Chapter 1: Introduction
Purpose of this document
1. This consultation document invites views on our proposals for a new national public health body in Scotland, to be known as ‘Public Health Scotland’. The proposals represent our current ambitions for the new body that have been developed by the Public Health Reform Programme and may continue to evolve in light of that ongoing collaborative work and stakeholder engagement.
2. The consultation is structured as follows:
Chapter 1: Introduction
Chapter 2: Overview of the new model for public health in Scotland
Chapter 3: Governance and accountability for the new model
Chapter 4: Outcomes, performance and improvement
Chapter 5: Functions of Public Health Scotland
Chapter 6: Health Protection
Chapter 7: Structure of Public Health Scotland
Chapter 8: Composition of the Board for Public Health Scotland
Chapter 9: Data science and innovation
Chapter 10: Transition arrangements – from existing structures to the new model
Chapter 11: Funding the model for public health in Scotland
Chapter 12: Equalities Impact Assessment
Chapter 13: Business Regulatory Impact Assessment
Chapter 14: How to respond
3. Consultation questions are set out in each of the relevant chapters.
4. For the purposes of this consultation, the following World Health Organisation definition of public health has been used:
4.1 Public health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO). Public health focuses on the entire spectrum of health and wellbeing, not only the eradication of particular diseases. Related activities to strengthen the public’s health aim to create and provide the conditions under which people can maintain and improve their health and wellbeing, or prevent the deterioration of their health.
4.2 Some key features help to distinguish a public health approach from other approaches to improving health and wellbeing, such as those delivered through personalised health and care. For example:
a. Public health is population based and is concerned with the factors that make populations (e.g. communities, cities, regions, countries) rather than individuals healthier or unhealthier;
b. Public health emphasises collective responsibility for health, its protection and disease prevention - through the organised efforts of society;
c. Public health recognises the role of the state and of the underlying socio-economic and wider determinants of health and disease, including the distribution of power, resources and opportunities within and across populations; and
d. Public health involves partnership with all those who contribute to the health of current and future populations.
5. Public health is about creating and protecting the conditions in which people can live healthy lives for as long as possible. Economic prosperity, a good start in life, effective education, rewarding work, good housing and strong, supportive relationships all play their part. A public health system can be defined as the set of connected agencies or entities working together that share the common goal to protect and improve the public’s health and reduce health inequalities. Public health functions are the range of activities (such as leadership, service delivery and professional standards) that support public health assessment, policy development and related assurance. Public health services are the coherent set of actions that directly benefit members of the public, their families and their communities within the public health system.
6. The new arrangements for public health described in this consultation are designed to ensure the effective delivery of improved health and wellbeing outcomes for the population of Scotland. If we are to create a Scotland where everybody thrives, we need to address the current challenges – our poor relative overall health status compared with other countries; the significant and persistent health inequalities that exist across Scotland; the need for our care services to respond to the needs of a changing population with more complex needs, such as more older people; and the particular effects of current key issues such as obesity, mental health problems, alcohol and substance misuse.
7. Our future economic success as a nation is dependent on a healthier Scotland. To achieve sustainable economic growth we need to recognise the fundamental importance of environmental, social and economic factors in determining health outcomes and the need to increasingly move towards the prevention of illness. We want to create a genuine ‘culture for health’ where citizens achieve the highest attainable standard of health by both taking - and being empowered to take - responsibility for their own health and care, within an enabling environment that makes it possible for them to do so.
Purpose and benefits
8. Consolidating the national public health functions into a single body allows for a new, single public health brand and identity, with revitalised leadership. The body will be committed to partnership working, innovation and meaningful change across the whole system at national, regional and local levels. By including the national data and intelligence function within the new body, we ensure that all public health activity and performance measurement is brought together in one place, providing a basis for innovation and ambition around our digital capability more generally. Public Health Scotland will support organisations, communities and partnerships to build local capacity and capability, facilitate access to national information and expertise, and share methods and results across Scotland. This will enable better planning, evaluation and targeting of resources across the whole system.
9. This document describes what we expect the new national body will look like and how we expect it will interact with other organisations and frameworks. Some of these arrangements will require legislative change and will be subject to parliamentary scrutiny.
10. A broad range of work is underway to reform public services in Scotland. This includes supporting new ways of working; a focus on tackling inequality; realising a demonstrable shift towards preventative approaches; and enabling individual and community empowerment. Across all of this reform work, national and local government are striving for more innovative and effective partnership approaches to improving the health of Scotland’s population and to creating greater equality in health. At the same time, there is a recognition of the need to respond to growing demands, expectations and resource constraints.
11. The Commission on the Future Delivery of Public Services (“Christie Commission”) argued for a radical change in the design and delivery of public services to address the intense pressures on budgets and to tackle Scotland’s deep-rooted social problems. The recommendations they identified include:
- Recognising that effective services must be designed with and for people and communities - not delivered 'top down' for administrative convenience;
- Working closely with individuals and communities to understand their needs, maximise talents and resources, support self-reliance, and build resilience;
- Concentrating the efforts of all services on delivering integrated services that deliver results;
- Prioritising preventative measures to reduce demand and lessen inequalities;
- Tightening oversight and accountability of public services, introducing consistent data-gathering and performance comparators, to improve services; and
- Driving continuing reform across all public services based on outcomes, improved performance and cost reduction.
12. In response, the Scottish Government and the Convention of Scottish Local Authorities (COSLA - the voice of Local Government in Scotland) have embarked on a shared public sector reform programme based around:
- a decisive shift towards prevention;
- enabling greater integration and collaboration between public services at a local level;
- greater investment in workforce development and leadership; and
- a sharp focus on improving performance.
13. In recent years, this reform work has seen the integration of health and social care. Health Boards and local authorities are now jointly responsible for the delivery of national agreed health and wellbeing outcomes, through the creation of Integration Authorities, with a greater emphasis on joining up services to improve care and support for patients, service users, their carers and their families.
14. There has also been on-going work to strengthen community planning in Scotland. The Community Empowerment (Scotland) Act 2015 introduced provisions designed to strengthen community planning, by placing new duties on public sector partners to play a full and active role in community planning partnerships and to deliver outcomes for communities through effective integrated working. Community planning now has a clear statutory purpose focused on improving outcomes and which will support an environment within which local partners can work closely to strengthen the public’s health.
Public Health Reviews
15. A number of reviews have considered Scotland's approach to tackling health inequalities and how related resources are used. These include Audit Scotland's 2012 report on health inequalities in Scotland and NHS Health Scotland’s 2013 Health Inequalities Policy Review. Both sets of recommendations confirm the need for a clearer focus on the public’s health in Scotland; greater coordination across structures and different levels of activity; and the need for partnership-based action informed by public health intelligence and evidence.
16. In 2013, the Scottish Government published ‘Equally Well’ which confirmed that our greatest health challenge continues to be the inequalities which exist between the poorest and richest in our society. Subsequently, Scottish Ministers announced in November 2014 that they had asked for a Review of Public Health in Scotland, the report of which was published February 2016. This Review found that Scottish public health needed to be more visible and that it needed to have a clearer vision. It concluded that public health needs to provide leadership which extends far beyond the NHS and health boundaries to influence wider agendas, policies and programmes in the public, private, third and independent sectors.
17. The Public Health Review emphasised the cost-effectiveness of preventive approaches and the need for a more proactive public health effort in Scotland. The Review Group's recommendations were:
- Further work to review and rationalise organisational arrangements for public health in Scotland, including greater use of national arrangements where appropriate;
- The development of a national public health strategy and clear priorities;
- Clarification and strengthening of the role of the Directors of Public Health (DsPH), individually and collectively;
- Supporting more coherent action and a stronger public health voice in Scotland;
- Achieving greater coordination of academic public health, prioritising the application of evidence to policy and practice, and responding to technological developments;
- An enhanced role for public health specialists within community planning partnerships and Integrated Joint Boards; and
- Planned development of the public health workforce and a structured approach to utilising the wider workforce.
18. These recommendations were translated into the relevant commitments within the Health and Social Care Delivery Plan published in December 2016. This document sets out a clear vision for the Health and Social Care system, including a more meaningful focus on prevention and a recognition that there must be a more comprehensive, cross-sector approach to the public’s health and wellbeing. The Delivery Plan also sets out specific commitments to publish public health priorities, deliver a new public health body and improve support for local health partnerships.
19. In 2017 Scottish Government and the Convention of Scottish Local Authorities (COSLA) established the Public Health Reform Programme to take forward these actions. The programme set a vision for ‘A Scotland where everybody thrives’, with an ambition for Scotland to be a world leader in improving the public’s health, using knowledge, data and intelligence in innovative ways and with an economic, social and physical environment which drives, enables and sustains healthy behaviours. Public Health Scotland will have a key role in leading, driving, supporting and enabling the change we need.
20. In June 2018, the Scottish Government and COSLA published Scotland’s Public Health Priorities, following extensive work with a range of partners and stakeholders from across the whole system. The six priorities are:
- A Scotland where we live in vibrant, healthy and safe places and communities;
- A Scotland where we flourish in our early years;
- A Scotland where we have good mental wellbeing;
- A Scotland where we reduce the use of and harm from alcohol, tobacco and other drugs;
- A Scotland where we have a sustainable, inclusive economy with equality of outcomes for all;
- A Scotland where we eat well, have a healthy weight and are physically active.
21. These new priorities reflect a widely-held consensus about the public health challenges that we must tackle over the next decade if we wish to see the greatest possible improvement in the public's health and wellbeing. They provide a focus for all public services and wider partnerships across Scotland to improve and protect the public’s health and wellbeing, reduce inequalities and increase healthy life expectancy. They also provide a basis, consistent with the Scottish Government’s National Performance Framework, to guide everyone working in the health system and beyond to align their efforts to make a real difference to the social conditions in Scotland.
22. The arrangements described in this consultation for a new public health body are informed by each of the reviews described above and by the work to deliver the new Public Health Priorities. The arrangements focus on simplifying the public health landscape at the national level; the need for better, more visible leadership and a stronger voice for the public’s health and wellbeing; the need to prioritise the application of public health intelligence and evidence into policy and practice; and the value of data to influence ever more meaningful connections both locally, nationally and in the widest sense. We want to support a step-change in how organisations and communities experience engagement, participation and empowerment in relation to decisions that impact health and wellbeing. This is about supporting the way in which individuals and families, the communities they belong to, community groups, community councils, charitable and voluntary organisations, and people working in the public, private and third sectors, collectively create and contribute to health and wellbeing in their local area.
23. Looking ahead, while there has been continual progress towards improving the public’s health and wellbeing over many decades, there is still much to be done. The public’s health and wellbeing is a complex issue and significant challenges in terms of the social conditions in Scotland persist, including poverty, homelessness, addiction and mental wellbeing. Additionally, the whole public sector faces financial challenges which make it crucial that we look at how services, including those for the public’s health, are planned, designed, evaluated and delivered to create more equal access, improve outcomes and make the best use of resources. In response, we recognise that a coordinated, whole system approach is required. Without such concerted action, the health of some individuals and communities will continue to suffer and health inequalities will remain and become more entrenched. The related economic and social costs are simply unsustainable. We require a shift in mind-set across the whole public services system and need to provide practitioners at a local level with support to think, adapt and work in new ways. Separate activity is underway to support the wider system in relation to delivering on our Public Health Priorities. We want the new public health body to have an important role in this work.
24. Separate work is also underway to consider how our specialist public health workforce should be best organised in Scotland. This work will seek to draw conclusions on how the specialist workforce can most effectively meet the needs of national, regional and local partners to deliver the most effective and efficient public health function for Scotland. This consultation is primarily about the functions and wider role of a new public health body – Public Health Scotland – which we propose will be the way in which we deliver on a number of the recommendations from the Public Health Review, and which will respond to the commitment from the Health and Social Care Delivery Plan to establish such a body.
25. The 6 week consultation will last until 08 July 2019. The new body is unlikely to be established and exercising its functions until April 2020. The current arrangements will remain in place until full implementation is complete.