Memorandum by Royal College of Nursing
of the United Kingdom (PH 14)
EXECUTIVE SUMMARY
INQUIRY TERMS
OF REFERENCE
To examine the co-ordination between central
government, local government, health authorities and PCGs/PCTs
in promoting and delivering public health.
In particular to examine the organisational
arrangements and address:
— the inter-operation of Health Action
Zones, Employment Action Zones, Healthy Living Centres, Education
Action Zones, Health Improvement Programmes and Community Plans;
— the role of the Health Development
Agency;
— the role of PCGs and PCTs;
— the role and status of the Minister
for Public Health;
— the role of the Director of Public
Health; and
— the extent to which current public
health policy is reducing health inequalities.
The committee will also study alternative models
of public health provision.
SUMMARY OF
RCN RECOMMENDATIONS
1. There should be explicit acknowledgement
by politicians, policy-makers, clinicians and senior managers
that there are a variety of public health functions, and that
both public health science and public health practice are essential
elements to improving public health. There should also be acknowledgement
of the varied and important contributions to be made to public
health by a wide range of people, and recognition that public
health will best be served by building an inclusive agenda.
2. NHS culture needs to adapt to bring public
health into the mainstream, including the introduction of performance
management indicators for public health in all health authorities,
NHS trusts, PCGs and PCTs.
3. Local public health teams should be created,
on a multi-agency and multi-disciplinary basis, including key
personnel and stakeholders from the NHS, local authorities, and
the voluntary sector and community groups. The aim would be to
bring together public health policy, planning and science alongside
public health practice and health promotion practice.
4. There should be greater investment in
public health education at all levels and available to a wide
range of professional groups, including those for whom public
health is one aspect of their overall work.
5. The Government should issue guidance
to ensure that there is full and meaningful public participation
in the HIMP development process.
6. The Government should make an early announcement
about how national health promotion campaigns will be led and
managed, now that the Health Education Authority no longer exists.
7. There should be investment in developing
leadership capacity and public health education amongst members
of PCG and PCT boards.
8. Every PCG and PCT should create a post
responsible for leading public health practice in primary care
(in addition to the PCT Board level public health specialist post).
9. The position of Director of Public Health
should not be restricted to doctors, but be open to any professional
group, and should become a joint appointment between health authorities
and local authorities, to reflect and foster the multi-agency,
partnership approach needed for truly effective public health
work.
10. Health authorities and local authorities
should be required to undertake Health Impact Assessments, which
should include Health Inequality Impact Assessments, for all policies
they develop jointly or singularly.
1. INTRODUCTION
The Royal College of Nursing (RCN) is the largest
professional union of nurses in the world with over 320,000 members.
The RCN has more than 80 professional forums, which are groups
of RCN members who work in related fields. RCN forums with an
interest in public health include the public health forum, nurses
in commissioning forum, health visiting forum, school nursing
forum, occupational health nursing forum, practice nursing forum,
midwifery forum, district nursing forum, mental health forum and
management forum.
The RCN also works collaboratively with many
public health organisations within and outside the health sector.
The RCN is a member of the UK Public Health Association, Non Governmental
Organisation of Public Health, Common Agenda Group of Public Health
and the Department of Health Stakeholder Group for nursing and
public health. The RCN Institute began a Masters Degree programme
in Public Health last year.
The RCN welcomes the opportunity to submit written
evidence to the Health Select Committee. The RCN has restricted
its comments in this evidence to public health issues in England.
Before commenting on the specific terms of reference set by the
Health Select Committee, the RCN would first like to make some
general points about the organisation of public health.
2. THE PUBLIC
HEALTH CONTINUUM:
BACKGROUND AND
CONTEXT
Despite the very welcome renewed focus on public
health amongst policy-makers, the RCN believe confusion still
remains. One of the key questions underpinning this confusion
concerns the central function of public health.
The organisation of public health in England
has an interesting history. The Acheson Report1 published in 1988
established a public health department in every health authority
led by a Director of Public Health. The report did much to pull
public health work in from the margins of the NHS and to develop
the public health medical specialism. However, the focus of these
new public health departments became public health science (epidemiology,
economics, medical statistics) and strategic planning. The work
of the public health departments did not include public health
practice in the sense of "hands-on" population-based
approaches to health work in the clinical field, for example using
community development approaches to health promotion, nor did
their work include the participation of the public in the strategic
health decisions.[1]
The birth of the purchasing and providing model
which arose from the NHS and Community Care Act 1990 further fractured
the involvement of public health departments in health care practice.
Public health departments became entwined with the then new function
of health authorities in purchasing health services (which is
not the same as commissioning for health improvement) and in the
management and audit of service performance.
Consequently, public health departments began
to be seen as remote and disengaged from the "real world"
by many health professionals, especially GPs and community nurses.
They did not provide leadership for the primary health care workforce
on taking a population-based or public health approach to their
work, nor on putting public health messages into practice. In
addition, their virtually exclusive focus on health service delivery
precluded any real engagement with agencies outside the NHS, such
as local authorities, on the broad fundamental public health issues
such as the social determinants of health and local facilities
for communities.
The RCN believes public health practice is still
a much neglected area of the public health function. Indeed, to
this day there are still some who would not acknowledge public
health practice as a legitimate part of public health work. So,
for example, we do not have firm descriptors of even what a public
health approach to practice is within the health service.
3. "OWNERSHIP"
OF PUBLIC
HEALTH
As outlined above, there is a recognised speciality
of public health medicine. With the publication of the Public
Health White Paper in England Saving Lives: Our Healthier Nation[2],
there is now also recognition of a (non medical) public health
specialist, which the White Paper says "will be of equivalent
status in independent practice to medically qualified Consultants
in Public Health Medicine and allow them to become Directors of
Public Health".
The RCN welcomes this and applauds the work
of bodies such as the Multi Disciplinary Public Health Forum in
achieving recognition for the role of the public health specialist.
However there is a danger that in crediting certain groups of
people as public health specialists, the contribution off others
to public health is overlooked and not valued. It is important
to recognise that in some senses, public health is everybody's
business: everybody contributes to public health regardless of
their occupation, but at the same time we need to recognise the
specific (and varying) responsibilities for public health that
are part of certain jobs and positions.
The RCN believes that the solution lies in acceptance
that there is a spectrum or continuum of public health, and within
this, a spectrum of public health work, functions and contributions.
The way forward to building public health capacity lies in recognition
that there is more than one public health function. Public health
science is an extremely important foundation for public health
work but only one area of the public health knowledge; skills
and knowledge in public health practice are an equally important
area, though frequently neglected. For example, undertaking a
community development approach to engaging local communities in
health needs assessment and health promotion is a very skilled
activity which needs to be recognised and valued as part of the
public health function.
The RCN believes it is vital to build an inclusive
agenda which values the many different contributions and skills
in public health. This means recognising that some people work
predominantly in public health, for example public health doctors,
environmental health officers and community development health
visitors. However, it also means valuing the contribution to public
health that professions make as part of their work, for example,
midwives, health visitors, and general practitioners. Furthermore,
it also means acknowledging the necessity of both public health
science and public health practice to improving public health
outcomes.
The RCN is concerned that progress in developing
public health capacity has too often been hindered in the past
by arguments over professional boundaries, and disagreements over
who is a legitimate public health professional/specialist. The
RCN does not believe that any one professional or occupational
group should have exclusive rights to claim to be the leaders
of public health—including doctors and nurses. What is far
more constructive is to recognise the varied and important contributions
that can be made by a wide range of people, whose work has the
potential to involve them directly or indirectly in improving
public health.
4. NHS CULTURE
The culture of the NHS does not lend itself
well to broader public health. This is largely because the core
business of the NHS is seen by both the professionals who work
within it, and by the public, to be about delivering services
to care for or cure individuals who are ill. Department of Health
circulars prioritise issues such as reducing waiting lists without
commensurate circulars prioritising public health issues, for
example the involvement of local communities in health promotion.
Much public health work is therefore at the
margins of NHS activity: it is still not regarded as mainstream
work. Almost all the community development approaches to health
promotion undertaken within the NHS, both past and present, are
funded as short term projects. They rely heavily on the efforts
of local charismatic leaders to keep the project going, in terms
of making funding applications and day to day operational work—and
in fact much of this work is undertaken in practitioners' own
time.
The case of three community nursing development
units (CNDUs) supported by the King's Fund in the early 1990s
demonstrates the point. Each was situated in deprived inner city
areas; Strelley CNDU in Nottingham, Stepney CNDU in Tower Hamlets
and Small Heath CNDU in Birmingham. Each sought to develop public
health by working with the local population in determining health
needs and taking action at local level. This led to varied initiatives
such as setting up a local food co-operative, breakfast clubs
at schools, road traffic calming schemes, introduction of legal
advice at child health clinics, working with local authority housing
departments on safe play areas and safe housing environments for
children, "get cooking" demonstrations, and interest-free
loans for fireguards and stairgates. Evaluations by the CNDUs
suggested they had made an impact on their local community in
terms of health and how health services were perceived. However,
they were not necessarily highly regarded by their local NHS organisations,
who regarded them at best as interesting but not core, and at
worst as a liability since they altered the way in which communities
perceived expertise in health. After the three years of King's
Fund funding and support had ended, not one CNDU was supported
or funded by the NSH to continue its work.
The RCN believes that one lever to change the
culture of the NHS and improve its receptivity to public health
practice would be the introduction of performance management for
public health. For example, performance management indicators
could be developed around achieving local targets in health improvement,
or around the public health process, such as the involvement of
local communities in developing health promotion activities. The
RCN hopes that a requirement to develop performance management
indicators for public health would lead to greater engagement
and greater weight being given to public health by NHS senior
management.
5. LOCATION OF
PUBLIC HEALTH
DEPARTMENTS
Another possible solution to the NHS culture
and public health problem would be to relocate public health departments
from health authorities to local authorities. The argument in
favour of this is that much local authority work is concerned
with, or impacts upon, the health of the public, and such a shift
would allow public health work to embrace the broader agenda in
health improvement.
The RCN believes, however, that relocation of
public health departments is not the key issue. The key issue
is how to build an organisational structure which is inclusive
and embraces expertise in public health science and public health
practice. It is likely that neither health authorities nor local
authorities as single organisations have all the appropriate pre-conditions
and structures in place for this at present.
The RCN believes that a more constructive way
forward would be the creation of public health teams for a given
locality, which would be multi-agency and multi-disciplinary and
bring together key NHS and local authority staff and other local
stakeholders such as voluntary sector and community representatives,
united in a common aim of bringing together public health policy,
planning and science with public health and health promotion practice.
The RCN believes it is quite extraordinary that, apart from senior
level strategic planning for certain issues, joint multi-agency,
multi-disciplinary co-ordinated team work on public health still
does not take place in a structured manner further down the hierarchy
at a local practice level.
The creation of public health teams would not
alter employment arrangements for its members, who could remain
employed by health authorities, local authorities, or the voluntary
sector. Nor would it preclude membership of other teams, for example,
membership of primary health care teams. Measures in the Health
Act 1999 to improve working between health and local authorities
such as the "duty of partnership" and pooled budgets
should enable new relationships to develop and real progress to
be achieved.
6. PUBLIC HEALTH
EDUCATION AND
TRAINING
It is clear that many different staff groups
will need further education, training and support to engage in
the new public health agenda. There is a need for formal higher
education programmes, such as the masters degree in Public Health,
however, many staff do not need or wish to undertake public health
education at this level. Their requirements are more about gaining
an understanding of the evidence base for health promotion work,
and an understanding of epidemiological research methods, the
implications and impact of policies on public health, development
skills in engaging with local communities in health promotion,
and most fundamentally, learning about the importance of public
health approaches. For many health staff, including doctors and
nurses, this is of real importance if we are to affect public
health since most of their training centres on working with individuals
rather than with communities and populations.
Unfortunately, at present there is very little
available to meet this need. In addition, gaining access to public
health education is impeded by the lack of funding available to
enable people to take up such courses. For example, when the RCN
advertised their new MSc in public health last year, it was inundated
with expressions of interest from nurses. However, as a direct
consequence of the dearth of funding opportunities, the RCN has
only 10 students on this course at present, almost all of whom
are self funded and none fully funded by their employers. Investing
in public health education is a priority if we are to improve
our capacity to undertake public health work and realise an improvement
in the health of the public.
The RCN is involved in a joint project with
other nurses' associations in Europe, with funding from the European
Commission, to develop modules to provide continuing education
in public health suitable for registered nurses who have had little
education or experience in public health, although to date funding
has not yet been achieved for the roll-out of these models once
they are developed.
7. PUBLIC HEALTH
RESEARCH AND
DEVELOPMENT
The evidence base for public health intervention
and dissemination of same is very poorly developed. Investment
in this area has been poor and does not match the commercially
funded basis of much UK health research.
The drive to implement evidence-based practice
has not always fitted easily with the nature of community development
work. The RCN believes that it is important also to recognise
and value other outcome measures which are equally important in
improving health status, such as quality of life measures. As
the King's Fund say in a recent report: "conventional approaches
to evidence are narrowly defined and biased towards bio medical
models of public health. There is a distinct lack of evidence
in many key areas of priority—and that in areas where evidence
exists it is often of limited use because of those constraints".[3]
The RCN supports the principles on evidence
and public health articulated by the Kings Fund:
1. Recognising the broad principles on health
improvement.
2. Valuing diverse types of evidence.
3. Developing good enough standards for evidence
that balance precision and innovation.
4. Working through building participation
and partnerships.
5. Building capacity in the public health
workforce to facilitate evaluation and evidence collation.
6. Building in evidence-generation to all
health improvement activities.
8. HEALTH ACTION
ZONES (HAZS),
HEALTHY LIVING
CENTRES AND
PERSONAL MEDICAL
SERVICES (PMS) PILOTS
The RCN does not yet have firm evidence concerning
the effectiveness of HAZs, and believes that it is too soon to
know their impact with any certainty. Anecdotal reports we receive
from nurse in the field vary widely. However, the RCN supported
the principle of creating HAZs, and realises that their achievements
are only likely to be seen in the medium to long term. The RCN
will follow the development and evaluation of HAZs with interest.
Nurses have expressed some concerns that the
creation of HAZs may lead to an increase in geographical health
inequalities, since not all socially deprived areas are in an
HAZ and thus have the extra resources associated with this status.
The RCN would wish to see meaningful investment in all areas of
social deprivation.
The RCN has welcomed the drive to develop Healthy
Living Centres in deprived areas and would like to see nurses
fully involved in their services.
The RCN also welcomed the decision to invite
a third wave of PMS pilots. The first two waves have given rise
to some very exciting and innovative nurse-led projects, some
of which are targeted at groups who traditionally have had poor
access to primary and secondary health services and poor public
health. The RCN hopes that many of the third wave pilots will
focus on new and enhanced nursing roles, public health and community
development.
9. HEALTH IMPROVEMENT
PLANS (HIMPS)
There is much goodwill and enthusiasm for the
development of HIMPs. However, the RCN is aware of a number of
problems emerging in their development and implementation.
Firstly, there is a distinct lack of public
involvement in any real sense in the development of an HIMP. The
RCN believes that specific government guidance is needed to ensure
this takes place.
Secondly there is a problem of synchronising
the cycle of planning and resource allocation of HIMPs with other
health agency and local authority plans.
Thirdly, there is the problem of HIMPs leadership,
championship and ownership. For example, in some areas, local
authorities complain that they are all but excluded from participation
in planning HIMPs. In other areas HIMP development appears to
have been marginalised away from corporate planning and relegated
to being the business of the public health department alone. Health
authorities face an uncertain future at the moment which cannot
help the cause of putting together corporate and collaborate HIMPs.
The RCN hopes that as PCTs develop, the HIMP
process will become increasingly sophisticated in relation to
public and community staff involvement. This should result in
future HIMPs having greater value and meaning in terms of the
health status and lives of local people.
10. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY (HDA)
The RCN welcomes the new role of the HDA in
developing and disseminating the evidence base for public health
and health promotion practice. As suggested above, we believe
the development of a public health research base has been neglected
over a considerable amount of time.
However, there is still a need for some centrally-led
national health promotion campaigns, for which the former Health
Education Authority had a remit. As far as the RCN is aware, no
formal announcement has been made regarding where or how the bulk
of these programmes will be run. It appears at the moment that
a temporary organisation has been set up to run these campaigns.
"Health Promotion England". The RCN is concerned that
no formal announcement has been made regarding this arrangement.
The Department of Health (England) must rectify this unsatisfactory
situation as soon as possible so that health practitioners and
others are clear who will be running national health promotion
campaigns and how their resources can be accessed.
11. THE ROLE
OF PRIMARY
CARE GROUPS
(PCGS) AND
PRIMARY CARE
TRUSTS (PCTS)
PCGs and PCTs clearly have an important role
in planning and delivering public health. However, they are very
new organisations and anecdotal evidence suggests that public
health is not high on their (long) list of priorities at the moment.
One problem for PCGs/PCTs is their capacity
to make strategic health decisions, given their varied boundaries
which do not necessarily correspond with those of other agencies,
the previous experience of PCG/PCT board members, and the fact
that board members have other jobs in addition to their board
responsibilities. A lack of time, resources and experience is
often cited as a reason for not fully engaging in the public health
agenda.
Too often an assumption has been made that primary
care is public health, and that therefore no further investment,
support, resources or education is needed. Clearly this is not
the case. One solution to improvement lies in developing the capacity
of PCG/PCT board members as a corporate team to undertake strategic
planning for health by investing in public health programmes of
education for board members.
The Government has already recognised the need
for leadership programmes in hospitals. A commitment to building
leadership capacity in community and primary health care services
is equally important. The RCN's leadership programme, which includes
a specific strand for nurses and other professionals based in
the community, is proving to be well evaluated in this respect.
The PCG/PCT boards will also need to develop
and strengthen their links to public health expertise within public
health departments, academic research centres, the new HDA, and
local authorities. PCT boards are already required to have a dedicated
seat for a public health specialist. This is welcomed by the RCN,
but public health could be further strengthened by the establishment
within every PCG/PCT of a dedicated public health post, with the
holders expected to have skills in health needs assessment, health
promotion, community development and building community networks,
and building multi-agency, multi-disciplinary teams. These posts
could then act as a bridge between the PCG/PCT, public health
department, local authority and the community. Nurses, especially
health visitors, are ideally placed to take on these posts. The
combination of strategic and operational public health responsibilities
has enormous potential for ensuring that primary health area integrates
with public health. The RCN believes that this approach could
make an enormous contribution to the reduction of health inequalities
and improving local public health.
Community nursing services are ideally placed
to deliver much of the public health agenda if they are adequately
resourced and supported. However, the distribution and resourcing
of community nursing services must be made more equitable in relation
to social deprivation to avoid the current situation where more
affluent communities are often better served than their poorer
and more deprived neighbours.
NHS Direct also has a role to play as part of
primary care in delivering health promotion and health improvement.
For example, young people appear to value the anonymity of telephone
helplines. NHS Direct could target young people advertising in
places where young people congregate for example, in order to
improve access to sexual health information for teenagers. Similarly,
evidence suggests that men are reluctant to use traditional primary
health care services, but data from NHS Direct shows that they
are more comfortable with the more anonymous service that NHS
Direct provides.
12. THE ROLE
AND STATUS
OF THE
MINISTER FOR
PUBLIC HEALTH
The RCN has no particular comment to make on
the role and status of the Minister of Public Health except to
state that wherever he or she sits in Government, they must be
able to marshal the contribution of all Government departments.
13. THE ROLE
OF THE
DIRECTOR OF
PUBLIC HEALTH
The RCN believes that the position of Director
of Public Health should be open to any public health professional
who has the requisite experience, knowledge and skills, and should
not be limited to doctors.
The RCN also believes that the post of Director
of Public Health should become a joint appointment between local
authorities and health authorities, in order to strengthen multi-agency
and multi-disciplinary working in public health.
14. PUBLIC HEALTH
POLICY AND
HEALTH INEQUALITY
REDUCTION
The RCN believes that health authorities and
local authorities should be required to undertake Health Impact
Assessments which include Health Inequality Impact Assessments
for all policies they develop jointly or singularly. Until this
is introduced systematically, it is virtually impossible to answer
the question: to what extent are public health policies reducing
health inequalities?
It is known, however, that health inequalities
are closely linked with social inequality, within which income
and material resources are a key issue. Therefore redistribution
of income must be a major part of any reduction in health inequality.
However, policies made at local level can also impact on health
inequalities, for example local policies on road speed can widen
or reduce the health inequality gap. Although reducing speed limits
to 20 mph in urban areas would reduce rates of road traffic accidents
involving children overall, it will not necessarily impact upon
children at the bottom end of the social scale who are more likely
to live in the town centres, on A roads, and areas without safe
play and recreational areas. Implementing such a policy without
undertaking other commensurate steps such as providing safe play
areas could in fact actually increase health inequalities. Health
Impact Assessments and Health Inequality Impact Assessments should
identify such issues as policy is being developed, and therefore
play a significant part in health inequality reduction.
July 2000
1 Committee of Enquiry into the Public Health Function
(1988), Public Health in England, DHSS, London. Back
2
Saving Lives: Our Healthier Nation, Cm 4386, July 1999, The Stationery
Office Ltd, London. Back
3
Evidence and Public Health: Towards a Common Framework, 2000,
The Kings Fund, London. Back
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