EHJ June 2003, page 172-174 While sustainable health and wellbeing strategies are vital in maintaining healthy communities, how will environmental health as a profession integrate with the new public health framework in Wales? Tracey Khanna reports

Back in 1998, the Government produced a green paper Better health - better Wales, which set out a new approach for "sustainable health through collaborative action".1 Focusing on preventing ill health, as opposed to the traditional emphasis on cure, the paper set out a vision of how local authorities could impact on health improvement. There is no doubt that Wales has significant health issues and the headline health statistics published by the National Assembly for Wales (2001) make interesting reading.

In a country populated by around 2.9 million people (national statistics census 2001), the average life expectancy is two to three years lower than the rest of Europe. More years of life are lost through cancer than any other cause of illness and morbidity, while heart disease tops the league table of cause of deaths. During 1999, over half of all GP consultations for children aged under five, and nearly a fifth of all consultations in total, were due to respiratory illness. Further, 12.5 per cent of the population (361,500 people) reported that their health was "not good" in the 2001 census, compared with 9 per cent in England for the same period. When it comes to lifestyle, the figures show that 33.5 per cent of males and 29.4 per cent of females smoke, 27.4 per cent of males and 11.2 per cent of females drink above the recommended sensible limits, just over half of both sexes are classed as overweight or obese while only a third of males and even fewer females take regular exercise.

There are various tools that environmental health practitioners (EHPs) can utilise in the fight for health improvement, including health impact assessment, health needs assessment and community strategies. However, in April 2003, the Welsh Assembly Government introduced the requirement for all local authorities and local health boards (LHBs) to formulate and implement a health, social care and wellbeing strategy for their local area.2 The purpose of such a strategy is to promote health, social care and wellbeing for particular population groups, including families, children, the vulnerable, homeless and needy, black and minority ethnic groups, and people with mental health needs and learning difficulties, for example.

The key to this is partnership working with a wide range of stakeholders, and local authorities and LHBs will be under a duty to co-operate with:

• NHS trusts;
• Health Commission Wales (specialised services);
• community health councils;
• county voluntary councils; and
• any other voluntary, business or private body with an interest in health and wellbeing.

According to the guidance document, strategies will have to set out in detail how local authorities plan to address, either directly, or in support of other local strategies and plans, the wider determinants of health, including poverty, employment rates, access to public and private transport, access to health and affordable food, the environment and environmental health, public health, lifestyle, housing, workplace health and crime and disorder. The guidance states that where these issues have been dealt with in other local strategies or plans, for example the community strategy, communities first partnership or health alliance activity, it is not expected that the strategy should repeat or revisit that work, but should simply take account of the strategic direction and operational targets set elsewhere and cross reference.

This is vital, as Kendal Davies, CIEH trustee and environmental policy manager at Carmarthenshire County Council explains. "Local health boards, based on unitary authority areas, are the building block for a variety of strategies, with the community strategy being the main driver," he says. "These health social care and wellbeing strategies are one of the planks that should complement them and contribute to sustainable development."

Mark Elliot, newly appointed CIEH trustee, goes further and declares that "there is a tremendous focus now, quite rightly, on the wide range of determinants and factors that influence our total health and wellbeing in every sense - social, environmental and economic; rather than just the symptoms of ill health and disease. Wales is uniquely placed, being relatively small geographically, having unitary authorities and a newly elected Assembly to exploit new and innovative ways of working to deliver outputs and outcomes that will really make a difference."

He reiterates that this focus is being pulled together by the over arching strategic direction of the community strategy partnerships for each unitary authority area. "The community strategies sit above all other local strategies and policies such as the health, social care and wellbeing strategy or the local housing strategy or communities first plans," he says. "What is truly remarkable is that environmental health practitioners are found everywhere, working in almost all of these areas from housing to environment and health, and community safety to substance misuse, integrating and working in partnership and helping to deliver real improvement actions on the ground in the communities they serve. Something I think is almost unique to our profession."

In agreement with this is Dr Ruth Hall, chief medical officer for Wales, who says that acknowledging the impact that the environment and lifestyle can have on health is a vital consideration of overall public health protection. "The provision of healthcare services is only part of looking after and improving the health of individuals, communities and society," she points out. "Environmental health as a profession must be part of any integrated system of public health provision. There is no single organisation or professional group that can provide the totality," she says. "Environmental health practitioners engage with the public as a matter of course and at many levels and, as such, they have many opportunities to influence behaviour as well as to implement sound public health regulatory provisions."

She stresses that as environmental health practitioners work directly with individuals and organisations at the local level, they are in a great position to contribute to assessing what public health provisions are best suited to their communities and how those services should be delivered. "Local authorities can have a tremendous influence on the health of people in their areas and environmental health considerations should be part of the corporate strategic activity to this end," she says. "Local authorities in Wales have been given a partnership role with local health boards in devising health, social care and wellbeing strategies and I fully expect that environmental health practitioners will be an integral part of the process."

But while such measures to promote the potential for joined-up working between local government and all interested organisations, agencies and other stakeholders it to be applauded, it would be na•ve to think that a joined-up public health function could be achieved overnight. Many obstacles that could inhibit collaborative working need to be overcome at all levels, and a number of key issues will no doubt prove challenging for some years to come. In a document recently published by the NHS Confederation, and considering the issues at UK level, a number of such barriers are described.3

The report, the result of a joint conference between the Local Government Association, the Faculty of Public Health Medicine, the NHS Confederation and Nexus, makes clear that while national government policy has, in recent years, supported a greater importance for public health and health improvement strategies, in practice financial and resource constraints, and cultural and historical barriers to partnership working, still have a negative effect on joined-up public health planning and action. The report emphasises that "at a local level, a joined-up approach to improving public health may still depend on exceptional efforts by a few committed individuals rather than becoming a mainstream part of local practice."

This is a sentiment echoed by Mr Davies, who says that, while the requirement for local authorities to draw up and implement community strategies and other health plans is clear, environmental health has to start having an active voice in the agenda. "Inherent in this is the contribution that the environmental health profession should be making," he pronounces, "which must become the norm as opposed to the exception."

Environmental health 2012 4 acknowledges that the mainstream practice of environmental health "has become fixed on the delivery of a narrow agenda, and a number of factors are preventing it from achieving its traditional involvement in addressing the wider determinants of health." Fragmentation of services, a lack of clarity about the future nature of the role of the profession in the overall health agenda and competition for resources are all mentioned as major concerns.

Yet, despite such difficulties, there is optimism within local authorities, the CIEH and other public health organisations that the future of working in partnership for health is brighter now than it has ever been. In Wales, the CIEH has established and is developing further, valuable links with the Welsh Assembly Government. Peter Farley, of the health promotion division at the WAG, is confident that environmental health will be at the heart of all future collaborative work. "Locally, EHPs are involved in the majority of health alliances," he points out, "and their agenda and work should be core elements of the new health, social care and wellbeing partnerships and strategies." It is up to the profession itself to grab hold of these opportunities and champion its involvement.

References

1. Better Health - Better Wales (1998) The Stationary Office, May 1998.
2. Health, social care and wellbeing strategies: preparing a strategy (2003). Welsh Assembly Government. February 2003.
3. Prevention is better than cure: a report from a conference on joined-up thinking on public health (2003). Published by the NHS Confederation.
4. Environmental Health 2012, Health Development Agency, 2002.