Review of the Public Health Function in Scotland

Implications of the new policy context for the public health function

51. The growing prominence of public health has increased the range and span of tasks to be undertaken by the public health function. The new challenges and opportunities call for a reappraisal of the role and locus of public health professionals, their skills, expertise and ways of working.

52. The public health function does not reside within a single institution or organisation. It should be identifiable across a range of bodies and reflected in their culture, corporate aims, organisation, way of working, accountability and deployment of resources (including the deployment of a competent and skilled workforce dedicated to improving the public’s health).

53. Specialist public health professionals must be organised in a way that can be readily seen and understood across Scotland. They need to be accessible, deployed equitably, able to exercise leadership in tackling public health priorities, and positioned optimally to support and guide the efforts of all those engaged in health improvement. In the drive for improved health, the NHS (and public health medicine and dentistry in particular) must be outward looking, maximising multidisciplinary teamwork, developing partnerships for health, and responding appropriately to the needs of all consumers of the public health function.

54. Consumers include the general public and patients (with particular concern for low income groups and those with chronically poor health), public and private sector organisations, clinicians and the NHS, and the full range of Government organisations at national and local level. The application of consumer principles (access, choice, information, safety, redress, representation and equity) to public health raises many questions.

• Do all consumers have good information about public health and the nature of the public health function and programmes? Do they know when and how to make contact with organisations that can safeguard and improve population health?

• Does public health advice and information get to those who need it? Is it acted upon? If not, why not? Is there more to be done to ensure that advice is timely and appropriate?

• Are consumers involved appropriately in the development of public health policy and programmes, and are they valued as equal partners?

• Does the public health function operate equitably, and does it concern itself to the greatest extent with issues that pose the greatest risk, and with groups in greatest need?

• Is the function clearly accountable? When and how should consumers seek redress for actual or perceived failures in the public health function?

55. The Review recognises the individual and corporate challenges in this agenda with its notions of "public health service", organisational ethos, equitable use of resources and accountability. The dividends likely to accrue are a more visible, more responsive, and more effective public health function, and an increased sense of ownership and involvement so that the people of Scotland can contribute optimally to their own health improvement. Any local reassessment of the public health function must review the extent to which the needs of all consumers of the public health function are being met.

56. Quality partnership at all levels is vital to success in realising the vision of a healthier Scotland. As we enter the new millennium there is a great sense of opportunity and a willingness to embrace and improve joint working, while at the same time acknowledging difficult areas of the partnership agenda that need to be addressed openly and jointly. Joint working and partnership between the NHS and non-NHS agencies, and in particular local government, are especially important. The post of DMO provides a bridge to local government and the opportunity to influence strategic planning, policy making and initiatives at their earliest stages.

    The role of public health professionals

57. Without exception, Scotland’s public health professionals have responded enthusiastically to the Review, helping to identify areas for change and improvement, and ensure that Scotland has a robust, vital and visible public health function that can deliver better health for its people.

58. Clear articulation of the role of public health professionals in health gain is key to optimising the public health function. The Annex to NHS Circular 1988(Gen)15 (para 23) is still a useful basis for describing the public health task but requires revision to take account of the changed health service and health policy context, the specific role of public health doctors and dentists, and the need for a multi-professional and multi-organisational public health function.

59. Within the new policy context, the Review sees the following as the core tasks of the public health function, tasks which require trained public health specialists with clear lines of responsibility and accountability:

• Surveillance of disease and its determinants;

• Developing health information services to support timely decision making;

• Providing epidemiological advice and education based on epidemiological knowledge, and the assessment of health and disease, its determinants and service needs;

• Accruing, appraising, interpreting and disseminating evidence about the effectiveness of interventions to improve health;

• Co-ordinating the prevention and control of communicable disease and other environmental threats to health, and taking executive action as required;

• Managing public health emergencies and ensuring that measures are taken promptly to prevent harmful exposure to environmental hazards to health or outbreaks of communicable disease;

• Planning, co-ordinating, and monitoring initiatives, programmes and services that prevent ill health and promote and protect population health;

• Serving as an advocate for population groups with unmet health needs or particularly poor health;

• Facilitating the development of partnerships for health;

• Influencing a range of health-related and health service policies and determining the priorities for health improvement;

• Evaluating the effectiveness, efficiency and equitable distribution of interventions to improve health, including health services.
  

60. As outlined in General Medical Council (GMC) guidance, public health doctors have a "duty of care" to the population they serve, a duty that is analogous to the clinician’s duty of care to individuals. In broad terms this includes both the formulation of advice on population health and the management of change designed to improve it. The major contribution is undoubtedly to policy development, strategy, and monitoring, rather than implementation, except in the management of public health emergencies. This recognises that others have the lead in many operational areas of public health (e.g. screening and immunisation, infection control, community development, health promotion) and underlines the need for doctors and dentists to work flexibly with a wide range of other professionals and interests.

61. In many areas of their work, public health doctors and dentists need others to take heed of their advice and respond to it, rather than respond to their direction. Thus they require not only the skills to formulate solutions to public health problems which others can take forward, but the skills to influence and persuade that a given course of action is correct, even though it may conflict with other options. This needs continuing engagement in the change management process if public health strategy is to be translated into appropriate action. Many examples attest the difficulties that can arise when sound public health advice is overlooked or ignored. For example, the delay in formulating and implementing sound anti-smoking policy; the past failure to take a broad approach to health inequalities; and failure to act early to comprehensively address rational use of antibiotics to prevent the development of resistant micro-organisms.

    Formulating population health advice

62. The development and communication of population health advice is the very cornerstone of public health practice and training. The best advice is informed and guided by:

• Quality epidemiological research into the prevalence, incidence and cause of ill health, including the ways in which life circumstances, lifestyles and environmental factors affect the health of children and adults;

• Quality evidence of the effectiveness of health improvement programmes and their ability to reach those with the greatest need;

• Systematic identification and synthesis of the best available epidemiological and effectiveness evidence;

• Careful definition of the public health problem to be solved and appropriate use of best evidence when defining its solution.

63. Partnership between academic and service practitioners will help to ensure that the public health research agenda includes important service issues, and that the best available evidence is brought to bear when service questions arise. Careful definition of the problem to be solved requires good local knowledge of both the problem and the context in which solutions will be applied. It goes without saying that every effort must be made to minimise wasteful duplication of such work at national, regional or local levels.

64. A number of initiatives already provide systematically acquired and reviewed evidence. These include the Scottish Needs Assessment Programme (SNAP), the Scottish Intercollegiate Guidelines Network (SIGN), and the collation of data by ISD (including Cancer Registry publications and the recent document, Deprivation and Health¹⁰). Initiatives in other parts of the UK, including "Effective Health Care Bulletins" (England) and the "Health Evidence Bulletins" (Wales) have also contributed significantly to public health practice in Scotland.

65. The Scottish Needs Assessment Programme was established to co-ordinate the identification and systematic review of best available public health knowledge and CsPHM have taken other steps to co-ordinate their activities (paras 284-309). The Review judges, however, that the overall degree of co-ordination has not been sufficient to prevent fragmentation of the public health function, leading to unnecessary duplication of work at Health Board level, uncoordinated research activity, and advice sometimes being formulated without full review of best evidence. These issues will be reconsidered when discussing the national infrastructure for public health (Section 4).

    The management of change

66. Change that is intended to improve the public health often requires change in the behaviour and mind-set of organisations and individuals. In addition to having specialist knowledge and expertise, those who work to improve health must draw on political, managerial, communication and influencing skills, show that they value the contributions of others, and work well as team members.

67. Public health doctors and dentists can effect some changes by direct action, for example, in the management of an outbreak of communicable disease and the exercise of statutory powers. However, as discussed earlier, desired change often comes through the actions of others with these doctors and dentists playing an ‘honest broker’ role to ensure that networks work efficiently and effectively. Public health professionals often act as a bridge between disciplines and agencies, helping to develop consensus and a sense of involvement in health planning. They may serve as facilitators and arbitrators in national, regional or local debates about the quality of evidence or the balance of care between sectors (e.g. mental health, acute services and cancer services) and geographical areas.

68. The Review believes that the role of public health professionals in managing change is a crucial one. Appraisal of the effectiveness of individual practice and of the public health function as a whole must include evaluation of the ability to manage change.

Clinical effectiveness

69. Public health doctors and dentists have an important role in shaping practice and services so as to maximise clinical effectiveness (see box below) and cost effectiveness and allow the best use of resources in health gain. Their focus on population health, rather than on the health of individuals or vested interest groups is critical. They need to be clear about the framework in which they act and their important roles include agenda shaping, information gathering, critical appraisal, mediation, challenge of received wisdom and management of change. Success depends in large measure on robust working relationships with clinicians, health service managers and those who use and benefit from services - patients, carers and the public. In future, their work at regional level will be informed by output from the Scottish Health Technology Assessment Centre (SHTAC).

Key features of the Public Health Function in Clinical Effectiveness

70. The Review heard suggestions that Scottish public health doctors and dentists spend more of their time on clinical effectiveness issues than their English equivalents. Achieving a correct balance will be a continuing challenge, and there are some who debate whether this is purely a job for doctors and dentists. The reality is that clinical doctors and dentists often relate more easily to a public health doctor or dentist than other professionals because they share the same core training and background, professional ethos, and broad understanding of clinical matters. But it becomes clear from consideration of the tasks identified below (box) that the range of skills needed is not necessarily embodied in any one person. By no means all of the tasks listed below need doctors and dentists for their execution.

Public health and communicable disease and environmental health

71. Infectious disease and environmental hazards cause fewer deaths than diseases such as cancer, coronary heart disease and stroke. However, they cause of significant morbidity, place great strain on resources and have the potential for rapid and catastrophic spread of disease.

72. The public health input to communicable disease and environmental health (CD&EH) requires specialist knowledge and experience, and all Health Boards have one or more CsPHM who take the lead in this area (paras 310-320). The CD&EH tasks relate to the control of communicable disease (including blood-borne and sexually transmitted infections), environmental hazards and emergency planning. Activity may be divided into proactive measures (to control communicable disease and environmental hazards, surveillance, action in response to surveillance reports) and reactive work (notably the handling of public health emergencies). It must be stressed that the CsPHM with special responsibility for CD&EH do not act alone; they need to work with other specialist colleagues, and in particular with public health infection control nurses.

73. The CD&EH agenda is expanding and contains many high profile issues such as food safety, meningococcal disease, blood-borne viruses, sexually transmitted disease and environmental threats. Factors responsible include:

• A growing knowledge and awareness of the importance of CD&EH coupled with increasing expectations of prompt effective control;

• The increasing complexity of control measures and public concern about the relationship between benefit and risk (eg immunisation programmes);

• The rapid development of intensive farming and the increasing commercialisation of food production and processing;

• the emergence of "new" infectious agents and environmental hazards;

• the re-emergence of "old" enemies such as tuberculosis;

• the need for appropriate prescribing of antibiotics to ensure that potentially lethal micro-organisms do not become resistant to treatment;

• the cost and morbidity associated with hospital-acquired infection.

74. The CD&EH function is a major component of a raft of measures designed to protect the health of the public by:

• reducing the risk of being exposed to hazards;

• effective surveillance;

• limiting the extent of exposure;

• reducing the mortality, co-morbidity and disability which can result; and

• ensuring an effective response when a major threat develops.

75. The inter-relationship of organisations responsible for protecting the public from CD&EH threats is shown below. The authority with the lead role is determined by the nature of the threat. The activities of public health professionals may extend into areas such as accident prevention and child protection. The need for strong partnerships is nowhere clearer than in health protection; relationships and organisational arrangements may be severely tested, particularly when managing emergencies that threaten, or even seem to threaten, public health.

    

76. Responsibility for controlling communicable disease in Scotland is shared by Health Boards and local authorities. The need for co-operation is enshrined in statute; Boards have a statutory duty to designate medical officers (para 20) and local authorities are required to provide DMOs with support. At operational level, DsPH and CsPHM collaborate with the Environmental Health Officers (EHOs) responsible for enforcing legislation.

77. The Outbreak Control Team is the focus for teamwork in the event of a significant or potentially significant outbreak and its effective function depends on the relationships and partnerships established before the outbreak. As well as CsPHM (CD&EH) and EHOs, the many other professionals who may be involved include microbiologists, representatives of SCIEH and Scottish Executive Departments, consultants in infectious disease, NHS Trust-based infection control nurses, general practitioners, and veterinarians.

78. The Short Life Working Party chaired by Professor Cairns Smith¹¹ has just reviewed the guidance for the investigation and control of outbreaks of foodborne diseases in Scotland in the light of the 1996/97 outbreaks of E. coli 0157 in Scotland and the subsequent Pennington Group recommendation.

79. Awareness continues to grow of the cumulative impact of environmental changes on health and the quality of life. The concept of "sustainable development" (meeting present needs without compromising future needs) underpins local and national Agenda 21 action plans to reconcile economic development with environmental protection. Public health professionals have an important role in the development and implementation of these plans.

80. In parallel with the present Review, a Working Group has been reviewing public health legislation and will report separately. The following areas of relevance to CD&EH have been discussed:

• Extending the statutory notification of infectious diseases to include relevant laboratory results;

• Updating the Public Health (Scotland) Act 1897 and port health legislation;

• Clarifying the role and powers of the Designated Medical Officer in relation to outbreaks.

81. Given the increasing public health role and emphasis accorded to the control of communicable disease and environmental hazards to health, the Review recommends that Health Boards, with local authority partners, keep under review their joint arrangements for CD&EH as a matter of priority.