Public health topics

Nursing roles

“Without nurses, much of the public health interventions essential to improving the health of individuals, families, and populations would not be possible on a large scale” (Savage and Kub 2009, p.2847). Many nurses as part of their role have long been involved in health promotion and health improvement activities and preventive work. These include nurses working in sexual health who tackle sexually transmitted infections and teenage pregnancy; nurses working with disadvantaged groups and on projects to reduce health inequalities; nurses involved in travel health and those who work for the health protection agencies; occupational health nurses (OHNs) who are key players in delivering the recommendations made around improving the health of the working age population.

All nursing staff have opportunities to deliver messages about healthier living and behaviours in their interactions with members of the public wherever they provide care. The importance of this and developing the skills to support it has been highlighted for example in the Prime Minister's Commission on the Future of Nursing and Midwifery in England and the Northern Ireland strategy for nursing and midwifery (Department of Health, Social Services and Public Health 2010; Prime Minister's Commission... 2010). The view of the Royal College of Nursing (RCN) is that “a new approach should be adopted across the nursing team to ensure all nurses have an increased and more explicit role in public health and sustainable health” (RCN 2012a, p.9).

To illustrate this and the potential of the nursing contribution to the current public health agenda the RCN has published a guidance document which demonstrates through practice examples how nursing staff in all four UK countries are actively engaged in upstream public health. Upstream approaches in public health are described as those that “seek the causes of disease and preventable disability in order to address problems through prevention, rather than treatment” (Royal College of Nursing 2012a, p.3). The document presents a framework which identifies the core ingredients of the nurses contribution to better health outcomes and suggests how practical approaches for nurses working upstream can be linked to key priorities facing service planners and commissioners.

In addition “nurses also have a key role in minimising the impact of illness, promoting health and function (capabilities), and helping people maintain their roles at home, at work, at leisure and in their communities” (RCN 2012a,p.3). For example the roles of community nurses in delivering quality care to people with long-term conditions (LTCs), supporting self-care and preventing further ill-health are key to reducing the burden of LTCs, though an article by McHugh et al (2009) identifies a need to strengthen nursing and public health roles.

Alongside this there have also been initiatives, which impact on the public health agenda, relating to specific roles. The Government has released a five year plan and programme to expand and strengthen health visiting services in England and “to re-emphasise health visitors as key public health professionals” (Department of Health 2011, p.19).

The RCN has published position statements on both health visiting and school nursing which underline the vital contribution these groups make to health in childhood and beyond. All four countries have policies which emphasise the importance of support in the early years for health improvement across the lifespan and these are highlighted within the position statements.

The RCN position statement on health visiting focuses on the role of health visitors in child health and development in the context of community nursing reforms in the four UK countries (Royal College of Nursing 2011). The document sets out a series of statements which “must be applied in their entirety to developments taking place across the UK reforms of early years to be successful" (RCN 2011, p.7). The RCN position statement on school nursing highlights the significance of the school nursing role in the context of health agendas in each of the four UK countries and the impact school nurses can have “ in breaking intergenerational cycles, facilitating behaviour change, promoting healthy lifestyles, and choices for the benefit of children, young people and their families” (RCN 2012b, p.15).

The extent of the contribution these groups make is also illustrated by the Scottish career and development framework for public health nursing developed as part of the Scottish Modernising Nursing in the Community programme (NHS Education for Scotland 2011).

Tackling health inequalities

The health of populations in industrialised countries in many ways has never been better (World Health Organization 2008). However these health gains are not shared equally by all members of society. Wealthier people tend to live longer and lead healthier lives than people in lower social classes. For example “even excluding the poorest five per cent and the richest five percent, the gap in life expectancy between low and high income is six years” (Marmot 2010, p.37). Other differences, such as ethnicity, gender, sexuality, age, area, community and religion also affect life chances.
 
The socioeconomic determinants of health have long been recognised. How central this is to future improvement in health is a point which is made forcefully in the review Fair society, healthy lives by the Chair Professor Sir Michael Marmot - “this link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus” Marmot 2010, p.3).

Not surprisingly tackling health inequalities is a key concern of public health policies across the UK:

  • In Wales Our healthy future focuses on tackling health inequities as an approach (Welsh Assembly Government 2009).
  • In England the independent review on health inequalities has identified the six policy objectives and the action required around these to achieve reductions in health inequalities (Marmot 2010). 
  • In Scotland the Equally well implementation plan acting on the report of the Ministerial Taskforce on Health Inequalities sets out "an ambitious and radical programme for change across the key priority areas of: children’s very early years; the big killer diseases of cardiovascular disease and cancer; drug and alcohol problems and links to violence; and mental health and wellbeing" (Scottish Government 2008, p.2).
  • An All Ireland report on tackling health inequalities identifies the key challenges for Ireland and Northern Ireland in addressing health inequalities as income inequality, child poverty and fuel-poor housing (Farrell et al 2008).

Common themes across the UK countries include the importance of interventions early on and the need to give children the best possible start in life, but also recognition of the potential impact of different social determinants and how they influence health at different stages of life. A “commitment to learn from the best available evidence of what works in tackling equalities in health” (Scottish Government 2008, p.10) is echoed by the other countries, for example a key task of the Marmot review was to identify “the evidence most relevant to underpinning future policy and action” (Marmot 2010, p.4).

Also highlighted across the different policy and implementation documents are the structures and systems for implementing policy and initiatives with recognition that “complex, multifaceted and collective action is required” (Welsh Assembly Government 2009, p.13). For example, in Wales a unified public health system has been developed with Public Health Wales providing the specialist public health support (Public Health Wales 2010).

The involvement of a wide range of stakeholders in working to improve health is essential – central and local government, health and public services, the third sector and communities with an emphasis on activities at local level. In England in his vision for a new Public Health Service Andrew Lansley, Health Secretary, emphasises the need for "genuinely local strategies, based in neighbourhoods and schools" (Department of Health 2010a, para 6), with greater use of local voluntary and charitable organisations.  

Partnership working and cross-sector collaborations are important. Examples of collaborative activity can be found in the Year of healthy communities calendar which showcases some of the work which was undertaken by local councils and their partners focussing on what was identified as ‘strategic levers’ critical to success in improving health and reducing health inequalities (Improvement and Development Agency 2010). Healthy Places, Healthy Lives is a partnership programme which helps to reduce health inequalities and improve population health (NHS Institute for Innovation and Improvement 2012). It was originally tested in thirty areas of the country (Department of Health 2010b).

References

The items referenced below were last accessed on 2 March 2012. The majority are in PDF format - see How to access PDF files.

Department of Health (2010a) Health Secretary sets out future of public health. DH website.

Department of Health (2010b) New programme to make health inequalities everybody’s business. DH website. 

Department of Health (2011) Health visitor implementation plan 2011-15: a call to action. London: DH.

Department of Health, Social Services and Public Health (2010) A Northern Ireland strategy for nursing and midwifery 2010-2015. Belfast: DHSSPS.

Farrell C et al (2008) Tackling health inequalities – an All-Ireland approach to social determinants. Dublin: Combat Poverty Agency / Institute of Public Health in Ireland. made available by The Health Well.

Improvement and Development Agency (IDeA) (2010) Year of Healthy Communities Calendar: April 2010 to March 2011. IdeA website.

Marmot M (2010) Fair society, healthy lives: Strategic review of health inequalities in England post 2010 (the Marmot Review). UCL Institute of Health Equity.

McHugh GA et al (2009) Specialist community nurses: a critical analysis of their role in the management of long-term conditions. International Journal of Environmental Research and Public Health 6(10) pp.2550-2567 (special issue on nursing and public health).

NHS Education for Scotland (2011) Career and development framework for public health nursing – health visiting and school nursing in Modernising Nursing in the Community. NES website.

NHS Institute for Innovation and Improvement (2012) Health places, healthy lives. NHS Institute website.

Prime Minister's Commission on the Future of Nursing and Midwifery in England (2010) Front-line care: the future of nursing and midwifery in England 2010. London: The Commission.

Public Health Wales (2010) Local public health. Public Health Wales website.

RCN (2011) RCN's UK position on health visiting in the early years (PDF 576KB). London: RCN.

RCN (2012a) Going upstream: nursing’s contribution to public health: prevent, promote and protect. RCN guidance for nurses (PDF 342KB). London: RCN. 

RCN (2012b) The RCN’s UK position statement on school nursing (PDF 240.5KB). London: RCN.

Savage C and Kub J (2009) Public health and nursing: a natural partnership. International Journal of Environmental Research and Public Health 6(11)  pp.2843-2848 (Special issue on Nursing and public health).

Scottish Government (2008) Equally well implementation plan. Edinburgh: Scottish Government.

Welsh Assembly Government (2009) Our healthy future: technical working paper. Cardiff Welsh Government.

World Health Organization (2008) Responding to the challenges of a changing world. WHO website.