EHJ February 2004, pages 44-46
The profession is being barraged with requests to work in partnership to combat health inequalities. But how realistic is this for front line EHPs? Lisa Harvey has researched the obstacles to engaging with the new public health agenda

Tackling health inequality has become the new Labour mantra. It is almost impossible for EHPs to attend a public health conference without facing entreaties to move forward the new public health agenda. But how practical is it for EHPs to address health inequality in their borough?

The message to the profession has been loud and clear. In 1997, a broad review of the future of environmental health within the wider public health context was published in the form of Agendas for change. Many of the recommendations from this groundbreaking document went on to appear in the government's white paper Saving lives - our healthier nation. But while local authorities may be adapting to their new role, the EHP on the ground appears not to be getting involved. The Environmental health 2012 [1] vision sees EHPs as key partners in improving health and quality of life for local people. As the report makes clear, the chief medical officer believes EHPs to be the only full-time public health practitioners in local government.

So why are EHPs at ground level not fully engaging with the new public health agenda? The 2012 vision identifies key obstacles that need to be overcome, but do EHPs agree with these?

To identify the real barriers to the profession, 50 EHPs from local authorities in east and west Sussex were interviewed. Rural, town and city-based councils were represented from housing, food, pollution, and health and safety. These EHPs work in the community on a daily basis with little or no management responsibilities and range from being newly qualified to highly experienced. All disciplines felt that the majority of their time was spent on enforcement activities.

Interviewees were asked to consider 28 possible barriers stopping them from moving forward the public health agenda and to rate them in order of importance. A strong consensus emerged over the top seven, with the most important barrier being the emphasis placed on statutory functions and enforcement. The barriers identified were often interrelated.

Limited time emerged as the biggest personal barrier, with public health activities thought of as discretionary. Interviewees believed that more time needed to be set aside for the public health role, much in the same way as it is for food, and health and safety inspections. This, they claimed, would help to raise the profile of public health within environmental health departments.

For this to happen, current workloads need to be looked at to ensure they are in line with government goals and local objectives. Some activities may easily be adjusted, for example focusing health and safety visits on specific issues rather than general workplace inspections. Other activities, such as converting air quality monitoring data into useful information for promoting changes in road usage, may need to be expanded. Such a review is likely to identify a need for more resources and reprioritising statutory and discretionary functions.

One area easily overlooked is the administration workload. The size of support teams for EHPs has, at best, stood still and, at worst, shrunk. Many EHPs have taken on administrative functions that they now believe are part of the job. For many, the time spent on the district is less than the time spent in the office. EHPs need to be released to deliver the service, whether statutory functions or public health activities.

Lack of knowledge about the goals of the public health agenda is also seen as a barrier to becoming involved. An audit of public health skills [2] carried out two years ago echoed this feeling when it identified that EHPs lack a broad base of public health skills, while rating themselves as lacking a public health mindset. This may reflect the specialist roles EHPs have taken on.

Not surprisingly, training and incorporating the PHA in every day duties is seen as key to overcoming this lack of awareness. But maybe the question should really be "how can the statutory duties of environmental health be focused on delivering the agenda?".

A subtle difference, but the traditional disciplines are based on public health issues of the last century. Today's public health is about smoking bans, dietary issues, asthma in children, road traffic pollution, increased leisure activities, and so on. Statutory inspections rarely focus on issues like these, but through partnership working EHPs could contribute to the success of public health initiatives.

Partnership working might also provide a source of training for EHPs and other public health professionals. CIEH branch seminars regularly invite speakers on specialist subjects. But there is a need to widen the circle of partners and show EHPs what links can be forged with other agencies at all levels. The CIEH can also play a pivotal role through the continuing professional development (CPD) scheme. Another of the top seven barriers is the lack of encouragement from management to get involved in public health activities and issues. Perhaps there should be a separate CPD requirement for public health, raising awareness at ground level of how individuals can get involved. This may lead to innovative and effective initiatives that managers would be foolish to ignore.

The longstanding debate over specialisation leading to a loss of the holistic approach has produced a wide variety of opinions on its importance as a barrier.

EHPs are generally highly motivated individuals and the interviewees agreed that barriers such as "a lack of EHP interest", "resistance to changes in working practices and structures" and "not in my job description", were all unimportant. It appears that, given the chance, most would want to get involved.

The most important barrier to come out of the study is the emphasis placed on statutory functions and enforcement. External audits and the threat of being named and shamed focuses managers and councillors on the quantity of work achieved rather than the quality. Combine this with a general squeeze of resources for local authorities in recent years, and the result is that statutory duties and audited programmes get priority. One suggestion is to produce public health performance indicators to help raise its profile, using public health observatories to assess the effectiveness of any single initiative.

Management and councillors also need to be better informed about EHP skills and the contribution they can make to improving public health and reducing health inequalities. It is not enough to know how many inspections are being carried out. It is also necessary to know why they are being done, the impact they have, the problems encountered and new methods for tackling recurrent issues. The value of EHPs may then be fully realised, with the potential for more successful resource bids.

Staff shortages, particularly in pollution and food/health and safety teams, are a very important barrier. The obvious way forward is to increase staff numbers but shortages of EHPs and low student numbers make this difficult. EHPs expect the CIEH to promote the profession, but individuals and local authorities can also play a role. EHPs have daily contact with the public and other professionals and can raise the profession's profile. Local authorities should sponsor more student placements and reinstate environmental health to the top tier of local authority management.

Poor communication with environmental health managers, as well as other organisations, is a recurrent theme running through the study. Partnership working revolves around good communication at all levels on a regular basis. If people work in isolation then the public health agenda goals will not be achieved. Communication takes time which has already been identified as being in short supply. Without a change in emphasis away from statutory functions to public health, or an increase in resources, it is difficult to see how communication will be improved.

Management and corporate issues are complex with many objectives, both locally and nationally. Central government's change of direction on public health, backed by statutory duties and partnership working, adds to the complex role of local authorities. It is likely that many councils do not realise the expertise they already have in EHPs to help fulfil their public health role. EHPs need to educate their own organisations, and sell themselves.

The promotion of the EHP role and expertise by the CIEH is not considered to be an important barrier. However, some comments demonstrate strong opinions about the need for the CIEH to be more proactive, particularly as a lobbying body. The CIEH has reviewed its career material to attract more people to the profession and to promote the EHP role. Changes in the degree curriculum, with public health stressors and their implications at the foundation of the course, will help to address some of the skills gap identified by the public health skills audit.

The CIEH appears to be directing training towards a greater competency base that will allow individuals to expand their skills and take an active role in public health. In the meantime, attention must be paid to providing current EHPs with the skills and knowledge to get involved in the public health agenda.

Finally, from this research, it appears that it is not individuals who create a barrier to getting involved, but the circumstances in which they find themselves. Most EHPs are natural communicators, flexible, can think laterally and enjoy working with the public and other professionals. But many find themselves specialising and feel they are losing touch with the bigger picture. Local authorities need to recognise the skills and expertise that their EHPs can offer and provide the circumstances for environmental health to get involved in the profession's original objectives of protecting public health. Hang on - isn't that what the public health agenda is about too?

References

1. Burke S, Gray I, Paterson K and Meyrick (2002) Environmental health 2012 - a key partner in delivering the public health agenda. Health Development Agency
2. Meyrick J, Burke S, and Speller V (2001) Public health skills audit 2001 - short report. Available: www.hda-online.org.uk/Search/Results.asp

Lisa Harvey is an environmental health officer at Horsham DC and winner of the gold medal for the Ronald Williams Award 2003. This paper formed part of her presentation at CIEH conference in Belfast. She can be contacted at lisa.Harvey@horsham.gov.uk