Select one of the public health targets in England and critically assess the appropriateness of the current policy environment.

University Degree Subjects allied to Medicine

Select one of the public health targets in England and critically assess the appropriateness of the current policy environment, including Saving Lives: Our Healthier Nation (DOH 1999) and associated initiatives (such as a related NSF) in terms of whether strategies are in place that are conductive to achieving the selected target. Conclude by making recommendations for action to achieve the public health target you have chosen.

The nature of major causes of work-related ill health makes occupational health fit more closely than ever before into the public health agenda. The government has been quick to recognise the role of occupational health nurses in reaching the public health targets set in recent public health policy such as Saving Lives: Our Healthier Nation (1999). Securing Health Together (HSC 2000) is one of the latest government strategies to reduce ill health caused by work and aims to meet the government’s agenda to reduce health inequalities within the workplace. This long term occupational health strategy is one of several public health targets within the United Kingdom that has roots within Saving Lives: Our Healthier Nation (1999). The appropriateness of the current policy environment and the associated initiatives such as Securing Health Together will now be discussed in order to identify how they evolved and whether the strategies currently in place are in fact conducive to achieving the selected health targets.

Health is subject to wide individual, social and cultural interpretation. Individuals experience health and illness, but it is through influences such as culture, class and gender that the experiences are shaped. Images of health are also built on media messages and prevalent ideas about health rights, levels of service, access, awareness and so on. These images of health also include social expectations about what it means to be healthy in a particular society. The nature of health is that the different aspects are inter-related. There is a general consensus that health is multidimensional and that the holistic view of health currently prevails (Aggleton and Homans 1987; Ewles and Simnett 1992) therefore the different influences and interactions of the different dimensions must be taken into account. Britain has inequalities in wealth and income, which are associated with inequalities in health (Townsend et al 1988). Naidoo and Wills (1994) argue that one reason for this is that the distribution of health mirrors the distribution of material resources within society. The government are aware of the continued inequalities in health and have therefore developed public health policies including the Saving Lives: Our Healthier Nation initiative that has the two key aims of increasing life expectancy by reducing ill health and tackling the inequalities in health (Health and Safety Executive 1998). The government in introducing such policies has recognised that health promotion is a multi-professional activity that takes place in a variety of settings such as work places, schools and communities. Health promotion surrounds the activities of information giving to empower individuals to make informed decisions and actions regarding their health. The use of appropriate levels of health promotion be it at primary, secondary or tertiary levels, by the health professional will ensure comprehensive approaches to health promotion are encompassed. Although, one critique of health promotion is that the increase in the health gap is due to health promotion as individuals in social groups one and two listen to the health promotion ideas and are able to afford the life changes such as joining gyms and eating organic food.

Health policy is often concerned with resolving the tensions between the desire for collective good on the one hand and moves to bring a service closer to individual choice on the other. Health has a unique resonance in people’s lives; it is both a uniquely public good on one hand and intensely private on the other. The complexity of the term ‘health’ may further impact on the professional due to the tensions between the medical model of health and the social model of health. For example tensions within Saving Lives: Our Healthier Nation have been there from the outset due to medically driven targets being set within a social policy. Health policy is therefore increasingly operating within tensions. Each component is desirable by somebody, to some extent and Dargie (2000) therefore argues that it is possible that shifts and trade offs between these tensions will increasingly determine policy.

The examination of health policy is therefore challenging because it covers many different types of policy, for different groups of people and for different types of outcome (Dargie 2000). Health policy such as Securing Health Together (HSC 2000) and Revitalising Health and Safety (DETR 2000) is judged in the terms of making improvements in national indicators over a given time span. This target driven approach was first identified by the WHO, with the development of Health for All and the setting of targets to be achieved throughout Europe by the year 2000. Public health strategies and policies are shaped by the interplay of political forces in government and society at large (Baggott 2000). The British Government faced increasing pressure during the 1970’s to adopt a formal health strategy. Therefore this decade saw the start of dramatic changes in health policy bought about by the pressures of cost and the changing patterns of disease with the resultant impact of a health service that could not meet the projected demands required. This combined with the scepticism regarding the role of health services in the promotion of health led to the first emerging health policy of the 1970’s. From Canada, A New Perspective on the Health of Canadians emerged and was considered a watershed policy in that a focus on lifestyles emerged, although it can also be criticised for not recognising that the locus of control is not always with the individual. However it remains that this landmark policy was the first policy in which the term health promotion was used.

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Soon to follow was the 30th World Health Assembly in 1977 where Health for All by the year 2000 evolved. This health policy idealised that all citizens of the world should, by the year 2000, be at a level health that would enable them to lead a socially economic and productive life. The policy had six major themes, set prerequisites for health and set 38 targets to be achieved throughout Europe. This capitalist policy looked towards health for economic productivity and was, and remains highly significant regarding the future development of health promotion. However, it can be argued that as a policy it is vague and idealistic with unrealistic goals considering the short time scale. Despite this, this has remained an important document. Health For All set the blueprint for public health policy and health development as a whole with the realisation that whilst health is a fundamental human right, the highest levels of health will only be achieved through partnership and a multi-sectoral approach. The main importance of the Health for All document is the evolving ideas of devising a strategy for health which is based on target setting. This principle formed the core of The Health of the Nation, with other similarities being observed in time scales for the targets to be achieved and the actual wording of some of the targets, for example ‘adding years to life’, and ‘adding life to years’

Ottawa was the venue of the first international conference on health promotion. From this conference evolved the The Ottawa Charter for Health Promotion which is inspirational within the field of health promotion in that it identified the principles of health promotion, and moved away from the medical model of disease diagnosis and treatment. The conference identified the future role of healthy public policy as the foundations of health promotion, with the ‘New Public Health’ emphasis based on the creation of supportive environments and reorienting of health services. From this evolved a seminal policy document that set the gold standard and remains highly important in that it was used as a guiding document for international health promotion, however it has since been superseded by the Jakarta Declaration which was seen to lead health promotion into the 21st Century. The Jakarta Convention identified major global challenges with the continued widening of the gap between the rich and the poor, the globalisation of markets and the challenges that these issues provide for the promotion of health. The Jakarta Declaration called for the formation of a global health promotion alliance and set the agenda for individual communities to develop policy investment in health improvement. This collaborative way of working further reinforced the Ottawa Charter. However, it took another step forward in that it identified the need for private, public and business partnership and support with regard the sharing of knowledge and investment in health improvements; in order for the realisation of the common goal of socio-economic development within the ever moving agenda of health promotion taking into account the new evolving determinants of health.

The Health of the Nation was the first government policy in the UK to provide a strategy for health for the future and is therefore an important policy document. The ideas, policy structure and strategy of The Health of the Nation stemmed directly from the WHO and the underpinning medical model of healthcare (Macdonald 1998). This is identified in that the policy has disease onset targets and is expert led, with need being identified through epidemiological data and health being identified as the absence of disease. However it moves towards a more multidisciplinary, multi-sectoral joined up approach to healthcare. The Health of the Nation however in total discord with the WHO, the policy ignores the findings of health inequalities within the UK as found in The Black Report (Townsend et al 1988), and instead focuses on individual lifestyles and efficiency of the health service. Targets have been set within The Health of the Nation document as with the WHO, however it is difficult to identify where the figures for the targets have derived from, whether from epidemiological data or simply following the basis of Health for All.

With the change of government in the 1990s came a change of policy. Health promotion remained an important element of the government’s health agenda. On forming a new government New Labour set public health policies in line with its health agenda. Out of this rose a new white paper Saving Lives: Our Healthier Nation, which sets ambitious targets for life expectancy to be increased, and inequalities in health to be reduced. The Labour Government plan to achieve this through it’s public health policy in a “third way” (Connelly 1999). Labour’s policies in line with the WHO are aimed at strengthening communities, and encouraging individuals to seize opportunities and take responsibility for their action.

The election of the first labour government for over 18 years, thus bought about significant changes in the public health policy arena. Policy makers were once again discussing how to tackle the health inequalities rather than health variations as discussed in The Health of the Nation, and were looking to tackle the structural as well as lifestyle factors that contribute to health and illness (Pavis 1998). Saving Lives: Our Healthier Nation (DOH 1999) was once again a policy based on the medical model with disease led targets and the absence of disease being the goal. The policy was using a traditional approach in that it was expert led in order to achieve change and is open to the structuralist critique in that change and the promotion of health is promoted from the top down in order to achieve normalisation of behaviour. The needs identified within the Saving Lives policy are normative with the use of some comparative needs where comparisons are made with the European Union in order to justify the policy and targets. Saving Lives: Our Healthier Nation (DOH 1999) acknowledges that the workplace can provide opportunities to improve the health of the workforce and to address health inequalities, thus drawing on the multi-sectoral approach advocated by the WHO. The Blair Government policies have shown a commitment to communitarian ideals by combining individual rights with responsibilities and invoking state authority where necessary to uphold the common good (Baggott 2000). Saving Lives: Our Healthier Nation (DOH 1999) reflected these themes, setting out contracts for health in which Government, other agencies and individuals all had a part to play. Previously, within central government, public health policy has too often been seen as the responsibility of health departments, thus leading to a very narrow view of public health. The Blair government’s approach to a ‘joined –up government’ is a welcome development from this perspective but more still must be done in co-ordinating and integrating decision making if this is to become reality at all. The government appears to be taking the approach to health promotion advocated by Tones et al (1990) in that the government are tackling the health inequalities and attempting to increase the nation’s health through policy and education.

One such strategy for tackling the inequalities in health provision has been the implementation of National Service Frameworks (NSFs). National Service Frameworks form one of the range of measures to raise the quality and decrease variations in service and is one of the drivers in delivering the NHS Modernisation Agenda. The National Service Frameworks are based on evidence based practice and defines service models for the promotion of health. However the National Service Frameworks are once again based around normative need and using the medical model approach. One such National Service Framework is the mental health NSF, which defines service models for the promotion of mental health and sets performance indicators and time scales that can be audited. This mental health framework sets out action to be taken by health and social services to deliver their contribution to achieving the target for mental health as set in Saving Lives: Our Healthier Nation. Mental health in the guise of work related stress currently has a high profile in the workplace at this point in time with 13.4 million working days lost annually due to stress, depression or anxiety (HSE 2003). The HSE is currently launching it own stress assessment tool to assist employers in carrying out stress risk assessments, tackling stress in the workplace, and thus reducing absence attributed to mental health that is caused or made worse by work. The mental health NSF once again uses epidemiological data with the aim to reduce suicide rates, whilst this mortality data provides measurable targets it is once again using a negative model of health.

The Government recognises that the workplace provides opportunities to improve the health of the workforce and to address health inequalities (DOH 1999), after all it is where many people spend the majority of their waking hours (McFall 1999). Interventions carried out within the working environment may affect any health differences between social classes by diminishing exposure to the determinants of health problems in the lower socio-economic groups (Hogstedt & Lundberg (2002). The contribution of Occupational Health Nurses was underlined in Making a Difference (DOH 1998) in that the workplace has enormous potential as a setting for improving the health of the adult population (DOH 2003). Firstly there is the access to large numbers of people who are at risk from adverse health effects. Secondly the working population remains a relatively stable population. Thirdly the cohesion of a working community that can offer the benefits of peer positive pressure and support with established channels of communication.

Whilst employees are more likely to prioritise their own health and security, an employer’s requirements are for a fit workforce (Thompson 1998). The health of employees is a core management issue as a healthy workforce is required for a business to succeed. A healthy workplace brings with it increased productivity through lower rates of sickness absence due to fewer accidents and less illness. As well as improving the health of individuals at work, experience demonstrates that a strong health and safety culture contributes significantly to profitability (HSC 2000). The Government’s proposals for healthy workplaces are a key strand of the public health strategy (Thompson 1998). The government also recognises that for health policies in the workplace to be effective they must be professionally led; therefore, the government has singled out occupational health nurses as the key to promoting health at work (Thompson 1998). In light of this recognition and within the remit of promoting a “healthier nation”, the Health and Safety Commission has developed a ten year strategy for occupational health. Securing Health Together (Health and Safety Commission 2000) is a ten-year occupational health strategy for Britain. The Health and Safety Commission recognise that whilst individuals who suffer most from ill-health are those without a job, the work environment is an ideal opportunity to promote health of individuals who may not necessarily be reached by other healthcare professionals due to their state of wellness. The occupational health strategy provides the opportunity to promote health and reduce ill health.

These Securing Health Together targets are linked to Saving Lives: Our Healthier Nation and are designed to focus individuals and inspire action (HSC 2000). If this strategy is to succeed then occupational health nurses need to set their own targets that are appropriate to their working environment and associated ill health problems (HSC 2000). “The estimation of the gross benefits to society of reaching three of the Securing Health Together targets is between £8.6 –21.8 billion by 2010”. (HSC 2000). The cost benefit implications is enormous in both in terms of the general economy and the releasing up of funding that can be redirected into other areas and begin to assist in addressing the health inequalities that there are currently.

Whilst it is good that the government appears to recognise the importance of occupational health with regards to the focus on primary healthcare, the recent documents and strategies however, “offer few realistic measures on how it can contribute to the nation’s health” (McFall 1999). The strategies are non-prescriptive in that they provide targets to inspire action but not ideas as to how the subject areas can be tackled. The occupational health nurse must therefore set their own programme of health promotion within the workplace with an approach that is relevant to their working environment. One such approach to health promotion that is widely accepted (Downie et al. 1996; Naidoo and Wills 1994) as appropriate for use within the work setting is the Tannahill Model (Tannahill 1985), which encompasses three overlapping spheres of health education, prevention and health protection. The aim of occupational health is to promote conditions at work to guarantee the highest degree of quality of working life by protecting worker’s health, enhancing physical, mental and social wellbeing, and preventing ill health and accidents.

The Securing Health Together strategy proposes four priority targets: heart disease, accidents cancers and mental health, all which link directly to Saving Lives: Our Healthier Nation and associated National Service Frameworks. Gyngell (1998) argues that these are ideal topics for the occupational health nurse to become involved with. The two, most important causes of ill health at work that lend themselves to a wide approach are musculoskeletal disorders and stress (Gyngell 1998). The need to reduce stress and mental health issues in the workplace that can be caused or made worse by work has once again been identified by epidemiological data such as sickness absence records. The awareness of stress and mental health needs in the workplace have been increased due to the Health and Safety Directive and the pressure of expressed need from collective unions on behalf of their members. At this point in time unsurprisingly, there has therefore been a rise in the number of claims for stress related disease or injury, especially mental health problems caused or exacerbated by work (Kloss 1998). The Health and Safety Executive (HSE) have therefore taken action in an advisory capacity and published guidance for employers in 1995, (Stress at Work – a Guide for Employers) and are currently piloting a stress risk assessment tool in partnership with various organisations and are in the process of developing draft management standards. However, currently the HSE believe that it is unlikely that the stress management standards will become an approved code of practice (ACOP) which would make the standards compulsory. The Securing Health Together Strategy is once again a medical model with the absence of disease being the focus and targets of a 20% reduction in the incidence of work related ill health and a 30% reduction in the number of work days lost due to work related ill health by 2010. The strategy can lead itself to a structural critique with a top down, professional led approach to change behaviour, with the need for the strategy being identified through epidemiological data which is compared with other EU countries and normative need identified through statutory legislation and surveillance. The new government document, Taking a Public Health Approach in the Workplace (DOH 2003) once again reinforces the role of occupational health and workplaces in health promotion. This collaborative approach continues to be fostered with this Department of Health document reinforcing the Health and Safety Commission’s strategy Securing Health Together (2000), The National Health Service Frameworks and all linking with the original targets to be met by 2010 in Saving Lives: Our Healthier Nation.

Overall it would appear from the preceding analysis that the current policy environment has elements that are conducive to reducing mental health and stress within the UK and constraints especially where work related stress is involved. As previously discussed the nature of the major causes of work related ill health makes occupational health fit more closely to the public health agenda than ever before. Despite this, more effective prevention, especially in the arena of work related mental ill health and stress will probably not be achieved without changes in employment law. Recommendations would be to take the radical structuralist approach with regards workplace stress and for the Health and Safety Executive to enforce its stress at work guidance by making it an Approved Code of Practice. This would require all employers to adhere to the stress guidelines which would be enforceable through criminal court rather than the voluntary stance that is currently in place and obviously not working as the number of companies taken to court by their employees due to work related stress continues to soar.

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Select one of the public health targets in England and critically assess the appropriateness of the current policy environment.

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