Public Health Review: Analysis of responses to the engagement paper

Executive Summary

1. In November 2014, Michael Matheson, then Minister for Public Health, announced that the Scottish Government would be undertaking a review of public health. An expert group, chaired by Dr Hamish Wilson, was established to take this forward.

2. The review was given the task of examining: public health leadership and influence both within the health sector and more widely; workforce planning and development, succession planning and resourcing; and 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.

3. An engagement paper was published to seek input on five questions:

• How can public health in Scotland best contribute to current challenges? What is your view and evidence of the Strengths, Weaknesses, Opportunities and Threats (SWOT) to the contribution of the public health function in improving Scotland’s health and reducing inequalities?
• How can public health leadership in Scotland be developed to deliver maximum impact?
• How do we strengthen and support partnerships to tackle the challenges and add greater value? How do we support the wider public health workforce within those partnerships to continue to develop and sustain their public health roles?
• What would help to maintain a core/specialist public health resource that works effectively, is well co-ordinated and resilient?
• How can we provide opportunities for professional development and workforce succession planning for the core public health workforce?

4. Responses to the engagement paper were received from 117 respondents – 6 from individuals and 111 from organisations. Organisational respondents included NHS Boards (23), community planning or health and social care partnerships (17), third sector organisations (17), royal colleges or other professional groups (15) and local authorities (11), among others.

5. Responses to the engagement paper were highly diverse, and represented a wide range of understandings and perspectives about the nature of the public health endeavour, the domains of public health and the organisational structures which would best support a strong public health function. Many responses were lengthy and complex and there was a lack of consistency in the use of key terms in relation to the public health function.

Strengths and weaknesses (Question 1)

6. Respondents saw the local positioning of public health as a strength. Other strengths included: the skills and qualities of the public health workforce; partnership working at a local level (although it was also thought this could be improved); and the availability of good-quality data, information and evidence. However, respondents also thought there was insufficient co-ordination of public health functions at national, regional and local levels. Respondents highlighted the large number or organisations involved in public health; a lack of agreement about when it is best to act locally, regionally or nationally; and a lack of coherence between what is happening at the ‘grassroots level’ and what is happening nationally. Moreover, the public health function was perceived to be not particularly ‘visible’, and this was seen as a weakness.

Opportunities and threats (Question 1)

7. A range of national policies were seen to provide opportunities for taking more of an ‘upstream’ approach to addressing inequalities. The integration of health and social care was also seen as an opportunity in some respects, but as a threat in others. Concerns were expressed specifically about the potential for fragmentation of the public health workforce. The main threat to the public health function identified was funding constraints and austerity

Leadership in public health (Question 2)

8. Current public health leadership was described as ‘patchy’, ‘disparate’ and ‘not cohesive’ at national and local levels. There was a view that, in some areas, public health leaders do not always have the skills required for leadership – in particular, the skills of influencing, lobbying and advocating for local populations. Respondents highlighted the importance of developing a clear, shared vision – or national strategy – for public health in Scotland, which would provide a coherent focus and agreed set of priorities for public health.

9. The role of the Director of Public Health was seen, particularly by health organisations, to be very important for providing leadership at a local level, and it was suggested that this role could be strengthened in relation to its contribution to national policy. However, respondents also emphasised the importance of developing public health leaders across a wide range of policy areas and topics (not just in health), for example in employment, education, welfare and economic development.

Strengthening partnerships (Question 3)

10. Respondents thought that good partnerships were vital to the public health endeavour. Thus, a focus on strengthening and supporting partnerships was thought to be essential. This could be done by clarifying roles and remits (i.e. who is involved in the public health endeavour and what outcomes should be achieved), and by finding ways to improve communication between partners. Respondents spoke of the need to develop a ‘shared language’ and for public health documents to be more accessible.

11. Community Planning Partnerships were seen to be the main mechanism by which improvements in public health can be achieved at a local level, and some respondents commented that the public health function should be better aligned with and more accountable to local community planning arrangements. Respondents also thought that Health and Social Care Partnerships offered new opportunities for partnership development, and there was an emphasis on strengthening asset-based approaches to working with communities, and developing stronger partnerships with the third sector.

Maintaining a core public health resource (Question 4)

12. Respondents’ views in relation to maintaining a core public health resource were wide ranging. While some suggested the creation of a national public health resource unit – or a centre for public health – it was more common for respondents to discuss workforce issues. The diversity of the public health workforce was seen to be a strength, enabling flexibility and resilience in responding to public health needs. However, there was also a view that the public health workforce needs to be properly identified and developed. Concerns were particularly raised regarding the need for better career progression and pathways, and the registration of public health practitioners.

Opportunities for professional development and workforce succession planning (Question 5)

13. Respondents highlighted the challenges of workforce succession planning; the point was made that the small number of public health specialists across Scotland makes it difficult to plan for the number of trainees required each year. There were calls for a national workforce development plan, and respondents specifically thought the review should take into account work currently being undertaken by the Scottish Public Health Workforce Development Group.

14. The importance of developing the wider workforce was emphasised, together with the need for greater flexibility in training opportunities and programmes.

Concluding remarks

15. A consistent theme across all responses to the engagement paper related to the importance of focusing on reducing (health) inequalities. There was almost unanimous support for directing the public health endeavour towards this aim, with some respondents explicitly arguing that this focus on health inequalities should form part of the formal definition of public health in Scotland. There was agreement that reducing health inequalities would require action far beyond the reach of NHS Boards and that community planning partnerships were key to this. However, there were differing views about what the consequences of this should be in organisational terms. Local authorities, in particular, thought the health improvement domain of public health should be more co-ordinated and driven from within local authorities. Among health organisations, there was a recognition that some organisational change may be necessary, but there was no clear consensus about what that change should be. Health organisations requested that any future reorganisation of the public health function should: i) be clear about what public health is intended to achieve; ii) be undertaken in a staged way rather than attempting to change everything at once; iii) ensure that a ‘critical mass’ continues to be available within the workforce to be able to respond quickly to unforeseen events / pressures; and iv) take into account the particular challenges of delivering public health in remote and rural areas.

16. The advent of health and social care integration was important in setting the policy context for responses, and it was suggested that different local areas were at different stages in developing their integration arrangements. This ‘work in progress’ aspect meant that there was no clear sense (yet) emerging of the impacts of integration on public health. However, there were calls to ensure that public health objectives (including reducing inequalities) should be set for the new Integration Joint Boards.