You may not know it, but one of the national representatives of the UK Public Health Association started out as an EHO. Rachel Flowers talks to Cathy Savage about the evolution of a public health career

Rachel Flowers is instantly likeable, although she claims to irritate people. She readily admits she's "a bit of a talker" and energy fairly sparks from her as she speaks. Undoubtedly it's this ability to communicate with vitality and vision which has helped her rise so quickly from district EHO to the forefront of public health work within the community and nationally. As she talks, and explains her beliefs and her actions, she worries about sounding holier than thou. It is evident she believes in living by her principles (how many EHOs who struggle to get community involvement actually go home and get involved in their own communities?) but self-righteousness isn't apparent at all - she's too down to earth for that.

If Rachel is asked what she does now, she says she's a "public health specialist", but again and again she comes back to the broad-based training and the strength of the EHO in "looking at what works". Pragmatism - or realism as she insists - seems to be the element of her first profession which she has cherished the most. Rachel's interest in public health stretches back to childhood. "When I was little the inequalities between the haves and have-nots really bothered me," she remembers. "I was very interested in health and at first I wanted to be a doctor; then someone at school told me about environmental health and I thought that's what I want to do - it sounded far more real, dealing with people and society."
She secured a sponsorship with Coventry City Council to train as an EHO, but ironically had to pass it up the first time round, as a nasty case of salmonella stopped her from sitting her A levels. Happily when she reapplied for the sponsorship, Coventry took her on and so, in 1981, she began the sandwich course at Aston.

At the time, public health was making headlines. HIV had arrived in the UK and Rachel lost a friend to Aids just a few months after Terence Higgins' death.
In 1985, she qualified and started work as a district EHO at Coventry, working mainly in food and health and safety, but it was soon clear her heart was elsewhere.
"My passion was health and inequalities - poverty - trying to give people a better quality of life," she explains.
Her first foray into the kind of work she wanted to pursue was involvement in a scheme to prevent accidents in the home. "I contacted the Health Education Authority to ask about the role of the EHO in health promotion. I could see that we had an enormous amount of contact with the public and I wondered how I could make the most of that."

It's clear that Rachel is an educator by vocation. It's also unsurprising that the current enforcement v education debate in EHN is beginning to depress her.
"What I always enjoyed in enforcement was sitting down with people and explaining what was needed and why. It has to be a two-way process," she insists. "It would depress me greatly if we became Judge Dredd type characters, walking round claiming 'I am the Law'."
Rachel was lucky to enter environmental health when she did. The now-old "new public health agenda" appealed to many local authorities and in 1988 Coventry decided to join other big cities (London, Sheffield, Liverpool) and set up a health unit. Rachel was appointed to the new unit, along with about six others.
Initially her title was "promotions officer" - a Mickey Mouse title which soon drew accusations of Mickey Mouse work. On this point she is fierce.

"I would challenge anyone who's been in a shop to enforce the law to go back a couple of months later and say 'Have you thought about joining this healthy eating scheme?'. Being in enforcement gives you assertiveness, confidence - even arrogance - but if that is removed and you are still working with the same people, then you really need to develop influencing and negotiating skills, because essentially you're going in without any power at all."
The learning curve was steep. "After a while we realised the problem in the areas we were looking at wasn't access to healthy food, it was more to do with the skills of people in the community and their ability to deal with food... Then after a while we realised it wasn't enough to teach people to cook outside their own environment. You need to go into people's homes to see their reality. This sort of scheme really works best on a one-to-one basis." The unit's work has evolved in this trial and error way ever since, moulding itself to serve the community with impressive results.

Not content with being busy at work, Rachel spent the first few years of the unit throwing herself into health promotion in her spare time, helping to develop an Aids liaison network for Coventry and Warwickshire. "It gave me a useful insight into how tough it is to set up a voluntary agency, particularly when there is a stigma attached." She has understandably bitter memories of standing in the middle of Coventry on World Aids Day and watching people deliberately leave a huge gap between themselves and her. Sexual health is now part of the unit's remit too.
In 1991 Rachel's title changed to the more logical "health development officer". One of the food workers did an MSc in dietetics and became one of the first local authority dieticians. It was great for the unit, but also, very usefully, gave the dietician legitimacy among her peers, who had not always been impressed by her council credentials.

Rachel - a strong believer in partnerships - is evidently frustrated by this experience, repeated time and time again in the unit's history, of barriers between professions.
"There were GPs who wouldn't talk to other professions," she says disbelievingly. "And plenty of people in the health profession saw me as an EHO 'playing at health'."
In her view, the way to beat this is to force yourself onto the playing field - to gather the qualifications or the training which get the recognition. Consequently, in 1993, Rachel studied for an MSc in health promotion at the University of Central England. "I was in a grey area where I was EHO trained, had a clear public health specialism, but was neither one thing nor the other," she explains.
At around this time the unit decided to concentrate on area-based work, asking communities what they needed and planning around that. "It takes years - it really does take three or four years to really involve the community," says Rachel. "The first thing is to get activists enthused," she says. "But really, how many people get involved in their community in their own time?" She laughs: "Except me, of course. I make sure I do because I don't want to be a hypocrite."

Developing trust in the community has meant forging bonds that go beyond seeing a council officer as "The Council".
"I didn't realise how intimidating council officers are," admits Rachel. "We're confident, articulate, we use long words, we have presence and we have backing."
But to Rachel's delight, at a community group meeting at the end of last year, people were criticising the council and then one turned to Rachel and said: "Not you Rach, we know you're council, but you're not..." She smiles. "It's taken four and a half years to get there..."

precarious but vital
The funding of the unit has not been such a rosy story. "I think we work on what you would call a 'pot-pourri' of funding and grants," says Rachel. This means that half of the posts are temporary and specific. "Being non-statutory is almost like being in the voluntary sector," she adds.
But despite its precarious position, the unit has played a vital role in improving the council's understanding of what it means to be poor. "People talk about how poor people live on fish and chips - the people we work with would love to eat fish and chips," Rachel says.
Hardship doesn't necessarily mean despair though; a survey Rachel did in deprived areas for her MSc found that people overwhelmingly liked living where they did, which, again, surprised a lot of her council colleagues.

The sort of work the Coventry unit has been doing for 12 years has since caught on everywhere. Health inequalities are, finally, a recognised national issue, and joint-working is encouraged everywhere. These days most of the work Rachel is involved with is in partnership with NHS Trusts and primary care groups, as well as the community and voluntary sector. She has been writing the health improvement chapter on accidents for the health authority, while the environmental services manager at Coventry, Brian Camfield, writes the environment chapter. "Partnership working has developed over many years and means that people like me are leading on strategic development on behalf of multi-agency partnerships," she explains. "These are promising times."
Coventry's position at the head of the game has also seen the council, and Rachel, attract national recognition. In 1998, a year after she was promoted to principal health development officer, Rachel was called by the Department of Health, asking whether she'd heard of the Social Exclusion Unit's policy action teams... and whether she would like to be on a team looking at access to shopping and food deserts. She jumped at the chance and found she was the only actual local government officer there and that only one other member had recent experience of working with the community.
"It meant getting to work with people who I'd seen speak, people like Tim Lang," she explains. "It turned out I was the lowest ranking local government officer on any of the policy action teams."

She's been able to share the lessons learned at Coventry, about working one-to-one, about area-based approaches. The public health minister at the time, Tessa Jowell, visited and was so impressed that she used the unit's work as an example in later speeches. "I think people wonder why we've had a fuss made over us," says Rachel. "But it's just that we've been doing this work for longer than most."
And it is paying off. There have been 120 fewer accidents in the home each year. More people from deprived areas of Coventry are going on to further education.
"But it's not just those things that count," insists Rachel. "Children who were eating crisps are eating fruit. People are saying 'thank you, we want more of this'. I hope that what we do will mean that kids being born now will have a better chance."

As the principal officer in the department, more of her time is now spent in strategic planning and area co-ordination. She is a facilitator for three health action groups, she works on a corporate anti-poverty group and will be on the corporate steering group for SRB round six. She is project manager for a small block grant to help promote local health initiatives and she delegates decision-making to the community where she can. The year before last, she joined the West Midlands public health leadership course - as the only local government officer on the programme.
If it sounds hectic and confusing, then that's no surprise to her. "My work is very, very fragmented," Rachel smiles. "And the whole history of the unit is confusing - mainly because we were making the unit up as we went along."

What is surprising, as it slips out, is that somewhere along the way (and there are no discernible gaps), Rachel has had two children - boys now aged four and six. Her energy evidently verges on the superhuman.
Her confidence is growing too. And rather than hide it under a bushel, she's pushing herself onto the regional and national scene with ever greater determination. "We've been so busy focusing on the community here that we haven't always shared our experience. Now, as other people are involved in similar work, I see them trying out things that we abandoned years ago - if they talked to us they could save a lot of time and grief."

Rachel had long been a member of the Association of Public Health and the Public Health Alliance, and last year decided to stand for the council of the merged UKPHA.
She won her place as a national representative on the council by one vote. But her success was clouded by another example of professional pigeon-holing. The other four national reps - and a couple who failed to get onto the council - were mentioned in the Health Service Journal after the elections. Rachel's name did not figure at all.

High hopes
Rachel has very high hopes for the UKPHA, which gathers in health professionals, environmental health, trading standards, the voluntary sector and many special interest groups. Already she has represented the association at the All Party Parliamentary Group for Primary Care and Public Health. But her dearest hope is to see other environmental health professionals wedded to the cause, particularly as it seems some members are concentrating on a narrow enforcement remit - a move she believes can only marginalise the profession and its worth.
"I hope plenty of people will want to be engaged with the public health agenda we're pushing forward," she says. "I believe environmental health departments are best placed in a local authority to develop public health initiatives in partnership, both because of the training and legacy of the profession and also the fact that they engage with more members of the public than most other departments."
"Training as an EHO gave me skills to assess situations and be variable and flexible. EHOs do 'what works'," she stresses.

As for her own future, she remains determined to make a difference. "There is so much that can be done at a local level," she says, "but there is a lot of strategic work to be done at national level as well."
She sits back for a moment. "I know I conform to a type," she says. "I would guarantee I'm like so many others involved in this sort of work, who are passionate about inequalities and what can be done in local authorities."
And so where will she be in 10 years time?
"I hope I'll be doing something in public health or regeneration at national level," she pauses. "I know it sounds funny, but you need more people like me at national level." Who could disagree?

The UKPHA aims through its members, activities and co-operation with others, to be a unifying and powerful voice for the public's health and wellbeing in the UK, focusing on the need to eliminate inequalities in health; and to promote sustainable development, environmental and social regeneration to improve health and wellbeing.
Anyone interested in joining should call: 0121 643 7628.