Public Health Review: Analysis of responses to the engagement paper

5 Leadership in public health (Q2)

5.1 One of the objectives of the Public Health Review in Scotland is to examine public health leadership and influence both within the health sector and more widely. In relation to this, the engagement paper asked: ‘How can public health leadership in Scotland be developed to deliver maximum impact?’

5.2 Ninety-eight (98) of the total 117 respondents addressed this question, and in general, comments suggested that there was a need for, and scope to, strengthen public health leadership to make it more effective.

5.3 Respondents returned to the issue of leadership in public health in their responses to other questions in the engagement paper. Leadership was a theme raised in relation to strengthening and supporting partnerships (Question 3), helping maintain a core public health resource (Question 4) and providing opportunities for professional development and workforce succession planning (Question 5). The comments on leadership in the responses to these other questions have been integrated into the text in this chapter.

Perceived weaknesses of current public health leadership in Scotland

5.4 Current public health leadership was described as ‘patchy’, ‘disparate’, ‘not cohesive’ and ‘fragmented’ at both national and local levels. There was a perception that public health leadership was not very visible, and that (at least in some areas) public health was seen as more of a support service, rather than making a key contribution to the development of local services. There was also a view (again, in some areas) that public health leaders do not necessarily have the skills required for leadership – in particular, the skills of influencing, lobbying and advocating for local populations.

5.5 Respondents often commented on the plethora of individuals and organisations with some type of remit for public health, and expressed a desire for greater clarity about the roles of these individuals and organisations.

5.6 The lack of clarity and uncertainty about roles, both at national and local level, was seen as limiting the effectiveness of public health leadership, and there was a suggestion that leadership could be strengthened if local partners were aware of the role and skills of public health leaders.

The public health contribution of professional leads at national and local level should be articulated e.g. CMO, CNO, Chief Pharmacist, Chief Dentist, Chief Allied Health Professional, etc. (NHS Board, 88)

Clarity is required on the population health improvement roles within the Scottish Government and how public health structures and bodies relate, e.g. the Directors of Public Health Group. There is confusion at practitioner levels of the role of government and agencies such as the Joint Improvement Team and Health Scotland. (NHS Board, 85)

Challenges to public health leadership

5.7 Respondents highlighted the challenges to public health leadership in Scotland. The move towards integrated health and social care services was seen as one of these and respondents highlighted the importance of public health having a strong role in the new Integration Joint Boards (IJBs).

5.8 A further challenge for public health leadership was the need to work within very complex systems, far beyond NHS and health boundaries, to influence wider agendas, policies and programmes. Moreover, the wide range of partners involved in public health and the diversity of partner perspectives, make leadership a very demanding task.

The role of a national public health strategy in strengthening leadership

5.9 Respondents highlighted the importance of developing a clear, shared vision – or a national strategy – for public health in Scotland:

We can strengthen leadership in public health by providing a clear vision and goals for public health, at a national, regional and local level. (NHS Board, 74)

5.10 A public health strategy would provide ‘a coherent national policy’ and an agreed set of priorities, thus also providing a focus for leadership effort. In particular, a national strategy would provide the basis for a more consistent, and potentially more streamlined leadership structure and leadership arrangements (which were more clearly aligned to national priorities), as well as improving the accountability of leaders.

What should public health leadership look like?

5.11 Respondents frequently identified what they wanted to see from public health leadership in Scotland. This included:

• Being a ‘population advocate’: This would involve advocating and lobbying on ‘upstream’ issues that affect public health (e.g. welfare reform, local development planning, etc.).
• Being independent: The independence of the public health voice was emphasised as this would allow public health leaders to challenge policy makers at a national level, to say things that were ‘uncomfortable’, and to address poor performance at a local level.
• Engaging with local communities: Respondents highlighted the need for greater engagement and better communication between public health leaders and local communities – to give communities greater ownership of health improvement and prevention.
• Being more visible: This would involve building relationships with key partners in health, social care and third sector agencies, being able to influence their agendas effectively. It would also involve building and maintaining the profile of public health at all levels.
• Making the case for public health: This would involve making an effective case for increased priority and resources for public health.
• Understanding the evidence: In order to ensure that organisations which distribute resources for public health and public health interventions do this in an effective – and cost effective – manner, leaders in public health should have a good understanding of the evidence base
• Working in partnership: Respondents highlighted the importance of good leadership in strengthening partnerships.

5.12 Respondents reflected, more generally, on the very broad range of skills, qualities, and shared approaches required for public health leadership. These included:

• The ability to work strategically within complex systems
• The ability to work across organisational boundaries with a wide range of stakeholders to influence and facilitate system-wide change
• The ability to look beyond current pressures to understand future challenges and opportunities to do things better
• Evidence synthesis skills and the ability to communicate evidence succinctly, and translate it into effective practical action
• Good people and management skills, including team building, networking, building trust, negotiation and facilitation skills
• The ability to consult and work with communities using asset-based approaches to co-produce local solutions to public health problems.

5.13 Respondents wanted to see greater opportunities for the development of public health leaders from a wide range of backgrounds (not just medical and clinical backgrounds). The point was made that there are numerous leadership roles across a range of disciplines in the wider realm of public health, Respondents believed that leadership is not necessarily about a particular skill set, rather that it requires certain qualities, including the ability to adopt shared approaches and work in partnership.

5.14 Some respondents also highlighted the need for public health leaders to build strong relationships with academic or other research organisations. More important, however (as noted above), was the need to be able to develop effective action (i.e. in terms of interventions, programmes, policies and strategies) based on evidence.

5.15 While respondents expressed some confusion about the roles of particular individuals and organisations (as discussed above), they were clear that the boundaries of public health should be drawn very widely. Respondents emphasised that public health leaders should not only be found in health and NHS services. Rather, public health leadership needed to be demonstrated in areas as diverse as employment, education and skills development, poverty and welfare reform, planning, housing, children’s services, climate change, etc. Some respondents (including NHS respondents) specifically argued for the importance of non-NHS staff, including third sector and community champions, taking on leadership roles in these areas.

Leadership also applies beyond the public sector, particularly in relation to the third sector and community champions. Place based change is reliant on community champions and ‘anchor’ organisations. It is time to acknowledge this more within public health. (Partnership, 42)

Developing leadership at different levels

5.16 Respondents discussed the importance of having – or developing – public health leadership at all levels (both within organisational structures and within geographical areas). The levels at which public health leadership is required to operate and be effective included: governmental, national, NHS Board, Local Authority, Community Health Partnership, Health and Social Care Partnership, Joint Strategic Board, regional, local, community and neighbourhood. One respondent commented that the question about leadership has to be answered in the context of the ‘public health system we are designing’. Moreover, respondents argued that public health (and public health leadership) was everyone’s responsibility and noted that the leadership for public health at (Scottish Government) ministerial level lies not only within the Public Health and Health spheres, but also more broadly within employment, education, welfare, and finance portfolios.

5.17 The importance of better linkages and better coordination between leadership at different levels of organisational and geographical hierarchies and structures was emphasised. These comments reinforced the earlier discussion (paragraphs 5.9-5.10 above) about the benefits of having a national strategy for public health in Scotland. However, it was also recognised that leadership arrangements would vary according to the local context. There was a suggestion that local leadership capacity in particular needed to be strengthened.

Different ‘models’ of leadership

5.18 Respondents highlighted a range of different ‘models’ that could provide insight or learning in relation to how leadership in public health might operate at different levels. Some of these ‘models’ were very general, and covered leadership at all levels; others were more specific and related only to one type of leadership post or one set of relationships. The first example below was described by a wide range of respondents; the other models were described by just one (or occasionally two or three) respondents.

‘Peloton’ leadership / ‘Distributed leadership’ / Network leadership

5.19 The model which was most often referred to as offering the potential to strengthen leadership within public health was the ‘peloton’ model.^[5] This model was referred to variously as a ‘distributed’, ‘distributive’, ‘dispersed’ or ‘diffuse’ model of leadership. This model recognises that leadership is not restricted to public health specialists, but is also exercised by individuals in partner organisations who lead and advocate for the public health agenda from a wide range of disciplines and perspectives. The work of the national and regional public health networks and the more informal groups within public health that share knowledge and expertise across Scotland were thought to be good examples of peloton leadership in practice.

Distributive or peleton (sic) leadership is the most effective to meet the scale of this challenge as it maximises the use of the workforce. (Royal colleges or other professional grouping, 86)

5.20 One specific example of a network which was thought to offer a useful way to maximise learning and minimise duplication, was the (newly established) Scottish Health Protection Network. However, it was recognised that it was still too early to consider this a proven model which might work across the wider domain of public health. For example:

The Scottish Health Protection Network is a good opportunity for leadership and communication to emerge and tackle the challenges ahead, utilising all resources available from the various participants involved. (Local authority, 115)

Other leadership models

5.21 Other leadership ‘models’ discussed, sometimes by just one or two respondents, included:

• Public Health England ‘model’: There were differing views about whether the recent creation by Public Health England of a single leadership agency for public health was a positive step. Some organisations saw the advantages, whilst others focused on the disadvantages. In any case, it was thought important to monitor how this model develops.

A move to having one single leadership Scottish agency, taking responsibility for improving health and tackling health inequalities would be a good way forward. This could be similar to that as Public Health England. (Partnership, 21)

• Public Health ‘Tsar’: A research / academic respondent suggested the appointment of a public health ‘Tsar’, supported by expert advisory group (a Scottish public health advisory committee), which would have representation from NHS, academic and voluntary sector organisations.

Its role would include advising government on actions needed, commenting on policy proposals (a NICE for public health), ensuring policies are implemented in a way that will maximise benefit and that they are properly evaluated. (Research / academic organisations, 8)

• Joint appointment (between NHS and local authority) of Director of Public Health: A fourth leadership ‘model’ highlighted by respondents was that of the ‘joint appointment’ for the Director of Public Health, whose contract was shared between the NHS and the local authority. Such an arrangement was in place between NHS Borders / Scottish Borders Council and between NHS Greater Glasgow & Clyde / Glasgow City Council. Some the many advantages of such an arrangement were that it: provided a ‘check and counterbalance against short-termism’; prevented the prioritisation of acute services from compromising the longer term prevention agenda; acted as a mechanism to support collaborative leadership; and provided better links to political decision making at a local level because of the closer links to local elected representatives.
• Senior health improvement manager: This model was highlighted as successful in NHS Greater Glasgow & Clyde. This senior-level post was considered to provide an effective means of bringing about a strategic health improvement influence upon health and social care partnerships.

Role of Directors of Public Health

5.22 The role of the Director of Public Health (DPH) was thought to be very important. However, respondents commented that, in some cases, this role had become diluted over time. It was thought that the DPH role could be strengthened through fuller implementation of the responsibilities set down in the Public Health etc. (Scotland) Act 2008. However, it was also noted that the specific role of a ‘Director of Public Health’ was not itself set out in the legislation.

5.23 The role of DPH was seen to be essential to provide leadership at local level, to challenge policy, to link the domains of public health, and to work with the Chief Medical Officer and Scottish Government in relation to the development of policy. On this latter point, it was suggested that the DPH leadership role could be strengthened in relation to the bridge it provided to national policy.

5.24 It was specifically suggested that the DPH should have a role in relation to the new Integration Joint Boards, local authority committees, and community planning partnerships, as well as having an executive role in the Health Board. Indeed the DPH role in relation to strengthening partnerships of all kinds was thought to be vital.

5.25 The annual reports provided by the DPHs were thought to be a significant contribution in highlighting effective action and practice. However, there was comment that greater consistency between these reports might be helpful.

5.26 It was not clear how the DPH role would translate into the new policy / organisational context, as it was not thought realistic for each IJB to have its own DPH. It was suggested however, that leadership capacity in public health could be increased by providing greater opportunities for non-medics to take on public health leadership roles.

Leadership training

5.27 Paragraph 5.12 (above) sets out the skills which respondents thought were required by public health leaders. The final theme discussed by respondents was in relation to the training and professional development of public health leaders. The subject of training and professional development for the wider public health workforce will be discussed in detail in Chapter 8, in relation to Question 5.^[6] This section, therefore, focuses mainly on leadership training.

5.28 There was a general view among respondents that ‘more’ and ‘better’ leadership training opportunities were needed, both for the core public health workforce and for the wider public health workforce. It was noted that the development of leadership and management capabilities across the NHS is a key priority of the 2020 Workforce Vision.

5.29 In relation to training for the core (specialist) public health workforce, there were comments that the leadership aspect of post-graduate public health training could be developed further – although the point was also made that ‘creating effective leaders in public health requires a lot more than just training’. Respondents suggested that the inclusion of leadership skills in postgraduate courses and continuing professional development should be more systematic and consistent.

5.30 While respondents believed there was some value in the ‘generic’ leadership programmes currently provided within the NHS in Scotland, there was a view that a specific public health leadership training programme could be better. One respondent pointed to Durham University’s ‘Leading Health and Wellbeing’ programme as an example. There was also a suggestion that it may be necessary to review the leadership training currently delivered by NHS Education for Scotland (NES) to ensure that this programme addresses the challenges of providing leadership across organisations.

5.31 More generally, respondents suggested that providing opportunities for ‘peer challenge’ and ‘shared learning’ could be beneficial.