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Population programmes
Immunisation programmes aim to reduce or eliminate the effects of particular infectious diseases, while screening programmes aim to detect disease before it becomes symptomatic and treat it early to reduce the burden of ill health. A number of population programmes are prescriptive, that is, determined by local or national policy, and these include the national childhood immunisation programme and the UK cervical screening and breast screening programmes. Public health professionals play a major part at national and local level in the development, implementation, co-ordination and monitoring of such programmes. Their role complements that of other scientific, clinical and management colleagues.
To be effective, population programmes must be organised according to an agreed policy. Without active planning, such programmes may not achieve their intended health impact and may incur great and unpredictable costs. The complexity of organisation required for success is illustrated below (Box).
Organising a screening programme: key elements 12
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Health Boards are responsible for ensuring that screening and immunisation programmes for their resident population are properly commissioned (locally or nationally) and must assure themselves that programmes are effective and efficient. This responsibility is normally delegated to the Director of Public Health. Either the DPH or a consultant colleague acts as programme co-ordinator, a responsibility that must be made explicit in job descriptions and underpinned by the allocation of dedicated time and resources.
The Board’s responsibility includes anticipatory planning for policy change; securing public awareness through health education; working with Trusts and primary care teams on implementation; and monitoring clinical governance and quality assurance arrangements that can deal promptly with critical incidents. Regular meetings of co-ordinators at national level have proved invaluable in terms of consistency of policy implementation. They also allow innovative approaches and good practice to be shared with colleagues in other Boards and with the Public Health Policy Unit of the Scottish Executive Health Department. We can see great value in having Health Boards consider the annual reports of population programmes in public session.
Priorities for action
The emphasis just given to CD&EH, clinical effectiveness and population programmes should not be taken to mean that these are the only important parts of the public health function. Other key areas covered elsewhere in this report include health promotion, needs assessment, the development of partnerships, and health impact assessment.
The public health agenda is wide-ranging and can generate potentially limitless activity. In order to ensure the best use of public health expertise, there must be a clear shared understanding of national, regional or local goals and priorities. This includes a need to appreciate the "opportunity costs" of involving practitioners and organisations with one arena or topic rather than another.
In the NHS internal market, much of the time of public health doctors was taken up with the contracting process. The demise of this market and the new public health agenda has shifted emphasis towards partnership working and community development. More than ever before, there is an opportunity for public health professionals to deploy their experience and expertise in the drive for improved public health and effective and efficient health services.
Towards a Healthier Scotland sets out a framework for a co-ordinated approach to health improvement based on a three-pronged attack on:
life circumstances: including poverty, unemployment, adverse social structures, poor housing and a polluted environment;
lifestyles: including, smoking, diet, exercise and alcohol and drug misuse, and;
health topics: including cardiovascular disease, cancer, mental health, sexual health (including teenage pregnancy) accidents, child health and dental and oral health.
The overarching need to address health inequalities will remain a major priority and the agenda of Health Boards will continue to be set within the Priorities and Planning Guidance issued by the Management Executive. Continuing public health priorities include the control and prevention of CD&EH threats as described above, (paras 71-81) and the continued co-ordination and development of population health programmes including immunisation and screening programmes. The creation of a Public Health Strategy Group within the Scottish Executive and a cross-cutting approach to public health will greatly assist the further development of coherent national policy.
As well as identifying priorities, Towards a Healthier Scotland set targets for attainment by 2005 or 2010. These priorities and targets will be addressed at local level by the HIPs developed by Health Boards in concert with local authorities, NHS Trusts and other stakeholders. Within the prioritised public health agenda there must be enough flexibility to respond to urgent public health issues. There must also be room for innovation and the development of public health practice, but not at the expense of services developed to meet existing priorities.
Public health currently operates at national, regional and community levels, and appropriate linkages and joint working across sectors are major determinants of effectiveness. It is, nevertheless important that there are defined organisational loci for the specialist public health function, and that this is a matter of national policy. Such defined loci will:
Ensure corporate accountability for the public health function;
Lay the foundations for equitable provision of public health expertise across Scotland;
Allow explicit and continued assessment of the resources and support needed to deliver the function;
Provide a focus for the development of best practice in public health;
Ensure a coherent overview of the health status of populations and of public health priorities;
Help to provide a critical mass of staff to respond to public health emergencies;
Ensure that public health expertise is not spread so thinly that the effectiveness of the public health function is compromised;
Minimise wasteful duplication of effort.
The Review holds strongly to the view that the public health function should have a defined locus in each region. It recognises that the current arrangements whereby Scotland has fifteen Health Boards does not always lend itself to making the best use of scarce public health expertise. A strong regional locus would favour the achievement of critical mass, ensure accountability for the full range of public health tasks, maintain a coherent, whole-population overview of health, and make best use of specialist resource. This in no way ignores the fact that public health skills will be required increasingly in various organisations with a major interest in health improvement. In determining the locus of the public health function, we see four over-riding considerations:
Public health doctors and dentists must be able to work in an integrated and co-ordinated way with other public health professionals, and with those responsible for delivering key public health programmes. We are concerned particularly by the relationship between public health doctors/dentists and health promotion specialists will return to this issue later;
Public health professionals must be able to work effectively across organisational boundaries and strata when addressing a shared public health agenda;
The public and their representatives should be able to identify and communicate with those responsible for the public health function in their area;
Sufficient specialist expertise should be available to fulfil the function, including the provision of 24-hour cover and ability to respond to major emergencies.
The Review emphasises that the "deployment" of public health expertise is a different issue to the "locus" of the public health function. Public health professionals work increasingly in a large range of settings and within multi-disciplinary and multi-professional networks. The eventual arrangements must ensure that there are no isolated or poorly supported professionals who are attempting to deliver an unsustainable range of functions. There must be clear accountability for delivery of the whole set of specialist public health tasks.
The current locus of the public health function and the new policy context
While much of the public health function currently rests with Health Boards, it is clear that the function has changed significantly, just as the role of Boards has evolved. The White Paper Designed to Care stresses the responsibility placed on Health Boards to understand and meet the health needs of their populations through the development and implementation of a rolling HIP.
Designed to Care also created larger NHS Trusts with statutory responsibility for the quality of their clinical care (clinical governance) as well as financial performance. Primary Care Trusts and the new LHCCs now have a key role in addressing the health needs of smaller populations and communities and this represents a significant opportunity for health improvement.
Towards a Healthier Scotland further underlines the shift in the role of Health Boards from organisations concerned principally with commissioning health care services to organisations charged with health improvement. Their role is no longer that of "purchasers" (of health care) but that of "public health organisations" expected to tackle, in partnership, the determinants of ill health as well as their effects.
Achieving this transition will be a significant challenge. The Health Board may be perceived by many as a creature of the NHS and, to an extent, of central Government. On the other hand, its main planning partner, the local authority, is seen as accountable to the local electorate. Non-departmental public bodies such as Scottish Homes and the Scottish Environment Protection Agency (SEPA), voluntary organisations and patient/consumer organisations, have a range of experiences of Health Boards and have their own views on public health matters. A major difficulty has been failure of the public health element of Health Board work to come across consistently strongly to outside bodies. Boards and their public health professionals must now take the opportunity to ensure that partner agencies are fully aware of their public health role, function and aspirations.
The development of local authority-led "Community Planning" provides a further opportunity to integrate the Health Boards’ health improvement agenda with plans developed by local authorities and other organisations. There is a need not only for "joined up" plans but for "joined up thinking" if health improvement is to be central to all relevant local authority and Health Board work.
Alternative loci for the public health function
The Review received comparatively few written views on this matter but made a point of stimulating discussion during its meetings. From the outset it was clear that the public health function, however defined, can never be confined to one group of professionals or one set of institutions. Regardless of its main locus, the organisation responsible for delivering improved public health will strive to amass sufficient skills and resources to enable it to plan strategically and influence other organisations. A "penumbra" effect is desirable so that people working at all levels in partner organisations develop public health skills and can appreciate and apply public health perspectives to their own work. The following paragraphs discuss a range of models that ground the public health function predominantly in one organisation or another.
The influence wielded by local authorities over a number of important determinants of health is emphasised in Towards a Healthier Scotland. Relevant responsibilities include those for housing, education, leisure, environmental health, economic development, transport, community resources, and social care planning and provision. Many authorities have an impressive commitment to better health, although this is not as yet an explicit core aim for all.
The major advantage of locating the public health function within the local authority would be democratic accountability, the facilitation of healthy local policy development, and joint working across local authority departments to implement a shared public health agenda. However, the local authority does not have an overarching responsibility for health improvement and its prime responsibility is to provide services other than health services. It would also be impossible to sustain a separate public health function in each of the 31 local authorities. We also have concerns that public health professionals would be detached from health service colleagues who are agents for health improvement and with whom they must work to improve clinical effectiveness and service organisation.
Local authorities share statutory responsibility with Health Boards for the control of communicable disease and have prime responsibility for environmental health. The Review believes that separating the Board’s CD&EH function and locating it alone within local authorities is not tenable. It would divorce CsPHM (CD&EH) from the rest of their public health colleagues, impair team working, and have adverse effects on career development and recruitment.
In the course of the Review, several local authority commentators stated that their organisations would not be the "natural home" for the public health function. To such commentators, it is however crucial that public health expertise is deployed in a way that allows it to contribute adequately to the local authority health agenda. We share this view, believing that this provision of public health input to support the health agenda of local authorities is a vital consideration. Local authorities and Health Boards must collaborate to ensure that the appropriate expertise is readily available.
Primary Care Trusts
These Trusts came into being on 1 April 1999. They hold out much promise for improved working of primary care, community care and mental health services, and for an enhanced population approach to health. There is no doubt that public health input could contribute to their strategic thinking and development. Pilot projects in England are deploying public health trained medical care epidemiologists in Acute Trusts and Primary Care Groups to provide public health input to the Trust agenda. In Scotland, "natural experimentation" has resulted in some public health doctors taking management positions in the newly organised Trusts.
There is general acknowledgement that strategic public health activity should now extend right across the NHS and into non-NHS organisations. The public health function should not be the subject of "turf wars" or boundary disputes; it is no more the exclusive preserve of Primary and Community Care than it is the preserve of Acute Trusts or Health Boards. It is also important to avoid creating the impression in the minds of non-NHS partners that public health is totally embedded in one part of the NHS. The major role of Primary Care Trusts remains the provision of services and care to individuals and local communities. While these organisations require appropriate specialist public health input, the Review does not consider that a significant part of this scarce resource should be embedded within them.
It can be argued that the public health function would be better organised and professionals better deployed through a single structure, rather than the 28 organisations in which public health specialists work at regional and national levels in Scotland. A single structure could give coherence to programmes of work, promote communication, deploy available resources to maximum effect and avoid duplication of effort. During the Review, we have been aware of a spectrum of public health opinion; at one pole, public health sees itself as predominantly monitoring and communicating health agendas through research and evaluation, at the other it sees itself as mainly concerned with implementation and the management of change. We consider that the full spectrum of activity is essential and that the system cannot afford the luxury of allowing individual practitioners to select and retain a fixed position on this spectrum. In large Health Boards, well-organised departments of public health can ensure that the full spectrum of necessary activity is undertaken. It remains a matter for debate as to whether a national agency would allow more uniform and equitable use of skilled resources.
Several commentators remarked on the difficulty of positioning themselves appropriately on another spectrum of public health activity, namely that which ranges from local to national involvement. We recognise this difficulty and the need to retain enough flexibility to allow movement and periodic repositioning. We appreciate that a great deal of public health activity already takes place (appropriately) at national level and that effective national agencies are already in place for important parts of the public health function.
A National Agency would have significant drawbacks, even if some of its workforce remained embedded in Health Boards. It would frustrate a key component of modern public health practice, namely the ability to combine strategic thinking and action through implementation and management. It could undermine the corporate activity of Boards and weaken them as public health organisations. Therefore, while the concept of a national function has some attractions, greater co-ordination rather than centralisation is seen as the way forward. It should be clearly understood that we are not arguing for "hermetically sealed" regional public health functions with all of the obvious disadvantages. However, the public health function must relate to and remain in touch with its local population and key stakeholders and must not be detached from them. It must retain a position in which it can influence and contribute to the management of change.
The Health Board
The new emphasis on Health Boards as ‘public health organisations’ underlines their need to hold within them a body of trained professionals who can support their evolution and help partner organisations to maximise their health contribution. Implementation of the White Papers Designed to Care and Towards a Healthier Scotland allows the public health role of Health Boards to become the very centrepiece of their activities, ethos and sense of purpose. All of this will depend critically on Boards being able to develop a strong identity as public health organisations rather than as a tier of NHS management.
In conclusion, we see significant danger in splitting the public health function into constituent parts that could then be based in different organisations (for example, locating the CD&EH function within local authorities). We see greater merit in retaining critical mass in one location while ensuring close working relationships with the organisations with which public health specialists need to interact. These relationships should be underpinned by arrangements to deploy public health expertise in partnership working with local authorities, NHS Trusts and LHCCs, and other organisations. We see the Health Board as the optimum locus for the public health function at regional level. Of all the regional organisations, it is the one entrusted with health protection and improvement as its main purpose, and it is in the best position to deliver the objectives set out earlier. We do not support the creation of a national agency to take over delivery of the public health function but believe that Boards should take full advantage of existing national organisations, agencies and networks (including academic interests) in pursuit of its goals.
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