This section considers the way in which the public health function is perceived from outside and from within its host organisations. Although we heard concerns about the visibility, identity and self-belief of public health, we encountered many examples of effective projects and partnerships that had been initiated and promoted by public health professionals. It is clear that several individuals and public health organisations have developed impressive regional and national profiles and are held in justifiably high regard.
The challenge repeatedly stressed to the Review was that the almost limitless potential for public health activity made for difficulty in priority setting. The demands placed on a finite resource and the effort needed to maintain vital public health functions (e.g. communicable disease surveillance, emergency planning, and management of immunisation and screening programmes) is not always fully appreciated. Successful partnership also takes time and effort, and tangible returns on initial investments often need the passage of considerable time.
The Review was particularly interested in the views of organisations outside Health Boards. Some saw the very concept of ‘the public health function’ as difficult to grasp while others held widely differing views as to what the function is and what it should be involved in. Some respondents felt that this uncertainty was a major factor in public health appearing to have ‘lost its way’. The perception was often one of a fragmented function that lacked co-ordination, integration and a coherent image at both national and local level.
Some commentators volunteered that senior members of their organisations had had only limited interaction with public health professionals, but that when they did the input was welcome and useful. They appreciated the range of skills possessed by public health professionals, but saw the need for the involvement of such specialists to be much more overt and ‘up-front’. Others drew attention to the many projects and initiatives that needed different degrees of involvement at different stages. Public health professionals need to be absolutely clear about their roles and responsibilities and the objective(s) of their involvement; this clarity must extend to managers and partner organisations.
Several commentators, particularly at community level, appreciated that public health medicine and dental consultants were a limited resource and found difficulty in approaching them. The purchaser/provider split had not helped this perception of distance. Some clinicians felt that public health doctors and dentists were an ‘arm of management’ rather than colleagues with whom they could collaborate in a drive for clinical effectiveness. In the minds of some local authority respondents, the mere fact that CsPHM were medically qualified meant that there were always connotations of disease and the prospect of awkward professional relationships. Finally, there was a perception in some quarters that public health professionals brought values and approaches that were so strongly-held as to be incompatible with the work of others.
The Review is clear that the public health function needs to recapture a strong sense of its own identity, developing its profile as an approachable expert service that has much to contribute and that wishes to work with others to improve the public health. We draw the following lessons:
Public health organisations need to be clear about who their customers are, their obligations to them and their accountability. For the most part, public health practitioners are accountable to their employing organisations for their actions and practice, and to their professional organisations in matters of competence. In reality, most practitioners are accountable to Health Boards and in turn, Boards are accountable to the public that they serve. The public health function is bound up inextricably in the success of the function of Health Boards.
All public health professionals need to project a clear image of what they have to offer, collectively and individually. The principal image is one of expert practitioners with specialist skills and approaches who can add value in the identification of health problems and their solutions. Given the dynamics of public health, the modern public health doctor and dentist needs to be flexible enough to apply a wide range of skills and principles to a spectrum of issues. Clarity of purpose and the ability to communicate this purpose is the key to successful public health involvement in health improvement partnerships. Over time, partners will become clearer about when to seek public health input, while public health professionals will become clearer about when to engage, disengage, delegate or move to a new role in partnership projects.
Senior public health professionals must be able to participate fully in policy making and influence decision makers in the upper echelons of organisations. While it goes without saying that public health skills should be available at other levels, the current policy context has increased the range of arenas in which such skills are needed and the resource needs to be husbanded and deployed carefully. Effective team working and appropriate allocation of tasks can optimise the use of time and skills. Specialists other than doctors and dentists can readily undertake some tasks while others can be delegated to non-specialists who have had appropriate training, given appropriate supervision. This does not mean that anyone with a little training can perform the job of a CPHM or CDPH. However, it does mean that many professionals, given additional training can work as part of a multi-disciplinary team to strengthen the public health function.
Approachability, especially by local organisations, is a key factor in being able to relate at all levels and know what is happening on the ground. Senior public health specialists are not normally involved directly at an operational level and are rarely the driving force behind local planning activities. However, they need to support and facilitate such activities and engage with local health networks that are working to a shared agenda.
Quality is at the very heart of the public health function and its governance. In every aspect of public health practice there is a need to define which organisations and individuals are in lead roles and which have support roles. Accountability rests on explicit agreement about individuals’ roles in the overall task of health improvement.
None of the barriers to joint working is insuperable. Successful partnership is based on clear, shared goals and objectives. Staff development must enable them to work flexibly across boundaries and disciplines, and greater understanding of partner organisations can be promoted through joint training programmes. As mentioned earlier, strong leadership and commitment from the top of partner organisations are key to success. Organisations contributing to the public health function must promote a ‘learning culture’ and provide a cultural and financial framework in which staff working in partnerships are empowered to commit their organisations to action.
Health improvement and the success of the public health function depends critically on a number of important relationships and linkage. At organisational and sector level, key relationships are those between the public, communities, Health Boards, local authorities, the new NHS Trusts, academic departments, voluntary organisations and Scottish Executive.
Local Authorities
Local authorities contribute significantly to public health 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. Their contribution has a major influence on life circumstances and lifestyles, inequalities and social inclusion. The past few years have seen major changes in the way local government delivers services. The focus now is on "best value" and social inclusion, with greater accountability for resources spent, and an emphasis on continuous quality improvement and partnership working. Community planning is an important new development in which local authorities lead joint working with other agencies and communities to ensure that services best meet local needs and priorities. Local authorities’ leadership of social inclusion partnerships also provides an important opportunity to deliver the objectives of Towards a Healthier Scotland.
Public health consultants are frequently involved in joint work with local authorities. Traditionally, the closest links have been between CsPHM with CD&EH responsibilities and Environmental Heath Departments. Other areas of joint work include accident prevention, promoting physical exercise, child protection and the planning of continuing care services for children and those with mental health problems or learning difficulties.
In recent times the scope of joint work has extended to partnerships for health, such as the "Healthy City" partnership in Glasgow, the "Corner" project for young people in Dundee, and the Community Plan for Highland. In future, Health Impact Assessment will be an integral part of the development of local policy and is another area where joint working will be required. The move to maximise the impact of resources derived from both local government and the NHS is exemplified by the development of new community schools, and projects involving the pooling of local authority and Health Board budgets for community care. Respondents felt, however that these local initiatives relied too heavily on the interest and commitment of those involved, and were not representative of partnership activity across Scotland. The Review shares the view of some commentators that national work is needed to identify and disseminate best practice in translating health strategy into action. The Convention of Scottish Local Authorities (CoSLA) has a key role to play and its new CPHM post will provide it with professional and policy advice and assist local authorities to discharge their public health responsibilities.
Local authority evidence to the Review suggests that cultural differences between local government and the NHS need to be addressed if there is to be more quality joint working. Local authorities are democratic bodies that are locally accountable to communities and increasingly performance orientated. Their relationship with their communities and with the Scottish Executive is different to that which exists between populations, the NHS and the Executive. Strategic planning and service delivery are part of the same process within local authorities, whereas in the NHS they are the tasks of Health Boards and Trusts respectively. Joint training initiatives, joint appointments and secondments could all increase mutual understanding, partnership and development of a shared agenda.
Good partnerships were seen by many respondents as the key to the success of effective health and social inclusion strategies, and addressing ill health arising from socio-economic factors. We support this view and believe that close relationships between Boards and local authorities at all levels are crucial. . The development of HIPs should be an inclusive process that recognises the contributions of other organisations to health improvement. HIPs in turn should represent a major contribution to community planning. Those bodies engaged in the HIP process should look increasingly for opportunities to pool and share their resources in support of their objectives.
A number of local authority commentators drew our attention to innovative joint executive structures that ensure appropriate Health Board input to local authority-led functions such as environmental safety, economic development, community learning and community safety. The development of a forum in which non-executive members of the Health Board and councillors can share policy papers and act as the focus for the consultative process is another useful way forward.
The public health agenda needs a high profile within local authorities. The relationship between the General Manager of the Health Board and the Chief Executive of local authorities is key, as is the extent of involvement of the DPH and his/her staff in the work of local authorities. There should be a close relationship between the Department of Public Health and the Chief Executive’s department (and other appropriate departments) within the local authority. The following mechanisms can further enhance partnership between local authorities and Boards in the drive to improve population health:
use of shared health information systems to define local health problems and needs;
jointly agreed plans that are reflected in the HIP and the Community Plan, and underpinned where possible by joint resourcing;
development of joint management groups to ensure the public health agenda is appropriately addressed through all relevant local authority functions (the DPH and colleagues should play a key role in such groups);
secondment at senior levels between local authority and Health Board;
joint planning for emergencies including major outbreaks and regular testing of plans;
involvement of local authorities in the appointment of DsPH and CsPHM;
a move to consider joint funding of posts by local authorities and Boards;
formulation by CoSLA and the Scottish Executive Health Department of a joint protocol to ensure that the post of DMO is used to maximal effect and that DsPH and their consultant staff have regular input at a level which influences committee decisions;
Other regional and community organisations
Important relationships for health protection and improvement exist with a number of other regional and community organisations. These include water companies, Scottish Environmental Protection Agency (SEPA), the Police and Fire Services (emergency planning), the Fiscal and other parts of the Criminal Justice System (drugs and blood-borne viruses), regional Enterprise Agencies, Chambers of Commerce, Trades Union Councils, voluntary organisations, community associations and Local Health Councils.
Located in local authorities, EHOs are central to health protection and delivery of the CD&EH element of the public health function. An increasing number of issues concern the interface between communicable disease control and environmental health. Food safety, variant Creutzfeldt Jakob disease, E coli 0157, and the human effects of environmental pollution are topical issues which underline the need for ever-closer relationships between EHOs and public health specialists. The Review welcomes the establishment of the Food Standards Agency with its responsibilities in relation to food safety. We see joint training opportunities for public health specialists and EHOs as a way of promoting understanding and joint working, and suggest that SCIEH, CoSLA and the Scottish Public Health Medicine and Environment Group (SPHMEG) should be invited to consider this further. We also heard of the difficulty in providing specialist EHO input (eg on food safety issues) in every local authority area. The potential of networks to optimise the use of this scarce resource bears further consideration.
The Health Education Board for Scotland and Health Promotion departments
The Health Education Board for Scotland (HEBS) has a national role in the development of health promotion policy, particularly in relation to "lifestyle" and "health topic" issues. It also has an operational role and important relationships with NHS health promotion departments and more broadly with a number of organisations involved in the public health function.
Evidence from Scottish Health Promotion Managers emphasised the contribution of health promotion specialists to health improvement, highlighted the need for multi-disciplinary working, and identified key tasks for health promotion departments. As well as contributing to needs assessment and the development of health improvement strategies, health promotion specialists have significant expertise in:
the use of campaigns and social marketing techniques to keep health high on the public’s agenda;
building partnership to promote "joined up" delivery of services;
enabling communities to maximise their health potential;
initiating projects and health promotion campaigns in a wide range of settings including the health service, workplace and schools;
providing training for professionals and the community;
developing, producing and disseminating resource materials for use in health promotion.
NHS reorganisations have resulted in different models for the provision of health promotion expertise at regional level. In some areas the department is located in the Health Board, often as part of the public health directorate. In other areas it is part of the Primary Care Trust. A third model retains a small core of specialists to inform strategy development in the Health Board while most health promotion officers are based in a Trust.
Whatever the model, the relationship between health promotion specialists and the department of public health must be close and co-operative if efforts to improve health are to be optimised. The two groups have much in common; an emphasis on health improvement rather than treatment, a similar set of relationships, and a need to work through others to achieve change. Health Promotion Officers have an important role in strategy development, contributing to local health needs assessment and translating research and theory into effective programmes on the ground. They lead the implementation of health promoting programmes, often working to empower other professionals and communities. Some health promotion officers have also undertaken specialist public health training and can contribute to a wide range of public health activities.
The Review spent some time considering the relationship between departments of public health and health promotion. While we did not arrive at a uniform view on the locus for health promotion it was clear that:
The two departments must have strong and effective working relationship;
All models of provision require a critical mass of health promotion officers with sufficient capacity to work in a range of settings and sectors, including those outwith the NHS;
The health promotion needs of the NHS should not overshadow the need for partnership working, particularly when it involves local authorities and communities;
There should be clear lines of accountability for health promotion activity; the DPH must have a role in this, either directly or indirectly (through the monitoring process for HIPs and Trust Implementation Plans);
Health promotion activity should be driven increasingly by evidence of effectiveness and subjected to objective evaluation;
Priorities for health promotion activity should mirror those in the HIP;
Nurses
The Review recognises the crucial part already played by health visitors, practice nurses, community nurses, liaison nurses, and midwives in protecting and promoting health and preventing illness. The roles are perhaps most clearly defined in relation to the CD&EH function in which four groups of community nurses are involved:
Public health infection control nurses employed by Health Boards to work with CsPHM (CD&EH);
Infection Control Nurses/Advisers employed by Acute and Primary Care Trusts to provide advice to healthcare workers on preventing infection that can arise in healthcare settings or from treatments used in people’s own homes;
Health Visitors and School Nurses ( notably those involved in immunisation);
Other nurses whose work relates to public health, including TB Contact Nurses, Health Advisers in Genitourinary Medicine Services, and nurses concerned with the prevention of infection in injecting drug users.
The Review sees considerable scope for the further involvement of nurses in improving the public health, and is particularly impressed by the potential for health visitors to support developments in local communities. The Chief Nursing Officer’s review of the contribution of nurses to the public health function is awaited with interest but we are confident that its findings will dovetail readily with those reported here.
Pharmacists
The response from the Scottish Chief Administrative Pharmaceutical Officers (CAPO) Group stressed the "largely untapped" potential contribution of pharmacists (as members of a multi-disciplinary public health team) both at Health Board level and in the community. They see pharmacy as one of the core public health specialties and argue that each Health Board should have access to an expert pharmaceutical adviser working closely with (or serving as a member of) the department of public health. Areas of potential involvement include the development of pharmaceutical strategy, needs assessment, introduction of new drugs, and development of new pharmaceutical services.15 The Review recognises the health improvement role of pharmacists in providing safe and effective pharmaceutical care, and fostering health promotion and disease prevention. We suggest that this should be considered further at national level, paying particular attention to the potential for pharmacists to contribute to community-based health improvement.
Other professional groups
Improve population health through screening and immunisation programmes;
Promote no-smoking policies and encourage healthy eating by patients and staff;
Promote health as an integral part of the care of pregnant women and babies;
Embrace the WHO concept of the "Health Promoting Hospital";
Embrace the concept of the "Healthy Workplace" and so promote the health of staff;
Strive to improve the outcome of care, reduce disabling complications of illness and enhance the quality of life;
Contribute to health promotion and education in community settings;
Implement infection control policies;
Work with public health professionals and others to manage public health emergencies such as outbreaks of communicable disease.
Public health professionals can make a significant contribution to health improvement by working with Primary Care Trusts, LHCCs and Acute Trusts in areas such as:
Needs assessment;
Service planning and development;
Development of HIPs and Trust Implementation Plans;
Clinical governance and clinical effectiveness (eg through critical appraisal of evidence, local outcome measures, local evaluation of the use of interventions and diagnostic tests);
Develop health improvement partnerships.
The public health contribution of clinicians to the CD&EH agenda deserves emphasis. Clinicians working in microbiology, genito-urinary medicine and infectious disease are a vital resource. The recent NHS Circular Resistance to Antibiotics and other Anti-microbial Agents stresses the importance of strong Control of Infection services while the Scottish Hospital Infection Manual emphasises the role of Control of Infection Committees. Health Boards must liaise effectively with Trust Control of Infection Committees and LHCCs to control infection throughout the community and the NHS.
Population-focused clinical services
Within NHS Trusts, a number of services have a particularly important role in delivering the public health agenda. Those delivering population health and screening programmes are obvious examples, but a number of clinical services also have a major responsibility for implementing public health policy. These include maternity services, sexual health and family planning services, child health services and the community dental service. The need for excellent relationships with partner organisations, communities, primary care, and innovative health improvement projects (such as those designed to meet the needs of young people) should be an important determinant of the location and development of these services. We can see huge benefits from public health input to all such clinical services with a population focus and recommends that there should be a well-defined relationship between them and departments of public health.
Primary care
Designed to Care charges LHCCs with improving the health of their communities. If these Co-operatives and their parent Primary Care Trusts are to develop a community focus (in addition to their traditional concern for the needs of individual patients) they will need support to build systematically on their knowledge and understanding of population health status and needs. Strong partnerships with local bodies such as schools, employers, and housing and social work departments will also be needed while the role of LHCCs in community control of infection could be developed. Health Boards and their public health specialists can make a major contribution to this agenda by addressing unmet need, developing networks and assisting the acquisition of public health skills by those working in primary care teams and the community.
A number of CsPHM employed by Health Boards and academics employed by University Departments (notably Public Health and Primary Care) are already working with the primary care sector. The allotment of CPHM time varies greatly between Boards but seems likely to increase. The submission from the Public Health Medicine (Primary Care) Scottish Consultants Group provided a detailed overview of their current activities. The model of input of public health into primary care varies across Health Boards but practice includes:
work at Trust level to define the areas where public health input is most needed;
deployment of public health skills at Trust, LHCC and practice level in areas such as health needs assessment, clinical effectiveness and audit, care evaluation and outcome assessment;
CD&EH and other health protection work;
linkage with other community initiatives such as health alliances and the community planning processes;
Public health departments have a history of involvement with the acute sector in that most Boards have one or more CsPHM with a specific acute services remit. Reduced emphasis on contracting has been accompanied by increasing collaboration with clinicians and managers in areas such as critical appraisal, clinical audit and datasets, outcome measures, and the strategic development of new acute services. Public health consultants are actively involved in the development of clinical networks, particularly those that straddle the acute and primary care sectors, and in the evaluation of clinical interventions and diagnostic tests. The role of Acute Trusts in improving lifestyles and life circumstances will be enhanced if there are clear links with public health departments and these departments contribute to clinical effectiveness programmes.
The Review supports the call for public health input to NHS Trusts and notes the pilot project in England to develop the role of Medical Care Epidemiologist in Trusts. Health Boards and Trusts are encouraged to collaborate in the health improvement work of Trusts. Major goals of such collaboration include the development of public health skills by clinicians and the development of health information systems to support clinical governance and service planning.
Voluntary organisations
The Review received relatively little comment about the relationships between the public health function and the voluntary sector. This sector plays a complementary role to that of the statutory sector in service provision and is an important stakeholder in health and social care planning and implementation. The HIV/AIDS field is one example of successful partnership with the voluntary sector.
Voluntary organisations are involved in partnership working at national and local level, although it appears that their expertise and knowledge are not being used to maximum effect. Cultural and organisational differences between the voluntary sector and the NHS may be barriers to joint working and voluntary organisations may not fully understand the work of public health practitioners. These barriers must be tackled if the potential contribution of the voluntary sector is to be realised.
Communities
Although tackling health needs at community level underpins one of the key principles outlined in the WHO Health for All Strategy, public health specialists do not usually have an operational role at community level. This is traditionally the province of the primary care teams, health promotion officers, and local government professionals, and increasingly involves a range of community development workers from other organisations. As discussed earlier, the advent of LHCCs offers new opportunities to address the health needs of communities.
There are several pioneering examples in Scotland of community level public health action. Such community approaches provide important opportunities to address health inequalities, and are being fostered through the implementation of Government initiatives such as Social Inclusion Partnerships and new Community Schools. A framework for community health activity has been provided by the Scottish Needs Assessment Programme in its Rough Guide to Primary Care Needs Assessment; several community needs assessment projects in Scotland are being led by health visitors and health promotion officers.
A key factor in improving the health of communities is the capacity to effect change. Community priorities for health improvement may be substantially different to national priorities and the desired outcomes may be far removed from the provision of health services. For instance, one of the main achievements of the Dumbiedykes project was to re-route public transport into the area, so enhancing people’s access to shops and services outside the locality.
The main role of the public health professional in improving the health of communities is to provide advice when called on to work with other professionals and community-based representatives. This may include providing evidence of best practice, designing health needs assessment and facilitating process; signposting access to outside advice and agencies is a further component of the role. Public health professionals are a finite resource and care needs to be taken in prioritisation so that they are not spread too thinly or detached from the available critical mass. Evidence taken by the Review suggests that having public health doctors and dentists engage in operational aspects of community health development is rarely appropriate. On the other hand, health promotion specialists and community-based staff (eg health visitors and other community nurses, pharmacists, optometrists and community dental staff) are ideally placed to take such initiatives forward.
Government
The Scottish Executive has established the public health policy framework, and is co-ordinating policy across its Departments to ensure that they all realise their potential in health improvement. This thrust is underpinned by the Government’s emphasis on public health as a cross-cutting issue and the implementation of Towards a Healthier Scotland. The Scottish Executive Health Department and its PHPU sponsors and integrates the work of national agencies which support the public health function, notably SCIEH, CSO, HEBS and ISD, while its Chief Medical Officer is the leading doctor charged with protecting and improving health in Scotland. Establishment of the Health and Community Care Committee by the Scottish Parliament offers further opportunities to raise the profile of public health issues and ensure accountability.
Action at national level is also essential in bringing forward legislation and regulating the collection of the health and health services data on which the public health function depends. Integration, synergy and avoidance of duplication are themes that are as relevant at national level as they are at regional or local level. Effective interplay between the various layers of the public health function makes for much greater effectiveness of the function as a whole. The Review endorses wholeheartedly the example of the Scottish Executive in encouraging the full collaboration and participation of all agencies and organisations in the drive for improved public health.
Scotland, the United Kingdom and the international public health community
Devolution and the coming of the Scottish Parliament have renewed Scotland’s sense of national identity and concern with its place in the international community. European influences, such as the recent Treaty of Amsterdam, are likely to have profound effects on public health policy through the working of the European Union. Europe, in its turn, has long been interested in Scottish developments in public health, its health service and health information. During the Review, members of the Steering Group reviewed models for public health organisation in various parts of the UK, cross-border Irish Institutions, Scandinavia, the Netherlands, the United States, Canada, New Zealand and Australia.
Although Scotland has traditionally trained a specialist and organised public health workforce and invested significantly in its public health function, it has not developed the type of strong national institute that has appeared in some other countries. Some of these institutes have close interplay with national Government, provide a central home and/or focus for a significant proportion of the entire public health professional establishment, and relate to regional public health offices that support local action tailored to local needs.
The case for a Public Health Institute in Scotland will be argued later. An alternative view is that Scotland does not need to undergo major organisational and structural change in its public health function, and would be better advised to ensure that its current investment was maximally effective. Forging strong relationships between national centres and agencies, and between each centre and regional public health resources will be essential in any event.
Links between academic and service public health departments