Public Health Review: Analysis of responses to the engagement paper
Analysis of responses to engagement questions to inform the Public Health Review in Scotland 2015
3 SWOT analysis – strengths and weaknesses (Q1)
3.1 The first question in the Engagement Paper was, ‘How can public health in Scotland best contribute to the challenges discussed [in the engagement paper]? Specifically, 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?’
3.2 Seventy-three (73) respondents submitted comments in relation to one or more of the SWOT headings. It should be noted that there was considerable overlap in the themes identified for all four headings. So, for example, comments in relation to ‘opportunities’, were often expressed as future actions that could be taken to address identified ‘weaknesses’ or ‘threats’. Similarly, some respondents identified ‘strengths’ which other respondents considered to be ‘weaknesses’, and issues identified as ‘weaknesses’ by some respondents were seen as ‘threats’ by others.
3.3 Thus, to provide a clear structure and to avoid undue repetition in discussing the themes identified, we have used the framework below as our approach to analysing the full range of material submitted across all four headings. This section presents an analysis of those that related specifically to strengths and weaknesses.
Helpful |
Harmful |
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Internal |
Strengths
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Weaknesses
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External |
Opportunities
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Threats
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3.4 The rest of this chapter addresses the material raised in relation to strengths and weaknesses. As noted above, topics / issues were often raised as strengths by some respondents, and as weaknesses by others.
3.5 The main (9) themes are set out below. These are: the locating / embedding of public health at a local level; the coordination of (and relationship between) the public health function at national, regional and local levels; public health networks; public health approach to improving health services; the public health workforce; partnership working; data, information, intelligence and evidence; the poor visibility of public health; and examples of successful programmes and initiatives.
The locating / embedding of public health at a local level
3.6 The advantages and strengths of the public health function being embedded in local structures was referred to repeatedly. In some cases, respondents talked about the public health function being positioned locally within NHS Boards whilst in other cases they talked about it being positioned within wider local partnership organisations (particularly Community Planning Partnerships).
3.7 This local positioning was thought to be vital in bringing public health close to decision making structures at local level. The other advantages of this local positioning included: being able to influence local partners, building strong partnerships, having direct access to data and information which were required to understand local population health issues, being ‘on the inside’, being an integral part of the planning and delivery of local services, being able to provide ‘surge capacity’ (for a health protection issue, for example), being well placed to understand local needs, and developing the local understanding of national issues.
There are number of advantages to being locally based (management could be centralised) – this facilitates a proximity to decision making both within NHS Boards and wider partner organisations. The internal Board position of Public Health enables direct access to local population health systems and data vital in improving health services. The inherent local positioning enables the sharing of knowledge and data between partner organisations and the local intelligence gained by such positioning strengthens the application and contextualisation of national policy, evidence base, etc., to reflect local needs and priorities. An additional advantage to being based locally is the ability to influence, through being part of a local organisation, rather than working remotely from outside an organisation. Change happens most effectively through working relationships and partnerships and the importance of the local dimension cannot be underestimated [sic]. (Senior public health staff groups, 63)
3.8 However, there was also discussion about the weaknesses of the delivery of public health at the local level. Two main issues were raised. These were the possibility of duplication of function and / or effort across localities, and variation in capacity, structures and the quality of the public health function at local level. The issue of duplication will be addressed below in relation to the co-ordination of the public health function at national, regional and local levels, and in relation to public health networks. The following comment illustrates the kinds of points made in relation to the variation in capacity, structures and the quality of the public health function across localities.
Fragmentation and variation in local public health structures compounded by different accountability models in health and local authorities (National NHS organisation, 25)
3.9 It was also suggested, less often, that a further weakness was the lack of local integrated service delivery models within neighbourhoods.
The coordination of public health at national, regional, and local level
3.10 On the whole, when respondents discussed the coordination (and relationship between) public health at national, regional and local level, it was in the context that there was insufficient coordination and leadership across these various spatial levels. However, an exception to this overall picture was the discussion of the positive coordination and leadership offered within specific networks, which was seen as a key strength. The discussion of the networks follows at paragraph 3.16 below.
3.11 There were a number of different aspects raised in relation to the (lack of) coordination and leadership across the various levels. These covered:
- The large number of organisations involved in public health (described as ‘a cluttered landscape’) which could lead to confusion, a lack of clarity about roles and responsibilities, and inadequate coordination
- A lack of agreement about when it is best to act locally, regionally, or nationally
- A lack of coherence between what is happening at the ‘grassroots level’ and what is happening at national (Scottish Government) level.
3.12 The following quotes illustrate some of the points made in relation to this theme.
There is sometimes a disconnect between national agencies and the local public health workforce, creating some confusion amongst partners and a sense of lack of co-ordination across Scotland. (Partnership, 47)
There is confusion, even amongst the Public Health family, as to who [and] which organisations are leading on particular elements of Public Health – organisations which play into this are NHS Health Scotland, ScotPHN, Health Protection Scotland, NES, etc., etc. (Royal colleges or other professional groupings, 65)
3.13 There was considerable discussion by respondents about the best ways to address the problem of poor co-ordination. There were three suggestions:
- Improve co-ordination of different ministerial portfolios at Scottish Government level: While respondents largely saw the commitment by the Scottish Government to tackling health inequalities as a strength, there was also a view that various policy initiatives were not always joined up well.
- Develop a national public health strategy: There was a common view that a national strategy for public health (one respondent suggested a Scottish Health and Wellbeing Plan) is necessary to bring about a more cohesive and coherent approach across Scotland, both at a national and local level. This could also provide the basis for better integration with community planning partners at a local level.
- Consider the potential for more regional (and national) approaches: Although respondents clearly valued the local positioning of public health, some also saw merit in developing a more regional (cross-NHS Board boundaries) ‘shared service’ approach for certain aspects of the public health function. For example, this type of approach was seen to be appropriate for the health protection function, and in remote / rural areas, and respondents referred in positive terms to the Health Protection Network and North of Scotland Public Health Network. Those who offered this suggestion commented that this type of approach would improve efficiency, resilience and sustainability and avoid duplication.
3.14 While a “once for Scotland” approach was seen by some respondents to offer greater efficiencies, the importance of balancing such an approach with the need to engage with local communities and act at a local level was also emphasised.
There are clear opportunities to strengthen resilience by regional networking and development of shared services. There are 14 Boards but not everything has to be done 14 times for Scotland but this must be balanced by the need to engage with local populations and to have strong local knowledge and commitment to local needs. (NHS Board, 66)
3.15 Furthermore, other respondents were concerned about a move towards greater ‘centralisation’ of the public health function, and this will be discussed below in relation to ‘opportunities and threats’.
Public health networks
3.16 Comment about public health networks was often made in the context of a wider discussion about the national, regional and local co-ordination of the public health function. However, the topic of public health networks also appeared to be a separate and significant theme in its own right. Comments on this topic were generally made by respondents representing public health networks and forums.
3.17 Respondents thought that the networks which had been developed were highly effective. The fact that Scotland was a relatively small country was thought to be helpful in developing close networks and good links which could operate at national and regional levels and could support the development of best practice and minimise duplication of effort.
3.18 The networks were sometimes specialism specific, and sometimes more broadly based. The Scottish Public Health Network, the Scottish Public Health Observatory, the Regional Dental Health Network, the Pharmaceutical Network / Community Pharmacy Network and the Health Protection Network were all mentioned specifically as providing examples of good and effective collaboration, and partnership working which could offer models for further development. Academic input into the networks was also mentioned as a strength.
The size of Scotland and systems in place such as networks for some specialisms allows for a national approach to issues where there is benefit in working towards a single solution. (Public health forums and networks, 14)
The links with the academic institutions further strengthen the network, bringing independent research and expertise to investigate and analyse current service delivery and support the adoption of best practice. (Public health forums / networks, 55)
Public health approach to improving health services
3.19 Respondents across a range of sectors discussed the ways in which they ‘took a public health approach’ to improving services. The point was made that the Scottish Government had identified the importance of aiming to deliver health services which were equitable in terms of access, patient experience and outcomes in the Healthcare Quality Strategy.[1]
3.20 Organisations with a remit for providing pharmacy services commented in detail on the integration of public health perspectives within their clinical work and confirmed that public health is a core part of the provision of pharmacy services, especially by practice nurses and community pharmacists. For example:
… a wide range of healthcare staff [are] aware of public health in their role and committed to delivering health improvement and protection messages and functions (NHS Board, 19)
3.21 Other aspects of a public health approach to improving health services were also highlighted including: designing services that are easy to access; encouraging recognition that many public health work strands are undertaken by health and social care staff whose main role is not defined as public health; delivering opportunistic lifestyle interventions from within health services; taking action to address the ‘inverse care law’[2]; working to reduce variations across different settings; and monitoring access, use of services and equity of outcomes.
3.22 Much of this type of work was described as not very visible because it primarily involved public health in an influencing and advising role.
By its very nature much good public health practice entails influencing and advising others and enabling change. For example, in the area of health services public health such change is more sustainable where owned by services themselves, even when public health is the key catalyst and facilitator. This is successful public health practice that can have the effect of reducing the visibility of the public health activities though the public health contribution will be clearly recognised and valued by the services involved. (Royal college or other professional grouping, 80)
3.23 While the public health approach to improving health services was often seen as a strength, and something that should be developed further, it was also noted that passing public health responsibility to frontline healthcare staff is problematic without proper training on the health improvement role.
3.24 Most of the comments made in relation to the improving health services domain were raised by local organisations, public health networks or other professional groups. Among national organisations, there appeared to be consensus that there is no clear ownership of the improving healthcare service domain at a national level, as Healthcare Improvement Scotland do not currently have a strong public health role. It was also acknowledged that public health had not made a clear contribution to the quality improvement work of Healthcare Improvement Scotland.
[Healthcare Improvement Scotland] do not view themselves primarily as a public health organisation. The work that HIS undertake is important and has certainly not been without success, but there are unquestionably differences of approach when compared with a public health view of improving services. (National NHS organisation, 25)
... the contribution [of public health] to improvements in service quality and safety, effective care, and care that is person-centred is less clear (National NHS organisation, 46)
Public health workforce
3.25 Respondents often highlighted the (skills and qualities of the) public health workforce as a key strength. The workforce was described as highly skilled, professional, knowledgeable, committed and enthusiastic. It is also multidisciplinary, with staff from a wide range of backgrounds and this was seen as a key strength. Much was made of the workforce’s ability to work collaboratively across issues and boundaries.
3.26 Other qualities of the workforce were also highlighted. These included their objectivity, their ability to offer an independent view and voice, their qualities as advocates for the public health function, their flexibility, adaptability, and responsiveness.
3.27 The following quotes illustrate the positive comments made about the public health workforce and its strengths.
Key strengths include multi-disciplinary professional practice, well educated workforce, adaptable workforce, responsive workforce (Local authority, 97)
The Public Health workforce is multi-disciplinary and as such provides expertise from a range of backgrounds. They are highly skilled and have an expert knowledge base. In addition they are able to offer an independent and objective voice. (NHS Board, 31)
A committed, enthusiastic workforce that is knowledgeable about local needs and priorities whilst maintaining the flexibility and resilience to direct public health activity according to need and to maximise the efforts of the workforce (Partnership, 47)
3.28 Whilst the skills of the public health workforce were identified as a key strength, there was also substantial focus on the weaknesses of the career structure and career pathways for the public health workforce, especially for those who were not in the core or specialist workforce, but who were part of the wider public health workforce.
3.29 These workforce issues are discussed in greater detail in Chapters 7 and 8 in the analysis of the material offered in response to Questions 4 and 5 of the engagement paper. However, some of the main points raised are briefly mentioned here.
There is a need and an opportunity to further develop and strengthen career pathways for the PH practitioner workforce both in NHS and Joint Settings and Environmental Health workforce employed in Local Authorities. The value of professionalisms such as health psychology, social anthropology and health geographers to the broader PH workforce is yet to be fully realized. (NHS Board, 92)
Developing defined specialist accreditation and accreditation for public health practitioners (especially in health improvement areas) is lacking and out of step with the rest of the UK. This can lead to different standards of professional practice becoming normalised locally and- in the long run – undermine the professional development and career aspirations of public health practitioners and the wider workforce. (Senior public health staff groups, 89)
Partnership working
3.30 Partnership working (particularly in relation to working at a local level within Community Planning Partnerships or Health and Social Care Partnerships) was often identified by respondents as a strength. However, partnership working was also mentioned frequently as a weakness, and something which needed to be further developed and / or strengthened.
3.31 Those who identified partnership working as a strength highlighted the ways in which partnership working operated effectively, both in relation to topic specific areas (e.g. tobacco, food and health, physical activity, mental health, etc.) and in wider (whole population) approaches. Partnership working was thought to offer advantages in terms of ‘economies of skills and scale’ by sharing resources in terms of both staff and equipment within and across local authority boundaries. It was built on the development of skills and expertise which facilitated multi-disciplinary working.
Successes in local collaboration, championing and delivering on cross-sectoral programmes, e.g. in healthy weight and physical activity, engagement with local communities, and using board members and other community leaders as local champions. Historical successes on tobacco, alcohol, both good examples of action across the whole system from national public policy and legislation through range of public sector and partnership programme development and delivery, right down to working with local communities at locality and neighbourhood level. (NHS Board, 81)
3.32 However, other respondents identified weaknesses in partnership working, and suggested that there was scope for public health to become more embedded in the work of Community Planning Partnerships. Respondents called for public health to be ‘a strong voice at the table’ to ensure that partnership priorities and outcomes are more focused on reducing inequalities. Respondents also saw a need for public health to engage more, and more effectively, with non-public sector partners in the third / community sector.
3.33 There were also practical concerns in relation to performance management systems and accountabilities across partners which made it difficult to work effectively in partnership.
Cross-sectoral engagement including the private and third sector could be strengthened in some areas. (Royal colleges or other professional grouping, 17)
The NHS and Local Government have different performance management systems and accountabilities. Collaborative approaches to improved performance are therefore difficult to achieve. (National NHS organisation, 79)
3.34 Chapter 6 will explore in further detail respondents’ views on the ways that public health can be involved in strengthening and supporting partnerships.
Data, information, intelligence and evidence
3.35 The availability of data, information and evidence was perceived as a strength. Substantial resources had been, and continued to be, devoted to developing high quality datasets. This had been undertaken at national level, (for example through the Scottish Government’s ‘big data’ initiatives), at local level, (for example the development of the KnowFife Dataset) and within specialisms (for example the development of child health dental data).
3.36 Moreover, through high quality analysis (often involving academic partners) these datasets had become important strategic assets.
Data sets are good to very good, and are amongst the important strategic assets on which to improve a public health system (National NHS organisation, 79)
3.37 However, alongside these positive views of the data and intelligence functions, there were some more critical views, particularly in relation to gaps in the evidence base, and poor translation of evidence into practice. It was thought that one of the greatest weaknesses of public health was the lack of a robust evidence base as to what works.
Lack of coordinated approach to health needs assessment and translating evidence into policy (National NHS organisation, 25)
Data is not yet sufficiently robust to assist in evaluating progress and identifying next steps. (Partnership, 32)
3.38 This was partly due to the intrinsic difficulties of evaluating the public health endeavour and attributing causation within complex systems; but it was also mentioned as a (political) failure to implement evidence where it was available.
Failure to implement water fluoridation to effectively narrow dental health inequalities. … Ineffectiveness of educational approach still not recognised by policy makers; especially when trying to address health inequalities. (Royal colleges or other professional grouping, 65)
Making sense of the huge body of evidence, data and research to avoid duplication, share learning and respond appropriately. This is a function both of the volume of material and learning available, and of the challenge of translation into service change, including the ongoing challenge of diverting resources to preventative approaches. (Research / academic organisation, 99)
3.39 However, respondents believed there was scope to do more. Suggestions included:
- Conducting natural experiments between Scotland and the rest of the UK where different public health policies are being pursued
- Developing more partnerships with academic researchers in universities and think tanks
- Improving cross-sectoral record linkage (linking data between health and other sectors) and strengthening surveillance (for example, in the areas of environmental hazards, communicable diseases, health improvement activities)
- Setting out a stronger conceptual understanding of public health challenges and evidence.
Lack of visibility of public health
3.40 Respondents commented on the perception that the public health function was not particularly ‘visible’ or well understood, and that insufficient effort had been directed at making a clear case for investment in public health. This was seen as a potential weakness (or threat) when resources were under pressure.
Public Health has a wide scope and consequently experiences pressure from a wide range of sources. There is a lack of appreciation of the breadth of the work and consequently public health teams are rarely seen to excel in any particular area. This leads to lack of priority for investment and further challenges the workforce. (NHS Board, 66)
3.41 The visibility of public health was thought to be particularly poor in the improving health services domain of public health. The explanation for this was that the role of public health in improving health services is largely an influencing and advisory role.
3.42 Respondents often commented that the Public Health Review provided an opportunity to re-energise and raise the profile of public health. There was also a view that the success in developing progressive public health policies (i.e. the smoking ban, minimum pricing for alcohol, the multi-buy ban for alcohol products, etc.) provided a platform for public health to advocate for further progressive policies.
Examples of successful programmes and initiatives
3.43 A number of successful programmes and initiatives were highlighted by respondents as strengths, and they were offered as examples which demonstrated what could be achieved with political will and commitment, combined with effective implementation.
3.44 The main programmes discussed in this context were: nursery toothbrushing and fluoride toothpaste distribution schemes, the national health screening programmes, the immunisation programmes (for children), and the coordinated efforts (in terms of national policy and legislation, partnership development and local implementation and action) in relation to smoking, alcohol and drug use. Other, less developed programmes were also mentioned as success stories including: early years strategies, long term conditions strategy, the ‘Deep End’ initiative for GP practices in Glasgow, and the ‘Glasgow Council for Voluntary Sector Connectors Project’.
3.45 However, even in these widely praised population health programmes, cautionary notes were sounded as to whether the aim of reducing health inequalities was actually being delivered. For example:
Population wide health improvement initiatives are likely to have exacerbated this with higher take up amongst more affluent communities. (Research / academic organisation, 99)
Contact
Email: Heather Cowan
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