Select Committee on Health Minutes of Evidence

Memorandum by Royal College of Nursing of the United Kingdom (PH 14)



  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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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