EHJ June 2005, pages 24-25

Many EHPs feel housing initiatives have a low profile. Jill Stewart and Ian Gray ask whether evidence-based practice could be the missing link in private sector housing renewal

Front line housing EHPs tasked with delivering healthier housing and communities are deluged with scientific data that links housing and health. Which is all very well. But what EHPs really require is evidence to show what is needed and what works in such a complex physical, social and emotional health relationship. While this is a regrettable gap, it is one in which EHPs are well placed to make a difference.

Evidence-based practice is about focusing on health determinants and asking what the most effective interventions are to protect and improve people's lives. Environmental Health 2012 sets out the case for EHPs to move away from a rigid, enforcement-led approach and ensure that their work tackles health inequalities. Barriers need to be challenged so that EHPs can improve lives using evidence-based activities. Having said that, there is an increasing need for EHPs to display and demonstrate the effectiveness of interventions. This is a problem. While EHPs across the UK are responsible for delivering health improvements, there is currently a lack of accepted evidence on these activities being pursued in the right places.

Our fundamental role should be about improving health and wellbeing and focusing our attention on reducing health inequalities. In environmental health, activities should mobilise around the social, psychosocial, economic, environmental, biological, chemical and physical determinants of health and wellbeing and enable people and communities to increase control over their own health and wellbeing. In order to do this, it is first necessary to understand the evidence (with research and evaluation) to develop effective strategies.

WHAT IS "EVIDENCE" IN ENVIRONMENTAL HEALTH?

Evidence-based practice really began in the medical health sector in the 1990s. More recently, it has become associated with the nation's need to maximise health gain as part of the public health agenda. That means delivering best practice that focuses on audit, efficiency, value for money and accountability.

Evidence can comprise both quantitative and qualitative data. It should be contemporary, valid and reliable, based on sound research and good practice that should help deliver quality assured, effective approaches in the longer term. It is not an end product in itself, but part of a developing process, which should be accessible and regularly evaluated, but not over-simplified.

Evidence-based practice also sits within a wider political agenda in a modernised approach to governance. It is to some extent based on the concepts of "risk" and "personal responsibility". These are themes running through the 2004 Choosing health white paper, which largely focuses on lifestyle issues. Most agree that risk reduction can be achieved by making more public health information available, which in turn, it is argued, fosters a more rational approach to decision making.

THE WANLESS REPORT AND HEALTH IMPROVEMENT

Securing good health for the whole population argues that although there is a great deal of public health information, there remains little assessment of the long-term impact on health of key policies, especially in disadvantaged communities where inequalities are most acute. The paucity of information is compounded by a lack of funding for research and the continuing low evidence base about the cost-effectiveness of public health and preventative policies. There needs to be more of a focus on health, not just on health care, accommodating wider targeting.

Health Needs Assessment (HNA) and Health Impact Assessment (HIA) are becoming increasingly important tools to assess a community's need and to develop strategies that are able to maximise positive health impact and outcomes. Both HNA and HIA entail partnership working, participation, equity and efficiency, use of evidence-based quantitative and qualitative data and - importantly - ensuring that the needs of marginalised communities are met fully.

HNA is important to identify the health needs, as well as health assets, of the community and to inform strategic decisions so that health is improved and health inequalities are reduced. Need might be normative (ie determined by the professional) or comparative (ie the situation is better or worse than another area or community). Joint needs assessments are essential to assess where inequalities are greatest and partnership strategies can be developed that are founded on overlaps where they are at their most acute. This may challenge what has gone before. Setting up a baseline of data is essential to dynamically and longitudinally map progress in reducing health inequalities.

HIA, on the other hand, is an important tool to help maximise the health gains from policy and to inject a health focus back into policy and strategy, so that adverse health impacts are minimised. HIA focuses around health determinants so that inequalities can be tackled in a sustainable way. HIA methodologies and processes are still at an early stage and there is a need for more work in this area.

Nevertheless, despite the obvious place for HNA and HIA in public health, neither is a statutory requirement. There are also no national methodologies or templates for action. The extent to which either is routinely applied remains unclear although their use is advocated in Choosing health.

SO WHICH WAY NOW FOR EHPs AND EVIDENCE?

The Health Development Agency's evidence base (see website address at the end) is a relatively new resource to support, build and disseminate both research and good practice in public health, and focuses on reducing inequalities. At the moment, most of the resources on the HDA website are academic papers. These are now being consolidated into evidence briefing papers across a range of subjects to help identify available evidence and gaps, with recommendations for future research, which includes discussion on the implications of the evidence for policy and practice.

What is currently missing - particularly for EHPs - is how to deliver their front line work in a way that effectively tackles and reduces health inequalities. The Learning from Effective Practice Standard System (LEPSS) is currently within the NHS remit, but should in time be introduced across all government departments in England. LEPSS is about learning lessons from practitioners to identify, assess and collate evidence and learning from examples of effective practice that might not normally be published or disseminated. In this five-year project, there is an increased emphasis on developing and establishing national standards for planning, evaluating, recording and retrieving effective practice.

The combination of evidence briefings and effective practice briefings would feed into HDA recommendations for action, guidance etc to help promote practitioner operations - and good practice - more effectively. This would expand the evidence base to inform public health action. EHPs might now want to start to collate more evidence around work they are doing, based on the HDA's draft national standards framework for effective health improvement. These include a focus on intervention, intervention aims and objectives, intervention methodology and the cost of intervention. Such activities could help to develop the evidence basis for EHPs.

For the HDA's evidence base, visit: www.hda online.org.uk/evidence

References

1. Burke, S, Gray, I, Paterson, K, Meyrick, J (2002) Environmental health 2012 - A key partner in delivering the public health agenda (London, HDA).
2. Department of Health (2004) Choosing health? Making healthier choices easier. (London, Department of Health Publications).
3. Health Development Agency (2004) Learning from Effective Practice Standards System (LEPSS): outline programme 2004-2007, (London, HDA).
4. Muir Gray, J A (2000) Evidence-based public health in L Trinder with S Reynolds (Eds) Evidence-based practice: a critical appraisal (Oxford, Blackwell Publishing).
5. Trinder, L (2000) Introduction: the context of evidence based practice in L Trinder with S Reynolds (Eds) Evidence-based practice: a critical appraisal (Oxford, Blackwell Publishing).
6. Wanless D (2004) Securing good health for the whole population. HM Treasury.
7. Watterson, A and Watterson, J (2003) Public health research tools in A Watterson (Ed) Public health in practice (Hampshire, Palgrave Macmillan).

Jill Stewart is senior lecturer at the School of Health and Social Care at Greenwich University. Ian Gray is a policy officer for health development at the CIEH.