Conclusions and Recommendations
1. This Review of Public Health in Scotland has identified the need for the function to be clearer about its priorities and delivered in a more coherent manner. The changing organisational context (including the clear emphasis on partnership and integration and the importance of community empowerment and engagement) has implications for how public health is organised and operates. Major public health challenges such as obesity, mental health problems and inactivity, together with the persistence of health inequalities, require a concerted population health response, achieved through the organised efforts of society. They cannot be addressed solely through treatment. The evidence received by the review group emphasised the cost-effectiveness of preventive approaches and a wide appetite for a more active public health effort in Scotland. The Review Group's recommendations seek to support that through:
a. Further work to review and rationalise organisational arrangements for public health in Scotland. This should explore greater use of national arrangements including for health protection.
b. The development of a national public health strategy and clear priorities;
c. Clarification and strengthening of the role of the Directors of Public Health(DsPH), individually and collectively;
d. Supporting more coherent action and a stronger public health voice in Scotland;
e. Achieving greater coordination of academic public health, prioritising the application of evidence to policy and practice, and responding to technological developments;
f. An enhanced role for public health specialists within Community Planning Partnerships (CPPs) and Integrated Joint Boards (IJBs); and
g. Planned development of the public health workforce and a structured approach to utilising the wider workforce.
2. The Executive Summary outlines the review process and key themes which inform these recommendations. These are expanded on in the full report.
Public Health Review
3. The Public Health Review has been given a specific remit to examine public health systems and functions and their contribution to improving population health and reducing (health) inequalities. Ministers have asked for recommendations to seek to strengthen the contribution; maximise the effectiveness and efficiency; and ensure the responsiveness and resilience of the public health function in Scotland for the future.
4. The material described in the first part of this summary, and in Part 1 of the report, reflects the population health and policy analysis undertaken to ensure recommendations are made on the basis of a good understanding of public health. The second part of the summary, and Part 2 of the report, describe the key themes emerging from the engagement processes undertaken by the review (full report published separately at www.gov.scot/publichealthreview-analysisofresponses-engagementpaper), and the additional research evidence commissioned around the specific areas of public health leadership, partnership and workforce (summary report published separately at www.gov.scot/publichealthreviewresearchreport-keyfindings). Collectively this work reflects the review process and has been undertaken on behalf of the Review Group. The Group's recommendations take account of all these strands of the review.
Population Health in Scotland
5. Good health is beneficial for individuals and families, and also strengthens capacity for participation in learning, employment, caring, and many other activities. In short, good health is a resource for society.
6. The population health challenge remains complex and persistent and current measures are not seen to be sufficiently accelerating improvement in the country's public health:
- Life expectancy is increasing, but is not improving equally or improving to the levels seen in other Western European countries. Scotland continues to experience 'excess' mortality, even when deprivation is accounted for. There is no single explanation.
- The overall challenge is to increase the years of life that people in Scotland live in good health. Behaviours detrimental to health remain prevalent and the burden of disease is now with longer-term conditions and associated with lifestyle and economic and social circumstances. An increasing proportion of people live with multiple conditions including, in particular, concurrent physical and mental health conditions.
- The impact of the public health challenge is greater in the more deprived sections of the population than the more affluent. The importance of tackling poverty and inequalities is reiterated in this report given the clear links between social deprivation and poorer health outcomes. Greater equality in society is associated with better population outcomes on a range of domains. Scotland, like many countries, continues to see a stark difference in the life circumstances, experiences and outcomes of people in different groups. These differences are perpetuated across generations. The challenge of impacting on these inequalities has been identified as one of the top priorities for Local Government and Scottish Government.
7. Specific population health priorities in Scotland now encompass health inequalities with their social determinants, inactivity, nutrition, obesity, and poor mental wellbeing, concurrent with the demography of an ageing population. Solutions go beyond the direct control of public health and require work across complex systems, far beyond NHS and health boundaries, to influence wider agendas, policies and programmes, and these require new ways of working.
8. Addressing these challenges matters for individuals and communities as there is a significant burden of disease and suffering that is avoidable, especially among the less affluent, and having caring responsibilities can preclude carers from working or living full and meaningful lives. It matters for health and social care services and wider public services as the sustainability of services depends on improving population health. It matters for a flourishing and successful Scotland as a healthy working population contributes to sustainable economic growth.
9. In a number of areas of public health, both within the health sector and beyond, Scotland is recognised as being at the leading edge. In each case there has been bold, committed, leadership with local and national political support; effective partnership working; an applied evidence-base; clear accountability and monitoring processes; a critical mass of effort and investment; and action at national, regional and local levels. Creating the conditions for similar success across the breadth of population health in Scotland is now the immediate task to enable effective responses to ongoing and emerging local, national and international challenges for the benefit of current and future generations.
10. At the centre of the public health endeavour is the core public health workforce, largely employed in the NHS in Territorial Health Boards and National Boards, but also within Local Authorities and Academia. Responsibility for public health action also rests with the wider NHS, with national and local governments, the pivotal role of CPPs and IJBs. The third sector, other public services, communities and the private sector make a major contribution, as does the wider workforce across the public sector and voluntary and community sectors. These are considerable organisational and people resources, but not all of the potential is currently being realised.
11. Public health supports the shift to prevention and to tackling the inequalities in our society with a wide-range of preventative approaches shown to be cost-effective. Given the significant and rising costs associated with ill-health, there is both an economic and health benefit from taking a public health approach.
12. The landscape of public sector reform provides new opportunities for Public Health to respond to both the persistent and the emerging challenges facing Scotland's health. Responses to the engagement processes undertaken as part of this review indicate that the public health community in Scotland wants to be supported to capitalise on these opportunities.
Public Health Review - Key Themes
13. Some clear themes emerged from across the various sources - the material generated during the review from the engagement process supported by the research analysis and the population health and policy analysis. There were strong messages about the importance of both national and local perspectives and the need for greater coordination between these. The process highlighted the need for greater visibility and a clearer identity for the public health function. The challenges and opportunities for public health featured the need to respond more effectively to large-scale strategic challenges (such as the desired shift to prevention) and to focus more clearly on identified priorities. The desire for strengthened leadership from individuals and organisations was a reoccurring theme, including to increase impact in partnership areas including IJBs and CPPs. There was also clear support for the fundamental importance of effective partnership working as a prerequisite for better population health. The value of the existing workforce came through strongly, but the process also noted the changing nature of the workforce and the challenges of supporting and strengthening multi-disciplinary public health.
14. Many of the themes and issues are in fact interconnected. The main report presents these findings in more detail, with specific discussion on the key themes.
- Organisation - the perception of there being a cluttered public health landscape; the need for greater efficiencies; more clarity on organisational roles; better links with Local Authorities and Community Planning; and taking forward those actions which could be categorised as 'once for Scotland' nationally.
- Strategy - the need for a single, over-arching public health strategy for Scotland and clear priorities.
- Leadership - the need for strengthened local and national leadership across the breadth of public health endeavour, including the role of Directors of Public Health (DsPH).
- Evidence - the importance of data, information, intelligence, research and evidence as a basis for public health decision-making and action.
- Partnership and collective responsibility - the need for responsibility for public health to be shared widely across different organisations, sectors, communities and individuals to ensure we are able to address the determinants of population health, as well as particular health priorities. This includes Local Authorities and the third and voluntary sectors.
- Workforce - the need to respond to the challenges associated with a dispersed workforce involving varied skills and professions to ensure a robust, resilient and competent workforce of the future, and that new talent can be attracted to the field of public health.
15. Implementation of the recommendations in the report, and outlined at the start of this summary, will require an overarching implementation plan to ensure that all elements are taken forward as a subsequent phase of the public health review. Delivery of a future public health strategy will require the contribution and collaboration of many partners, recognising that responsibilities for addressing public health issues sit not only within the health sector but also with national and local governments; public, private and third sectors; and communities and individuals.
Email: Gareth Brown