Feature

Promoting a clear vision for health

Improving the public health is a key responsibility of health authorities. Yet the professional resources and organisational structures to support this role seem to be in disarray, argues Lee Adams

iIn recent years the promotion of health has been given a higher profile in the NHS. The 1990 GP contract, the structural reforms of 1991 and more recently the Health of the Nationpolicy have made health promotion an explicit part of the role of health authorities and GPs.

It seemed clear from this that HAs had two key roles stemming from the assessment of need. First, purchasing and commissioning health services, increasingly with, or in support of, GPs; and second, being responsible for people’s health in their area — promoting health, protecting the public health and acting as ‘champion of the people’s health’, i.e. advocating on their behalf.

This is still the case, and it is vital for HAs to take an active stance in this latter role. Yet very often, it seems, this second role is not acknowledged or even understood, let alone acted upon. Many seem to feel that the prime business (and for some, the only business) of the NHS is to ensure health services are in place.

There is often lip service paid to the public health role of HAs, but one should not be taken aback when senior HA staff and members, and even public health officers seemingly cannot understand this vital function (though not in my area, I hasten to add!).

This is deeply worrying if you subscribe to the view that health services are limited in what they can do to promote and protect health, and the more so since many local authorities have not redeveloped a broad public health role.

The 1991 reforms of the NHS have left in their wake confusion as to whether health promotion specialists should be regarded as purchasers or providers and there is now a plethora of models around the country.¹ If the business of HAs is to promote health, then health promotion specialists are a key — not the only, but a key — resource and set of skills for working strategically on such issues. Surely they must be a core part of any HA, together with a multidisciplinary public heath function? It is ironic that although there is a national strategy for promoting health, a dedicated professional resource for this is in organisational disarray and in many cases marginalised from HA influence and decision making. It is symptomatic that many HAs have placed their health promotion departments apart from themselves in trusts, not seeing them as at the heart of the HA role. Where a health promotion department is in a trust, it can be contracted simply to perform a health education role rather than occupying a strategic role in promoting health and formulating district policy.

There are also problems facing public health doctors, who often find themselves spending much time on inter-trust medical politics, effectiveness reviews, and so on, and acting as medical advisers to HAs which can detract from space for public health issues. Nor are there strong national health promotion or education agencies in the NHS; their roles are unclear and relationships with local health promotion and public health specialists, at least in England, are patchy to say the least. This makes delivering a national health strategy problematic.

There are several public health organisations working at national level, as well as the professional bodies concerned with public health. Unfortunately, this potential movement is neither co-ordinated nor working in harmony and as a result the public health advocacy role it could play is fragmented.

In primary care, the health promotion role of GPs has collapsed in confusion in the wake of various changes to their contract and related finances in the name of what is termed ‘health promotion’, but in reality has often been disease management, screening and prevention programmes and data gathering.² This has left GPs unclear about their health promotion role and even dismissive of health promotion per se.

If an HA takes seriously its health promotion function, it is likely to adopt a Health For All approach, that is, to develop work in reducing inequalities, enabling community participation and working in partnership with other agencies to promote and protect health.

HAs working closely with GPs and other primary health care staff and having strategies to involve local people can adopt health promotion approaches using various mechanisms: within the contracting process, through provider development and support, within strategic planning and policy development and implementation, locality focused development work, staff health programmes, research and evaluation, quality monitoring and audit, community development, information provision and communications, education and training and public health advocacy work, to name a few.

The Ottawa Charter, an influential document for health promotion, identified three ways in which health could be promoted:³

Advocacy. Health promotion should work to empower people to argue for the rights and opportunities to health and to negotiate changes in their environment;

Enablement. Health promotion should aim to reduce differences in health status and ensure equal opportunities to enable people to achieve their full potential. It should increase knowledge and understanding of individual coping strategies. Health promoters should work with communities and individuals to identify needs and develop support networks;

Mediation. Health promotion requires co-ordination and co-operation by many agencies and sectors. Health promoters have a major role in mediating between different interests by providing evidence and advice to local groups, by influencing local and national policy through lobbying, media work and participation in working groups.

It is becoming increasingly accepted that health is primarily affected by social, economic and environmental factors and that improving health will require action in relation to these on a national and global level.

HAs need to establish and assert their roles at local level in promoting public health, in creating change to reduce inequalities and discrimination, and the impact of poverty on health. They need to consider sustainable development and how health agencies together with other local bodies—notably local authorities, industry and commerce—can create sustainable regeneration which enhances health and the environment. They need to generate local public policy on health such as for transport and housing; ensure access to services and social support; work with local people to develop and build community capacity; and ensure provision and support for individuals to be able to cope with their circumstances. Above all, HAs, often through their directors of public health, must have a role in advocating on behalf of their population’s health to other agencies locally and to national governments and the EC.

Health For All and Agenda 21 interagency structures at a local level are a fruitful mechanism for HAs to work with others to pursue health goals which go beyond the NHS.

The Labour Party and the Association for Public Health are talking of the need for a minister for public health. This may be a way to create legitimacy for a national public health policy based upon a Health for Allagenda that involves government departments, as long as ‘public health’ is interpreted broadly. There are serious doubts about such a minister operating within the Department of Health, whose main business is the NHS. Perhaps a separate mechanism is required with links to government departments so there is, for example, an urban policy with health as an integral part of it and similarly, national food, transport and education policies, and even economic and environmental policies, which are health focused.

The NHS is a vital resource for promoting health, but concern for the public health has to be broader and has to re-focus on the root causes of ill health and distress.⁴ HAs have to take a strong and vigorous stance on public health issues, and ensure they have the skills and the space to do this adequately—because if they will not, or cannot, lead this, then who will?