EHJ July 2004, pages 216-217
CIEH policy officer Ian Gray explains why he thinks the profession has to change attitude and embrace the new public health agenda

When did we stop doing public health? Some of the older EHPs who qualified as public health inspectors will find difficulty pointing to a time when the nature of our work changed. Perhaps, like much change, it was imperceptible at the time, it is only now as we cast an eye over the past 20 years that we now notice an erosion of our role. Others may point the blame squarely at the Thatcher era which saw a start of our mania for accountability, productivity and performance indicators.

Whatever the origins, the time has come to re-engage with the modern concepts of public health. That is not to say that food inspections, health and safety visits, decent housing standards and environmental protection are not key to keeping the nation healthy. But, they are just part of the story.

We know that where we live and how we live determines our health and quality of life. We also know that the UK population suffers from health inequality.

Compare the relatively affluent boroughs of Merton Sutton and Wandsworth (see right), in London, with Manchester. Mapping out the overall health picture, taking into account health services, environment, behaviour and the age at which people die, we find a stark contrast. In Manchester, we find smoking rates well above the national average, as is alcohol consumption, poor diet and poor environmental conditions. It is therefore not surprising that mortality and morbidity rates are above average. And yet what is perverse is that the health provision, such as numbers of GPs, are so low when compared to areas with relatively less health problems, such as the London boroughs. This is at the heart of the government's policy to drive down health inequality and this is what is driving the new public health agenda.

So how do we tackle health inequality? The Health Development Agency tells us that as much as 70 per cent of what influences our health lies within our social economic and environmental conditions (see facing page, top). These are known as the underlying determinants of health and are largely controlled by community action. The former chief medical officer, Sir Donald Acheson, summed up this process by describing public health as "the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society." Derek Wanless, who headed up the government's recent treasury-led review of public health, added to this definition, saying in February that informed choices also influence public health and that these choices can be made by private and public communities as well as individuals.

The government tells us that it recognises all this and that it wants to use a multidisciplinary work force to improve health. This is where the environmental health profession enters stage right. EHPs working in local government are increasingly identifying themselves with this agenda, which is not just about death and disease but also about health and wellbeing. The reason why they need to engage is that local government is an enormous resource which is far more used to delivering on health and wellbeing than the NHS, which is still very much absorbed with treating illness rather than preventing it.

This raises the thorny issue of resourcing. How can the profession rise to the challenges set out under the new public health agenda while struggling to resource its statutory duties, such as food hygiene inspections and health and safety? It is not easy, but if EHPs doing food inspection could allocate a tenth of their time, that is half a day a fortnight, to the broader public health agenda it will be a start. Having made initial contact with the public health director of your primary care trust, environmental health departments may find the resources being made available. Primary care trusts are where public funding is being channelled. Local government can no longer expect money for public health initiatives, unless it is by collaborating with their pcts on projects that have clear health outcomes.

To help EHPs achieve this, the CIEH along with the Health Development Agency have broken away from the traditional model of environmental health, encompassing health and safety, food hygiene, environmental protection and housing. The new scope (see above) looks at the entire living environment and isolates the stressors that affect it. These are broken down into biological, chemical, physical and social stressors so that EHPs are able to look at something that harms health in a more holistic way. An example is lead. Under the new model we can look at the impact lead has on health in food, water, paint and vehicle emissions. Under the old model it would have taken four different environmental health disciplines dealing with different pieces of legislation to tackle lead as a pollutant in our environment.

With the new scope for environmental health in place we can now look at our skill set and see what as a profession we have to offer our public health colleagues. Our role in investigating incidences and inspecting premises, along with offering advice and education roots as firmly in the community in a way that is unique to those working in other public health agencies. It is this intimate knowledge of our communities that allows us to act as advocates, speaking on behalf of citizens and helping them to express their concerns about health and their environment. Our role is also to challenge organisations that fail to deliver a healthy environment and to champion causes, like banning smoking in the workplace.

So, what obstacles are we facing in reclaiming the public health agenda? The biggest stumbling block is our own attitude. As I travel the length and breadth of the country talking to the profession working in local government, I keep hearing over and over how problematic it is to broaden our public health remit because of the failings of elected members, senior executives, leaders of councils, the pcts, the Food Standards Agency, the Health and Safety Executive, poor resources, everything and every one apart from ourselves. It is, in truth, down to each EHP to change their attitude to public health and think in far broader terms than we have been doing for the last 10 years.

What EHPs must do is first recognise that they are doing public health work and label it as such. We have fancy titles but the more we tell people we are improving health outcomes, the more recognition we shall get. We must also work in partnership, particularly with the pcts. If we work on our own without collaboration it is not surprising that people do not know we are out there. We must also be prepared to prioritise our work based on heath outcomes. It is legitimate to question why you are doing something. If you cannot be satisfied that you are actually improving health then question whether you should be doing something else. The evidence base is there. EHPs should be able to say that they are doing this because it contributes to that line of intervention that has this health outcome. If we get that right then the additional resources will be made available, as we will be seen to be contributing to the government's public health agenda.

And if we fail to change? We as a profession will become de-skilled and over time attract fewer and fewer young EHPs to environmental health and attract less and less funding. There are strong signs that the pcts and Health Protection Agency will be only too pleased to entice our better students away from local government.

Also, to develop practice as an EHP you need to do progressive and innovative work. So, it is perfectly reasonable for EHPs in local government to ask if their work is having an effect and to insist that they are not prepared to do work that is repetitive and boring, even if it is a performance indicator.