11 Making it work: standards and success

'the quality of public health practice is mixed'

Standards

11.2 In some local areas the quality of public health practice is excellent but across the country as a whole the picture is mixed. Many organisations want to do much more to improve the health of the populations they serve. Yet they are often unclear about what they should expect from the programmes they create or from the staff they employ to deliver public health goals.

11.3 Setting standards and measuring progress is now an integral part of the planning and delivery of services to patients in primary care and hospitals within the new NHS.

11.4 Standard setting for public health is not nearly so straightforward. Public heath is multi-disciplinary and multi-agency so standards need to be flexible enough to apply in different organisations and to staff with different backgrounds and training. In addition we do not yet have enough robust evidence in many fields of health on which to base standards. But that does not mean that standards do not have to be set. They do.

'the Government has decided to establish
a Health Development Agency'

11.5 To help address these issues the Government has decided to establish a Health Development Agency. The Agency will ensure that organisations and individual practitioners base their work on the highest standards and over time raise the quality of the public health function in England.

'advising on the setting of standards for public
health and health promotion practice'

11.6 In advising and supporting the Secretary of State for Health the new Agency's key functions will include:

• maintaining an up-to-date map of the evidence base for public health and health improvement

• commissioning such research and evaluation as is necessary to support and strengthen the evidence base in areas where action programmes are required to improve health and tackle inequality, within an agreed framework governed by the Secretary of State's overall research strategy for health

• in the light of the evidence, advising on the setting of standards for public health and health promotion practice, and on the implementation of those standards by a range of organisations at national and local level

• in particular, providing advice on targeting health promotion most effectively on the worst off and narrowing the health gap

• through regular bulletins, guidance and advice, disseminating information on effectiveness and good practice in an authoritative, timely and effective manner to those working in the public health/health promotion field

• commissioning and carrying out evidence-based national health promotion programmes and campaigns which are integrated with the Department of Health's overall communications strategy and linked with regional and local activity

• advising on the capacity and capability of the public health workforce to deliver Ministers' strategy in these areas to the agreed standards, and on the education and training needs of the workforce, ensuring throughout that such advice is informed by research evidence and the appropriate quality standards.

11.7 The Agency will be a statutory body, with the status of a Special Health Authority. It will be established within existing public health resources. The resources of the Health Education Authority will be used to form the core of the new Agency and, consequently, subject to Parliamentary approval, the new Agency will supersede the Health Education Authority. The newly-appointed Chair of the Authority - and its new Board of Non-Executive Directors - will be invited to become the first Chair and Non-Executive Directors of the Agency. The intention is for the Agency to come into being on 1 January next year, subject to passage of necessary legislation through Parliament. The Agency will work closely with the Department of Health including the NHS Executive and its Regional Offices, Government Offices for the Regions, Regional Development Agencies, local authorities and other key players in the field, including the proposed Food Standards Agency.

EDUCATION AND TRAINING FOR HEALTH

11.8 We need to make sure that the public health workforce is skilled, staffed and resourced to deal with the major task of delivering our health strategy.

11.9 Medically-qualified public health staff have played a vital role in the development of the public health movement from the first Medical Officers of Health in Victorian England to the Directors of Public Health today. They must continue to do so in the future but as part of a modern public health workforce made up of people from a wide range of professional backgrounds.

'Those without medical backgrounds have had to
put together "do it yourself" careers in public health'

11.10 The challenge of achieving these goals is enormous but the potential benefit of ensuring that a diverse grouping of individual professionals becomes a true public health workforce is huge.

11.11 There are a number of barriers to achieving this. First is the absence of a true multi-disciplinary basis to public health practice. In the past the rhetoric has been strong but it has not always been followed through into practice. Those without medical backgrounds have had to put together "do it yourself" careers in public health. Even then they have often had relatively low status and recognition for their skills and expertise. Secondly, because public health has seemed a less pressing priority than financial and workload imperatives, many managers in the NHS have spent little of their skill and energy on implementing health strategy. Thirdly, there has been insufficient interdisciplinary working across organisational boundaries.

11.12 We intend to address these traditional deficits: to unlock the potential of the entire public health workforce. So we will produce a Public Health Workforce National Development Plan. In doing so we will work particularly with the professional bodies responsible for training and education of this diverse range of professional groups.

'to unlock the potential of the entire public health workforce'

11.13 To help with the plan we will also rapidly complete a Public Health Skills Audit to determine the current baseline of capacity and capability to deliver our goals through a skilled workforce. We will then expect local health organisations to decide whether they have the right mix of skills to prepare themselves for the shift to the new population- and health-focused agenda of the 21st Century.

Nurses and public health

11.14 Nurses, midwives and health visitors play a crucial part in promoting health and preventing illness. People have close contact with them at key points in their lives - in infancy, during adolescence, pregnancy and childbirth, and in sickness and old age - creating significant opportunities for health promoting interventions.

11.15 We are developing a strategy for nursing, midwifery and health visiting which will help strengthen the public health aspects of their roles. While recognising the potential of all nurses to contribute to public health it will include a focus on the roles of health visitors, school nurses, infection control and occupational health nurses as public health practitioners.

Health visitors as public health practitioners

11.16 We are modernising the role of health visitors to enable them to respond effectively to the challenge of the Government's new policies. So we are encouraging them to develop a family-centred public health role, working with individuals, families and communities to improve health and tackle health inequality.

'modernising the role of health visitors'

11.17 As a result of this modern role:

• parents will receive improved support including parenting education, health advice and information

• individuals and families will be able to have a tailored family health plan agreed in partnership with the health visitor to address their parenting and health needs

• the health needs of families and communities will be met by a team led by a health visitor including nurses, nursery nurses, and community workers

• health visitors will initiate and develop programmes for outreach, based on the experience of organisations such as Homestart, New pin and 'community mothers', where local parents use their experience to support others

• neighbourhoods or special groups such as homeless people within a practice or primary care group will have their health needs identified by health visitors, who will lead public health practice and agree local health plans

• local communities will be helped to identify and address their own health needs, for example accident prevention for older people.

'health visitors will lead public health practice
and agree local health plans'

11.18 A team led by the health visitor will provide a range of health improvement activities including:

• child health programmes

• parenting support and education including support to
  Sure Start, parenting groups and home visits

• developing support networks in communities, for example tackling social isolation in older people

• support and advice for breastfeeding mothers and women at risk of post-natal depression

• health promotion programmes to target cancer, coronary heart disease and stroke, accidents and mental health

• advice on family relationships and support to vulnerable children and their families.

School nurses as public health practitioners

11.19 School nurses are ideally placed to help children, young people and their parents find the support and services they need. The potential to develop school nurses is a growing element within the Healthy Schools programme and their role is being increasingly considered within other Government initiatives, such as tackling teenage pregnancy. Responses to the Home Office document Supporting Families have highlighted the importance of the work of school nurses with families.

'The school nursing team will provide a range
of health improvement activities'

11.20 School nurses can provide advice and help in areas such as personal relationships, managing stress and risk-taking behaviours. They can complement primary care services by providing a safety-net for children, particularly the most disadvantaged, who may not have had a full child health service before starting school. Their role needs to be developed and supported to enable them to:

• lead teams

• assess the health needs of individuals and school communities and agree individual and school health plans

• develop multi-disciplinary partnerships with teachers, general practitioners, health visitors and child and adolescent mental health professionals to deliver agreed health plans.

11.21 The school nursing team will provide a range of health improvement activities including:

• immunisation and vaccination programmes

• support and advice to teachers and other school staff on a range of child health issues

• support to children with medical needs

• support and counselling to promote positive mental health in young people

• personal health and social education programmes and citizenship training

• identification of social care needs, including the need for protection from abuse

• providing advice on relationships and sex education by building on their clinical experience and pastoral role

• aiding liaison between, for example, schools, primary care groups, and special services in meeting the health and social care needs of children

• contribute to the identification of children's special educational needs

• working with parents and young people alongside health visitors to promote parenting.

'Midwives are uniquely placed to improve health and tackle
inequality through services to women and their babies'

Midwives

11.22 Support for expectant mothers and families with very young children was identified as a high priority by the Acheson Inquiry. Midwives are uniquely placed to improve health and tackle inequality through the innovative services they provide to women and their babies at home and in hospital.

11.23 Midwives can:

• target vulnerable groups through, for example, pregnancy clubs for young single mothers or link workers for black and minority ethnic groups

• provide preconception counselling for prospective parents, targeting smoking cessation, alcohol intake and diet to reduce the risk of low birthweight and premature babies

• work with health visitors and others on post-natal depression, breastfeeding and best practice to avoid Sudden Infant Death Syndrome (cot deaths).

'creating the post of Specialist in Public Health of equivalent
status to medically qualified Consultants'

Occupational health nurses

11.24 We are developing the public health role of occupational health nurses and communicable disease control nurses to enable them to use population approaches to assess and manage health needs. Occupational health nurses will be an important source of support for a range of action to improve health at work.

Specialists in public health

11.25 We want to develop future cadres of Consultants in Public Health Medicine in a way which recognises the
multi-disciplinary basis of public health practice and removes the glass ceiling which limits their career paths at present. Thus, within the NHS we are creating the post of Specialist in Public Health which 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. And their expertise would apply to other public sector bodies as well as the NHS.

Medical care epidemiologists

11.26 Public health is not just about the wider aspects of population health. For those with chronic and longstanding conditions, improving the outcome of care can mean reducing disabling complications and enhancing quality of life. Specialist skills are necessary in developing and using outcome measures at local level, in ensuring that information systems capture data and in evaluating clinical interventions and diagnostic tests. NHS Trusts and primary care groups will address these issues in different ways but we will be encouraging them to look at the results of a pilot scheme in the Northern and Yorkshire Region in which Medical Care Epidemiologists have been employed by NHS Trusts.

INFORMATION FOR HEALTH

11.27 We need a clearer national picture of health and health inequality so that we can track changes over time. Many agencies are involved in collecting and using information about health and disease in the population. Yet in some cases information may not be available, or may be unreliable.

11.28 At local level data may be even patchier. Data derived from national health surveys, for example, although offering an excellent national picture will often not be enough to provide the necessary level of information at a more local level.

'we will ensure that there is a Public Health Observatory
in each NHS region of the country'

11.29 We will be carrying out a Review of National Sources of Public Health Information to see where they need to be strengthened to increase our ability to assess health and track progress in achieving the goals of this White Paper.

11.30 In order to strengthen the availability and use of information about health at local level we will ensure that there is a Public Health Observatory in each NHS region of the country. These observatories will be closely linked with universities to help bring an academic rigour to their work. Their main tasks will be to support local bodies by:

• monitoring health and disease trends and highlighting areas for action

• identifying gaps in health information

• advising on methods for health and health inequality impact assessments

• drawing together information from different sources in new ways to improve health

• carrying out projects to highlight particular health issues

• evaluating progress by local agencies in improving health and cutting inequality

• looking ahead to give early warning of future public health problems.

11.31 Public health observatories will work closely with NHS bodies, local authorities, NHS Executive Regional Offices, the Government Offices for the Regions and Regional Development Agencies as well as the new Health Development Agency. They will be linked together to form a national network of knowledge, information and surveillance in public health and will be a major new resource for local bodies working in public health.

11.32 The Liverpool Public Health Observatory was established in 1990, and provides some of the key elements which will be necessary in establishing the new network of observatories.

11.33 We will strengthen the information base on chronic diseases in the population by establishing a series of Disease Registers in different parts of the country. These registers will enable us to know, for example, how many people in a population are suffering from coronary heart disease, stroke, diabetes, asthma, high blood pressure. They will act as a base for investigation into disease causes, for evaluating new ways of delivering services as well as tracking changes in disease occurrence over time. These registers will draw on the work which we have already put in train through our Information for Health programme, and will complement the existing registers for cancer.

11.34 We will also use in a more systematic way the annual reports by Directors of Public Health, which are an important source of information on the main health problems and issues. We will ensure that they are used as a basis for the formulation of health improvement programmes and are fully relevant to local authorities as well as health authorities. We will ensure that they meet a common set of standards.

RESEARCH

11.35 Research plays a major role in helping us understand better the causes of ill-health, including the different ways our lifestyle and environment affect our health and our children's health. Public health research is also important in establishing the effectiveness of health programmes but we need to widen the scope of the methods used beyond the randomised controlled trial. In the past it has been the gold standard for research but it is no longer applicable to all the kinds of research questions which need to be answered.

11.36 We are carefully mapping all available research and will draw on it to develop a Research and Development Strategy for Public Health. In doing this we will make sure that the results of research are easily accessible to those who need to use them, that the programmes of work tackle our priority areas, that methods are appropriate and innovative and that there is a skilled research and development workforce in place.

'We want to create a climate in which academic
excellence can flourish'

11.37 The NHS spends around £420 million annually on research. Much of this investment covers the four priority areas for this health strategy - cancer, coronary heart disease and stroke, accidents and mental health. The Central Research and Development Committee for the NHS has established review groups in each of the four priority areas. These groups will report in the autumn, and recommend any necessary realignment of this research and development spending to ensure the most effective contribution to Our Healthier Nation.

11.38 Given the importance of a sound evidence base to underpin public health there needs also to be a strong and high-quality academic base to support both research and teaching. Unfortunately at present academic public health is not as rigorous as we would like to see it. Younger people are not opting for careers in the discipline and senior academic posts are becoming more difficult to fill. We want to create a climate in which academic excellence can flourish. So we are setting up a Fast Track Development Programme for young public health academics who will be the catalyst for the transformation we are seeking to achieve. As a first step we are setting up a pilot project in which research fellowships are jointly created between the Medical Research Council and the NHS Research and Development Directorate linked to a new initiative, The Health of the Public.

INVESTING FOR PROGRESS

11.39 We are creating a Public Health Development Fund as part of the Modernisation Fund for Health. It will be worth at least £96 million over three years. It will provide seed corn for new approaches in public health, to help and encourage the development of innovative ideas and to help tackle health inequality. The Fund will principally support action to save lives within the priority areas set out in this White Paper.

'We are creating a Public Health Development Fund'

11.40 Spending plans for the first year, amounting to £25 million, are already well advanced and cover a range of national, regional and local initiatives. The Fund will focus on four distinctive, though complementary, programmes, each designed to underpin the strategic framework in this White Paper. The first (£9 million in 1999/00) is directed primarily to the priority areas of cancer, coronary heart disease and stroke, accidents and mental health, but includes also work on infant feeding and the Health Visiting and School Nursing Innovation Fund. The second programme (£3.5 million) will help to develop the range of healthy settings. The third (£3.5 million) will fund key aspects of our Healthy Citizens programme that are not already being resourced in other ways. And the fourth (£9 million) will support the public health strategy as a whole in areas such as health impact assessment, the development of public health observatories and the improvement of infection control. This programme includes £4 million to be spent at regional level on a range of activities that, among other things, will help to develop the public health function.

'we have decided to set interim milestones in
each of the four priority areas'

Success

11.41 We are setting out an ambitious programme to achieve our goals and targets for a long-term sustained improvement in health. They will take many years to deliver fully; and we need to be able to check our progress along the way. So we have decided to set interim milestones in each of the four priority areas for 2005. These milestones will tell us if we are on course to achieve our targets for the year 2010.

11.42 Our assessment of progress will cover:

• the targets themselves - reduction in mortality rates in our four priority areas of cancer, coronary heart disease and stroke, accidents and mental health

• improvements in the risk factors which have a direct bearing on our four targets

• movement in underlying factors which reflect social, environmental and economic change which the evidence shows to have an influence on health and inequality

• effectiveness of programmes - as part of assessing progress we need to know that action of the right kind is in place, supported by the development of capacity and capability in public health. We will monitor these aspects of progress through a range of mechanisms including health improvement programmes, local authorities' community plans and Best Value and the national service frameworks.

Fig 11.1 Cancer: how the strategy will save lives

Fig 11.2 Circulatory disease: how the strategy will save lives

Fig 11.3 Accident injury: how the strategy will save lives

Fig 11.4 Suicide: how the strategy will save lives

11.43 We shall support this process by publishing a Technical Supplement to this White Paper setting out the scientific basis for target setting and the indicators available for the assessment of progress across the whole range of influences on health - environmental and behavioural risk factors, as well as health outcomes.

11.44 To complement our continuous monitoring, every three years we will review and publish changes at national level to:

• expectation of life

• healthy life expectancy

• health inequality

Local targets for improving health

11.45 Much of the action that we are putting in place will be delivered at the level of local communities. We expect health authorities and their partner local authorities as well as other local agencies to set out in their health improvement programme how they plan to achieve the national priorities through targets at local level. Health improvement programmes will be required to include additional local targets to address particular local priorities and to cut health inequality.

Managing performance

11.46 We want the achievement of results in delivering Saving lives: Our Healthier Nation to matter as much to local agencies as hitting the targets in the other important programmes they deliver. A health organisation should take as much pride in reaching the targets set out here as in achieving its targets on waiting lists and times. The goals in this White Paper must be as rigorously pursued by performance managers as any other targets.

'We will hold NHS bodies to account through the new NHS performance assessment framework'

11.47 We will hold NHS bodies to account through the new NHS performance assessment framework. The NHS Executive Regional Offices will ensure that they set realistic but demanding targets for local achievement, and will monitor their performance. Where appropriate they will "benchmark" a body's objectives by comparing them with the plans of other bodies in broadly similar circumstances. A parallel performance assessment process applies to social services authorities, while local government overall is subject to the Best Value regime. External auditors will provide a rigorous check on the information provided by authorities in local performance plans, and on the management systems that underpin them. There will also be an objective and independent process of regular inspection for all local services.

'the new rigour and drive we are bringing
to public health'

11.48 To strengthen accountability the Audit Commission is developing ways of auditing areas of joint working between these agencies at local level, using its experience of carrying out local value for money studies.

CONCLUSION

11.49 This White Paper sets out our health strategy for England: the goals, the targets, and how we propose to reach them. Success will be built on the new rigour and drive we are bringing to public health. We expect everyone to play their part in making this strategy deliver its full potential. We shall ensure that public health is subject to the same concerted development and performance management as every other area of Government policy, so that we can secure real and rapid progress. We all stand to gain. This strategy will give us all longer lives, healthier lives, and make ours a fairer country.

'We shall ensure that public health is
subject to concerted development and performance management'

We welcome your comments on this site. Prepared 5 July 1999