Public Health Review: Analysis of responses to the engagement paper

10 Comparisons between sectors

10.1 As noted at the start of this report, the responses to the engagement paper included a very diverse range of views, and there was not necessarily a unified view, even among respondents within a single sector. However, there were some differences in focus and emphasis between respondents in different sectors, and this chapter explores those differences – specifically between health organisations, local government organisations, partnership bodies and the third sector.^[7] The focus in this chapter is on the views expressed by each sector which were distinct from those expressed by other sectors.

10.2 Health organisations often discussed all three domains of public health as well as the fourth area of public health intelligence. Thus, in setting out the perspectives of health organisations below, an attempt has been made to draw out some of the key points made by this group in relation to the different domains. Local government organisations and partnerships often equated ‘public health’ with the health improvement domain, while also occasionally highlighting the importance of public health intelligence. Responses from the third sector contained comments in relation to all the domains of public health.

10.3 The engagement paper did not specifically ask for views on the organisation of the public health function. However, respondents frequently raised this issue – often in the context of a discussion about the lack of co-ordination between national and local public health functions, and the poor visibility of public health among local partners.

Perspectives of health organisations

10.4 The responses from health organisations comprised 42 responses in total – 23 from NHS Boards, 7 from public health forums and networks, 6 from senior public health staff groups and 6 from national NHS organisations. The latter group included organisations with national responsibilities for two of the domains of public health, namely health improvement (NHS Health Scotland) and health protection (National Services Scotland). NSS also has a leading role in the area of public health intelligence. It is relevant that coverage of the domains of public health varied substantially between the respondents in this group and thus there was a particularly diverse range of perspectives.

10.5 Among the health organisations, recurring themes included a lack of capacity (particularly in relation to some specialist roles), duplication of effort, fragmentation of the workforce, and confusion about which organisations were leading on particular aspects of public health. These were all identified as weaknesses in the public health function as currently delivered.

10.6 Health organisations often acknowledged that there was currently poor co-ordination between national, regional and local public health functions, and a need for clarity about what should be delivered at each of these levels. There was a recurring view that the development of a national strategy for public health would help to address this. There was some mention that a single national Centre for Public Health might also be created.

10.7 Some respondents offered detailed comments about organisational structures that they believed would offer improvements -- as well as those they thought would not be beneficial. Other respondents expressed concerns about any kind of reorganisation. There was no clear consensus about which structure would be best for public health, and there were also mixed views about whether a ‘shared services approach’ represented an opportunity or a threat.

10.8 Reference was also made to the Public Health England model. While some saw this type of model as potentially positive and worth considering for Scotland, others described it as not working well. It was thought that this type of reorganisation could lead to: loss of critical mass through fragmentation of the workforce; professional isolation; loss of access to (health board) data; constraints on the independence and advocacy function; loss of influence and ultimately, widening health inequalities.

10.9 It was suggested that ‘any structure can be made to work’ – and too much focus on finding the ‘perfect’ structure, rather than one which is ‘fit for purpose’, would be unhelpful. Nevertheless, health organisations seemed to anticipate that some change may be necessary, and there were requests that any future reorganisation should:

• Identify what the purpose of the public health function is, and what it is intended to achieve
• Be undertaken in a staged way rather than attempting to change everything at once
• Ensure that a ‘critical mass’ continues to be available within the workforce to be able to respond quickly to unforeseen or ‘rare event’ pressures (such as flu pandemics)
• Take into account the particular challenges of delivering public health in remote and rural areas.

10.10 Health respondents recognised the importance of partnership working and pointed to the many ways in which they were involved in supporting and working alongside local partnerships. However, they also agreed that more could be done. It appeared that in some cases, partnership working was well developed, while in others, public health professionals were reported to work with a more limited range of partners on a narrowly defined set of ‘health’ initiatives.

10.11 There were differing views expressed among the health organisations about the implications of health and social care integration to the delivery of the public health. On the one hand, there was a view – and a desire – that public health should have a strong role in the new partnerships. However, there was also a concern that the integration of health and social care may result in further pressure on the capacity of the workforce. There was also a question about the extent to which health and social care partnerships would be able to bring about changes in the wider determinants of health. Thus, it was thought that a strong shift in focus by public health agencies towards these new structures could be counterproductive.

10.12 In discussing the issue of leadership, health organisations tended to speak of the specific leadership role provided by the Directors of Public Health and they offered views on how these roles could be strengthened. For example, respondents thought DsPH should have a key role in the new Integration Joint Boards, but thought that capacity problems made this difficult. Health organisations also suggested that efforts need to focus on recruiting a broader pool of leaders, and that leadership could be strengthened through more integrated partnership working across organisational boundaries.

10.13 In terms of the public health workforce, health organisations referred to the work of the Workforce Development Group and suggested that the Public Health Review should take the recommendations of this group into account.

The perspective of national NHS organisations

10.14 The national NHS respondents who took part in the engagement exercise each operated in different parts of the public health landscape. These responses expressed very different views about the role of the national agencies in the public health endeavour. However, there was general agreement among them that a national public health strategy would help in bringing about greater co-ordination and coherence. Two of the national respondents offered (different) suggestions about the reorganisation of the public health function.

Health improvement

10.15 Health organisations recognised that, to address health inequalities, action would have to be taken outside of the health sector, and that resources should be oriented to reflect this reality. However, there were also concerns that the available resources were inadequate to allow this to happen.

Improving health services

10.16 Many of the NHS respondents saw their organisations / groups as having a major role in improving health (and in some cases social care) services, and adopting a population approach to the delivery of services. This was a key theme particularly among allied health professionals (AHPs), dentists, pharmacists and the Scottish Ambulance Service. The response from the Public Health Service Improvement Interest Group (PH SIIG) set out in some detail the role of public health in advising on the design of health services to maximise the population benefits of healthcare.

10.17 AHPs, dentists and pharmacists commented on the advisory and supporting role that they have with other health and social care professionals. In particular, pharmacists highlighted their role in working together with other professions and patients to obtain optimal outcomes from the use of medicines and to prevent adverse events.

10.18 Respondents referred positively to national policies (in Patient Safety and Healthcare Improvement) which clearly articulate the relevance of public health to these areas, and they pointed to successful initiatives such as the Health Promoting Health Service. At the same time, there was a feeling that increasing demands on acute services are pulling resources away from prevention and anticipatory care interventions.

Health protection

10.19 Health organisations frequently highlighted the recent Health Protection Stocktake and the recommendations which came out of that exercise. Leadership in this area was seen to be provided by the (new) Health Protection Oversight Group, Health Protection Scotland, and the (new) Scottish Health Protection Network groups.

10.20 The need for a critical mass in the specialist workforce was emphasised – to allow for short-term reorientation of resources to deal with immediate issues (i.e. flu pandemics, e-coli outbreaks, etc.)

10.21 Partnership working in relation to the health protection function involved the development of local joint health protection plans to agree local priorities and support local health protection initiatives. Those with expertise in this area particularly highlighted the importance of working with and learning from third sector partners who have experience of working with particular groups (for example, in relation to needle exchange or sexual health services). They also saw scope for improving links with education, police and animal health and veterinary services in relation to health protection initiatives.

10.22 With respect to workforce development, registration of non-medical public health practitioners was seen to be important within the health protection domain, but was thought to need more support, and there were positive comments in relation to the joint development and implementation by NES and HPS of the ‘Framework for Workforce Education Development for Health Protection Scotland’.

Perspectives of local government organisations

10.23 Altogether, there were 11 responses from local government organisations (including one from the national body, COSLA). This group of respondents thought the top priority for public health should be to reduce health inequalities which meant, from their perspective, taking action to address the wider determinants of health (e.g. in education, employment, physical and social environments, and quality of services). Linked to this, local government organisations wanted the outcomes which the public health endeavour should seek to achieve, to be defined by local community planning partnerships.

10.24 This group highlighted and welcomed the opportunities to develop the involvement of public health staff in community planning; however there was also comment that there is currently not enough capacity within the public health workforce to allow this to happen across the country.

10.25 There was agreement within this group that the health improvement domain of public health (which this group equated with tackling inequalities) needs to be co-ordinated and driven from within local authorities. This would require a rebalancing of public health resources, with more resources allocated to local authorities and / or directed by community planning partnerships (for, amongst other things, investment in the wider workforce and a greater focus on prevention). It was thought that this positioning would give public health greater reach and influence, and would also enable community engagement to become more fully embedded in community planning processes.

10.26 There was a suggestion that a national public health organisation could be beneficial; COSLA suggested that this organisation would ‘plan and deliver specialist services which coordinate strengthen and support activities aimed at improving the public’s health and protecting the public from infectious and environmental hazards’.

10.27 Local government respondents commented that the public health activity of NHS Boards will increasingly need to operate within the new environment of integrated health and social care partnerships. It was thought that there was an opportunity to make these partnerships into effective public health organisations. This would also provide the context for discussions about the future balance of expenditure between acute services and preventive approaches; the local authority perspective was that acute services were currently drawing resources away from preventative approaches.

10.28 Local authority respondents commented that cultural barriers and the ‘hierarchy of professions’ prevent health professionals from always being effective advocates for public health. However, the Scottish Health Protection Network was seen to be providing good leadership for the environmental health function in local authorities.

Partnership perspectives

10.29 There were 17 responses to the review from partnership bodies around Scotland – nine from community planning partnerships or subgroups of CPPs, and eight from health and social care partnerships or subgroups of HSCPs.

10.30 These responses mainly focused on the health improvement domain of public health, and provided little comment on either the health protection or health service improvement domains. A clear message from these responses was that the public health function needed to be rebalanced to focus more directly on tackling inequalities as a top priority; this would require the ‘definition’ of public health to be reframed to reflect this change in focus.

10.31 Public health intelligence (particularly in relation to needs assessment, evaluation and evidence review) was highlighted as very important to partnerships in deciding local priorities and in planning services and interventions. Partnerships valued the input from public health colleagues in providing rigour and ‘asking tough questions’ in discussions about service planning.

10.32 The lack of capacity within the public health resource was thought to be a problem in some areas, and some respondents highlighted particular difficulties in involving clinical colleagues in local partnerships.

10.33 Health and Social Care integration was a major theme among this group, and several respondents commented that the health improvement function in their area was being relocated into Health and Social Care Partnerships. In other areas, there was a perception that public health had not fully engaged with the integration agenda, and there appeared to be some disagreement among respondents about the extent to which HSCPs were conceived (at a national level) as overtly public health entities.

10.34 Regardless of this, respondents saw an important role for public health in community planning partnerships, and commented that reducing inequality should be the main priority of all CPPs. It was thought that public health could support community planning partners not only in relation to providing good quality intelligence and evidence, but also in helping to build capacity within the wider workforce.

Third sector perspectives

10.35 In all, seventeen (17) third sector organisations submitted a response to the engagement paper. Most of these organisations had a specific topic focus (e.g. alcohol, smoking, asthma, early years, environmental health, food and diet etc.). In addition there were two organisations that described themselves as intermediary and network organisations (Health and Social Care Alliance, Voluntary Health Scotland), two (community) development agencies / organisations (Glasgow Council for the Voluntary Sector, Community Health Exchange) and one funding organisation (Big Lottery Fund).

10.36 All third sector organisations emphasised the importance of reducing health inequalities and the role of public health in reducing health inequalities. Reducing health inequalities was seen to be the core aim of public health.

10.37 Linked to this focus on inequalities, there was widespread comment from third sector organisations about the importance of taking a very broad view of public health. In particular respondents emphasised that public health was not the sole preserve of the NHS; many partners outwith the NHS were also involved, and their input was crucial to tackling the wider social determinants of health. Moreover, third sector organisations highlighted that national ‘upstream’ measures (e.g. taxation measures, legislation on tobacco control, and poverty reduction programmes) were also required.

10.38 On the whole, third sector respondents viewed the integration of health and social care as an opportunity for more effective working and better delivery of public health outcomes. However, it was emphasised that the integration of health and social care would only deliver improvements in public health if the third sector / voluntary sector were fully involved, and on an equal footing with statutory services.

10.39 The current situation was seen to be unsatisfactory. Respondents commented that the third sector’s role had not been fully realised, and that the resources required for the third sector to operate effectively and to contribute fully to the achievement of public health outcomes were not available. Respondents specifically commented that: i) the signposting from the NHS to the third sector services was inadequate; ii) the core public health workforce currently excluded the third sector; and iii) the short term funding arrangements meant that third sector programmes / projects were often not able to be sustained – even if of proven worth – after an initial pilot period.

10.40 The Community Empowerment Bill was also mentioned by respondents as a positive step. It was thought this would enable community led approaches to health improvement to develop. Again, this came with the caveat that delivering public health outcomes (and specifically reducing health inequalities) would not be achieved without a significant transfer of resources to communities – and by implication to third sector organisations. Comments emphasised the importance of adopting asset-based approaches, focusing on self-management approaches, and working with the public and with communities.

10.41 The comments from the third sector organisations touched on all domains of public health. There was a particular focus on taking a public health approach to improving services (by, for example, supporting self-management, improving screening uptake, being sensitive to the impact of inequalities within services, and reducing variation in the delivery of services), as well as a substantial amount of comment about approaches to health improvement and health protection.