General Research Findings No. 4Overview of Written Evidence Received as Part of the Review of the Public Health Function in Scotland
This paper presents an analysis of written evidence received as part of a Review of the Public Health Function in Scotland. As part of the Review consultation process an invitation to submit written evidence was extended to approximately 5,000 organisations and individuals in Scotland. A total of 133 responses were received and this paper presents a summary of the content of those responses. The work was undertaken by Karen Croucher (Research Fellow) and Diana Sanderson (Senior Research Fellow) of York Health Economics Consortium at the University of York.
- The 'public health function' was seen by many respondents to require greater co-ordination and integration to achieve a more cohesive image, both at national and local levels.
- There was a widely held view that the public health agenda would be best served by a multi-agency approach. Respondents felt that the Review should recognise the significant roles played by all the various organisations and professions whose activities impact on health and well-being, and consider ways in which these activities could be harnessed and coordinated to drive the public health agenda in Scotland more effectively.
- Many public health practitioners and organisations believed that the objectives of Towards A Healthier Scotland cannot be achieved without strategy and leadership to coordinate the various activities that make up the public health function. Suggestions for a new national public health body were put forward; however the role, profile, and activities of such a body were envisaged in various different ways.
- There were divergent views as to whether the public health lead at a local level should be taken by Health Boards, Primary Care Trusts (to ensure close links with local populations), or local authorities (to ensure that education, housing, transport and other services can be linked to the public health agenda).
- Many respondents felt that greater effort should be made to utilise the skills and clarify the roles of different professional groups, and that further work should include a skills audit of all public health professionals, and the identification of future training requirements.
- There was a common perception of the need for better integration between public health academics and the NHS.
Following the 1997 White Paper Designed to Care - Renewing the NHS in Scotland (Cm3811), the Government's vision for improving health for all in Scotland was put forward in the White Paper Towards a Healthier Scotland (Cm4269), which was presented to Parliament in February 1999. Recognising Scotland's ill health as a cause for serious concern, it proposed coordinating resources capable of influencing health to take action at three levels: to improve life circumstances; to improve life styles; and to address particular health topics including coronary heart disease, teenage pregnancy, cancer, smoking and alcohol misuse. The overarching aim was to tackle health inequalities. Against this background a Review of the Public Health Function in Scotland was established in November 1998 undertaken by a Steering Group chaired by Sir David Carter, Chief Medical Officer. The remit of the Review was to 'reassess the role, relationship and locus of public health medicine and public health dentistry to ensure the optimal use of all available resources in the drive to safeguard and improve Scotland's health'.
As part of a wider consultation process invitations to submit written evidence to the Review were sent to approximately 5,000 individuals and organisations, both within and outside the NHS. A total of 133 responses were received, ranging considerably in content, from concerns about local health and dental services, to consensus responses from national organisations, groups and networks.
Collectively the responses provided a detailed overview of the public health function in Scotland, and the challenges that are perceived to be facing public health practitioners, with many suggestions for change in current national and local structures. Respondents defined the 'public health function' in different ways. The 'public health function' was seen by respondents to require greater co-ordination and integration to achieve a more cohesive image, both at national and local levels.
Locus of the public health function
Many respondents suggested that a new national body for public health should be established. However the role, profile, and activities of such a body were envisaged in various ways. Some respondents saw a national body as having an independent advisory and coordinating role. Others saw it as a national provider of public health skills, equally available to all Health Boards, Primary Care Trusts and other agencies. Some respondents however did not feel that a new body was required, but that the roles and responsibilities of the existing public health organisations should be clarified, and their activities better coordinated. It was felt that managed public health networks could support the main strategic public health function at Health Board level.
Role of research
From within the NHS the view emerged that academic public health research is failing to address the pragmatic issues of most concern to those in the health services. Much research was seen to have little direct impact on public health. There was a clearly articulated need for the links between practice and research to be strengthened.
A multi-agency approach, with partnership working between Health Boards, other health agencies, and local authorities was seen by many respondents as the key to addressing ill health arising from socio-economics factors. However, there were concerns about the lack of a structured overview across different agencies as to how to promote the well-being of communities, and the lack of clarity about the location and responsibility for public health strategy.
Many respondents felt that the strategic public health role should remain within Health Boards, to ensure a 'critical mass of skills' to support the essential activities of communicable disease control, health protection, needs assessment, disease surveillance, interpretation of evidence, and partnership working. There were concerns about the adequacy of the arrangements for communicable disease and environmental hazard (CD&EH) in both large and small Health Boards.
Primary care trusts
There were also concerns as to how public health skills would be injected in Primary Care Trusts and Local Health Care Cooperatives, particularly with respect to needs assessment, addressing local priorities, and evaluating effective interventions. Some respondents advocated the relocation of the public health function to Primary Care Trusts, to allow public health practitioners to be closer to local communities and to develop links with local organisations and health care professionals with potential to influence the community's health.
The necessity of multi-disciplinary working
Multi-disciplinary working was seen by many as the only way to achieve the targets of Towards a Healthier Scotland. They felt greater efforts should be made to utilise the skills and clarify the roles of different professional groups, including nurses, health visitors, pharmacists and health promotion specialists, and identify areas where their particular skills would add value to the public health function. It was suggested that the Review should address questions about staffing levels and skill mix in Health Boards,and that a public health skills audit should be undertaken.
Public health medicine and dentistry
Consultants in public health medicine felt that there was an expanding role for public health medicine, given the broad agenda of Towards a Healthier Scotland. They also recognised the need for multi-disciplinary working, with public health medicine best suited to take the lead. Medical training, understanding of clinical sciences, epidemiology, demography, and behavioural sciences were seen to be a unique blend of skills which enabled practitioners to ensure a population perspective in service planning and priority setting, to support Trusts in the process of clinical governance, and to work with Primary Care Trusts and Local Health Care Cooperatives in areas such as needs assessment. Medical training was seen as essential for certain key public health tasks particularly disease control. Consultants felt that their skills fit most comfortably in multi-disciplinary departments of public health medicine within Health Boards, sharing skills and developing partnerships with other health and non-health agencies. The image of public health medicine was still felt to be linked to 'drains and infection', and respondents felt that efforts should be made to promote the discipline and increase awareness of the range of activities undertaken by practitioners.
Relatively few responses referred to public health dentistry. These all echoed the concern that there was no uniform coverage of public health dentistry across Health Boards. Some respondents recommended that all Health Boards should have a Consultant in Dental Public Health. Others suggested that there should be a 'Public Health Dental Caucus' to offer uniform advice, support training, provide a focus for best practice, and give public health dentistry an independent role removed from the inconsistent approaches taken by Health Boards.
The potential contributions that could be made to the public health function by different disciplines (both at strategic and operational levels) was highlighted. It was felt that public health departments should better utilise the local knowledge of health visitors, community nurses, and pharmacists to inform needs assessment, identify local priorities, and to plan and deliver appropriate services. Respondents felt that other professionals could gain from closer links with public health departments' expertise in research and evaluation. The need for health promotion departments to work closely with public health departments in Health Boards and with other agencies, and to target resources on shared priorities was emphasised.
Training and continuing professional development
Many respondents felt that only those public health departments where there was a critical mass of medical and other public health skills were able to provide the opportunities and supervision necessary for general higher training in public health medicine and dentistry. Policy emphasis on the quality of clinical care and raising standards were seen to have placed a requirement on public health practitioners to develop standards of best practice, performance audit, and professional regulation. Current provision for continuing professional development was not seen to offer opportunities to develop expertise in specific areas. New training initiatives that were inclusive of different professions (thus promoting multi-disciplinary working) were seen to be required.
It was widely believed that the objectives of Towards a Healthier Scotland could not be achieved without strategy and leadership - both at national and local levels - to coordinate the various activities that make up the public health function.
Respondents felt that existing resources could be better utilised to maximise their potential effectiveness; however additional resources would also be required to support Primary Care Trusts, and develop partnership working. Various tasks could be examined to better understand where public health medicine skills were most needed, and where the skills of other non-medical professionals could be appropriately used. Many respondents highlighted the need for guidance on work force structures and staffing levels.
There was a perceived need for evidence-based models of good public health practice.
About this study
As part of the Review of the Public Health Function in Scotland, a letter was issued to approximately 5000 individuals and organisations in Scotland with an interest in public health issues. The letter extended an invitation to submit 'views, comments and proposals' as 'written evidence bearing on its remit'. A total of 133 responses were received from a range of individuals and organisations including GPs, public health clinicians, local authorities, NHS Trusts, Health Boards, professional and voluntary sector organisations, and academics. The invitation to respond was very general in its nature and responses provided views on only some of the issues the Review was asked to address. This is reflected in the analysis presented in this paper. A full report summarising and analysing the written evidence received has been published on the SHOW website ( http://www.show.scot.nhs.uk).
Other forms of consultation were also undertaken as part of the Review (eg. the gathering of oral evidence, and the holding of themed meetings), all of which were drawn on by the Review Steering Group in preparing its report, The Review of the Public Health Function in Scotland. This report can be accessed on the Scottish Executive website ( http://www.scotland.gov.uk).
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