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

Annex D. Public health policy: recent history

1. The 1999 White Paper Towards a Healthier Scotland (Scottish Executive, 1999 ) established the public health agenda in Scotland following devolution. It set out a 3-level approach to better health involving action focussed on life circumstances, lifestyles and health topics, with an overarching focus on tackling health inequalities. It called for a concerted drive to improve child health, a sustained focus on priority diseases, and established a cross-government approach supported by local demonstration projects.

2. Around the same time the 1999 Review of the Public Health Function in Scotland (Scottish Executive, 1999) was carried out. It confirmed the need for public health to have a high profile within Health Boards and Local Authorities, recommending that Boards develop as public health organisations and that there be a "health in all policies" approach to policy making. Like the current review there was a focus on strong leadership and on relationships and partnerships. The 1999 Review of the Public Health Function in Scotland focused largely on the specialist workforce, and there was a subsequent Review of Nurses' Contributions to improving the Public's Health (Scottish Executive, 2001). Following the 1999 Review of the Public Health Function in Scotland there was activity and enthusiasm, particularly around the creation of the Public Health Institute for Scotland. Nevertheless, despite the passage of time, some of the issues identified in the 1999 review remain relevant now and tackling them has become even more important.

3. In 2003, the Scottish Executive's paper Improving Health in Scotland - The Challenge (Scottish Government, 2003) described the health improvement challenges and the importance of clarity and shared aims with cross-sector senior level leadership. The paper detailed the Government response, with 44 actions across four areas: early years, teenage transition, the workplace and the community. These actions included the creation of a new Directorate for Health Improvement within the Scottish Executive, and the creation of NHSHS (through merging the Public Health Institute for Scotland with the Health Education Board for Scotland) to lead national activity on health improvement.

4. HPS was established by the Scottish Executive in 2005 to strengthen and co-ordinate health protection in Scotland. Health Protection Scotland took over the functions of the Scottish Centre for Infection and Environmental Health (SCIEH), and has since developed as part of a Division of NHS National Services Scotland.

5. Scotland has a strong tradition of specialist dental and oral public health. In 2005 the Scottish Executive published An Action Plan for Improving Oral Health and Modernising NHS Dental Services which set out the strategic direction, inter alia, for tackling poor oral health. The measures identified, supplemented by further developments after 2007, have involved both upstream and downstream approaches for tackling a public health problem. The crucial role of partners in the community (e.g. child development officers in nursery schools) was also emphasised.

6. In 2007 the Scottish Government launched Better Health, Better Care: Action Plan for NHSScotland (Scottish Governement, 2007). Its central message was the development of a "mutual" NHS in Scotland, with patients as partners in care and the opportunity for individuals to take more control of their own health and to have more say in how the NHS is run. The action plan supported delivery of a 'Healthier Scotland', with actions to make progress on health improvement, tackling health inequality and improving the quality of health care.

7. As part of the Better Health, Better Care Action Plan, the Scottish Government established a Ministerial Task Force on Health Inequalities, which reported in 2008. This report, Equally Well (Scottish Government, 2008), reinforced the cross-government approach needed for tackling inequalities and the role to be played by all sectors in society. It established a set of principles for policies to have a greater impact on health inequalities, identified critically important roles for the NHS, re-stated the importance of activity in the early years, and examined the interface between health inequalities and the Government's commitments to make Scotland Greener, Safer and Stronger, and Wealthier. The report identified a number of actions brought together in an implementation plan. There have been subsequent reviews following publication of Equally Well in 2008. The most recent, reporting in March of 2014, established a central role for CPPs, emphasised the need for a greater focus on delivery and highlighted the need for inequalities work to more successfully broaden out noting that Equally Well had largely remained a health and well-being initiative.

8. The Public Health etc. (Scotland) Act 2008 set out the duties of Scottish Ministers, Health Boards and Local Authorities to continue to make provision to protect public health in Scotland. These are without prejudice to existing duties imposed on the Scottish Ministers and Health Boards in the National Health Service (Scotland) Act 1978 and existing environmental health legislation. Protecting public health is defined in terms of "protecting the community, or any part of the community, from infectious diseases, contamination or other hazards that constitute a danger to human health".

9. A Force for Improvement: the Workforce Response to Better Health, Better Care (Scottish Government, 2009) was published in 2009 and emphasised the role of all NHS staff in Scotland in promoting better public health, with every interaction offering an opportunity for health improvement and for individuals and communities taking responsibility for their own health and wellbeing. It set out the workforce response in the context of five core workforce challenges: tackling health inequalities; shifting the balance of care; ensuring a quality workforce; delivering best value across the workforce; and moving towards an integrated workforce.

10. The Health Works, a review of the Scottish Government's Healthy Working Lives Strategy published in 2009 (Scottish Government, 2009) underlined the Scottish Government and COSLA commitment to working together to tackle the causes of ill health and social inequalities. It emphasised the importance of addressing health as a barrier to work as a key mechanism for reducing poverty and deprivation; contributing to the Scottish economy through increased productivity; and helping individuals to sustain and improve their own health and wellbeing. Recommendations were also made about improving access to support for employees with ill-health and for improvement in the understanding by healthcare professionals of the links between health and work, and the importance of encouraging return to work as a key health outcome. A review in 2013 (Scottish Government, 2013) looked at implementation of the 25 key actions that aimed to encourage employers to be more proactive in supporting the health and wellbeing of workers and noted the increasing awareness that work is a key social determinant of health.

11. The Health Protection Stocktake Working Group was established in autumn 2010 to ensure that the arrangements put in place in Scotland in 2005 were still effective. The final National Health Protection Stocktake report was published in 2012 (Scottish Government, 2012). Further work, published in 2013, carried out by the National Planning Forum on behalf of the NHS Chief Executives, included a number of key recommendations, one of which was the establishment of a national health protection governance structure for Scotland. This newly formed obligate network, the Scottish Health Protection Network, consists of a number of topical and enabling groups and is overseen by the National Health Protection Oversight Group.

12. The Scottish Government's Healthcare Quality Strategy for NHS Scotland (Scottish Government, 2010) is a development of Better Health, Better Care (2007). In 2011 the Scottish Government set out the 2020 Vision, which gives the strategic narrative and context for taking forward the implementation of the Quality Strategy. The Vision is that by 2020 everyone is able to live longer healthier lives at home or in a homely setting. These two strategic documents, together with the major programme of reform through the integration of health and social care under The Public Bodies (Joint Working) (Scotland) Act, provide the main strategic and legislative context for health and social care services today. The Scottish Government is currently building on its 2020 Vision for Health to shape a transformational change in Scotland's approach to population health and the delivery of health and social care services by 2030.