EHJ July 2004, pages 204-207
What will you be doing in eight years' time? Stuart Spear talks to the new breed of EHPs who are working outside local government to deliver the new public health agenda and discovers that under the surface environmental health is undergoing a quiet revolution

John F Kennedy said: "Change is the law of life. And those who look only to the past or present are certain to miss the future." He was talking in Frankfurt about the need for a united Europe. But the quote's sentiment equally reflects the views of a vanguard of EHPs who are forging new careers for themselves outside the traditional security of local government. Talking to this new breed of EHP it does not take long to realise there is a quiet revolution afoot. The environmental health profession is changing, and many now believe that the fundamental question facing most EHPs in local government is whether to look to the future and adapt, or remain focused on the present and die.

At the heart of this revolution is the new public health agenda. At first glance it is a world filled with bewildering terminology and acronyms. But beneath the murky surface the waters become clearer. The primary objective of the new public health agenda is to reduce health inequality by looking at what determines healthy living. A man living in parts of Manchester can't expect to live much beyond 70. A stark contrast to a professional living in the southeast whose life expectancy is 78. The government now recognises that as much as 70 per cent of what determines life expectancy and health status is based on an individual's social, environmental and economic circumstances. And over the last few years there has been a dawning realisation among policy makers that there is one profession that probably knows more about the practicalities of this mix than any other, environmental health. In the joint National Health Service, Health Development Agency document Environmental Health 2012, which provides us with a vision for the profession in eight years' time, EHPs are placed squarely at the heart of the public health agenda.

EHPs work each day in the front line, trying to improve environmental and social conditions for their communities. The fact that housing, access to safe food, nutrition, noise, air quality, job safety and public health education all dovetail together and contribute to health and wellbeing is second nature to the environmental health profession. But, as EHPs who have stepped out of local government are realising, while policy makers may have grasped the complexities of environmental health, public health colleagues working in local primary care trusts (pcts) or in the nine regional offices of the Health Protection Agency (HPA) have not. This lack of understanding about the profession is seen by EHPs working in the new public health agenda as one of the first barriers to overcome, and they are looking to their local government colleagues to help.

In the brave new world of public health, it is the local pcts that are provided with funds and are set targets to drive down health inequality. The government recognises that a vicious cycle has to be broken. A recent treasury-led review on public health made clear where money is to be spent. To start, the government wants education initiatives to reduce smoking, especially during pregnancy, teenage births and infant mortality. Then the major killers have to be tackled, cancer and coronary heart disease. Access to public services and health services in deprived areas have to be improved and there have to be targeted interventions for groups such as the fuel poor, elderly, drug abusers and rough sleepers.

But the pcts have limited resources to meet these targets, so they have to work through other agencies, particularly local government. And it is here that you will find most of the profession's new public health vanguard working. It is also why when talking to an EHP who has crossed from local government into a pct it normally takes less than a minute before "partnership working" is mentioned.

Peter Wright, an EHP who became director of public health at Watford DC before leaving local government, recently took over as assistant director of public health for the Watford and Three Rivers PCT. "My main role is dealing with partners and health improvement," he explains. "I am responsible for working with local authorities and I am the lead at the pct for local strategic partnerships and for community safety." The way it works is that the NHS provides the funds which are in turn made available for organisations that can demonstrate they can meet at least one of the pct's targets, laid out in their local delivery plan. The decision on funding is made by a sub-group with pct, voluntary sector and local government representation. A member of Mr Wright's team is then attached to the scheme to monitor and help progress the project.

A recent funding example was an information day for local Muslim's on health for Asian men. The event was staffed by the pct, which paid for Urdu speaking specialists to talk on risks of coronary heart disease and diabetes. Groups are also sponsored through the trust. One such group is Girl About, made up of teenage girls who go into the community to talk to their peers about the risks of teenage pregnancy. Mr Wright believes that the reason why local government colleagues need to become more aware of the workings of their local pct is because they too can access funding. He cites a recent example where his pct provided project funding for two environmental health departments to reduce accidents to elderly people in care homes. Also, through their accident prevention unit, his pct was able to help fund a major heath and safety initiative tackling falls at work. "Local authorities did not have to put any money in, all they had to do was provide inspector time, which we felt provided a lot of added value," said Mr Wright.

Sarah Wilson, an EHP who moved from Herefordshire CC just six months ago and is now pubic health manager for the West Gloucestershire PCT, is also responsible for coordinating with strategic partners. Her job is to make sure that all the pct-linked projects meet with the trust's local delivery plan and with local community plans. But on top of responsibility for partnership working, she also represents the pct in specific subject areas. These include accident prevention, teenage pregnancy, sexual health, physical activity and older people. "My job is finding out the issues and then coming back to see what the pct can do to help, and finding the people who can do it," she explains. Ms Wilson's experience is not uncommon to most EHPs who have joined pcts or the new, regional Health Protection Agency (HPA) teams. Because of the breadth of experience that environmental health offers, EHPs soon find themselves tackling a whole raft of subject areas.

Managers are often surprised by their new employee's broad training and their ability to shift with ease from talking about the relationship between housing and health to environmental protection and then to food safety. "I was in a meeting the other day when the subject of Integrated Pollution Prevention and Control came up. No one was quite sure what it was and yet there is an onus on the pct director of public health to comment on any new application, and so I was able to provide the background information," said Ms Wilson. The reason colleagues are surprised at an EHPs' knowledge is because few people in these new bodies understand what environmental health is. In fact, few people really understand the role of local government. This explains why most EHPs in these new roles, see one of their most important functions being to champion the profession. Ms Wilson hopes that by dedicating a chapter to environmental health in her pct's annual report she may be able to go some way to spreading the word.

Another EHP who is proselytising for the profession is Rachel Flowers, who became assistant director of public health for the Milton Keynes PCT over a year ago. With 20 years in local government behind her she describes herself as "steeped in local government culture" and believes that her approach to things is very different from the organisation she is working in. "They like that, they like my different perspective and that is the joy of multi-agency work," she says. The fundamental difference, she believes, is that she knows about working locally around local needs, not something which the NHS has been familiar with in the past. But Ms Flowers recognises that at present there are not enough EHPs spreading the word in the new public health agencies. And that is why she is calling on colleagues in local government to take the initiative.

"I could easily have come here and missed out environmental health, but I didn't because I knew about what they contribute," she explains. "My strong message to local authorities is that you can't wait to be asked. So find out who the director of public health is, find out who the person around health inequality is, because they are desperate to work in partnership but they don't know who is out there because they are too busy working in their day job."

The new breed of EHPs is not just being attracted to pcts. Sarah Webb joined her then local health authority after 14 years in local government, disillusioned by the lack of career development she was being offered and finding the regime she was working under too restrictive. Initially brought on board to do health protection work, her boss quickly realised the breadth of knowledge that an EHP comes with and she was soon being asked to look at transport and housing issues, which led her into emergency planning.

Ms Webb's new job illustrates how complex the public health arena can be. She works for one of the nine regional HPA teams as the regional emergency health planning adviser for the east midlands. Her job is to coordinate and advise the NHS on its emergency procedures for 28 pcts, 11 acute hospitals, two strategic health authorities and five mental health trusts, across five major counties. Then grafted over the top of these organisations there are coordinating bodies such as the health community networks, which loosely operate according to county boundaries. But that is just the start of the story. There then needs to be co-ordination between the fire brigade, police, the army and of course all the local authorities in the region. "We are often known as the professional runners between all these agencies," explains Ms Webb. An emergency can range from anything between a major food poisoning incident to a plane crash or bio-terrorist attack. Her team is also involved in horizon scanning in the hope of anticipating any future crisis.

Traditionally, emergency planning staff has been recruited from the military or ambulance service or from NHS management. But Ms Webb believes this is changing and that an environmental health background offers the right skill set to do the job: "What is becoming clear is that the HPA wants emergency planning in the health service to be done in a much more public health focused way. What is needed for this job is a holistic knowledge and that is something you can't buy but only comes from experience."

Many EHPs working in these new roles are starting to recognise a threat to the traditional local government environmental health department that refuses to adapt to the new way of working. Soon students coming out of university and tutored in the new ways of working are going to find the prospect of just doing health and safety or food audits unappealing. Whereas in the past EHPs had little choice but to join local government, at least while training, now opportunities are opening up for young professionals. New bodies are starting to offer student placements, with one on offer at Milton Keynes PCT and another at the SW region of the HPA. There is a growing feeling that unless local government adapts it will find it increasingly difficult to attract young blood to its posts, or retain ambitious staff, as other employers recognise how EHP skills can be exploited to tackle broader public health issues.

One such EHP, who has not worked in local government for any significant period of time, is Helen Casstles who is the regional adviser to the HPA in the northwest, attached to Liverpool's John Moores University. A former nurse, Ms Casstles worked at Salford University doing research for the HSE's Local Authority Unit before moving to the HPA. Her only time in local government was during her student placement. Ms Casstles is also unusual in that she fulfils a need for more evidence-based research into environmental health interventions. She is currently mapping the relationship between social deprivation and environmental conditions in the northwest.

To engage in the new public health agenda it is not, of course, necessary to leave local government. The ethos of the new culture is partnership working, which should mean that EHPs, who are allowed to engage, will be pushing against an open door. For those who also want to develop their public health careers, possibly to become a director of public health working for a pct and local government as a joint appointment, there is the voluntary register for public health specialists. The register has been set up by the Faculty of Public Health to make sure that public health professionals receive long-overdue training and recognition. Andrew Jones, director of public health with Denbigshire local health board, has blazed the trail by becoming the first EHP to join the register, and others are looking to follow suit.

Most are preparing to get on the register through the portfolio route by acquiring competency in the 10 required areas of public health. But Caryn Hall, along with a handful of other EHPs, is taking the more courageous step of leaving her secure job as head of environmental health at Tewkesbury DC to join a government-run training scheme for four years, to take part 1 and part 2 examinations of the Faculty of Public Health, giving her access to the register.

All the signs are that EHPs are increasingly embracing the new public health agenda. The big question for local government is: what in 2012 will have happened to those EHPs who chose not to engage with this brave new world? The threat facing the profession can be summed up in Benjamin Disraeli's aphorism: "Change is as inexorable as time, yet nothing meets with more resistance."

See Opinion piece, Adapt or Die