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Health information is the raw material that informs judgements about the value of the health services and interventions to improve health, and allows progress to be measured. The complex and interactive nature of health determinants poses a significant challenge for the continuing development of health information and monitoring systems. Uncertainty about the impact of particular determinants and health interventions will remain, but it can be diminished by the use of both qualitative and quantitative information from multiple sources. Increasingly sophisticated use of information will underpin attempts to demonstrate the effectiveness of the public health function, and of the organisations and individuals that contribute to it.
The interpretation and application of health information is one of the core skills possessed by accredited public health doctors and dentists. However, health information is not the exclusive preserve or doctors and dentists; a range of specialist skills is often required to make maximum use of data. The spectrum of users of such information spans politicians and policy makers, the NHS and its clinicians, to the public themselves.
With the reforms following the NHS (Scotland) Act of 1972, leadership of the health information function was seen as the specific remit of the Community Medicine Specialist, the predecessor to the CPHM. This function was an integral part of the public health business of Health Boards and was usually based in the community medicine department. Since then the information function has drifted away from public health departments for a number of reasons. Fewer public health consultants meant dropping the remit as a full-time occupation for some. Systems development and the advent of contracting for healthcare meant that finance and purchasing departments had a more immediate interest in the use of datasets. The main function of many Health Board information departments became the production of contracting and financial information. Health commissioning still has a high information requirement.
Although relationships between the public health and health information departments are good, this drift has meant that public health information is not always available when needed or available in a readily useable form. We heard on a number of occasions of the difficulty public health practitioners have in securing timely access to what should be routinely available data, and the frequent need for ad hoc data analysis to answer oft-repeated questions. This approach to information support for the public health function is inefficient and significantly reduces effectiveness.
Whatever the organisational difficulties, Scottish health information has supplied many important insights into the nature of health and health care and inequalities in outcome. For example, Scottish Cancer Registry data have described variations in outcome between various units, the linkage between social class and breast cancer, and the effects of a public campaign raising awareness of melanoma. On a national basis, the combination of ISD, SCIEH and HEBS provides Scotland with datasets on health information and events which equal the best in the world. An example of the power of this combination is the ability to link individual health "events" such as admission to hospital, surgical operation for a particular disease and death, so building up a richer picture of the health status of the population and its health services.
There will be a continuing challenge to take full advantage of technological developments, and devise data collection sets and systems that best underpin the public health function. Several contributors used the phrase "data-rich; information-poor", and the Review recognises that there is also a challenge to translate data resources into evidence-based argument that can influence decision-making from policy formulation to individual patient level.
There are several key stakeholders in the health information function:
The public and their representatives, who have a rising expectation of their right to trustworthy information, a right that is increasingly enshrined in law. Ensuring good communication of health risk to the public is a particular challenge for public health professionals;
Professionals who generate health care and health research data, who are entitled to receive aggregated information based on their contributions. They also have a heightened sense of the need for information to facilitate clinical audit and governance;
A range of organisations and agencies that can influence health. These include NHS managers who account for health service resources. In the changing environment heralded by Designed to Care, emphasis on activity has given way to stress on quality and clinical governance;
Policy-makers, whose needs for health information services must be anticipated and reflected in the information collected;
Researchers, who can contribute to Scotland’s health by providing new insights into determinants of health and disease and the effectiveness of services.
A number of respondents to the Review called for:
A strengthened national data and information resource that encompasses the new policy challenges of health and disease in the community (eg inequalities and the health of children). This needs leadership and excellent links between the suppliers, collectors, holders and those who interpret data. The Review see encouraging signs that both ISD and SCIEH are grasping this initiative;
A strategic approach to health information (which integrates information needs, streamlines data collection, and invests in information management and technology);
Improved accessibility and presentation of information in ways which address the needs of both suppliers and users of information, including the public.
Respondents also called for greater investment in information systems which reflect health rather than illness episodes, developing our understanding of "health expectancy" rather than "life expectancy", and linking health, disease and environmental data. We support these calls, recognising that this will require greater linkage with data from non-health sources and that careful thought will have to be given to prioritisation of data collection and linkage by the key national organisations, ISD, SCIEH and HEBS. However, we see such linkage as important in taking forward the white paper Towards a Healthier Scotland. We also regard the Scottish Council Foundation’s publication The Possible Scot16 as a useful source for the further development of a "Scotland Index" with which to monitor health improvement.
Health Board respondents called for better access to nationally collated data, and several called for a return of the health information function to the public health department of Boards. While we have sympathy with this view, we believe that the organisational structure is less important than functional relationships. However, it is clear that if Boards are to be effective public health organisations they will need the best possible "public health intelligence". This has a number of components:
good access to regularly updated health and health service data, routinely available, (eg as a "public health common dataset"), capable of easy manipulation to answer frequently posed questions, and allowing comparisons at national, Board, local authority and LHCC level;
timely and informed analysis with expert interpretation to support both strategic decision making and the interpretation of data to members of the public;
access to good library services, including on-line search services and access to an increasing number of public health networks and electronic information sources;
good networks with the public health community in Scotland and further afield to capitalise on new approaches to the definition and solution of public health problems;
keeping the entire organisation abreast of intelligence that can inform its work.
Some respondents encouraged further development of Scotland’s community-based morbidity recording (that is, recording of episodes of illness that do not require a hospital appointment) with improved electronic methods of collecting and disseminating data more efficiently. The Review commends the work that has already been done (and continues to be done) in this important area of primary care.
Part of the debate concerning the apparent distance between public health professionals and the main groups with which they interact centres on the need to produce timely data to inform problem solving and so demonstrate the worth of the public health function. At community level, an important function of public health professionals is to advise those who wish to gather their own information. This facilitatory role is perhaps under-recognised within the professions, but is greatly valued in communities. Information empowers community organisations and its provision and interpretation provides a powerful practical demonstration of public health skills that will strengthen partnership.
It is important to emphasise the implications of the guidance provided recently by the Caldicott Committee for the public health function (see also NHS MEL(1999)19 Caldicott Guardians and NHS MEL(1999)48 Protecting and Using Patient Information- A Manual for Caldicott Guardians). The ‘Guardian’ role is essential if public confidence in the NHS is to be retained and confidentiality of information about individual patients is to be respected. The Review sees an important Guardian role for DsPH in preserving individual confidentiality while allowing responsible use of data at population level to define and solve public health problems.
Conclusions
Health Boards as ‘public health organisations’ need ready access to excellent ‘health intelligence’ and a cadre of professionals able to analyse and interpret relevant data for the organisation, its partners and the public. Boards need to review their requirements and arrangements for accessing public health intelligence in their development as public health organisations. At national level, the Review recommends that the Scottish Executive Health Department continues to work actively with ISD and related interests to release the potential of data resources in support of the public health function. A Public Health Institute for Scotland (paras 349-357) would have an important role in such developments.
All information-holding organisations need to respect confidentiality while remaining responsive to the public and their main customers and their changing demands for information. Scotland has a rich resource of health data and linkages between databases that will continue to provide important insights into health and disease. This key resource must be used judiciously to maximise its effectiveness. Investment in the development of key public health professionals will maintain Scotland’s position at the leading edge of information technology and its use in population health.
Good public health practice requires a strong knowledge base founded on good research. Research is important for two reasons. First, it provides the evidence on which to base practice; and second it ensures that the skills are available to locate and interpret the evidence, and to turn it into reliable advice. The two are related but should not be confused. Research should only be carried out if the information is needed, not primarily as a training exercise. But public health professionals should be aware of gaps in the evidence-base and seek opportunities to fill them where appropriate.
The new focus of public health policy set out in Towards a Healthier Scotland implies a new research agenda which gives higher priority to work on inequalities in health, and on understanding the impact on health of the entire range of Government policy. This is a broad and challenging agenda that Scotland cannot tackle in isolation. It entails the development of new methods to evaluate policy and measure small relative risks. The work required ranges from genetic epidemiology, through large cohort studies to explore life-course influences, to pragmatic mixed-method approaches to evaluate community level public health interventions. The recent MRC review of epidemiology17 identified significant concerns about the research capacity, skills base and strategic direction of public health research across the UK; Scotland is not exempt from these concerns.
There are four University Departments of Public Health in Medical Faculties in Scottish Universities. Many other departments also have public health involvement, not least Primary Care. Most Scottish Universities offer courses in disciplines relevant to public health - for example pharmacy, nutrition, nursing, community care, environmental health and health promotion.
There is a range of central funding sources for public health research in Scotland, in addition to conventional higher education funding streams, Research Councils and Charities. They include the Chief Scientist Office (CSO), the Public Health Policy Unit, the Health Gain Division within the Scottish Executive Health Department, and the Health Education Board for Scotland. For example, the Health Department funds five lectureships in University Departments of Public Health (see below) while the CSO provides core-funding for five university-based research units working wholly or partly in this area (box) and some £1.5m (depending on the definition used) annually in project grants. HEBS has a substantial research programme of its own, funds lectureships in several Scottish Universities, co-funds one research unit with the CSO, and is about to fund a chair in Health Promotion Policy in Glasgow University.
Chief Scientist Office (CSO) Funded Units
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Core funding is meant to provide a platform on which a larger programme of work can be developed with funding from a variety of sources. It also provides longer term support for research career development than is usual with grant-funding.
CSO units are reviewed at intervals of five years or less. A specially convened review team drawn jointly from the Scottish Executive, any co-sponsors and the research community assesses past performance and future plans in terms of scientific quality, strategic relevance and potential for health improvement. Basic questions can be asked about whether core-funding is still the best option for supporting research in the fields covered by the unit. Reviews therefore provide a good opportunity to focus effort on public health priorities as well as on those of the health service.
All applications for CSO grants are also reviewed in terms of their policy relevance as well as their scientific qualities. However, the flow of applications tends to reflect the current pattern of interests and strengths of the public health research community, and may be slow to respond to policy changes or to close gaps. The CSO is actively considering ways of aligning research more closely with the changing policy agenda, as well as plugging strategic gaps in the public health research base.
The Review took evidence from a range of academic sources and CSO Units linked with the public health function, devoting a meeting in Aberdeen to the academic, research and training issues. Academic Departments of Public Health contribute to the overall public health function through research and teaching as well as through their service links. They need to take account of the requirements of the Research Assessment Exercise (RAE) and the Teaching Quality Assessment, exercises to which Universities attach great importance. The Departments emphasised their multi-disciplinary approach to public health and several demonstrated Health Board links in the form of sessional activity, on-call commitments, and joint projects. All made the point that academic excellence and the future strength of academic departments depend on their conducting research that is generalisable and not just of relevance to the NHS or local populations.
Evidence taken from England indicated that some units core-funded by NHS regions were exempted from the RAE by their parent departments to allow them to meet service requirements. Possible disadvantages are a loss of research revenue and future difficulties in attracting the best researchers. An alternative is to frame the remit of a unit so that RAE pressures are balanced by carrying out research that is relevant to policy and service issues. The Social and Public Health Sciences Unit is a model which is warmly commended by the Review. Jointly funded by the MRC and CSO, the unit conducts work of the highest academic quality yet it makes a huge practical contribution to our understanding of the effects of deprivation on health.
The Review does not wish to convey the impression that Scotland’s academic public health strength lies only in its Public Health Departments and CSO units. Other University Departments (notably Primary Care) and units such as the Medicines Monitoring Unit in Dundee, the Dementia Services Centre in Stirling and the Department of Gerontology in Paisley continue to make major contributions. There is potential for further linkage between service public health and these units, and for collaboration between the various elements in Scotland’s public health constellation.
A great deal of research into public health aspects of communicable disease and environmental health in Scotland is undertaken by SCIEH, a service organisation. The Review encourages the continued strengthening of research and teaching links between SCIEH, University departments, Health Boards and research organisations funded by the Scottish Executive.
The dynamic nature of the public health agenda demands responsiveness and a lack of rigidity in our academic and research infrastructure. In common with the rest of the UK, and indeed much of Europe, Scotland lacks the epidemiological resource to investigate its serious population-based health problems comprehensively. Scotland’s extensive high-quality data systems allow monitoring and measurement of health events but the epidemiologists drawing on these data frequently work in isolation and work is rarely focused on long-term strategic aims. CSO, working in concert with relevant parts of the NHSiS and UK agencies such as the MRC, has a key role to play in developing the skills needed to enhance our understanding of Scotland’s poor health.
The Review is impressed by the development of the public health function in the West Midlands. Evidence to the Acheson Committee over 10 years ago showed that this region had one of the worst public health manpower positions in England although it had the largest training scheme in public health medicine. At the same time Birmingham City Council was experiencing a chronic problem in recruiting environmental health officers (EHOs). These parallel crises led the Regional Health Authority to invest in new buildings to strengthen the academic function, while the Council used their EHO salary underspend to pump prime an MSc course in Environmental Health. Ten years later, the region has the best manpower position for NHS public health staff in England, while the University’s MSc course in Environmental Health is thriving and its research profile in public health is greatly enhanced. A new Public Health Building has allowed co-location of Epidemiology, Occupational Health, Environmental Health and the West Midlands Cancer Intelligence Unit. This encouraging model of rapid development, focusing on one regional centre, has implications for Scotland in terms of the development of a Public Health Institute (paras 349-357) and the integration and strengthening of population-based research, teaching and training.
Mechanisms to promote and assure best practice are central to the effectiveness of the public health function. The Review devoted part of a themed meeting to quality assurance and is particularly grateful for the paper developed with colleagues by Dr Karen Foster, then Consultant in Public Health Medicine and Deputy Director of Primary Care at Grampian Health Board.
The independence of public health professionals
We also heard much during the Review of the need for public health professionals to act as advocates for the communities they serve, developing the skills needed to influence others and convince by reasoned argument. As Health Boards develop as public health organisations, it will be desirable for public health professionals to win the Board’s commitment to their point of view; the same is true of other organisations where public health is a major strategic priority. However, the public would not be well served if public health professionals were somehow autonomous and independent of organisations charged with responsibility for health improvement. Rather, such professionals must make their impact through corporate accountability by influencing decision-making and expenditure.
This is not to say that a public health professional’s view would necessarily become the settled corporate view of the organisation they were advising. The Review can envisage situations in which a Health Board decided not to adopt the advice of its DPH or CsPHM. The significance of any such disagreement would depend on the importance of the issue under consideration. In most circumstances, we imagine that the public health professional would abide by the Board’s corporate decision. In the event of major disagreement on an important matter of principle, we see discussion between the DPH and CMO (and/or the DPH group) as important avenues in seeking resolution. In the event that a CPHM found him/herself in major disagreement, the DPH would normally play a key role in resolution.
Some respondents expressed the view that Directors of Public Health were too firmly bound by their corporate duty to support and justify the actions of Health Boards and seen as too distant from the communities and populations that they serve. We trust that the increasing emphasis placed on the public health role of Boards will change this perception. We see no need to pursue the suggestion made in some quarters that public health professionals should be employed by a "central independent health agency" accountable to parliament through the CMO and with service links to Health Boards and local authorities. Indeed, we can see immense difficulty and potential for confusion in this model.
In essence, the CMO is in a similar position to the DPH in terms of the balance between independence and corporate responsibility. He serves as an ‘independent’ source of medical advice to the Scottish Executive while functioning as a member of its Department of Health and its Management Executive. For the CMO to function only as an ‘independent’ source of advice would undermine his ability to participate in and influence the work of the NHS and its public health agenda. In reality, the present CMO has never felt that his ability to express his own view on health matters was in any way compromised or threatened, either by the Scottish Executive or the Health Department Management Executive. In the last resort, resignation on a matter of principle would be available to him in the event of a substantive disagreement.
Accountability for the public health function and health improvement
Accountability for improving population health is a wide issue which rests with "society" at large as well as public health professionals, organisations charged with leadership of the public health agenda, and other stakeholders responsible for the development and implementation of healthy public policy. It is outwith the competence of this Review to consider the wider accountabilities for health improvement; further work at national level will explore the roles of central and local government and other stakeholder organisations. However, the Review is very much concerned with accountability as it applies to professionals and organisations directly responsible for securing and improving the public health. In this context we suggest that the term "clinical governance" means the process by which organisations are accountable for the quality of their public health practice, while "public health governance" is the process by which organisations are accountable for the continuous protection and improvement of the public’s health.
The following discussion deals with accountability for the public health function. This has two main components. Firstly, there is the accountability of a public health doctor or dentist to the population served, to his/her professional bodies and to the employing authority. Secondly, there is the collective corporate accountability of bodies that provide the public health function. The following discussion is confined to the accountability of public health doctors and dentists for their practice, and of Health Boards for provision of the public health function (ie. clinical governance). A subsequent section (paras 247-248) deals with the accountability of Health Boards for health improvement (ie. public health governance as it applies to Boards).
The relationship of a public health professional to a population lacks the immediacy of a one-to-one clinical consultation with its diagnostic, treatment and return visit components. Nevertheless, there is an analogy between the two roles. For the public health doctor and dentist, understanding a population’s health needs is equivalent to the clinical diagnosis, while determining the changes or services required is equivalent to the prescription of treatment for the individual, and monitoring outcome equates with the return visit.
The public health practitioner and the clinician both have a duty of care, to their population and patient respectively, and both are responsible for the quality of their practice and ensuring that they keep abreast with developments in their specialty. The accountability of individual clinicians to their patients is increasingly well defined, as is the recognition that difficult choices have to be made between competing priorities. Accountability for the quality of public health practice is becoming better understood and the basis of quality practice and quality assurance mechanisms will be discussed later.
Moving on to corporate accountability, this is increasingly well defined for clinical practice in that "clinical governance" now requires NHS Trusts to monitor the quality of their clinical services. By analogy, the quality of its service public health function must be a corporate responsibility of Health Boards in their role as public health organisations. The development of clinical governance within Health Boards will provide a corporate framework within which good public health practice can flourish and professionals can discharge their individual responsibilities.
Measuring the quality of public health practice
The endpoints of health improvement are lowered burdens of disease, with many intermediate measures such as better life circumstances (e.g. environmental quality and employment levels) and lifestyle changes. Key outcome measures for health service change are higher quality clinical care, achievement of the best possible outcomes for patients, and elimination of undesirable variations in clinical practice. All of these outcomes will be concerns for the Clinical Standards Board for Scotland; they are subject to a range of influences, just one of which is public health practice. This consideration, taken in conjunction with the multi-disciplinary nature of public health, and the long-term nature of many of the outcomes makes it difficult to measure the specific contribution of public health professionals to improved population health. Thus, while it remains essential to monitor progress towards key health outcomes, it is necessary to develop separate assessment of the quality of public health practice.
The quality of public health practice can be defined at three separate levels: that of the individual practitioner, that of the department of public health (within Health Boards, Universities or other organisations) and that of the organisation(s) which hosts the public health function.
Individual practitioners
Any criteria used to assess quality in public health practice must be transparent, open to scrutiny, and externally validated. As professionals, public health doctors and dentists are bound by the codes of practice provided by the General Medical Council (GMC) and the General Dental Council (GDC). These codes underpin the concept of professional self-regulation. The Academy of Medical Royal Colleges and the GMC have recently published papers relating to clinical governance, professional self-regulation and revalidation, and the Faculty of Public Health Medicine has issued a draft working paper which discusses the practice of public health medicine.18 The Public Health Medicine and Environment Group is doing the same in respect of the CD&EH function.
Although continuing professional development has long been recognised as a critical component of professional practice, the concept of revalidation for doctors and dentists is relatively new. It acknowledges that following training and accreditation, appropriate standards of practice need to be maintained and assured by an ongoing monitored educational process and periodic re-statement of an individual’s fitness to practice. While re-examination is not (currently at least) under consideration by the GMC, there is intensive debate about the extent to which audit of practice will inform the process of revalidation. It is clear that there is considerable overlap in a clinical context between clinical governance (of institutions or services) and the revalidation (of individuals).
The following discussion examines elements of the process that could provide quality assurance in respect of the practice of public health professionals. While phrased as if it applies only to public health doctors, the elements are relevant for all public health specialists:
Trainees, their selection and training
As discussed earlier (para 116), doctors entering public health medicine have a broad background experience, usually in the NHS. There is competition for training posts in Scotland and trainees are generally considered to be of high calibre. Good quality training will ensure the uninterrupted progression of able trainees through vocational training, Masters’ degree and FPHM examinations, and the award of a Certificate of Completion of Specialist Training. The Review believes that involvement in training programmes helps to maintain the quality of public health departments, in that training duties act as a stimulus for new learning by trainers. Indeed, we see such involvement as a desirable part of the practice of senior staff, while recognising that not all individuals have the aptitude and skill to serve as good teachers. In many service departments, teaching and training is enhanced by links with an academic department.
Accreditation of specialists and assessment of trainers
Accreditation by the appropriate professional body is clearly a major feature of quality practice and is covered elsewhere as is the need to assess trainers (see para 259).
Appraisal of specialists
Regular individual performance reviews and appraisal should be undertaken against agreed objectives. The FPHM has indicated that such reviews will contribute to revalidation of public health physicians on the GMC Specialist Register. The Review endorses the Faculty’s view that the DPH should play a key role in the appraisal of consultants in public health medicine and sees Health Board General Managers as having a central role in the appraisal of DsPH.
Each public health doctor is responsible for ensuring that he/she keeps up to date in specific areas of expertise as well as in the wider aspects of public health practice. The CPD programme of the FPHM is now in the final year of its three-year establishment phase. From the year 2000, only those members who have demonstrated adequate involvement in CPD will be able to undertake responsibilities within the Faculty and within education and training in public health medicine generally. The accreditation of programmes that address both knowledge and practice and the development of distance learning programmes are further Faculty initiatives. The Review agrees that all public health doctors should demonstrate adequate uptake of good quality CPD that should meet explicit development needs. The appraisal review should result in a personal development plan, one of the aims of the process being to identify adequate resources with which to underpin the plan.
The Review also supports the view that there are some areas of CPD in which all practitioners should participate. A priority for such "core" CPD is the maintenance of the CD&EH skills of staff participating in on-call rotas.
Approaches to public health problem solving appear to be very variable. While there are often valid reasons for the variability, we advocate common structured approaches to major areas of work. Guidelines should be evidence-based where possible, or based on accepted good practice where evidence is not available. A number of guidelines which underpin specific areas of work, particularly communicable disease control, have already been developed by bodies such as the FPHM and the consultants in public health medicine (CD&EH) group in concert with the UK Public Health Medicine and Environment Group (PHMEG). The Review sees the need to draw together a programme of work in key areas where public health practice guidelines are needed. Scotland already has a strong Intercollegiate Guideline Network (SIGN) and we can see great potential for collaboration with the FPHM in guideline production and dissemination.
Contribution to national public health initiatives, audit, research and development
Individual practitioners must participate in clinical and organisational audit and use the departmental peer group to audit their performance against nationally/locally agreed standards. Undertaking work at national, regional and local level will provide further opportunities to maintain and develop essential skills. Such involvement should be a valued part of a practitioner’s work and the Review sees great utility in a national database which would record major pieces of ongoing and completed work within service and academic departments of public health (paras 349-357).
At national level, the development of managed public health networks (paras 284-309) will facilitate audit, research and development. There is clearly a role for the Faculty of Public Health Medicine and possibly for the Clinical Standards Board for Scotland in these developments. Audit of the use of clinical guidelines and evidence-based practice in public health will be an important part of governance and this underlines the need for robust information systems.
The accountability of departments of public health is an important part of the corporate accountability of Health Boards and is the primary responsibility of the DPH. This is not to say that departmental members do not share in the collective responsibility. In larger departments, a business manager can assist the DPH by undertaking day-to-day management and assuring optimal efficiency and effectiveness of the whole unit.
Departmental audit should embrace the work of all departmental members, including audit of the DPH Annual Report, communicable disease control, partnership and alliance work, clinical effectiveness work and communications. Risk management techniques can help to identify priorities for action, ensure good documentation (of advice and other work), systematically review complaints, and assess all critical incidents affecting departments. Incidents might include large outbreaks of communicable disease, environmental health incidents and failures in communication.
Regular review of priorities and resource deployment underpins departmental accountability for decisions to undertake some areas of work but not others and devote more or less resource to particular activities. All members of the Department should have a job plan that defines not only their areas of activity but sets out the expected time commitment. Other mechanisms to ensure appropriate deployment and avoid significant omissions or duplication of activity include optimal communication (particularly between CsPHM and the DPH), individual review and appraisal, and regular open review of departmental activities. The annual forward plan for the department has to be clearly linked to the Annual Report and the Health Improvement Programme. Project management techniques are used increasingly to assist all of the above activities.
The FPHM is proposing a system of three or five-yearly external peer review for departments in accordance with guidelines as they appear from the GMC. The appraisal would give service accreditation to departments visited and might be extended to constituent individuals. It would replace the current system where only those departments that wish to participate in training are subject to external appraisal. The Faculty will train assessors and in Scotland there will need to be discussion as to how this peer review system would relate to the work of the Clinical Standards Board. The Review does not see the development of external review as obviating the need for less formal continuing peer review at local level.
Public health governance within Health Boards
As Health Boards move increasingly to become the public health organisations envisaged by Towards a Healthier Scotland, a framework for their accountability for health improvement will be needed. This ‘public health governance’ embraces accountability for the public health function as a whole (using the mechanisms described above in conjunction with review of resource deployment) and extends to issues such as leadership, prioritisation, effectiveness of immunisation and screening programmes, health promotion and education initiatives, and the implementation of health strategy. The Review understands the difficulty of holding Health Boards accountable for meeting health targets when they are not solely responsible for progress. It does however believe that progress towards explicit health targets should be monitored as part of the accountability process and that Boards should instigate appropriate remedial action where targets are not being met.
Lack of a clear public health governance framework and a corresponding lack of clear responsibility for the quality of practice, may result in lost opportunities to improve population health, or worse, allow it to be damaged. As in clinical medicine, lack of governance may prevent early identification of dysfunctional or failing professionals and prevent timely remedial action. A number of Boards are now developing clinical and public health governance frameworks as part of their organisational development. The Review recommends collaboration at national level to develop a framework that will assist the further development of Health Board as public health organisations.
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