2015 Review of Public Health in Scotland: Strengthening the Function and re-focusing action for a healthier Scotland

Part 2: Findings, Conclusions and Recommendations

58. The material described in Part 1 of this report was drawn from documentary and data analysis undertaken to inform the considerations of the Review Group and to ensure that the conclusions and recommendations made were informed by a good understanding of the history of public health, the nature and scale of the function in Scotland, current and future challenges, and wider policy issues.

59. Here, in part 2 of the report, findings are presented from the engagement processes undertaken by the review and the additional research evidence commissioned. These relate to the particular remit of the review, to examine:

• public health leadership and influence, both within the health sector and more widely;
• opportunities for greater joined-up working and successful implementation of public health measures within the context of community planning, single outcome agreements, and health and social care integration; and
• workforce planning and development, succession planning and resourcing within the multi-disciplinary core public health workforce.

60. The Review Group's recommendations take account of material described in both Part 1 and Part 2.

Themes emerging from the Review of Public Health in Scotland

61. Some clear themes emerged from the material generated during the review process: from the contributions to the engagement exercise, the findings of the research review, and the policy and data analysis undertaken to inform the Review Group's deliberations. Collectively these reflect a wide range of perspectives and information. Across these sources there were strong messages about:

a. the importance of both national and local perspectives, and the need for greater coordination between these different levels;

b. the need for greater visibility and a clearer identity for the public health function;

c. the challenges and opportunities for public health, including the need to respond more effectively to large-scale strategic challenges (such as the desired shift to prevention) and to focus more clearly on identified priorities;

d. the desire for strengthened leadership from individuals and organisations, and in partnership areas including IJBs and CPPs;

e. the fundamental importance of effective partnership working as a prerequisite for better population health; and

f. the nature of the workforce and the challenges of supporting and strengthening multi-disciplinary public health.

62. What follows expands on these general themes under a number of headings, although many of the themes and issues are in fact interconnected. The report also mentions some additional specific issues highlighted through the review process and provides additional information and commentary where these relate to specific conclusions and recommendations.

1. Organisation

63. There was seen to be a cluttered public health organisational landscape in Scotland, with more clarity needed on organisational roles and responsibilities and, importantly, how they join up.

64. The responses to the review made frequent reference to the need for clarity about what might best be done at national, regional and local levels, which prompted this specific question being asked of stakeholders at the engagement workshops. There was a widespread sense that coordination between levels was currently weak, and that the status quo could be improved. The importance of balancing national or regional approaches with local activity was emphasised.

65. There was general agreement that activities that could be categorised as being delivered "once for Scotland" would be best taken forward at national level, and a view that some activities were currently being duplicated by 14 local public health functions. Stakeholders noted the opportunities for greater efficiencies where more could be done at a national level than currently, leading to greater coordination, resilience and a reduction in duplication. It would be necessary to maintain and enhance speed and flexibility of response, and important to recognise that local level arrangements/implementation may differ (for example in rural compared with urban areas).

66. Responsibility for the different domains of public health lies in different national bodies. NHSHS has the predominant national responsibility for population health improvement and tackling inequalities. HPS, within NSS, has responsibility for health protection at a national level. While ISD, as part of the Public Health and Intelligence Strategic Business Unit within NSS, has a national role in providing health intelligence, there is no national body specifically responsible for public health intelligence, and a number of national bodies make a contribution. There is no single organisational locus for the public health contributions to improving health services. These organisational arrangements potentially contribute to the lack of coherent, coordinated public health leadership in Scotland. Moreover, there remain questions about the balance of resource and effort between national, regional and local activity in each of the domains of public health.

67. The local positioning of much of public health was seen as a strength: it enables public health staff to interact with local decision making structures; to be an integral part of the planning and delivery of local services; to build strong relationships and partnerships; and to influence local partners. Stakeholders noted the need to engage with local communities and organisations, and to act at a local level. Access to local-level data and information was also regarded as being important in order to understand the composition, health needs and assets of local populations and trends in the determinants of population health. Research and evaluation of local policies and approaches was seen as a highly valued public health role.

68. Responses highlighted the need for clear links between the public health function and Local Authority and Community Planning structures, particularly in relation to strengthening action on the wider determinants of population health. There was recognition that some local communities face multiple challenges and that this calls for multi-faceted responses, working closely with communities themselves to develop more holistic approaches which meet their needs as well as possible. A number of respondents commented that the public health function should be better aligned with, and more accountable to, local community planning arrangements (Griesbach & Waterton, 2015).

69. There was less clarity about the role of regional structures, including those that might coordinate work across several NHS Board or Local Authority areas. Stakeholders noted the potential for more shared services approaches including, for example, for the health protection function (Griesbach & Waterton, 2015). The value of the North of Scotland Public Health Network, in its particular context, was also clearly recognised. The need for better integration at national level also raised issues about the potential benefits of some further regional-level arrangements.

70. The written engagement questions specifically prompted reflection on how best to organise the public health landscape in Scotland to ensure the most appropriate balance of functions at national, regional and local levels. Respondents recognised that the delivery of the public health function may need to change in response to the changing organisational and policy landscape, including the emphasis being placed on organisational and partnership responsibilities for addressing health inequalities and the wider determinants of health. Some responses suggested there needed to be a single strong national public health organisation, while others saw threats in the possible reorganisation of the public health function, with concern about the centralisation of the public health resource impacting on local relationships and responsiveness to local needs (Griesbach & Waterton, 2015). At the same time there was a concern that the drive towards localism may make it harder to deliver change on a national basis (Griesbach & Waterton, 2015). In short there was general recognition that some organisational change may be necessary, but no consensus about what that change should be.

71. Stakeholders also felt that the mechanism for connecting national and local public health roles and responsibilities could be improved in Scotland. Supporting evidence for this emerged from the research analysis commissioned by the Review Group (Curnock, 2015). This examined evidence on the relative merits of different governance and accountability structures. Among the different approaches adopted internationally there is a dynamic balance between the scope and scale of national and local infrastructures for public health. This balance changes over time and varies between countries according to their political context, structures, social attitudes and history of participative decision-making (Allin et al., 2004; Brownson et. al., 2012; Jakubowski & Saltman, 2013). International country case studies (including England, France and Sweden) demonstrate the tendency to counterbalance devolved responsibilities with national accountability and direction.

72. The benefits of a nationally-led and largely centralised public health infrastructure include: the capacity to employ strategic approaches to addressing health issues with global roots, with clear alignment between vision, strategy and objectives; the ability to address inequalities of access and resource when implementing and coordinating actions; and stronger core infrastructure for issues such as IT and health intelligence. These strengths sit in tension with the benefits of power being devolved to localised regions, which include: more democratic decision-making with greater engagement and access to the population; locally responsive strategies with opportunities for experimentation; and the ability to utilise local drivers for implementation. However, localised governance may be susceptible to inefficiencies of scale, unnecessary variation and exacerbation of inequalities, and individual interest agendas (Allin et al, 2004) (Jakubowski & Saltman, 2013) (Rayner, 2007).

73. The research analysis (Curnock, 2015) concluded that there "will always be a shifting dynamic balance between local and national, and therefore there is no single 'right' solution. There is no apparent direct relationship to better population health outcomes and the balance between local and national governance for public health. Each country seeks to find the balance between these that best fits its culture, politics and values."

2. Strategy

74. The Review Group and respondents noted the current lack of an overarching public health strategy for Scotland, including priorities, clear responsibilities and anticipated outcomes. Through the review process the development of a national public health strategy was proposed as one of the main mechanisms to bring about a more cohesive and coherent approach across Scotland.

75. By providing a coherent national approach and an agreed set of priorities, a national strategy would also provide a focus for the public health leadership effort. In particular a national strategy would provide the basis for a new set of leadership arrangements (more clearly aligned to national priorities), as well as improving the accountability of leaders (Griesbach & Waterton, 2015).

76. There was strong support from the engagement responses for directing the public health endeavour towards reducing inequalities in health and for making this more explicit in the focus for public health in Scotland. This would require bold leadership, reallocation of resources to areas of greatest need, tailoring of interventions to better meet the needs of different groups, and a focus on empowerment and social renewal. National Government would need to lead the way and create the context for all public services to demonstrate these features. The engagement responses noted the threats to population health from austerity and current welfare reform policies, and their effects on the most vulnerable individuals and families in Scotland.

77. The research analysis highlighted that no single approach can be identified as the basis for a highly effective public health function. "The effectiveness of the public health system is dependent not only on the skills, leadership, cohesion and adaptability within the various components and levels of that system, but also on the wider political, cultural and resourcing context in which the public health system operates" (Curnock, 2015). In line with this, one of the conclusions of the research analysis concerned the need for clarity about the 'leadership ask' in relation to both the specialist public health function and to the wider challenge of improving the public's health in view of emergent priorities (such as an ageing population, socioeconomic inequalities and the globalised social and cultural context).

3. Leadership

78. The importance of strengthening public health leadership was clearly expressed during the review process from a range of quarters, and engagement responses identified that Public Health needs to be more visible and the vision more clear.

79. In considering the dimensions of leadership that are needed, the following features were recognised:

a. enhanced leadership at all levels within and across the public health function (not solely located within a few senior leaders);

b. leadership that is cross-functional, working across the whole system that promotes and protects population health;

c. leadership (including advocacy) for priority public health issues;

d. leadership of the specialist public health workforce.

80. The research analysis and engagement analysis both highlighted the challenges facing public health leadership in Scotland. Stakeholders commented specifically on the challenges arising from changes to the public sector landscape and the need for the public health function to have a clear locus in influencing local structures, in particular CPPs and the new IJBs. Both areas of work recognised the need to provide leadership over complex systems, extending beyond NHS and health boundaries, to influence wider agendas, policies and programmes (Griesbach & Waterton, 2015). Stakeholders also wanted to see the public health leadership role of professional leads and interaction between Scottish Government and external organisations more clearly articulated e.g. Chief Medical Officer (CMO), Chief Dental Officer (CDO), Chief Pharmaceutical Officer (CPO), public health roles of Scottish Government, NHSHS, and Joint Improvement Teams, etc. (Griesbach & Waterton, 2015)

81. Improving population health, and within this the focus on prevention and tackling inequalities, is a strategic approach and should be an integral part of how leaders plan and make use of available resources to improve outcomes, prevent harm and ensure sustainability of public services in future years. There are a number of existing senior leadership forums in Scotland^[6] which provide the opportunity to strengthen the role of Public Health and to increase public health understanding and practice in other disciplines.

82. Through the engagement processes respondents stated that leadership at national level was vital. This should include leadership from Scottish Government, COSLA, national organisations, and professional groups (e.g. Scottish Directors of Public Health (SDsPH).

83. The Scottish Government's commitment to public health was well regarded and seen as being demonstrated in both policy and legislation. Stakeholders welcomed the Scottish Government's 'strategic focus on inequalities' and its recognition of the impact of the wider determinants of health, but there was a desire for more focus from the Scottish Government on public health as a key component of the health portfolios and for better coordination across ministerial portfolios on the wider determinants of health and inequality. (Griesbach & Waterton, 2015)

84. Stakeholders continued to see serious threats to the public health endeavour from powerful multi-national business interests (Griesbach & Waterton, 2015) and mentioned the crucial role of Government in developing more effective responses. More generally, the complex cultural change required to organise the efforts of society in order to protect and improve the public's health implies a role for Government in enabling that change to take place. Examples given to the Review Group included the need for a shift in focus from target setting to more 'upstream' activity, and from traditional performance management to an approach that supports systems change and enables long-term action, prevention, shared partnership responsibilities, and new types of relationships with communities.

85. Stakeholders also emphasised that leadership and action should reflect the breadth of the public health endeavour. Public health leadership needs to be demonstrated in areas as diverse as employment, education and skills development, poverty and welfare reform, planning, housing, children's services, and climate change (Griesbach & Waterton, 2015). Some of the engagement responses specifically stated the importance of non-NHS staff, including third sector and community champions, taking on leadership roles in these areas (Griesbach & Waterton, 2015).

86. The research analysis (Curnock, 2015) stated that emergent public health challenges (such as an ageing population, socioeconomic inequalities and the globalised social and cultural context) require new approaches to public health leadership (Beaglehole, R & Bonita, R , 2004); (Czabanowska et al, 2014); (Hanlon P. , 2013). In addition, the number of potential stakeholders with a public health agenda is 'wider than ever' (associated with increased recognition of the social determinants of health) and the nature of public health practice has shifted (Czabanowska et al, 2014) (Davies et al, 2014) (Koh H. K., 2009). Table 8 summarises some of these leadership functions, both in relation to the public health workforce and the wider agenda of improving population health.

Table 8: Features of leadership

Specialist and practitioner public health workforce

• Shaping, organising, networking, connecting, advocacy, gathering disparate groups together with a shared focus on a specific outcome (Day, M., Shickle, D., & Smith, K., 2014) (Koh H. K., 2009); (Mackenbach, J., & McKee, M., 2013)
• Identification of opportunities within seemingly 'chaotic' constantly changing environments with uncertain outcomes and an ability to employ systems-thinking (Czabanowska et al, 2014) (Hunter, 2009) (Koh H. K., 2009)
• Enthusiasm, vision and credibility underpinned by a commitment to social justice (Czabanowska et al, 2014) (Griffiths, S., & Hunter, D. J., 2007) (Koh H. K., 2009) (Rechel, B. 1., & McKee, M, 2014)
• Collaborative, flexible leadership as a function of group aims or values (as opposed to authoritarian or technocratic models) situated in a relational community rather than attached to individuals or specific roles ( (Brownson, 2012) (Czabanowska et al, 2014) (Howieson et al, 2013) (Koh H. K., 2009) (Rayner, 2007)

Wider leadership to improve population health

• 'Leadership without authority' embedded within multi-sector alliances; galvanising civil society through traditional and social media; building bridges with academia and practitioners; national bodies who can serve as a convener of diverse organisations; encouraging the cultural shift toward active citizenship; participation in emergent public fora that nurture 'public interest leadership' (Davies et al, 2014) (Drehobl et al, 2014) (Howieson et al, 2013); (Lachance et al, 2015) (Mackenbach, J., & McKee, M., 2013)
• Influence through political astuteness and persuasion (Hunter, 2009) (Koh H. K., 2015); (Mackenbach, J., & McKee, M., 2013) (Rayner, 2007) (Rechel, B. 1., & McKee, M, 2014)
• Environments of innovation, creativity, imagination and continuous learning (Czabanowska et al, 2014) (Rayner, 2007) (Czabanowska et al, 2014) (Rayner, 2007)

4. Directors of Public Health

87. The Directors of Public Health (DsPH) in Scotland have an important national and local leadership role to play, and the local role is perhaps more clearly described in expectations set out by Territorial Boards in the Faculty of Public Health's specimen job description for a Director of Public Health in Scotland (Faculty for Public Health, 2013). The job description describes the high profile senior leadership qualities required as the most senior advocate for public health within the Board and on behalf of the populations served by the post: The engagement responses yielded a similar list of features and skillset that stakeholders are looking for from Public Health Leadership in Scotland (Griesbach & Waterton, 2015):

• Being a 'population advocate': This would involve advocating and lobbying on 'upstream' issues that affect public health (e.g. welfare reform, local development planning, etc.).
• Being independent: The independence of the public health voice was emphasised as this would allow public health leaders to challenge policy makers at a national level, to say things that were 'uncomfortable', and to address poor performance at a local level.
• Engaging with local communities: Respondents highlighted the need for greater engagement and better communication between public health leaders and local communities - to give communities greater ownership of health improvement and prevention.
• Being more visible: This would involve building relationships with key partners in health, social care and third sector agencies, being able to influence their agendas effectively. It would also involve building and maintaining the profile of public health at all levels.
• Making the case for public health: This would involve making an effective case for increased priority and resources for public health.
• Understanding the evidence: In order to ensure that organisations which distribute resources for public health and public health interventions do this in an effective - and cost-effective - manner, leaders in public health should have a good understanding of the evidence base.
• Working in partnership: Respondents highlighted the importance of good leadership in strengthening partnerships.
• The ability to work strategically within complex systems.
• The ability to work across organisational boundaries with a wide range of stakeholders to influence and facilitate system-wide change.
• The ability to look beyond current pressures to understand future challenges and opportunities to do things better.
• Evidence synthesis skills and the ability to communicate evidence succinctly, and translate it into effective practical action.
• Good people and management skills, including team building, networking, building trust, negotiation and facilitation skills.
• The ability to consult and work with communities using asset-based approaches to co-produce local solutions to public health problems.

88. Stakeholders emphasised that DsPH are valued locally. They have a vital role to play in linking the domains of public health, using public health intelligence to advocate for population health, supporting the role of partnerships, and raising the profile of public health. The local leadership role is evolving in relation to supporting the new IJBs, local authority committees, and CPPs.

89. Stakeholder responses also indicated, however, that the DPH role had become diluted over time and could be strengthened, including in relation to its contribution to national policy (Griesbach & Waterton, 2015). DsPH were seen as providing a link to the Scottish Government and there was an expressed desire to develop their role in bridging local and national policy. There is an expectation that DsPH should provide local leadership and also deliver coherent national leadership as a Group of Directors.

90. In addition, the Review Group recognised that there are currently vacant DPH posts in Scotland and the potential for further vacancies in the near future. A focus on workforce planning and talent management, with investment specifically made in a future cohort of DsPH, will be of critical importance for the resilience and effectiveness of the function.

5. Evidence for action

91. The importance of data, information, intelligence, research and evidence featured prominently in the review process, with stakeholders emphasising the need for action and interventions to be informed by the best possible public health intelligence. This need was recognised both at a national level (national level data sets) and a local level (translation of data into local level action).

92. In general the available data, information, intelligence and analysis and evidence are of good quality. However, the review process highlighted the need for more coordination to ensure that the public health research and intelligence activities undertaken in Scotland are relevant to priorities; evidence is clearly presented and duplication is minimised; and for research processes to focus on processes of change and address the gap in translation of evidence into practice.

93. Academic Public Health and other research organisations could be better connected to policy and delivery processes: the intention would be to foster an environment for exchange of information, expertise and (potentially) resources between organisations.

94. The review has recognised the scale and value of the public health data, research and academic assets in Scotland, and the developments taking place in research-service collaborations. Scotland is a highly regarded host of international conferences and has conducted public health research which is genuinely world leading. These are strengths on which Public Health can build.

6. Collective responsibility: advocacy and partnership

95. To address the determinants of population health, as well as particular health priorities, responsibility for public health needs to be shared widely across different organisations, sectors, communities and individuals. Greater emphasis should be placed on this sense of collective responsibility. The core public health workforce should lead the collective effort, recognising that many population health challenges are the type of 'wicked problem' that can only be overcome through partnership working and a shift to prevention within and across systems. Political leaders have a critical role to play in this regard.

96. The research analysis highlighted that this sense of collective responsibility is reinforced internationally through the Health in All Policies (HiAP) approach ̶ a cross-sector approach that systematically takes into account the health implications of decisions across public policies in order to improve population health and reduce inequalities. This plays an important role in the European Health 2020 policy framework (Leppo et al, 2013) (McQueen, 2014). Conditions which reinforce and sustain this approach include a supportive political context with legal backing, development of policy proposals across sectors with an ability to seize policy-making opportunities, processes for inter-sectorial communication and implementation, resources (such as joint budgeting or delegated financing), and the technical skills and governance structures to implement policy decisions and evaluate their impacts on health and its determinants (Leppo et al, 2013) (McQueen, 2014) (Ståhl et al, 2006) (Wismar et al, 2012).

97. Effective partnerships are essential for an effective public health function. Recent policy in Scotland seeks to strengthen partnership working across public sector bodies, with the third and independent sectors, and with communities. This is a supportive cultural and policy environment which aligns with the public health agenda.

98. The engagement responses echoed these themes and stressed the need for partnerships to be appropriately resourced, with a request for more dedicated public health capacity and also for increased time to nurture, build and sustain partnerships (Griesbach & Waterton, 2015). The engagement responses proposed an inclusive approach for partnerships, utilising contributions from the wider public health workforce; the voluntary and third sectors; Local Authorities; communities; and the public (Griesbach & Waterton, 2015). The focus of the responses was on supporting existing partnership structures.

99. The engagement process also highlighted a current lack of understanding both about the scope of public health and the activities which comprise it (Griesbach & Waterton, 2015). There was a request for clarification on the various contributors to the public health endeavour and how they join up (the development of a national strategy was felt to be a helpful mechanism for achieving this). Respondents felt that there would be significant value in achieving a better (shared) understanding of the public health function and priorities, and of the partnership endeavour associated with improving health and reducing inequalities.

100. Stakeholders indicated that a clearer articulation of the partnership contribution made by the public health workforce (for example through its population health perspective, population needs assessment, evidence and prevention focus) would also be helpful. This would help to raise the profile and understanding of this contribution and to make clear that this role extends beyond 'health' initiatives to advocacy and action on the wider determinants of health and inequality. The need for a shared language within partnerships to describe and build a better understanding of public health was also highlighted. Establishing shared partnership outcomes was regarded as essential for successful partnerships and for working towards longer term change.

101. The responses received in this review process argued that genuine sharing of resources (financial, human, physical assets, data, evidence, and other forms of intelligence) across organisational boundaries needs to be at the heart of partnership. It was felt that the contracting/funding arrangements in Scotland should support and reinforce partnership working between the public, private and voluntary sectors.

102. There is extensive research literature which describes factors that facilitate (or provide challenges to) successful partnerships. These are summarised in Table 9 below.

Table 9: Task and people focused facilitators of partnership working, categorised in relation to Implementing (Imp) or Sustaining (S) phase

Task focused facilitators of Partnership Working	People focused facilitators of Partnership Working
Consideration given to alternative approaches to achieving outcomes; explicit consideration of the degree of involvement of each group to maximise resources; and agreement of pre-determined exit strategy (I) Source: (Carlisle, 2010); (Graham et al, 2015) (O'Mara-Eves et al, 2015)	Senior representation and senior engagement (I) Source: (Boydell & Rugkasa, 2007) (Stern & Green, 2005)
Clear success criteria / goals / aims / purpose (I) Source: (Boydell & Rugkasa, 2007), (Graham et al, 2015) (Hunter & Perkins, 2012) (Shaw et al, 2006), (Taylor-Robinson et al, 2012)	Participation of 'boundary spanners' - individuals who bridge organisations ('across'), connect with the policy agenda ('upward') and with communities ('downward'), partners with local or 'insider' status, boundary spanning mechanisms. (I) Source: (Carlisle, 2010) (Eilbert & Lafronza, 2005); (Oliver, 2013); (Powell, Thurston & Bloyce,, 2014) (Rugkasa, Shortt & Boydell, 2007) (Stern & Green, 2005) (Taylor-Robinson et al, 2012)
Transparent frameworks and fair conduct for decision-making (I) Source: (Marks, 2007) (Shaw et al, 2006); (Stern & Green, 2005) (Taylor-Robinson et al, 2012)	Where there is community involvement: community and front-line workers are primary drivers (engagement is empowering rather than consumerist), not just for 'representation' (I) Source: (Carlisle, 2010) (Carr et al, 2006) (Eilbert & Lafronza, 2005) (Marks, 2007); Marks, 2007; (Stern & Green, 2005)
Clear accountability structures and governance requirements which are similar across organisations or an ability to adapt to alternative structures; organisational performance management systems that include collaboration within criteria of each partner (I) Source: (Boydell & Rugkasa, 2007) (Carr et al, 2006) (Hunter & Perkins, 2012) (Marks, 2007); (Powell, Thurston & Bloyce,, 2014) (Stern & Green, 2005))	Collaborative leadership rather than 'control and command' (S) Source: (Carr et al, 2006) (Ferlie et al, 2010) (Hunter & Perkins, 2012)
Sufficient funding, infrastructure and resources; willingness to share information and resources; joint appointments (I) Source: (Carlisle, 2010) (Ferlie et al, 2010) (Hunter & Perkins, 2012) (Marks, 2007) (O'Mara-Eves et al, 2015) (Stern & Green, 2005) (Taylor-Robinson et al, 2012)	Appropriate communication, shared language, responsiveness (S) Source: (Carr et al, 2006) (Shaw et al, 2006) (Taylor-Robinson et al, 2012)
Connections and 'joined up thinking' between local and national agendas and between different national agendas, as well as policy stability (I) Source: (Carr et al, 2006) (Hunter & Perkins, 2012) (MacGregor & Thickett, 2011) (Shaw et al, 2006)	Time and space to develop trust and goodwill and enable 'emergence' and 'evolution' of activities; capacity to work through conflict; protection from top-down restructuring (S) Source: (Boydell & Rugkasa, 2007) (Carlisle, 2010) (Carr et al, 2006) (Hunter & Perkins, 2012) (MacGregor & Thickett, 2011) (Marks, 2007) (McMurray, 2007); (Shaw et al, 2006)
Shared geographical boundaries with an approach to planning organised at a similar level (I) Source: (Carlisle, 2010) (Marks, 2007) (Taylor-Robinson et al, 2012)	Job security, organisational stability and low turnover of staff; previous history of working together (S) Source: (Carr et al, 2006) (Hunter & Perkins, 2012) (Marks, 2007) (Powell, Thurston & Bloyce,, 2014) (Taylor-Robinson et al, 2012)
Permission to experiment to solve problems; ability for local 'customisation'; and an ability to frame problems and solutions differently from what training and professional customs may suggest (S) Source: (Ferlie et al, 2010) (Hunter & Perkins, 2012) (Pate et al, 2010) (Fischbacher & Mackinnon, 2010)	Shared values and priorities built on an evidence base that spans sectors; support for 'off-line' development spaces where different perspectives can be discussed (I) Source: (Carlisle, 2010) (Eilbert & Lafronza, 2005) (Ferlie et al, 2010) (Stern & Green, 2005) (Taylor-Robinson et al, 2012)
Commitment to outcome evaluation with published results; shared perceptions of 'good evidence'; access to high quality data; capacity to track multiple inputs and outputs over a long period; adaptive system to enable feedback from learning; continuum of outcome achievement (short and long-term) (S) Source: (Carr et al, 2006) (Eilbert & Lafronza, 2005) (Graham et al, 2015) (Hunter & Perkins, 2012) (Powell, Thurston & Bloyce,, 2014) (Taylor-Robinson et al, 2012)	Secure professional and organisational identities set within the context of strong identity for the partnership itself and the removal of unnecessary organisational symbols that emphasise cultural differences (S). Source: (Ferlie et al, 2010) (Pate et al, 2010)

103. Designated support from the public health function will be needed to support CPPs and Health and Social Care Partnerships (HSCPs) to maximise their public health contributions and to assess impact. Both offer opportunities for a partnership focus on prevention and public health. An important role of the specialist public health function within wider partnerships is to counter pressure to shift attention away from the preventative agenda towards high-profile downstream issues by locating health issues within an evidence-based public health framework.

104. There is also a need to support specific partners within CPPs, including providing support to Local Authorities. The necessity to support these partners and partnerships has implications for how the public health workforce is deployed. Responses to the review highlighted the very real challenge of ensuring the provision of support to local partnerships while maintaining the necessary critical mass needed to ensure a comprehensive public health function and avoiding dilution of input to key strategic organisations.

105. Review findings specific to Health and Social Care Integration, Community Planning, NHS Boards, Local Authorities, the third Sector and Communities are summarised in the following sub-sections.

6.1 Health and Social Care Integration

106. The overarching statement for health and social care integration set out in the National Health and Wellbeing Outcomes Framework is that "health and social care services should focus on the needs of the individual to promote health and well-being, and in particular to enable people to live healthier lives in their community" (Scottish Government, 2015). "Key to this is that people's experience of health and social care services and their impact is positive; that they are able to shape the care and support that they receive; and that people using services, whether health or social care, can expect a quality service regardless of where they live" (Scottish Government, 2015).

107. Currently there is one core outcome for integration related to the wider public health endeavour. The National Health and Wellbeing Outcomes also require Boards, Local Authorities and Integration Authorities to contribute to reducing inequalities through the services that they provide. The Scottish Government has issued a number of Guidance and Advice documents to support the Public Bodies (Joint Working) (Scotland) Act 2014.

108. From a public health perspective the engagement responses sought to ensure that HSCPs are also created as public health organisations. At IJB (or equivalent) level the over-riding purpose should be for strategic plans to reflect the needs of their population, reduce the health gap and give appropriate priority to population health improvement, health protection and prevention of ill-health, alongside delivery of health and social care services.

109. The engagement responses identified that Public Health specifically has an important role in supporting this process through strategic and service needs assessment; the provision of quality information, evidence and advice; and supporting capacity building and organisational development for IJBs or equivalents. Health Improvement Teams are an integral part of HSCPs in most areas and have an important role in working with communities, providing health improvement services, and connecting national policy and local activity.

110. The engagement analysis also noted specific opportunities arising from closer integration between the NHS and Local Authorities, including working together for shared outcomes; raising the profile and effectiveness of public health approaches in primary care (e.g. via GP and pharmacy contracts) and social care; and facilitating a population approach to service planning and opportunities for combined efforts, resources, and training.

6.2 Community Planning Partnerships

111. CPPs were seen in the engagement responses to be at the centre of the public health endeavour and the main mechanism by which improvements in public health can be achieved at a local level (Griesbach & Waterton, 2015) with a clear link to the determinants of health. CPPs can be a key way through which local partners collectively coordinate and tackle public health challenges as part of work on shared local priorities. Community Planning LOIPs will reflect the priorities set by the CPP based on their understanding of local needs and circumstances, and there is a crucial role for Public Health to provide the evidence and expertise to inform and support the priorities for improvement within CPPs.

112. The 2012 Audit Scotland report on Health Inequalities (Audit Scotland, 2012) highlighted the leadership role of CPPs, alongside the leadership role of Government, for tackling health inequalities, recognising that activity to tackle inequalities involves bringing together organisations, clarifying roles and responsibilities, and ensuring sufficient shared ownership of initiatives across a range of sectors, organisations and boundaries. This report also noted the associated challenges, given different organisational cultures and governance. The report described mixed CPP performance with different levels of priority being given to health inequalities in different CPP areas. The engagement process for the current review similarly portrayed a mixed picture.

6.3. NHS Boards

113. NHS Boards have corporate responsibility for the protection and improvement of their population's health and for the delivery of frontline healthcare services. Prevention and whole population approaches have long been a core role for NHS Boards. Health Boards should be visible leaders of public health through their own strategies and services, prioritisation and planning processes, and communications.

114. This was also recognised in the 1999 Review of Public Health in Scotland which saw Health Boards developing as "public health organisations", working closely with Local Authorities and others, and having the central role in protecting and improving population health at regional level with health improvement as the raison d'être of Boards. In practice the 1999 Review suggested that this would be evidenced through the following features: "

• The Board will provide high profile leadership for public health;
• Its organisational development will reflect public health values and methods;
• Many of its resources will be devoted to the public health function;
• Clear and shared public health goals and responsibilities will be reflected in the corporate activity of the Board and its partner Local Authorities;
• Board business and decision-making will be driven by public health principles, and informed by the best possible public health intelligence;
• The Board will drive the development of effective, well-managed multi-agency partnerships for health, with particular emphasis on partnerships with Local Authorities; and
• Boards are accountable for their role in health improvement and need a framework for public health governance."

115. Currently each NHS Board has a Local Delivery Plan (LDP) which contains within it the performance contract between the Scottish Government and the Board. From 2015/16 NHS performance is measured against LDP Standards (previously HEAT targets and standards) and Improvement Priorities (which contribute towards delivery of the Scottish Government's Purpose and National Outcomes; and NHS Scotland's Quality Ambitions). These Standards are largely focused on treatment and waiting times, including some with a specific focus on improving performance in areas of deprivation. 'Health Inequalities and Prevention' is one of six key strategic priorities and 'Antenatal and Early Years' is another, also strongly recognising the role of prevention. There is still, however, some way to go towards delivering on the recommendation in the 1999 Review which described a position where public health principles would be central to the ways in which Boards operate. The information gathered for the current review indicated that the performance targets and public/political expectations of Boards have tended to emphasise other priorities which guide investment and attention away from a focus on population health improvement, prevention and health protection.

116. This shift requires a change in thinking about health policy, recognising the respective roles of health care and the determinants of health in shaping the health of populations (Wilkinson & Marmot, 2003). The challenge for Health Boards is to reflect the wider perspective of creating the conditions for good health in their corporate functions and the services they provide (in a similar way to the repositioning of the fire service from treating to preventing fires). This would be apparent from Health Boards' ambitions and exemplar activities where there is a direct role - e.g. as an employer, procurer of services, and in implementation of Health Promoting Health Service duties; as a member of wider partnerships; in ensuring equity of access to services; and in their relationship to local communities.

6.4 Local Government

117. Local Government is also an important and equal 'sphere of government' in Scotland which is directly accountable to its electorate. The political leadership and democratic accountability for public health improvement offered by Local Authorities, individually and collectively, is essential to the public health and wider prevention agenda.

118. Local Government plays a pivotal public health role given the prominence, scope and scale of its contribution to supporting public health outcomes and addressing health inequalities. During the review Local Authorities were also regularly recognised for their role as statutory partners within CPPs. Like NHS Boards, Local Authorities have a number of facets to their public health role, both as a partner to the collaborative effort and also in their own right. The challenges for Local Authorities is similar to that of Health Boards - to operate as public health organisations through demonstrating their impact on population health through their corporate processes, core functions and services.

119. Local Authorities provide specific services and functions which impact on the public's health and are often underpinned by statutory duties (for example, environmental health and consumer protection are directly responsible for contributing to public health and safety). Local Authority responsibilities for key service areas such as social care, housing, education, employability and leisure also have a relatively well defined relationship with health inequalities and health improvement while wider responsibilities in relation to licensing, welfare reform, anti-poverty measures, planning and community development are often less well recognised for the important contribution they can make to public health.

6.5 Third Sector and Communities

120. The engagement responses highlighted the opportunity for public health agencies and leaders to develop stronger partnerships with the third / voluntary sector, enabling this sector to be "third among equals" in partnerships, with its skills and experience being better utilised. In its report, Living in the Gap, Voluntary Health Scotland suggests that the third sector lacks influence over statutory services (Voluntary Health Scotland, 2015). The third sector engagement responses to the review expressed the view that the relationship between the statutory and third sectors needs to change so that there is greater mutual trust and respect (Griesbach & Waterton, 2015). The third sector can enhance the public's health. In particular it has access to marginalised groups and an important role to play in reaching, working with, and empowering local communities.

121. Community empowerment, reinforced through legislation, has been a key theme in the review. The redistribution of power, and the associated enabling of a sense of control, can contribute to tackling health inequalities. Increased involvement in decision making within one's community can also increase feelings of belonging and participation. Stakeholders have highlighted, through the engagement process, that partnerships could be improved and strengthened if they engaged more effectively with communities. Strengthening asset-based approaches in working with communities was felt to be a valuable way of focussing on capacities and capabilities, rather than on need and deprivation. Community empowerment and co-production present a major opportunity for public health, not least in terms of building resilient communities.

122. There was general agreement that public health practitioners should be 'doing things with, not to' local communities and that activity should focus on supporting and developing co-production approaches to achieving outcomes (Scottish Public Health Network (ScotPHN) , 2015). The roles of Local Authorities, NHS Boards and other bodies in supporting community development and the individual and community resilience, which significantly contributes to better health outcomes, was also emphasised. The vital contribution to be made by the third sector and wider workforce in this wide context was highlighted.

123. The importance of co-production to reforming public services in Scotland, empowering communities and reducing inequalities, has been referred to as part of the "Scottish Approach" which covers (Ferguson, 2015): 1. assets or strengths of individuals and communities; 2. Co-production: policy developed with, rather than done to, people; and 3. Improvement - local ownership of data to drive change. This clearly underlines the importance of public health building on the good work that already exists to strengthen and value the role of communities in public health work.

7. Workforce

124. The current workforce was described in the responses to the review as being highly skilled, professional, knowledgeable, committed and enthusiastic (Griesbach & Waterton, 2015). Other qualities included objectivity, the ability to offer an independent view and voice, advocacy for the public health function, flexibility, adaptability, and responsiveness. (Griesbach & Waterton, 2015). The CfWI report - mapping the core public health resource in Scotland (Centre for Workforce Intelligence, 2015) - shows a relatively small (compared to NHS staffing), but nevertheless significant, core and specialist public health workforce in Scotland. However, the public health workforce is dispersed, risks further dilution, and lacks a clear programme and structure for development.

125. The workforce priorities in Scotland identified through the review relate to the core workforce at all levels (practitioner, specialist, consultant, directors of public health) and also to the wider workforce. They include:

• development of a public health resource that is clear in its own identity;
• development of leadership capacity (as described in paragraphs 78 to 86);
• development and implementation of succession planning and career pathways which support/accelerate a multidisciplinary workforce (all disciplines, including medical);
• maximising the potential of the NHS workforce to contribute to, and influence across, the three domains and enhance intelligence;
• structured approach to developing the wider workforce contribution to public health.

7.1 Workforce Development

126. The different levels of the core workforce and the wider workforce- all have specific needs. Leadership (covered earlier) is important at all levels. Engagement responses commented on the training requirements of the workforce. There was a general view that leadership and influencing skills could be improved and more training opportunities were needed, both for the core and wider public health workforce. There was also comment that there should be greater opportunities for senior people from backgrounds other than medicine to take on public health leadership roles. There was a view that public health leaders require considerable skill in influencing, lobbying and advocating for local populations.

127. It was noted that the development of leadership and management capabilities across the NHS is a key priority of the 2020 Workforce Vision. Responses noted the value in the leadership programmes currently provided within the NHS in Scotland. However there was a view that a specific public health leadership training programme could be beneficial for the core (specialist) public health workforce. There were also comments that the leadership aspect of post-specialist public health training could be developed further and that the inclusion of leadership skills in postgraduate courses and continuing professional development should be more systematic and consistent.

128. There has been a strong call for practitioner registration (whether the purpose is for the assurance of individuals themselves through professional value or for the public through quality assurance) and the Scottish Public Health Workforce Development Group (SPHWDG) (a cross-disciplinary group in Scotland chaired by NHSHS on behalf of the CMO) has agreed in principle to consult on a scheme to support public health practitioners towards registration, seeking views from stakeholders.

129. The workforce development group has also agreed to re-activate a scheme to help people to meet the requirement of the specialist registration scheme for a defined period. This would run in addition to the UK-wide Faculty of Public Health training scheme.

130. The multi-disciplinary nature of public health raises equality issues also. Despite the progress made to date with support for multidisciplinary public health, there are still historical barriers in Scotland relating to appointments, and to equal pay and performance structures for specialists from a non-medical background. During the review the Specialist Group in Scotland argued for a more systematic and equitable structure for career development that links across disciplines, and practitioner and specialist career pathways. It argued that this evolution would better utilise the existing resource, create standardised practice and strengthen succession planning.

7.2 Career progression

131. The engagement responses called for career pathways to be developed from the wider workforce into the core workforce, with the potential for progression within the core workforce to the specialist workforce by recognised routes. The development of pathways from the NHS into the wider workforce and other sectors should also be a goal.

132. The engagement responses also noted that the (older) age profile of the existing workforce and decreasing numbers of experienced staff warranted attention to workforce succession and development planning in order to sustain and make the best use of the specialist public health resource. REHIS, in its response to the review, similarly noted concerns with regards to the falling numbers of EHOs and Food Safety Officers (FSOs) employed by Local Authorities and the need to act to safeguard environmental health services in Scotland.

133. Public health is distinctive as an area of practice in the health sector and it reaches into other sectors of public and voluntary service where important resources also lie. There are conventional routes toward specialist practice, originally medical but (as noted above) now spreading out to other disciplines to reflect the potential that wider contributions and backgrounds can bring. This change reflects the need to nurture the wider, practitioner and specialist workforce, and create career progression pathways that balance:

• the changing challenges for public health;
• workforce requirements and future capability;
• the need for a pipeline of future leaders and talent management to ensure their development to meet capacity requirements and fulfil key functions;
• expectations of people with public health skills who wish to progress; and
• the blend of traditional routes to career progression with new and atypical routes, encompassing the contributions of specialists and leaders from other disciplines and sectors.

7.3 Recognising and supporting the wider workforce

134. The engagement responses highlighted that there are opportunities to develop the public health roles of wider NHS and other public service staff, building an inclusive approach to the contribution of people from diverse backgrounds and all sectors. There are specific opportunities to acknowledge, more overtly, the particular contribution to be made by primary and community care professionals. Respondents argued that the robust development of the wider public health workforce was essential to enhance influence and impact and deliver public health outcomes, not only in terms of health behaviour change, but also in reducing health inequalities. These points reflect the importance of investing in the wider workforce, as set out in recent reports from The Royal Society for Public Health (RSPH) (Royal Society for Public Health, 2015) and (Royal Society for Public Health, 2014).

135. The wider workforce is already engaged in public health activity in Scotland in many ways. However engagement responses indicated that plans to harness the potential of the wider workforce need to develop still further, particularly in ways to structure or facilitate involvement of the wider workforce. It will be useful in Scotland to monitor and draw from the work of the RSPH on wider workforce. The review supports the RSPH view that health is everyone's responsibility and that there is the opportunity to grow the contribution of the wider workforce as part of the organised efforts of society towards improving health and wellbeing and reducing health inequalities.

Recommendations

136. Based on the above findings and conclusions, and informed by the wider context described in Part 1 of this report, the following recommendations are made by the Review Group.

1. Organisational Arrangements

137. The current organisational arrangements for Public Health in Scotland should be reviewed and may need to be rationalised. This should explore greater use of national arrangements (including for health protection, public health intelligence and other areas deemed 'once for Scotland'), more collaboration between Boards at a regional level, activity that should clearly remain at local level, and how the three levels connect.

138. The NHS Scotland Shared Services Programme has identified Public Health services for review within its 'Health Portfolio'. In taking this forward the findings of the Public Health Review should be used to define the strategic direction for public health in Scotland. The shared services work should also be used to underpin the development and delivery of the overarching review of organisational arrangements for public health in Scotland.

139. The Health Protection Oversight Group and the Scottish Government should build on the creation of the Health Protection Network to ensure effective leadership and coordination for health protection in Scotland..

140. The engagement responses noted a cluttered public health organisational landscape in Scotland, with more clarity needed on the roles and responsibilities of different bodies and, importantly, how they join up. Objectives to be met in considering alternative structures include:

a. Achieving greater national cohesion, accountability and leadership across the various domains of public health. The current arrangements, with responsibility for different domains sitting within different organisations, lessens the effectiveness, awareness and understanding of the totality of the public health effort. The Scottish Government should consider any additional measures needed to provide a more coherent and more widely owned organisational structure. This should include allocating national responsibility for each of the domains of public health and the underpinning public health intelligence function, either clearly to existing national organisations or to a single national public health organisation.

b. Achieving a clearer allocation of the public health responsibilities sitting at national, regional and local levels, and associated accountabilities.

c. Sharing of resources across public bodies to ensure the most effective use of Health Intelligence Services, and the development of local strategies for health intelligence.

d. Supporting all public bodies, and specifically Health Boards and Local Authorities, to become more overtly exemplar Public Health Organisations, demonstrating core public health principles and activities. The core work of Health Boards should recognise the central place that prevention should have in promoting and protecting the health of the population, while maintaining the existing important focus on safe, equitable and effective care services. These principles are equally applicable to Local Authorities and other public facing organisations. Public health should be made more explicit as part of the remit for public sector bodies and be reflected in how they carry out their activity.

2. Strategy for public health

141. A shared vision should be developed for public health with common goals and outcomes agreed as part of a Public Health Strategy for Scotland. The strategy should include the following features:

• a) focus on identified public health priorities (including (in)activity, diet and nutrition, obesity, mental wellbeing);
• b) provide a clear public sector and public health focus on addressing inequalities;
• c) support the necessary shift to action on prevention;
• d) make tangible the health in all policy approach a cross-sector approach that systematically takes into account the health implications of decisions across public policies in order to improve population health and reduce inequalities;
• e) channel knowledge of what works into practical action; and
• f) demonstrate governance to ensure accountability and measurement of progress against outcomes.

142. The absence of a clear national strategy for public health was reflected in the perceived lack of cohesion in the public health work being carried out in Scotland. There is the potential for a Public Health Strategy, together with the National Clinical Strategy (in development), to provide an overarching strategic context for the delivery of health and care services in Scotland reflecting the triple aims of: improving population health, improving the quality and safety of care, and securing best value from health and social care services. The Public Health Strategy would also reflect the wider determinants of health and involve action by other sectors and services.

143. Delivery of an ambitious strategy for public health in Scotland will require attention to the infrastructure, capacity, effectiveness and resilience of the public health function. The following recommendations are intended to support this.

3. Leadership

144. There has been strong public health leadership from many individuals and on a range of issues in Scotland, but the current and emerging challenges require strengthened leadership on a number of fronts.

145. The role and contribution of the Directors of Public Health should be clarified and strengthened . The DPH role is pivotal to an effective public health function and there is a need to support DPH leadership individually and as a group. This will require: (a) clarity about expectations and accountability in light of new organisational landscape and the move to multi-disciplinary public health (b) the development of a more effective national leadership group with real impact at national level, determine resourcing of Group, including dedicated resource for a Chair, and clarify relationship to Government) (c) coordinated recruitment and development for a new cohort of leaders to fill vacancies and ensure ongoing succession planning.

146. The new Public Health Strategy should be used to generate a stronger public health voice and more coherent action at all levels. More consistent messages echoed throughout Scotland by all sectors will be essential and will help to raise the profile and increase the influence of public health. Political leadership is also needed to achieve improvements in public health, demonstrated jointly from Scottish Government and Local Government, with strong cross-portfolio commitment reflecting the wide policy responsibility for determinants of health.

4. Public health intelligence and evidence for action

147. Public health intelligence underpins the three domains of Public Health and should continue to underpin public health activity in Scotland and the work that follows on from the review. The mapping of the core public health workforce in Scotland (Centre for Workforce Intelligence, 2015) identified the significant scale of the public health research and academic resource. Through the review there have been consistent messages about the importance of evidence-based interventions; the need for population-based data sets, at national and local levels, to inform priorities; and the strength of the existing resources in Scotland. To build on these strengths, the following recommendations are made.

148. Action should be taken to achieve greater coordination of academic public health in Scotland, building on successful models of collaboration in other fields, to develop a more strategic collaborative mechanism for public health research in support of the national strategy.

149. Priority should be placed on ensuring that public health policy and practice is more strongly underpinned by research and evidence - and that the research and intelligence functions in public health are focussed on being policy and practice-relevant. This will require culture changes within policy, delivery and research organisations, as well as collaborative action to build the evidence base, incorporate a range of types of evidence, and to demonstrate the effectiveness and value for money of public health approaches.

150. Technological and other data developments provide opportunities that the public health function needs to grasp. It is, therefore, also recommended that the public health intelligence specialists in Scotland should rise to the information age opportunities in public health through greater use of big data and technological responses, underpinned by a public health data and technology strategy.

5. Partnership

151. Public Health consultants and other core public health staff should be highly visible and play a strategic influencing role in CPPs and HSCPs. Recommendations include:

• a) Public Health, as a discipline, needs to be represented and contribute effectively to the work of senior CPP and IJB groups such as the Strategic Planning Group in all local areas.
• b) The Director of Public Health Report will continue to provide independent advocacy and a voice for public health actions and responses across the Board's area and reflect the specialty's wider responsibilities for the population's health. The Report will reflect the priorities for action set by Community Planning Partnerships, Integration Joint Boards, NHS Board services and Local Authorities, and help to inform ongoing activity as part of the collective effort to improving population health and tackling inequalities.

152. These recommendations are contained within guidance set out by the Review at Annex F on the public health contribution needed by Local Authorities, IJBs and collectively through CPPs in order that the impact on population health can be strengthened. An important dimension will be to consolidate the public health contribution to be made by the third sector as part of these partnership arrangements.

6. Workforce

153. There should be a workforce development strategy for public health in Scotland Features should include:

a. Workforce vision which supports delivery of the public health strategy; provides a leadership statement; describes the breadth (both NHS and wider) of the current workforce; supports multidisciplinary public health; strengthens the role of NHS workforce in Public Health; and recognises the role and requirement for engagement with local government, third sector and, more generally, the wider workforce in delivering public health outcomes;

b. Workforce development covering leadership development, supporting and developing staff in existing roles, post specialist development, talent management and preparing staff for future roles, developing the public health roles of the NHS workforce;

c. Workforce Planning including: workforce deployment, development of a career pathway for the core public health workforce and succession planning;

d. Training: identify opportunities for training across all domains of public health and cross professional joint training to ensure a progressive, integrated and cohesive approach to education and training informed by the well-developed NES approach for Health Protection;

e. Registration: to consult on and develop progressive arrangements for practitioner registration where this adds value to the public health endeavour; and

f. A structured approach to informing, supporting and utilising the contribution of the wider workforce in pursuit of public health outcomes.

7. Conclusion

154. This Review of Public Health in Scotland has identified the need for the function to be clearer about its priorities and delivered in a more coherent manner. The changing organisational context (including the clear emphasis on partnership and integration, and the importance of community empowerment and engagement) has implications for how public health is organised and operates. Major public health challenges such as obesity, mental health problems and inactivity, together with the persistence of health inequalities, require a concerted population health response, achieved through the organised efforts of society. They cannot be addressed solely through treatment. The evidence received by the Review Group emphasised the cost-effectiveness of preventive approaches and a wide appetite for a more active public health effort in Scotland. Our recommendations seek to support that through:

a. A review and rationalisation of organisational arrangements for public health in Scotland, including national coordination of the health protection function;

b. The development of a national public health strategy;

c. Clarification and strengthening of the role of the DsPH, individually and collectively;

d. Supporting more coherent action and a stronger public health voice in Scotland;

e. Achieving greater coordination of academic public health, prioritising the application of evidence to policy and practice, and responding to technological developments;

f. An enhanced role for public health specialists within CPPs and IJBs; and

g. Planned development of the public health workforce and a structured approach to utilising the wider workforce.

155. Implementation of these recommendations will require an overarching implementation plan to ensure that all elements are taken forward as a subsequent phase of the public health review. Delivery of a future public health strategy will require the contribution and collaboration of many partners, recognising that responsibilities for addressing public health issues sit not only within the health sector but also national and local governments; public, private and third sectors; and communities and individuals.