MEMORANDUM BY PROFESSOR JENNIE POPAY (PH
77)
(Jennie Popay is Professor of Sociology
and Health Policy, at the Nuffield Institute for Health, University
of Leeds. She has recently taken up this post having previously
directed the Institute for Public Health Research and Policy at
the University of Salford).
1. PUBLIC HEALTH
RESEARCH
Britain has a long and distinquished tradition
of research into inequalities in health. However, there remain
major "gaps" in this literature: knowledge gaps; theory/explanation
gaps; process and application gaps.
Knowledge gaps
It is increasingly common for people to argue
that resources should shift from fundamental/basic research towards
research aiming to evaluate interventions, but this view is misplaced:
— There are important gaps in our knowledge
about the causes of inequalities that need to be filled before
we are in a position to develop appropriate and effective interventions.
This is particularly the case in relation to social interventions
focused at the level of communities. For example, we know quite
a lot about how a "sense of control" can protect individual
health. We know much less about the ways in which collective efficacy
at a community level might impinge on population health. Similarly,
our understanding of the relationship between the places in which
people spend their lives and health inequalities remains limited.
Without a better understanding in this latter area, major policy
areas such as those concerned with regeneration will at best have
little impact on population health at worse they may increase
inequalities.
— The distinction frequently drawn
between basic and applied research is too simplistic. There is
considerable scope for increasing the "applicability"
of basic research by changing the way in which basic research
is done to enable a more constructive dialogue between researchers
and those who could use the evidence generated.
Theory/explanation gaps
Scientists need to give more attention to the
development of theories, which have utility for policy and practice.
It is particularly important that our explanatory models capture
the complexity involved in the genesis of inequalities. In particular,
there is a need to "put people" and their personal and
social histories in the frame as active agents rather than passive
victims. Early public health research in the 19th century was
rich with the expertise of "ordinary" people. As we
enter the 21st century we need to revisit this tradition—
to "privilege the voice of experience" as E P Thomson
argued. Until recently risk factor epidemiology, for example,
with its emphasis on statistical work exploring the relative contribution
of what can be a bewildering array of risks has dominated this
field. This type of work can contribute little to our understanding
of the complex processes and interactions involved. The lifecourse
approach has much greater utility, giving prominence to the notion
of accumulated risk whist accepting the notion of "predisposition"
exemplified in Barker's programming hypothesis. This approach
to explanation helps to highlight key points for interventions
to have maximum effects pointing, for example, to early childhood
and the health of women as especially critical.
Press application gaps
Research in the UK, in the public health arena
as much as elsewhere, is elitist. The process of designing and
conducting research typically excludes those who are the potential
users of the product until the final stages of "dissemination".
The policy of major funders of health inequalities research, such
as the MRC, ESRC, the department of health and the NHS R&D
directorate reinforces this "culture" informed as it
is by a problem-solving model of the research/policy interface.
A potentially more fruitful way of conceptualising this interface
is as a relationship involving on-going dialogue between researchers
and research users at all points in the research process.
2. PUBLIC HEALTH
POLICY
The Acheson Report provides an important and
welcome contribution to the development of a coherent and holistic
strategy to reduce inequalities in health. However, there are
important limitations to the specifics of the report, as well
as the general approach, which need to be addressed.
Projectitus
Acheson, and much current public health practice,
focuses on the implementation of projects which seek to change
specific risk factors, be they aspects of lifestyle, such as diet
or sexual behaviour, or structural factors, such as low income.
This pre-occupation with projects is partly driven by the limitations
of current evaluation methods. Arguably, it is also driven by
limitations of imagination and the tyranny of evidence based medicine.
We need to develop new innovative approaches to the evaluation
of complex large-scale social interventions—the evaluation
in place around Health Action Zones is one such approach—rather
than let the methods currently available dictate policy.
Community involvement
The focus on community/public involvement in
policy development and implementation is important and will greatly
enhance the sustainability of health gain. Currently most attention
is directly to building community capacity for collective action
and individual "entrepreneurial" capacity. However,
there is a need for much more attention to be directed at the
capacity of public sector organisations and professions to engage
in an equal and constructive way with "lay publics".
3. PUBLIC HEALTH
PRACTICE
The current emphasis on a primary care led NHS
whilst welcome in many respects, does raise problems from a public
health perspective.
Public Health and Primary Care
There is much " fuzzy" thinking about
the relationship between these two "domains". For some
they refer to different professional groups, for others they relate
to areas of activity or "ways of working" that at least
in theory overlap. The expectations for primary care to "deliver"
the public health agenda, and in particular, to address inequalities
in health, are awesome. This is particularly the case given that
there is little if any evidence from research or practice that
past primary care organisations or primary care medical professionals
have the capacity or the inclination to do this.
Local Public Health Systems
More attention needs to be given to the potential
for developing local public health systems with population focused
work evolving within and alongside primary care and involving
local government, the voluntary/community sector and the private
sector. The current duality within local systems, in terms, for
example of activities and accountabilities around Health Improvement
Plans and Community Plans, can fragment activity around public
health. Important developments within the local government areas,
such as the work of the scrutiny committees have much potential
to move forward public health practice locally but this is still
to be exploited to any significant extent.
Public Health Referral Pathways
Primary care practitioners are already "doing"
a great deal of work that might be termed "public health
oriented" at an individual level but it is marginalised by
current incentive systems. This includes, for example work on
housing needs, occupational health and welfare rights/income maximisation.
The scope for developing richer and more accessible referral pathways
for people with social needs accessing primary medical care would
warrant further exploration.
Public Health Leadership
There are major questions around the public
health role of primary care organisations and professions, particularly
general practitioners. There is little evidence to suggest that
these organisations and professions are able/willing to develop
the strategic population perspective that public health requires.
In particular, the primary importance of questions of utility
to public health (reflected in resource allocation decisions)
does not sit easily with the individualistic caring value base
of primary medical care. The public health role of primary care/community
nursing professions remains to be demonstrated beyond the rhetoric.
Conflicting normative frameworks for action
Research has highlighted important discordance
between the perspectives of lay people and those of the professionals
and organisations that "serve" them. This is apparent,
for instance, in relation to lay perspectives on what is a "proper
place to live" and the perspectives of local government professionals
involved in implementing regeneration initiatives. A clash of
normative frames may reduce the effectiveness of interventions
intended to improve quality of life and reduce inequalities in
health and has major implications for professional education and
practice.
These are new times and new situations in public
health new patterns of ill-health in the midst of enduring inequalities.
There are also new emerging relationships between lay people and
professional experts including public health researchers, policy
makers and practitioners. We need knowledge, theories and research
processes as well as public health policy and practice that match
up to this challenge. This will require a more innovative and
inclusive public health which is truly multi-disciplinary and
involves lay people as equal but different. Whilst many of these
sentiments are captured in the current policy rhetoric they are
not yet apparent on "the ground".
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