Public Health

Building Innovative Practice

Linda J Jones, Jenny Douglas, Linda J Jones, Jenny Douglas

• Publisher: SAGE Publications Ltd
• Year: 2011
• ISBN:
  9781446271292
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Public Health: Building Innovative Practice examines the main challenges facing public health today and fosters an informed and creative response by practitioners. It explores effectiveness in team working, communication, managing change and inter-agency working, ethics and reflective practice. It addresses the key areas of public health practice including:

" analysis and use of information to improve health and wellbeing

" collaborative working to plan and implement programmes and interventions

" assessing evidence of effectiveness

" managing risk and reducing health inequalities

" reviewing and influencing public health policy.

Public Health: Building Innovative Practice provides students with knowledge and skills from which to build innovative practice. It is an ideal text for courses on public health and health promotion.

Chapter 1: Public health in context

Linda Jones

Introduction

Public health is a complex area of activity marked by changing ideals and shifting realities. It is an area of intense debate, not least because it involves political and value judgements about whether, when and how to intervene and limit people’s freedom. It is a growing focus of interest not just for professionals but also for the general public, who are encouraged to think of it as ‘everybody’s business’. It is becoming our business to make ‘healthy choices’ and to change to ‘healthier lifestyles’ and it is becoming the business of central and local governments to create social environments in which health can flourish. The public health workforce has a key role to play in both endeavours. But is any of this achievable and, just as important, is it appropriate?

This chapter explores the scope and focus of public health, unpacking its various dimensions and considering the shifting relationships between health, healthcare and public health. It suggests that there are important connections between people’s views about health and the types of public health action they are prepared to tolerate. Some important debates are outlined, in particular about the level and focus of public health work and the degree to which it should be concerned with a social change agenda.

1.1 What is public health?

Unravelling ‘public health’ is not a simple task, yet in its essentials it is clear. A good starting point is Donald Acheson’s description of public health as the:

science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.

(Acheson, 1998, p. 4)

The breadth of Acheson’s definition is surprising, encompassing action at all levels and across all sectors. It appeared in his influential report on inequalities in health (1998) and is reflected in subsequent statements by public health bodies such as the Faculty of Public Health, which views public health as encompassing health improvement, health protection and health services quality (Griffiths and Dark, 2006; Faculty of Public Health, 2011). So why has the National Health Service (NHS), which spends 95 per cent of its budget on treating disease and very little on prevention or health promotion, dominated public health for so long? Why has there been so much emphasis on ‘prolonging life’ rather than focusing on the other aspects that Acheson identifies: ‘preventing disease’ and ‘promoting health’?

With these questions we begin to move into more complex territory, since public health has had a chequered history. It has been bitterly contested: fought over by reformers and traditionalists; claimed by various parts of the health sector as their own; discovered and rediscovered several times; and generally been situated as a marginal player in society. Public health is not just practical, as Acheson makes it sound; it is also charged with ideology, shaped by competing politics and infused with conflicting values. In Section 1.3, we unpick a little of its history in order to understand the dynamics of contemporary public health and its multidisciplinary character. First, however, it is worth considering the scope of activity that Acheson’s definition includes.

Before you move on, compare Acheson’s definition of public health with your own. What similarities and differences can you see?

Preventing disease

‘Preventing disease’ embraces active measures to protect populations from infectious diseases, environmental hazards and so on, using legislation, public health regulation and emergency planning procedures. It relies on statistical surveillance at a population level, as do all aspects of public health, to understand disease patterns and potential threats to health and to counter these where possible. It also merges into primary prevention, which involves preventing the onset of disease in a population.

Immunisation is a good example of an intervention that both protects the population and prevents disease at a primary stage. Not everyone who was immunised with the ‘swine flu’ vaccine would have caught H1N1 influenza in the pandemic which swept through the UK between April and December 2009, but widespread vaccination of at-risk groups probably created a high enough level of immunity to help prevent a more prolonged outbreak (Box 1.1). Note the use of the word ‘probably’. We do not always know whether action has been justified because we do not know what might have happened had the action not been taken. Acheson acknowledges this in his characterisation of public health as ‘art and science’, relying on evidence, experience and judgement.

Box 1.1 The 2009 H1N1 ‘swine flu’ pandemic

H1N1/09 ‘swine flu’ reached the UK in late April 2009 and affected well over half a million people by the end of the year, 360 of whom died. It was declared a pandemic by the World Health Organization (WHO) in June 2009. There were two peaks in the UK: July/August, after which governments approved mass vaccination of at-risk population groups (including pregnant women, frontline health workers and under 5s) and October/November, after which it subsided. Mass vaccination in England and Wales reached around 40 per cent of an estimated nine million people in at-risk categories, but nearly 60 per cent elsewhere in the UK. The Health Protection Agency coordinated responses using its 2007 Pandemic Plan, monitoring trends, using specialist virus laboratories for diagnosis, building stocks of vaccine and anti-viral drugs and issuing guidance to the NHS and general public.

(Health Protection Agency, 2010)

Prolonging life

The second dimension of Acheson’s definition is ‘prolonging life’. This focuses on secondary and tertiary prevention (see Table 1.1, page 8), which involves detecting and curing disease at an early stage or slowing down/reversing the effects of an established disease. For example, bowel and cervical cancer screening are well established examples of secondary prevention. Although screening does not prevent disease, it aims to detect disease and treat it at an early stage. However, health services are mainly focused on tertiary prevention in sick people, such as bypass surgery, transplants, hip replacement, medications or interventions to help people manage longer-term conditions like diabetes, stroke or mental health problems. Tertiary prevention, or medical treatment as we should call it, is the most expensive and usually the least efficient form of public health. Increasing quality and efficiency by using guidance on clinical effectiveness produced by the National Institute for Health and Clinical Excellence (NICE), for example, is therefore very important.

Table 1.1 Primary, secondary and tertiary prevention

	Primary prevention	Secondary prevention	Tertiary prevention
Aim	To prevent the onset of disease	To detect and cure a disease at an early stage before it causes irreversible problems	To minimise the effects, reduce or slow the progress of an already established irreversible disease
Examples	Immunisation No-smoking areas	Cervical cancer screening Stress management	Hip replacement surgery False teeth

Promoting health

‘Promoting health’ is the third dimension of Acheson’s definition and it refers to efforts at an individual, community and population level to improve and enhance people’s health and wellbeing. It is the most challenging and problematic part of public health and focuses on improving health by tackling health inequalities and supporting community development and healthy lifestyles. It requires action on the wider determinants of health by improving socioeconomic infrastructure and the health-promoting potential of public policies. It cannot be achieved by public health alone and relies on a coalition of agencies and services.

The boundaries between ‘promoting health’ and ‘preventing disease’ are unclear. In the cause of disease prevention, for example, considerable legislation has been passed which regulates air quality, food hygiene and the wearing of seat belts. These can also be viewed as healthy public policy making initiatives. In a similar blurring of boundaries, population surveillance has uncovered deep-rooted health inequalities between social groups and this has led to an increasing emphasis on health improvement as one way of preventing avoidable disease. Thus the agendas of prevention and promotion are brought closer together.

Perhaps the distinguishing feature of ‘promoting health’ is its commitment to comprehensive intervention to enhance health as a progressive programme. The WHO Ottawa Charter for Health Promotion (1986) embodied this approach with its emphasis on five different dimensions of activity (see Box 1.2).

Box 1.2 Focus of the WHO Ottawa Charter for Health Promotion (1986)

• Build healthy public policy – putting health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their actions and to accept their responsibilities for health.
• Create supportive environments – systematic assessment of the health impact of a rapidly changing environment … protection of the natural and built environment and the conservation of natural resources.
• Strengthen community action – concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities.
• Develop personal skills – health promotion supports personal and social development through providing information, education for health and enhancing life skills.
• Reorient health services – the role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services.

(WHO, 1986)

The Charter situated health promotion as an overtly political and radical area of action, committed to changing priorities in health services, putting health higher on the public policy agenda, creating stronger communities and more healthful environments for people.

It required cooperation with other sectors that influence health – such as housing, transport, planning and retail – and framing policies to protect and enhance people’s health. It situated developing ‘personal skills’, which is often the main focus for governments which want to reduce costs by persuading people into more healthy habits (eating more fruit, taking more exercise, stopping smoking), as one aspect of an agenda that aims for societal change, not as the whole picture. It demanded a focus on the wider influences on people’s health – what we term the ‘social determinants of health’ – rather than just on individual behaviour change. These social determinants, which are explored in Chapter 2, have been described as ‘the causes of the causes’ of ill health (Marmot, 2010), encompassing:

the range of interacting factors that shape health and well-being. These include: material circumstances, the social environment, psychosocial factors, behaviours, and biological factors. In turn, these factors are influenced by social position, itself shaped by education, occupation, income, gender, ethnicity and race. All these influences are affected by the socio-political and cultural and social context in which they sit.

(Marmot, 2010, p. 16)

A shifting focus

In this way, a deceptively simple definition from Acheson uncovers a rich and contested territory that is in continual flux. Table 1.2 indicates the current ‘view from the top’ as seen by Faculty of Public Health specialists. The headings and ranking of various action areas have changed over time (e.g. inequalities have risen higher) and will probably do so again in the future.

Table 1.2 Domains of public health, 2011

Health protection	Improving services	Health improvement
Infectious diseases	Clinical effectiveness	Inequalities/exclusion
Chemicals and poisons	Efficiency	Education
Radiation	Service planning	Housing
Emergency response	Audit and evaluation	Employment
Environmental health hazards	Clinical governance Equity	Family/community Lifestyle advice Surveillance and monitoring of specific diseases and risk factors

(Source: Faculty of Public Health, 2011)

1.2 Interconnections: health, healthcare and public health

At the core of contemporary public health practice is the view that people have health needs which should be met and the right to a reasonable standard of health. An influential report for the W...

Table of contents

• Copyright notice
• Promoting public health: skills, perspectives and practice
• About the authors
• Foreword
• Introduction
• Chapter 1: Public health in context
• Chapter 2: The public health challenge
• Chapter 3: Working in organisations: skills and approaches
• Chapter 4: Developing as a reflective practitioner
• Chapter 5: Ethical issues in public health
• Chapter 6: Understanding and using theories and models
• Chapter 7: Building evidence-based practice: statistics and epidemiology
• Chapter 8: Building evidence-based practice: qualitative approaches and triangulation
• Chapter 9: Using evidence to plan and evaluate public health interventions
• Chapter 10: Educating for health
• Chapter 11: Working at the local level
• Chapter 12: Settings for promoting health
• Chapter 13: Building partnerships and alliances
• Chapter 14: Understanding and influencing policy change
• Chapter 15: Building healthier futures: barriers and enablers
• Acknowledgements