2015 Review of Public Health in Scotland: Strengthening the Function and re-focusing action for a healthier Scotland

The Public Health Review was asked to examine public health systems and functions and their contribution to improving population health and reducing (health) inequalities. This is the Report on behalf of the Review Group published with a Ministerial foreword from the Minister for Public Health

Annex E. The structural and organisational landscape

1. Scottish Government

156. The Scottish Government has devolved responsibilities which include health, education, justice, rural affairs, housing and the environment. Its stated purpose is to "focus government and public services on creating a more successful country, with opportunities for all of Scotland to flourish, through increasing sustainable economic growth". The Scottish Government sets out five strategic objectives underpinning this purpose, including a "Healthier Scotland", and 16 National Outcomes which include people living "longer, healthier lives" and "tackling the significant inequalities in Scottish society", as well as giving children "the best start in life". The National Performance Framework supports an outcomes-based approach to performance. Public health work is central to the delivery of a number of the national performance indicators.

157. Since November 2014 there have been three Ministers sharing portfolio responsibility for aspects of public health: Cabinet Secretary for Health, Wellbeing and Sport; Minister for Public Health; and Minister for Sport, Health Improvement and Mental Health.

158. The Scottish Government has a Public Health Division (since October 2015, operating as two divisions: Health Protection and Health Improvement and Equality) and, since January 2015, a Directorate of Population Health Improvement, which includes within it the Public Health Divisions and which works closely with Health Analytical Services and the Chief Medical Officer's Directorate. The dental public health strategic component falls within the Dentistry Division, under the Chief Dental Officer. All have a direct role in improving the public's health, as well as working with other areas of the Scottish Government which also have a direct contribution to make.

2. NHS Scotland

159. Most of the core public health workforce in Scotland is employed within NHSScotland in the 14 Territorial Boards and four National Boards. The wider NHS workforce also makes a crucial public health contribution, including through the delivery of services, employment practices, leadership and resource allocation decisions, and partnership working.

2.1 Territorial Board

160. The 14 Territorial Health Boards have corporate Board level responsibility for the protection and improvement of their population's health and for the delivery of frontline healthcare services. Each has a public health team led by a Director of Public Health (DPH). These public health teams are responsible for providing services across all of the domains of public health and for working in partnership within the Health Board and with external organisations and communities to improve population health outcomes. In a few areas the DPH is a joint appointment between the NHS Board and the Local Authority. Public Health Directorates vary in size, organisation and linkages.

161. The development of IJBs (HSCPs) in Local Authority areas (and the lead agency model in Highland) has led to Health Improvement Teams being located as part of these integrated bodies in some parts of the country. Other specialist public health inputs are provided from Territorial Boards and National Boards.

2.2 Directors of Public Health

162. The DsPH role is central to the effectiveness of public health across the country, ensuring locally-sensitive responses to national priorities and policies. A ScotPHN report (Scottish Public Health Network (ScotPHN), 2010) on the Role of the Director of Public Health described 13 functions agreed to be part of the role, as follows.

Table 10: Role of the Director of Public Health

(i) providing public health advice to the NHS Board;
(ii) providing public health advice to the Local Authority;
(iii) contributing to corporate leadership of the Board;
(iv) producing an independent annual report;
(v) providing leadership and advocacy for protecting and improving health and reducing health inequalities;
(vi) managing the Board's specialist public health team and associated support staff and resources;
(vii) ensuring the Board and its staff have access to timely, accurate and appropriately interpreted data on population health;
(viii) ensuring the implementation of NHS components of Scottish Government public health or health improvement policies;
(ix) overseeing the coordination and effectiveness of screening programmes;
(x) communicating with the public via the media on important public health issues;
(xi) contributing to emergency planning;
(xii)* ensuring all appropriate infection and environmental surveillance and control measures were in place; and
(xiii)* ensuring health needs assessments were carried out.

* i to xi form part of DPH role consistently across Scotland, xii & xiii agreed to form part of the role in all but one and two regional boards respectively.

163. Additionally, DsPH meet collectively and have scope to ensure appropriate consistency of approach across Scotland.

2.3 National Boards

164. The four National Boards with specific strategic roles impacting on public health are NHS Health Scotland (NHSHS), NHS National Services Scotland (NSS), NHS Education for Scotland (NES) and Healthcare Improvement Scotland (HIS).

165. NHSHS is the national health improvement body which works with others in the public, private and third sectors to reduce health inequalities and improve health and wellbeing. It is involved both in developing and disseminating evidence and in shaping policy and programmes to help achieve a fairer, healthier Scotland. ScotPHN and the Scottish Centre for Healthy Working Lives are part of NHSHS.

166. NSS provides a number of support services to the NHS and other bodies in Scotland. NSS also commissions and manages national screening programmes for Scotland. HPS is part of NSS and delivers specialist national services and provides advice, support and information to professionals and the public to protect people from infectious and environmental hazards. NSS also runs the Information Services Division (ISD) which provides a range of statistical information and analysis. HPS and ISD are both part of the Public Health and Intelligence Strategic Business Unit within NSS.

167. NES provides education and training for those who work in the NHS in Scotland, including its core public health workforce, and ensures that the wider workforce's contribution to protecting and improving population health is supported.

168. Healthcare Improvement Scotland is the national organisation responsible for providing quality improvement support to healthcare providers in Scotland and for delivering scrutiny activity. It supports and delivers health and care activities which impact on public health, including evidence-based guidelines; public involvement processes; and health care quality and effectiveness assessments.

2.4 Observatory

169. The ScotPHO collaboration is responsible for providing a clear picture of the health of the Scottish population and the factors that affect it, including through improved collection and use of routine data on health, risk factors, behaviours and wider health determinants. It is co-led by ISD and NHSHS, and includes the Glasgow Centre for Population Health, National Records of Scotland and Health Protection Scotland.

3. National Public Sector Bodies

170. There are also a number of public sector bodies with a specific public health remit which operate nationally in Scotland, working with the NHS, Scottish Government, Local Authorities, business and industry, consumers and others. For example, the Food Standards Scotland (FSS) is responsible for ensuring that information and advice on food safety and standards, nutrition and labelling is independent, consistent, evidence-based and consumer-focused. SEPA is the principal environmental regulator, protecting and improving Scotland's environment.

4. Local Government

171. Local Authorities in Scotland play a pivotal role in delivering preventative, universal services; addressing the social inequalities which underpin health inequalities; and improving health outcomes. They are a key partner in the overall effort to improve the public's health and prevent ill-health. Local Authorities can also provide public health leadership through their ability to operate as public health organisations, focusing on the health impact of their own decisions and actions, and by contributing to partnership structures that are similarly concerned with improving population health and wellbeing and reducing health inequalities.

172. Local Authorities share statutory responsibility with Health Boards for the control of communicable disease. They have prime responsibility for environmental health and employ core public health staff, most notably Environmental Health Officers. Local Government services also contribute to the public health function through important work within education, economic development, employability services, cultural and leisure services, responsibilities for the physical and social environments, and a range of other duties.

173. Local Authorities are statutory partners in CPPs and, together with Health Boards, are parent bodies for establishing integrated partnership arrangements under the Public Bodies (Joint Working) (Scotland) Act 2014.

174. The Health and Wellbeing Executive Group provides a focus for COSLA's considerations of public health issues, with COSLA's Leaders' meeting setting policy.

5. Community Planning

175. There is one CPP for each Local Authority area. Under the Community Empowerment (Scotland) Act 2015 public bodies work together and with the local community in CPPs to plan for, resource and provide services which improve local outcomes and reduce inequalities in the area. The National Community Planning Group, with membership drawn from strategic leaders in public services and the wider community, helps to inform strategic policy direction for CPPs. As a matter of policy, CPPs are encouraged to focus efforts on addressing a small number of priorities for their area which reflect their understanding of the key needs and circumstances of the area and its communities (likely to include particular deep-rooted and entrenched social and economic challenges) and on which partners can make the most significant impact through effective joint working. Public health challenges frequently feature within these local priorities, either in their own right or as part of related themes.

176. CPPs have Single Outcome Agreements (SOAs) which are intended to demonstrate a clear and evidence-based understanding of place and communities, including the inequalities facing different areas and population groups. Under the Community Empowerment (Scotland) 2015 Act Single Outcome Agreements are given the title of local outcome improvement plans (LOIPs), which CPPs are required to prepare and publish.

177. Community planning brings together all partners responsible for action on wider determinants of health and inequality and for promoting early intervention and preventative approaches. These partners include the Local Authority, Health Board, IJB, enterprise body, Police Scotland, the Scottish Fire and Rescue Service, regional colleges and Skills Development Scotland. Participation with communities lies at the heart of community planning involving the third sector and any community body that has the potential to make a contribution to the CPP.

6. Integration Partnerships

178. The integration of adult health and social care services is required, from April 2015, by the Public Bodies (Joint Working) (Scotland) Act 2014, through Health Boards and Local Authorities establishing integrated partnership arrangements for local adult services and deciding locally whether to include children's health and social care services in their integrated arrangements. Two models of integration are available: Lead Agency (delegation of function and resources between the Health Board and the Local Authority) and IJB (delegation of functions and resources by Health Boards and Local Authorities to a body corporate). This will mean Health Boards and Local Authorities working together effectively to deliver good quality, sustainable care services at local level, including through locality planning arrangements. National outcomes for health and wellbeing apply, and the Integration Partnership is responsible for joint strategic commissioning plans (widely consulted upon with non-statutory partners) for delivery functions and for the integrated budget under their control. Where children's health and social care services are not included within integrated arrangements, they will continue to be planned for and delivered on the current basis by Health Boards, Local Authorities and third and independent sector providers.

7. Third sector

179. There are a wide range of voluntary and community sector organisations with health interests, and even more with a focus on the determinants of population health. These all contribute to the wider public health function in Scotland. The third sector health organisations come together collectively through national intermediaries including Voluntary Health Scotland, Voluntary Action Scotland, the Health and Social Care Alliance and the Community Health Exchange. Voluntary Health Scotland is the national intermediary and network for Scotland's voluntary health organisations. The Alliance is the national third sector intermediary for a range of health and social care organisations, including for people who are disabled, living with long term conditions or providing unpaid care. Voluntary Action Scotland develops Third Sector Interfaces (TSIs) to support the third sector locally. The Community Health Exchange (CHEX) supports community development approaches to health improvement.

180. The Scottish Council for Voluntary Organisations (SCVO) is a membership organisation for a wide breadth of Scotland's charities, voluntary organisations and social enterprises. It estimates that there are around 45,000 formal voluntary organisations across Scotland with over 23,000 organisations regulated as charities by the Scottish Charity Regulator (SCVO/Office of Scottish Charity Regulator, 2010/2011). Health is estimated to comprise 22% of charitable purposes and beneficiary groups are estimated to be children and young people (46%), the community (46%), older people (22%) and people with disability/health problems (22%) (The Work Foundation , 2010).

8. Academic public health

181. Public health teaching and research takes place in all of Scotland's Universities and many members of the core public health workforce are employed in academic public health within Universities and Research Units. Public Health Research Units in Scotland include the Social and Public Health Sciences Unit in Glasgow, the Scottish Collaboration for Public Health Research and Policy in Edinburgh, and the Health Economics Research Unit in Aberdeen all of which receive core funding from the Government's Chief Scientist Office alongside research council funding. The Farr Institute, a collaboration between six Scottish universities and NSS, uses electronic patient records and other population-based datasets for research purposes. The Scottish School of Public Health Research is another cross-university collaborative mechanism to achieve a more focussed academic contribution to public health in Scotland. As a specific investment to develop evidence and insights to tackle urban inequalities, Scottish Government, NHS Glasgow and Greater Clyde, Glasgow University and Glasgow City Council collectively support the Glasgow Centre for Population Health.

182. The Academy of Medical Sciences is undertaking a project that aims to identify the main health challenges the UK population will face by 2040. One of the major focuses of the Academy's activities is to facilitate strong and equitable partnerships between academia, industry and the NHS - along with promoting effective engagement with regulators and policy makers.

183. There are also a number of issue-specific collaborations, such as MESAS (Monitoring and Evaluating Scotland's Alcohol Strategy) for alcohol policy, the Commonwealth Games legacy evaluation process, and Scotland's smoke-free legislation evaluation. In dentistry, the strategy for oral health research has given priority to public health, and the dental academic establishments, particularly in Dundee and Glasgow, are working together to ensure research is relevant and best use is made of resources. What Works Scotland, which was established in 2014, is an initiative involving public health academics working alongside other researchers and service-providers. It is funded by Scottish Government and the ESRC to improve the way local areas in Scotland use evidence to make decisions about public service development and reform, working in an applied way.

9. Networks

184. A number of networks of public health professionals operate in Scotland to enable sharing of expertise, coordination of efforts and collaboration to undertake joint work. There are networks for specific disciplines (e.g. the Dental Public Health Network and Pharmaceutical Public Health Network /Community Pharmacy Network), for special interests (e.g. the Alcohol Special Interest Group), geographical areas (e.g. the North of Scotland Public Health Network (NoSPHN)), and obligate networks such as the Scottish Health Protection Network (SHPN).

185. The Scottish Public Health Network (ScotPHN) is responsible to the SDsPH and NHSHS and its role is to bring together the public health resources within the fourteen Territorial NHS Boards, the National Health Boards, academic public health departments and wider public health agencies, including Local Authorities and the independent sectors. As well as facilitating information exchange, ScotPHN undertakes national prioritised pieces of work. Given the size of Scotland, there is also strength in informal networks which operate (e.g. in a given field/speciality) where core staff know one-another and can agree between them what activity needs to be undertaken and how to resource it.


Email: Gareth Brown

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