Public Health Review: Analysis of responses to the engagement paper

4 SWOT analysis – opportunities and threats (Q1)

4.1 This chapter presents an analysis of respondents’ comments related to opportunities and threats. There are two points to make about these comments. First, opportunities were often described as actions which could be taken to address weaknesses or mitigate the risk created by threats. Second, issues seen by some respondents as ‘threats’ might better be described as potential outcomes resulting from threats.

4.2 Again, we have applied the framework presented on page 9 to impose some coherence and structure on this material. Six (6) main themes were identified and these are set out below. The themes are: Scottish vs UK Government policies; the wider policy context; integration of health and social care; reorganisation; austerity and lack of funding; and vested interests.

Scottish vs UK Government policies

4.3 Respondents saw Scottish Government policy as providing a favourable context for public health, while UK Government policy was generally seen as a threat.

4.4 Respondents commented that the current Scottish Government has a ‘strategic focus on inequalities’ and an explicit focus on the wider determinants of health. The was a recurring view that the Scottish Government’s commitment to public health had been demonstrated in relation to both policy and legislation, and the reach across multiple policy areas beyond health was clear. This ‘receptive political environment’ was seen as presenting an opportunity for public health to provide greater leadership and advice, and to take a more active role as an ‘agent of change’ in bringing about policies focused on the wider determinants of health.

The current focus of the Scottish Government on the need to address the wider determinants is seen as a particular strength as is political willingness to address controversial issues to improve public health for example and alcohol and smoking restrictions. Public health can give both leadership on and advice to these agendas. (Public health forums and networks, 14 and NHS Board, 88)

Opportunity for public health to be agents of change, drivers of political and fiscal policy (NHS Board, 28)

4.5 However, alongside this positive comment, and the identification of political engagement and willingness to act on a wide agenda, there was also substantial comment that there was insufficient focus on the wider determinants of health at Government level, and that policy initiatives were not always joined up. In particular, respondents thought the current balance of activity was too focused on short term targets and individual behaviour, and did not sufficiently take into account the wider ‘upstream’ issues.

A focus on behaviour change activity at the expense of time devoted to wider determinants of health, e.g. housing and employment. (NHS Board, 85)

The public health agenda has been significantly determined by political focus such as that applied by HEAT targets and as such a focus on individual lifestyle outcomes has prevailed. This has created very much a service output focus rather than a community/population outcome which emphasises the risk of health improvement being seen solely as an NHS agenda. (Partnership, 21)

4.6 It was also thought that there was insufficient leadership at national level. This was needed in order to join up and co-ordinate the effort in relation to the public health endeavour across ministerial portfolios. As mentioned above at paragraph 3.13, it was suggested that a (national) public health strategy would help to achieve this.

There can appear to be disconnect between Scottish Government departments in relation to joined up public health outcomes. (NHS Board, 18)

4.7 Respondents saw UK Government policy as posing a threat to the public health endeavour, specifically in relation to austerity and welfare reform and their effects on the most vulnerable individuals and families.

The wider policy context

4.8 Respondents commented that a range of national policies provided greater opportunities for more of an ‘upstream’ approach to addressing inequalities. These included:

• The refreshed Economic Strategy
• The Health and Sport Committee report on inequalities
• The 2020 Vision
• The Early Years Collaborative
• The Community Empowerment Bill (along with recently published reports on the national audit of community planning^[3] and from the Commission on Strengthening Local Democracy^[4]).

4.9 The Community Empowerment Bill was specifically highlighted as presenting an opportunity to put empowered communities at the centre of planning. Respondents saw the potential for this agenda to have enormous benefits to the health of populations, but cautioned that political will and strong leadership at a local level would be required to achieve this. Respondents commented that public health is in a good position to capitalise on the changes being introduced as a result of this new legislation.

Integration of health and social care

4.10 The integration of health and social care was seen as both an opportunity and a threat. On the one hand, respondents highlighted opportunities for:

• Building better links with the wider public sector to address the wider determinants of health at a locality level
• Better integrating NHS with third and private sector service providers and engaging the wider workforce in the public health effort
• Strengthening existing links that support prevention and health improvement initiatives (e.g. access to screening and vaccination programmes; alcohol licensing; reducing drug-related deaths; etc.)
• Working together towards jointly agreed shared outcomes
• Adopting different / new, more effective ways of working
• Delivering multi-agency training
• Raising the profile of public health in primary care (via GP and pharmacy contracts) and facilitating a population approach to care planning
• Combining resources and reducing duplication in policy development, procurement and management.

4.11 There was also a view that public health had important skills to offer health and social care partnerships in terms of needs assessment, coproduction and evaluation. In a few cases where shadow boards had already been established, it was noted that the health improvement activity had already come under the umbrella of the health and social care partnership.

4.12 However, among some respondents, health and social care integration was seen as a possible threat, with the potential for fragmentation of the public health focus and workforce. Concerns were also expressed about loss of capacity and resilience; loss of clarity about the focus for prevention initiatives; and reduction in quality and breadth of health data. It was also suggested that integration could provide an impetus for further cuts to staffing budgets in a misguided attempt to demonstrate ‘efficiency’.

Integration of Health and Social Care is both an opportunity and a threat. A key challenge is that an already fragmented and confused workforce will become increasingly ineffective as key staff are pulled into the new Integrated Health and Social Care Partnerships. There is a risk that the Integrated Joint Boards (IJBs) interpret prevention as being about individual well being and anticipatory care. There needs to be clarity that the IJB’s are about adult health and social care and the CPPs are about health inequalities and health improvement. Health improvement teams should be empowered to focus on populations and inequalities. (NHS Board, 66)

4.13 Respondents noted that different areas may adopt different integration models; however, regardless of the structures put in place, it was thought that Directors of Public Health (or their deputies) should be represented in Integration Joint Boards.

Reorganisation of the public health function

4.14 It was evident within respondents’ comments that the announcement of the review had prompted debate about the configuration of the public health function, and about what is best to deliver at a national, regional and local level. (See Chapter 3, paragraphs 3.10-3.15 regarding the discussion on co-ordination.) Within this debate, there was recognition that the policy landscape is changing and therefore, the delivery of the public health function may also need to change. Specifically, it was acknowledged that community planning partnerships (rather than NHS organisations alone) have a key role in addressing health inequalities and the wider determinants of health. However, some respondents saw threats in the possible reorganisation of the public health function. In particular, there were concerns about the possible centralisation of the public health resource which could have an impact on the responsiveness to local needs. At the same time, there was also a concern that the drive towards localism may make it harder to deliver change on a national basis.

4.15 Some respondents commented that reorganisation is a threat simply because of the disruption it causes (to staffing, to capacity, and to the effective delivery of successful initiatives). The point was also made that a ‘fixation’ with finding ‘the perfect organisational structure for public health’ was itself a significant threat.

4.16 However, some respondents saw the possibility of reorganisation in a more positive light. There appeared to be some differences in views between respondents from different sectors and this issue will be discussed further in Chapter 10.

Austerity and lack of funding

4.17 Austerity was seen almost unanimously as a threat. A few respondents considered that financial pressures on public services provided an opportunity to review resourcing and to target resources more effectively, and there was a suggestion that public health needed to respond innovatively to financial constraints, rather than continuing to try to do more with less.

4.18 However, respondents were more far likely to identify the potential risks of continued public sector budget cuts. Austerity was seen as a threat because of its impacts on:

• Reducing the capacity of the workforce
• Shifting priorities and resources towards the provision of critical services and away from prevention
• An over-emphasis on short-term initiatives which undermine the widely held view that improving public health is a long-term endeavour
• The move towards increasing centralisation
• Making it impossible to mainstream successful short-term projects.

4.19 The focus on short term initiatives, at the expense of longer term commitment was mentioned frequently. Respondents wished to see the balance redressed in favour of a longer term approach which focused more on the ‘most important outcomes’ including ‘upstream’ activity rather than on ‘immediate priorities’ which were often related to acute services.

4.20 Respondents were concerned that, at a time of austerity, the public health function would lose resources, both in terms of funding for specific (long term) programmes, initiatives or projects, but also in terms of developing the capacity and skills of the (wider) workforce.

Current austerity measures and reduced employment opportunities risk increasing inequalities. Evidence suggests that young adults, disabled people, ethnic minorities and less skilled workers experience increases in unemployment during economic downturns. As well as the obvious financial consequences, unemployment can result in poorer mental health, such as anxiety and depression (Third sector, 60)

4.21 One respondent put forward an argument for the ring-fencing of funding for public health:

Currently the emphasis of funds being skewed towards the acute sector will not enable Public Health to undertake the necessary work to make the big impacts needed. Ideally, funding for Public Health should [be] ring-fenced given the known effectiveness and cost-effectiveness of prevention relative to treatment of ill health, including in the reduction of health inequalities. (Royal college and other professional groupings, 70)

Vested interests

4.22 Respondents saw serious threats to the public health endeavour from powerful multi-national business interests. Those mentioned specifically were:

• The powerful and influential alcohol industry in Scotland, and its associated well-organised, well-funded lobby group
• The tobacco (and e-cigarette) industry – it was noted that the popularity of e-cigarettes had had an effect on the number of people entering NHS smoking cessation services, and that policy responses and the evidence base had not kept pace with the speed of change in this area
• Soft drinks manufacturers, processed food manufacturers (including confectionery).

4.23 Concerns were expressed about the ‘disproportionate and undemocratic power of big business relative to that of the electorate’, and about global trade and finance agreements (i.e. the Transatlantic Trade and Investment Partnership (TTIP)) which could result in the increasing privatisation of the NHS and allow investors of multi-national businesses to sue governments whose policies cause a loss of profits.