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August 2003 |
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Keeping the Cogs oiled |  Back to contents | |
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A large number of medical and non-medical practitioners are tacitly acknowledging that improving public health requires close co-operation and co-ordination between NHS bodies, local authorities and the voluntary sector. Yet, there are many barriers to joined-up public health planning and action - financial, cultural and historical - and overcoming these is essential if the dream of preventing disease, improving health and reducing inequalities is to be fully realised. In an attempt to facilitate some of these issues, the Local Government Association, the NHS Confederation and the Faculty of Public Health Medicine (now the Faculty of Public Health) staged a conference last December examining the opportunities for public health improvements through joined-up thinking. The arguments for joined-up public health are compelling and these three authoritative organisations have publicly recognised that "the most powerful determinants of health and health inequalities lie outside the direct influences of the health services, and are largely determined by the physical and social environment". In short, this means that environmental health practitioners from a local government background have valuable knowledge and skills to bring to the table. Even so, in the published post-conference report, Prevention is better than cure, it is stressed that "much work has to be done to build the structures at local level, which will embed multi-sectoral public health in mainstream activity, so that this continues even though staff changes occur or a funding stream ends."1 Policy developments to support public health in the NHS and local government have been underway for some time, most notably in the creation of primary care trusts (PCTs) in England in April 2002. PCTs are now seen as the main instrument of primary care delivery from the NHS, and environmental health officers (EHOs) and their local authorities have a unique opportunity to influence their work and direction as long as they become involved and are prepared to work together (EHJ, August 2002, page 236). Yet as Peter Wright, CIEH trustee and public health manager at Watford and Three Rivers PCT points out, EHOs have still not fully "grasped the nettle" that this opportunity presents, and are even in danger of losing out while other less qualified individuals "fill the gap". He blames heads of services and chief executives for putting too much effort into meeting performance targets, with the result of being blinded to the wider public health picture. A passionate advocate of joined-up thinking and working, Mr Wright is part of a relatively rare, yet rapidly growing, body of environmental health practitioners that have applied their local authority experience and knowledge to the emerging public health structures. In 2000, he moved out of local government to take on the post of public health partnership manager at West Herts Health Authority, where part of his remit included liaison with local authorities to ensure they were informed and given the opportunity to participate in the Health Improvement Programme (EHJ August 2000, page 241). Mr Wright sees the creation of PCTs and the opportunities that they offer in improving the health of local residents as a welcomed move, recognising them as an important step change from that of health authorities, which he believes have little contact with, or feeling for, the needs and desires of local users of the service. PCTs, he claims, present a massive opportunity for the profession, not just in terms of working in partnership with the local authority but also for individual EHOs who may wish to consider training to become a public health specialist.2 In both cases, he points out, having an environmental health background gives practitioners an excellent start. The environmental health qualification is grounded in public health and it teaches the practitioner to look at the wider determinants of health. Policy tools like health impact assessments, for instance, are not that far removed from environmental health risk assessments. Mr Wright cites the CIEH policy and development board's recent decision to drop its call for the introduction of an approved code of practice on passive smoking at work and campaign instead for smoke-free workplaces (EHJ May 2003, page 138) as a significant development and an excellent example of how the profession is working to address the underlying causes of ill health. He also refers to the Department of Health's Tackling health inequalities - a programme for action, which was published last month, as an important policy area where environmental health can influence decisions and make significant improvements to public health.3 The programme, which "sets out a three-year plan to carry forward the recommendations in the 2002 cross-cutting spending review on health inequalities" recognises that improving the health of the most deprived in society has to be a priority if the widening gap in health inequalities is to be reduced. The document refers to key actions, which are likely to have the greatest impact on the most vulnerable groups. These include improving housing conditions and reducing fuel poverty; intervening to help reduce smoking and improve nutrition; and action to reduce accidents at home and on the road, all of which are traditional areas where EHOs have the knowledge and expertise to make a difference. As with PCTs, a growing body of environmental health practitioners are lending their public health knowledge and skills to other influential voices, most notably, the recently launched Health Protection Agency. Sarah Webb, who is on secondment from her post as public health specialist with East Lincolnshire PCT to the role of regional health emergency planning adviser for the East Midlands at the HPA, says her background in environmental health has proved invaluable in her roles since leaving local government five years ago. "My experience as an EHO gave me really useful problems solving skills," she says, "and an ability to look at health from an holistic view point, for example by looking at the impact that the environment, housing, transport and quality of life have on health." After qualifying as an EHO in 1984, Ms Webb worked for a number of local authorities specialising in housing and food safety before moving into the NHS in 1998, when she joined Lincolnshire Health Authority. At the time, she was one of only a handful of EHO appointments in the country. A vital aspect of Ms Webb's remit, during her time at the health authority, was the facilitation and liaison role with environmental health departments across the county. This covered a range of issues, including pollution, food poisoning outbreaks and chemical contamination incidents. This closer co-operation has directly helped strengthen the notification and surveillance of infectious disease and has also resulted in an improvement in the flow of information between district councils and the health authority. Taking up her new post as public health specialist with East Lincolnshire PCT, Ms Webb found herself working closely with its director of public health, helping to build up "health profiles of the local population as a form of needs assessment." It was a million miles away from her work at local government. "If I am honest, I found local government very narrow and restrictive," she says, "and not a place in which I could develop professionally. Working in public health in the NHS has brought me closer to my environmental health roots in many ways than life as an EHO in local government". While her current role as an emergency planning adviser at the HPA does not bring her into contact with the profession much, Ms Webb believes that EHOs should seriously consider the HPA as a potential employer. "I think EHOs have a broad base of skills and a pragmatic approach that make them good candidates for the work the agency does, ie protecting health," she says. "The agency is very much in its infancy but it needs to build strong relationships with local authorities and placements for part of the training period for students, and secondments for more experienced EHOs would benefit everyone." Dr Naima Bradley, chemicals and environmental team leader at the HPA East Midlands agrees. She says that EHOs have key strengths that would benefit the HPA, including a sound working knowledge of "what the local authority and what the health authority does" as well as excellent people skills that come from working closely with the community. This makes them perfect for co-ordinating and advisory roles, she adds. In return, the HPA can provide EHOs with an opportunity to put their public health skills to good use by getting more involved in health-based projects. Dr Bradley studied chemistry before retraining as an EHO in the mid-1990s. This varied experience has enabled her to "combine a hard science background as a chartered chemist with the people skills of being EHO". After working in an environmental protection unit in local government, and acting as an environmental adviser to the non-ferrous metal industrial sector, where she advised and represented industry at national and European level, Dr Bradley joined the Public Health Laboratory Service (PHLS) in July 2002, heading a team dealing with the Integrated Pollution Prevention and Control (IPPC) regime. The PHLS was absorbed into the HPA on 1 April and part of her work involves supporting PCTs in their role as statutory consultees in the new regime. "For the first time, PCTs are able to comment on the impact of the industry in their patch and be involved in broader issues relating to environment, chemicals and health," she says. As with other EHPs working in the emerging public health structures, Dr Bradley has found that her environmental health skills have proved invaluable. "The ability to address people at all level and the ability to consider the broader issues when faced with a problem have been extremely useful," she says. Opportunities for experienced EHPs to further their careers in public health have been enhanced with the launch of the Voluntary Register for Specialists in Public Health.4 The Tripartite Group (the Royal Institute of Public Health, the Faculty of Public Health and the Multidisciplinary Public Health Forum) has been developing national standards of specialist public health practice for three years. With the register going live in May 2003, the facility is now available for EHPs and other professions working in public health practice to access the register. The CIEH has been closely involved in the development of the portfolio route to registration, which is only available for a period of three years. "Top-up" training programmes are available to EHOs regionally through the PCTs to make good small identified gaps in their portfolios. The CIEH is also planning to run a workshop later this year for members compiling a portfolio for assessment. Through their holistic approach to public health, local authority EHOs are well placed to promote health improvements and help reduce health inequalities. However, as the drive towards joined-up thinking and working accelerates, it is important that they take up the opportunities that now exist to influence the very fabric of our society. References
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