Public Health Review Research Report: Summary of Key Findings

1 Summary of key findings

1.1 Public Health Capacity and Infrastructure

Robust public health infrastructure is required to fulfill essential public health functions such as surviellance, health protection, disease prevention and health promotion (World Health Organization, 2012). Whilst public health priorities may change in light of emergent challenges and changing contexts, it is is important to ensure the resource required to address enduring public health challenges is maintained and developed, for example provision of clean water, immuisations against communicable diseases and screening for chronic disease (Hanlon et al., 2011). Box one summarises an example of a simple framework to assess public health capacity (Aluttis et al., 2014). Such frameworks may be used for benchmarking and prioritisation of strategies to strengthen public health infrastructure and improve capacity.

Box 1: Dimensions of Public Health Capacity (Aluttis et al., 2014)

1.2 Leadership

Emergent public health challenges (such as an ageing population, socioeconomic inequalities and the globalised sociocultural context) require new approaches to public health leadership (Beaglehole & Bonita, 2004; Czabanowska et al., 2014; Hanlon, 2012). In addition, the number of potential stakeholders with a public health agenda is 'wider than ever' (associated with increased recognition of the social determinants of health) and the nature of public health practice has shifted (Czabanowska et al., 2014; Davies et al., 2014; Koh, 2009). Box two summarises some of these leadership functions, both in relation to the public health workforce and the wider agenda of improving population health. It is recommended the review group identify the leadership features required for the current Scottish context and use these to benchmark Scotland's leadership performance.

Box 2: Features of leadership

1.3 Partnerships

An extensive literature describes factors that facilitate or provide challenges to successful partnerships; these are summarized in box 3 at the end of this report. Some factors must be held in tension with others, and their individual relevance will vary by context and purpose of the partnership.

Reviews of evaluations of emblematic multi-agency public health partnerships (for example, Health Action Zones) find limited evidence of health impacts, reflecting the challenge of robust outcome evaluation of partnership working but also a lack of long-term sustainability and insufficient resources for implementation (Carlisle, 2010; Hayes et al., 2012; Smith et al., 2009; Spinks et al., 2009). Local government is a helpful context for the coordination of joint strategies and advocacy for macro-level sustainable change within a multi-sector 'settings' approach such as Healthy Cities, Healthy Workplace, Healthy Schools or Safe Communities initiatives (Dooris, 2013). An important role of the specialist public health function within wider partnerships is to counter pressure to shift attention away from the preventative agenda towards high-profile downstream issues, by locating health issues within an evidence-based ecological public health framework (underpinned by the epidemiology of the determinants and distribution of disease) and by articulating the evidence and ethical basis for potential interventions (Allin et al., 2004; Boydell & Rugkasa, 2007; Mackenbach & McKee, 2013; Taylor-Robinson et al., 2012).

Recent policy in Scotland seeks to strengthen partnership working both across public sector bodies and with communities, for example, the Christie commission, the Community Empowerment Bill, and Health and Social Care integration. This is a helpful cultural and policy environment which aligns with the public health agenda.

1.4 National Policy

Reviewing health policies across Europe (including tobacco, alcohol, food child health, mental health, screening, and air pollution) McKee and Mackenbach identify why some countries have been able to enact effective national policies whereas others have not (Mackenbach & McKee, 2013). Factors identified include the availability of resources (including funding for a skilled workforce, functioning IT systems and data intelligence), the values held by their citizens, the cultural heterogeneity of the population, the quality of democracy and the effectiveness of government (a high quality civil service independent from political pressures, effective systems of policy formulation and implementation, and the credibility of the government's commitment to implementation) (Mackenbach & McKee, 2013). Investment of resource and political space for strong public health associations and professional groups that conduct advocacy work can also be important, particularly where corporate interests seek to undermine government actions (Beaglehole & Bonita, 2004; Mackenbach & McKee, 2013; Leppo et al., 2013).

Health determinants may be seen as the mediators between policies and health outcomes (Ståhl et al., 2006). Health in All Policies (HiAP) is a cross-sector approach that systematically takes into account the health implications of decisions across public policies in order to improve population health and reduce inequalities and plays an important role in the European Health 2020 policy framework (Leppo et al., 2013; McQueen, 2014). Conditions which support this approach include a supportive political context with legal backing, development of policy proposals across sectors with an ability to seize policy-making opportunities, processes for intersectoral communication and implementation, resources (such as joint budgeting or delegated financing), and the technical skills and governance structures to implement policy decisions and evaluate their impacts on health and its determinants (Leppo et al., 2013; McQueen, 2014; Ståhl et al., 2006; Wismar et al., 2012).

Whether policies are developed and implemented collaboratively by the relevant policy sectors is a key challenge and includes engaging with non-institutional settings. This requires the need to consider more deeply what the 'think global act local' mantra means in specific contexts and may require a willingness to drop explicitly health language for that of wellbeing and sustainable development in recognition of the interconnectedness between human health, ecosystem health and public health (Dooris, 2013; Hendriks et al., 2014).

1.5 Governance and accountability

Evidence on the relative merits of different governance structures and relationships of accountability is mixed; there is a dynamic balance between national and local infrastructure for public health that changes over time and varies between countries according to their political context, structures, social attitudes and history of participative decision-making (Allin et al., 2004; Brownson et al., 2012; Jakubowski & Saltman, 2013). International country case studies presented in the full report (including England, France and Sweden) each demonstrate the tendency to counterbalance devolved responsibilities with national accountability and direction. The benefits of nationally-led, centralised, public health infrastructure include: the capacity to employ strategic approaches to addressing health issues with global roots with clear alignment between vision, strategy and objectives; the ability to address inequalities of access and resource when implementing and coordinating actions; and stronger infrastructure such as health intelligence, and IT resources. The benefits of centralization must be considered in tension with the benefits of power being devolved to localised regions, which include: more democratic decision-making with greater engagement and access to the population; locally responsive strategies with opportunities for experimentation; and the ability to utilise local drivers for implementation. However, localised governance may be susceptible to inefficiencies of scale, exacerbation of inequalities and is susceptible to individual interest agendas (Allin et al., 2004; Jakubowski & Saltman, 2013; Rayner, 2007).

As there is no apparent direct relationship to better population health outcomes and the balance between local and national governance for public health, each country seeks to find the balance between these that best fits its culture, politics and values. There will always be a shifting dynamic balance between local and national, and therefore there is no single 'right' solution to this, but the mechanism for the connection between the two is important.