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June 2003 |
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Leading the way |  Back to contents | |
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The reorganisation of the National Health Service in Wales from 1 April presents unprecedented opportunities for local authorities (LAs) to contribute to general health improvements and to reduce health inequalities among the Welsh population. The Welsh Assembly Government's acknowledgement that LAs are a major constituent in this process is reflected in the changes to the health service structure, the new duties laid on LAs and their participation in the commissioning of health services locally. At the same time, a cultural change has taken place within the NHS in Wales, perhaps most importantly in relation to the NHS Trusts - the direct service providers of most secondary health care and community health services. While the trusts have not undergone any organisational change (with the exception of Powys), in the new structure they are expected to work closely in partnership with the other players. This marks a shift away from the traditional model, which has formed the bedrock of the NHS for a decade. Changes in other areas of the NHS however, have been more radical.1 LOCAL HEALTH BOARDSFrom 1 April, the five health authorities were abolished and replaced by 22 local health boards (LHBs). Functioning as "stand alone" statutory bodies within the NHS, the LHBs are responsible for carrying out most of the functions previously held by the health authorities, and are coterminous with LAs. The LA-LHB relationship is an important one. To begin with, LAs, through their shared boundaries, are LHB partners. At the same time, LAs are required to nominate four officers to serve as board members. Although the exact number of members will vary, depending on local circumstances, it has been agreed that each board will have over 20 members. This obviously presents a unique opportunity for LAs to influence the decision-making process in each LHB, and consequently health outcomes in the community. While it is up to each local authority (LA) to decide who to appoint, according to the Welsh Local Government Association (WLGA), the most appropriate candidate is an officer that has strong links with the local community, an understanding of local health and wellbeing issues, and a commitment to improving health and wellbeing. Nevertheless, the demands of membership will also present significant challenges to those LA officers that end up serving on LHBs. Since each member has to formally agree to devote two days each month to carry out their duties, and attend board meetings every two months, among other things, officers will have to avoid any clash of commitments with their council duties. HEALTH AND WELLBEING STRATEGYAll LHBs has a joint statutory duty with the respective LA to develop, formulate and publish a health and wellbeing strategy for its area. While the LHBs and LAs share responsibility for developing these strategies, the Welsh Assembly is determined that all the relevant partners, such as local voluntary organisations, businesses and NHS Trusts, should have an input in the development process. LHBs and LAs are required to review and formally approve the health and wellbeing strategies every year and both must develop annual operational plans to implement strategy priorities. Because the strategies are meant to reflect local health and wellbeing needs, LAs have a great deal to bring to the table - not least, in sharing their valuable experience and knowledge of community work. Besides the health and wellbeing strategies, the LHBs are also responsible for the following:
NATIONAL PUBLIC HEALTH SERVICEAs well as working with LAs, LHBs have an important relationship with the new National Public Health Service (NPHS) for Wales (see "At your service" article). Since LHBs now have a statutory responsibility for undertaking most of the NHS's public health duties in its area, each LHB will have a service level agreement with the NPHS. This close relationship is consolidated further through the appointment of a public health director to each LHB. The LHB directors are employed by the NPHS and report to three regional public health directors, who in turn are accountable to Dr Cerilan Rogers, director of the NPHS. Her main role besides providing leadership to the service is to establish relationships with all the organisations that are involved in improving public health in Wales. Dr Rogers is professionally accountable to Dr Ruth Hall, the chief medical officer in Wales, who is the principal medical advisor to the Welsh Assembly government and head of the Office of the Chief Medical Officer (OCMO).2 Dr Hall sees the NPHS and LHBs as two fundamental developments, which will greatly enhance the delivery of public health in Wales. "The creation of the NPHS at a national level ensures that there is an increased ability to move resources to the areas where they are most needed and to make available specialist knowledge and expertise across the whole of Wales," she says. The creation of LHBs meanwhile, "enables the delivery of health services to be better focused on addressing local problems and need." As chief medical officer, Dr Hall receives advice from the heads of five professional groups within the OCMO - the medical sub group, the dental division, the pharmaceutical division, environmental health and the scientific division. In addition, the OCMO contains three policy divisions - public health protection, public health strategy and health promotion. HEALTH PROMOTION DIVISIONThe health promotion division was established in 1999 when the national health promotion agency, Health Promotion Wales, was integrated into the Welsh Assembly Government. The division is responsible for developing and implementing the national health promotion strategy, Promoting health and wellbeing.3 This strategy identifies five priorities that need to be addressed as part of a co-ordinated and sustained effort to improve health:
The health promotion division's remit is comprehensive, covering, for instance, lifestyle-related health behaviours and risk factors such as tobacco control and healthy eating, as well as health promotion research and evaluation. The division's health promotion activities extend across a range of settings, including the community, the workplace, the NHS, the voluntary sector and local government. It has also been responsible for developing and supporting a number of major programmes, such as local health alliances (LHAs). LOCAL HEALTH ALLIANCESFollowing the publication of the Welsh Assembly's guidance document, Developing local health alliances, in July 1999, which recognised the key role that LAs have in influencing the wider determinants of health, LAs were urged to establish a health alliance in their respective areas.5 The rationale behind LHAs was to add a public health and health promotion dimension to the LAs' existing statutory duties and responsibilities regarding community planning and public service delivery.6 By convening a partnership of local interests drawn from LA departments, the health service, and voluntary and private sectors, LHAs can help to ensure that all of the factors that impact on health and health inequalities are considered together rather than as separate policies. For this reason, the Welsh Assembly's public health strategy identified three major themes, which LHAs should embrace:
Since their inception, LHAs have done a great deal to bring about local health gains. EHPs, in particular, often hold vital co-ordinating roles, and as Angela Jones, head of protection at Rhondda Cynon Taff CBC explains, they will form an integral part of the LA-LHB partnership when it comes to developing the health and wellbeing strategies. WALES CENTRE FOR HEALTHAnother key player in the emerging public health structure is the Wales Centre for Health (WCH), an independent, statutory body, which was proposed in the green paper Better health, Better Wales in October 1998, specifically to improve the health of the Welsh population.8 Statutory proposals for the WCH are contained in the NHS (Wales) Bill and until this becomes law, the new centre has been set up in shadow form as part of the Velindre NHS Trust. While it is anticipated that it will have full statutory status later this year, the Trust has been working to put the centre's supporting staff and structures in place so that progress can be made on tackling Wales' health inequalities and improving the population's general health. Dr Eddie Coyle, director of the WCH, explained the body's overall vision earlier this year when he spoke to the Faculty of Public Health Medicine. The WCH, he said, will "seek to engage all organisations that have a potential contribution to improving health, and will work in new ways by facilitating partnerships with all stakeholders." One of the ways in which the WCH aims to improve health is by acting as a national focus where information and evidence can be brought together and then used to provide public health advice and advocacy to policy makers. The WCH's role also entails co-ordinating the professional surveillance of health trends and carrying out risk assessments of threats to health and wellbeing. According to Dr Coyle, the establishment of strong public health links in the NHS (through the NPHS) and in local government (through the WLGA), means that the WCH will be able to concentrate on less developed areas, for instance, health links to crime and disorder partnerships and the Communities First Programme in Wales' most deprived areas. Established at the heart of the public health partnerships, the WCH will exploit this position in working with the NPHS, the WLGA and LAs "to develop the knowledge management tools needed to identify health issues and to address them effectively". In this respect, the new body will provide a similar function in Wales to those carried out by the English observatories. One of the WCH's main roles will be in building a multi-disciplinary public health workforce of specialists and practitioners, who will take lead roles in the new structures. Despite being in shadow form, progress has already been made in training and developing a workforce. According to Dr Coyle, the WCH has started a scheme of fellowships and bursaries to "open up wider public health training, and has commissioned a scoping exercise of current training and development for practitioners." Angela Jones is one of the first EHPs to be granted a fellowship from the WCH and is currently undertaking a part-time placement in the public health service. She is in the process of gaining accreditation from the Faculty of Public Health Medicine as a public health specialist. The Faculty, with the Royal Institute of Public Health and the Multi-Disciplinary Public Health Forum (the Tripartite Group), recently launched the Voluntary Register for Specialists in Public Health, a long-awaited system of recognition for specialists in public health who come from a non-medical background. Its purpose is to protect the public by maintaining the professional standards of practice of Specialists in Public Health.9 Once qualified, Ms Jones will have the opportunity to work in a number of key posts, for instance, as a director of public health on a LHB, working as a public health specialist in the WCH or taking on a strategic role within a LA. She urges other EHPs to take up the opportunities available by considering the option of training to become a public health specialist. The way public health has been organised in Wales has focused efforts on trying to meet the specific needs of the Welsh population. Last year, Dr Ruth Hall recognised the key role that environmental health has in meeting these needs at an all Wales study course (EHN 10, 15 March 2002, page 1). Whether it is by using their skills to support LHAs on the ground, by competing for director of health positions or by becoming a LA representative on the LHBs, EHPs can make a real difference. References
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