public health services in other countries and regions of the European Community.
Threats:
Health improvement is not recognised as a "long game" and there is undue emphasis on short term gains;
The importance of a good "sickness" service continues to overshadow the need for a "health improvement service";
An inadequate, unsustained response by all stakeholders to the new public health agenda could limit demonstrable health improvement, leading some to question the "added value" of the public health function.