The fundamental goal of public health is to ensure that the community can live long healthy lives and Public Health England (PHE) has made considerable progress in establishing structures and policies that link health to coherent locally-led public policy.
Public Health have identified seven priorities or spheres to focus efforts on over the period 2014 – 2021. As set out in the PHE’s Strategic Plan1.
- reducing smoking and stopping children starting
- tackling obesity particularly among children
- reducing harmful drinking and alcohol-related hospital admissions
- ensuring every child has the best start in life
- reducing the risk of dementia,
- tackling the growth in antimicrobial resistance
- achieving a year-on-year decline in tuberculosis incidence
PHE has taken an integrated approach to the delivery of public health. It is a widely recognised concept that health determinants lie in factors wider than just health. Maximum impact on people’s lives can only be achieved by PHE working in partnership with other key stakeholders such as local government, NHS, Department of Work and Pensions, Education sector etc in developing and implementing economic and social policies that affect people’s health.
There are several theoretical models of health behaviour that underpin public health strategy e.g. the Health Belief Model (HBM) which “emphasizes beliefs of susceptibility and severity of a health problem, and perceived benefits and barriers of taking action”2The Social Cognitive Theory, the construct of this theory is that “people learn not only through their own experiences, but also by observing the actions of others and the results of those actions. The key constructs of social cognitive theory that are relevant to health behaviour change interventions include observational learning, reinforcement, self-control and self-efficacy”.3 Thus, the use of social cognitive theory (SCT) in public health relies on the use of role models and reinforcements in bringing about change in human behaviour. The HBM can be used to address the issue of barriers faced by women in attending breast cancer screening programme and designing strategies to overcome this. Similarly, the SCT can be used to promote prevention and disease management.
The key elements of PHE approach today centre around improving health, empowering the public, delivery through a robust workforce, evidence-based activity and tackling health inequalities. The success or effectiveness of public health strategies lies both in understanding human behaviour i.e. why people behave the way they do and what is needed to influence and change those behaviours, along with evidence based intersectoral intervention to bring about the desired health outcomes. One sector alone will not have the necessary tools, knowledge, evidence and delivery mechanism to have the desired public health impact.
Thus, there are two critical elements that together shape policy framework in the sphere of public health in the 21st century – governance in health and governance for health. World Health Organisation (WHO) defines governance for health as “the joint actions of health and non-health sectors, of public and private sectors and of citizens for a common interest”4. Several determinants of health and causes of health inequality lie outside the remit of just health sector. Therefore, health sector alone cannot have the sole responsibility of addressing all health-related issues. The society has transformed gradually from industry-base to knowledge-base. A wholly integrated governance model is needed comprising whole of government and whole of society approach5. The key players in relation to governance for health could be the following: various sectors within government including local government (LA), private sector, academic institutions, non-governmental organisations (NGOs), community-based organisations(CBOs) and individual members of public; all working together towards agreed common goals. The main features of governance for health are moving away from one size fits all approach and the acceptance that wicked problems require complex and evolving solutions. Governance for health tends to function more at macro level.
On the other hand, according to WHO, governance in health is “governance of the health system and strengthening health systems”4. It is the system by which a health organisation performs and manages its functions and keeps its stakeholders engaged. Thus, governance in health implies, “the way relevant health related organisations manage their business, determine strategy and objective, go about achieving these objectives”. (Ref – https://www.health-ni.gov.uk/topics/governance-health-and-social-care/governance-health-and-social-care-introduction)
Examples of key players in relation to governance of health are health service commissioners, health service providers and several health regulators including National Health Service (NHS) Improvement, NHS England, Care Quality Commission and other licensing authorities for the professionals. Main features of governance in health are regulation, service related targets, monitoring of a variety of health delivery indicators, standards, mandatory reporting of wide range of performances and inspections by the regulators. Completion of board governance self-assessment tool on an annual basis, completion of National Audit Office Audit Committee checklist on an annual basis, reporting compliance with controls assurance standards are examples of implementation of governance in health. Governance in health tends functions more at micro level.
The key difference between the two is that the former works across sectors embracing different governance styles and systems, policies, workforce, financial and political interfaces whilst the later works within a sector with greater uniformity of organisational systems and interfaces. The skills needed to develop and deliver governance for health are quite different and more complex than those needed to deliver a governance in health framework. Influencing societal and individual behaviours cannot be achieved purely through a governance in health approach. Whilst this can achieve excellence within the health sector, improving achievement of performance and health delivery standards, it is not sufficient to bring about a change in the population’s behaviour nor reduce complex need through a place-based prevention strategy. The latter needs more actors on the stage than just health.
Critically discuss how ‘Health in All Policies’ can help to deliver governance for health (40%).
Learning outcome:
- Be able to identify the essential components of delivering “health in all policies” for achieving effective and intersectoral approaches
- Identify potential public health interventions that will be able to meet the policy objectives for population health improvement, with a context or locality.
“Governance for health promotes joint action of health and non-health sectors, of public and private actors and of citizens for a common interest. It requires a synergistic set of policies, many of which reside in sectors other than health as well as sectors outside government, which must be supported by structures and mechanisms that enable collaboration”5.
HiAP is a vehicle for delivering governance for health as it is about “ensuring that there is a common understanding of health and health inequalities across the council, a common way of analysing the health impact of the range of council functions and a common commitment to maximising the positive health impact of all of these functions, exercising them in a way that will reduce inequalities”6. Whilst Professor Marmot is referring specifically to the work of local authorities as a major service delivery arm for local communities, this approach applies to all agencies involved in developing and delivering public policy.
The WHO in its manual “Health in All Policies (HiAP) Framework for Country Action January 2014” 7, sets out a framework comprising the essential elements for the delivery of HiAP by the involvement of all relevant stakeholders. For HiAP to successfully deliver governance for health it must both engender a strong belief that health and wellbeing are critical for a successful society and a flourishing economy and that this can be achieved only through whole government and whole community approaches.
Through HiAP public policies must be so designed that they consider the impact that public policy decisions have on population health, avoiding and mitigating harmful impacts, especially in the light of conflicting priorities and financial pressures across the key stakeholders.
Framework for HiAP:
- Establishing the need and priorities for HiAP: Public policy plays a critical role in helping to identify priorities and design feasibility studies for progressing HiAP. At this stage the opportunities for different sectors and organisations to collaborate and develop joint protocols need to be addressed. Intelligence from agency sources can be pooled to design coherent and effective interventions across sectors and communities. Governance for health requires knowledge and an understanding of how health is determined and how it works at a community level to govern better. Additionally, building capacity in professionals to operate effectively in an interagency and cross-sectoral setting is essential for success in delivering governance for health.
- Framed action plan and support: this stage can help to develop the cross sectoral involvement, identifying the roles and responsibilities and how the integrated activities help deliver the strategic objectives of HiAP. Joint Committees as well as Partnership Forums can be formed to provide oversight and input of sectoral interests into the final plan. Such integrated forums can also help resolve some of the sectoral conflicts and help to resolve competing priorities. The action plan will also identify cross sectoral resource requirements and specialist skill sets needed for successful delivery. Getting an appropriate lead agent e.g. a high level political support, may help to provide impetus. This stage, through the involvement in planning, will help to build commitment and engagement from all parties. The health impact of public policy on different sectors can be assessed in a collaborative and non-adversarial setting. One must be cognisant of the “virtuous circle of communication, trust, commitment and understanding; the choice of tools and mechanisms; and transparency and accountability”5. This recognises the important fact that not all health impacts emerge from the health sector nor can they be dealt with purely by the health sector. For example, public policy on dealing with congestion and its impact on health. Development of such policy requires a co-ordinated approach across transport, health, highways, local government, automobile sector, fiscal policy determinants etc.
- Structures/processes: Governance for health is becoming “more fluid, multilevel, multi-stakeholder and adaptive”5. Traditional hierarchical governance structures are now being increasingly complemented by self-regulation, governance by persuasion, alliances, networks and open methods of coordination. Behavioural insight approaches and nudge policies are being increasingly used for health promotion, fitting in with modern lifestyles and choices. Thus, smart governance uses hard and soft instruments to achieve maximum change in behaviours.
- Facilitating assessment and engagement: assessing health impacts of policies can be done in multiple ways using both health-specific methodology and assessment techniques from other sectors such as policy audits, gender audits, environment impact assessment and budgetary reviews. Engagement with a wide range of audiences will help gather feedback on sectoral/community impact and help design more bespoke interventions. Smart technology makes this engagement easier in the 21st century. “Public policy can no longer just be delivered … successful governance for health requires co-production as well as the involvement and cooperation of citizens, consumers and patients”5.
- Monitoring, evaluation and reporting: It is essential that evidence is gathered post implementation to measure the effectiveness of policies in achieving set outcomes and lessons learnt. HiAP component must be incorporated into all monitoring and evaluation activity and the lessons learnt disseminated to all agencies involved.
HiAP is not just a national or regional imperative, it is a globally recognised need. The Helsinki Statement on Health in All Policies8 states “The health of the people is not only a health sector responsibility, it also embraces wider political issues such as trade and foreign policy. Tackling this requires political will to engage the whole of government.”9
An important challenge to HiAP recognised in the Helsinki statement8 is the presence of opposition from powerful lobbying groups that resist regulation e.g. tobacco industry, food industry etc. Business interest and market power affect the government’s ability to deliver health promotion. HiAP can play a powerful role in mitigating such forces by using a partnership approach all stakeholders can participate and help shape practical and positive interventions. Whilst this approach may take longer to implement, the outcomes will be more sustainable due to co-production and involvement of a wide range of interests.
WHO European region has developed a new Health policy called Health 2020 4. This also emphasizes the need for intersectoral collaboration and HiAP approach to public policy development. It sets out the following criteria for HiAP to be successful on a whole of society platform:
- “Strong and sustained commitment of all actors at all levels
- Good communication, adequate time and resources
- Shared and innovative accountability arrangements
- Clarity of different responsibilities and tasks
- A common understanding of objectives
- A valid theory of cause and effect and of managing change” 4.
There are several key areas of different interventions that will be able to meet the policy objectives specifically in the context of local authorities. These are discussed in detail below.
a) The best start in life – for a child begins before the birth of the child. The mother needs to be healthy with adequate nutrition, free from the effect of alcohol and other substance misuse to enable the child to have a best start in life. Following birth, the quality of start of life is related to birth weight, early life (0 – 4) experience10. Local authorities have statutory responsibility for welfare of children. Examples of the possible ways of interventions to promote best start in life could be: targeting vulnerable mothers and involving health visitors and specialist nurses to ensure appropriate supports resulting in improved prenatal health, reduced childhood injuries and future unplanned pregnancies11.
b) Healthy schools and pupils – The evidence for many positive health indicators from successful school education is strong12. The school environment is conducive to increased physical activity. Local authorities can introduce healthy eating by increasing portions of fruit and vegetables13, physical activity and targeted wellness programme for vulnerable group of children.
c) Helping people find good jobs and stay in work – Unemployment has wide ranging negative impact on health. The local authorities can consider increasing the employment probabilities in various ways. They commission many services. The Social Value Act can be a mechanism to re-tender services and introduce increased social value to improve local employment situation14. Collaboration with local industry can also have positive effect on local employment opportunities15.
d) Active and safe travel – Increased physical activities in relation to travel can make a major contribution to better health. There is evidence for higher injury and death from road traffic accidents in lower socio-economic groups16. Local authorities can play a key role in making people taking the healthy choice of walking and cycling by promoting these forms of travel and making roads safer.
e) Warmer and safer homes – Warmer and safer homes have direct impact on health and wellbeing for all ages, but lack of it may affect children and elderly more. Local authorities have statutory responsibility for housing for its population. The number of attendances at the Accident & Emergency departments by children after accidents at home is high17. Local authorities can develop evidence-based fall reduction programme18, initiate risk assessment in target population, provide home safety aids, promote home improvement programme.
f) Access to green and open spaces and the role of leisure services – Physical and mental health benefits from access to green and open spaces have been demonstrated in several studies19,20,21, 22. Local authorities have direct roles in planning and maintenance of parks. Local authorities should collaboratively work with local communities, industry, local GPs and NGOs in planning, utilisation further financial investment and maintenance of open green spaces and sports centres.
g) Strong communities, wellbeing and resilience – A coherent and asset-based community development approach has significant beneficial impact on health23. Utilisation of social capital and community resources has positive effect on recovery from illness24, lower level of loneliness and increased resilience at societal as well as individual level. Active engagement in social networks can help in choosing healthy life styles, building will power and resilience25. To address the above, local authorities can foster several schemes26,27,28namely, befriending, volunteering, creating health champions and mapping community assets.
h) Public protection and regulatory services – The local authorities have considerable number of statutory power in protecting its population. Local authorities can regulate the location and number of fast food shops in their locality in addressing the negative impact of fast foods. They can also work with local schools to reduce fast food intake by school students. Air quality has direct links with life expectancy29 and respiratory diseases.
i) Health and spatial planning- Health and spatial planning is a prime setting where through HiAP local authorities can function as an enabler in improving health of its population. Spatial planning can promote higher density of shops and school, increasing cycle users and access to green spaces. All these can reduce BMI30, road safety 31,32 and increased level of physical activity33. Local authorities should rigorously adhere to HiAP and ensure public health leadership.
SECTION 3
What leadership skills, knowledge and competencies are critical for the public health workforce/practitioners if they are to be active in the development and Implementation of ‘Health in All policies’? (30%)
Learning outcome:
- Identify and know how to influence and negotiate with key stakeholders in the development and implementation of public health policies and interventions within a variety of organisations, including democratic organisations such as local government.
Health in the 21st century is a complex matter. The way people live their lives has transformed in a couple of decades. The nature of work and family has shifted with increasing impact on individual health and well-being. The determinants of health range from diet and housing to social isolation. Improving health and closing the gap between those with good health the those with the least requires a partnership approach that goes beyond the field of health and needs to embrace local authorities, voluntary and community groups, educational sector, adult social care, businesses and housing providers, amongst others. Similarly, any intervention, to be most effective, must be integrated and place based, focussing on prevention and reducing complex dependency. The health sector should be considered “one of a number of intersectoral players in a web that makes use of new kinds of leadership, skills, information and intelligence”34.
The above cannot be achieved purely by PHE efforts. It requires systems-based leadership, collaboration and co-production to drive these changes both by using PHE expertise and by negotiating and influencing policy and strategy adopted by other key partners and stakeholders, ensuring that a common vision of public health is shared, and resources and skills are focussed on areas of most benefit, internally and externally.
PHE needs to build support and commitment for improving health, making evidence and knowledge on ‘what works’ available to all stakeholders in a way that is easily recognisable and can be used to influence and spread best practice. Most critical, is the ability to influence to bring about behaviour change through an active partnership with the target population, so they take greater charge of improving their own health.
Key Leadership Skills and Competencies:
1. Evidence Based Approach: a greater investment in prevention, integration and supporting health is necessary to sustain the NHS going forward. It requires a knowledge and understanding of the use of cost benefit approaches so that scarce resources are utilised effectively. There is a need to develop ever more “sophisticated economic cases for prevention, being clear on the return on investment in the public’s health, including the practicalities of how to implement and how to ensure the expected returns are realised and savings cashed”35. This evidence-based approach is needed to influence and negotiate with stakeholders on the combined benefits of HiAP, even where some partners may face constraints.
2. Transparency: “Leadership belief in transparency and sharing meaningful information with partners and stakeholders is essential. This will ensure that everyone can access information on performance or need, and the evidence on ‘what works’. Meaningful data and information allows communities and decision-makers to make better decisions about how to improve health and will increase accountability”36. Again, transparency is essential to engender trust and co-operation between partners in delivering HiAP. Navigating the interests of different stakeholders requires honesty and transparency from the initiation to project completion. If stakeholders feel there are hidden agendas, especially where financial resources are heavily involved, this will lead to parochialism and lack of commitment to the common goals.
3. Digital and technological knowledge: the understanding and knowledge of behavioural sciences approach using information technology allows us segments of population that have been hitherto inaccessible. Using the social and behaviour theories of public health we can provide bespoke health solutions on a mass scale or on an individualised basis e.g. activity apps, fit bits etc. The use of innovative approaches to bringing in and applying digital technology to promote behaviour change and improve health will be essential to achieving PHE priorities.