Nurturing Infectious Ideas

• What is it that public health can do?
• Where does it add value to the wider system?
• Who are its natural allies and how can it recruit them to its cause?

Core Competencies in Public Health

Firstly, the tools. Public health has a set of core competencies, some historical, some new. These competencies must be explicitly recognised before they can be engaged in a strategy to bring about change. A core competency is something which:

• an organisation (or sector) does better than others
• is hard to imitate
• applies across a whole organisation and over time.

It is by leveraging core competencies that an organisation adds value in its interaction with stakeholders and customers. If an organisation does not know its own competencies it does not know how it can add value. A core competency covers a wide variety of knowledge and skill areas, for example, relationship management, supply line management, niche technology or niche marketing could all be core competencies.

This article proposes that the core competencies of public health are:

• health surveillance
• applied epidemiology
• applied health risk analysis and management
• public communication
• programme management.

Many of the small public health services through New Zealand do not have the critical mass to develop these core competencies into active marketable capabilities but the root training has still been undertaken.

In order to add value, these competencies or tools need to be applied in an environment where they will best achieve health gain. There are many sectors that have an impact on health, such as education, housing, local government and social support. However, the sector where the greatest influence can be generated in the shortest period of time is the health sector itself.

The competencies outlined above are missing or sparse in most parts of the health sector yet they are core to any movement away from episode-based treatment into integrated population health management. Further, they are necessary to create a common language for the health sector and to develop within the health system the capability to pass to the community itself the information and tools required to modify the emerging risk factors associated with technological urban societies.

Colonisation of the personal health services with the public health competencies would have a significant effect on the sector capability to deliver health gain.

Health Surveillance
If GP groups are to move towards having responsibility for the health of populations, they require an understanding of current health status in their ’patch’ and of the relationship between risk factors and outcomes. They also need to have the capability to see whether their own activities have any effect on health outcomes. Without health surveillance information there is no denominator for the financial enumerator of the health equation. Needs cannot be determined and outcomes cannot be measured.

Modern public health surveillance brings together laboratory data, hospital discharge data, GP disease diagnoses data and risk factor data and can present it in a traditional epidemiological analysis or in a geographic format. With information on the health status of the population within their immediate environment, GPs have their foot on the first step of the ladder to being advocates for community health. The historic role of the family doctor is a person immersed in the health of their community. However, 20th century advances in drug treatments and technological intervention have diluted that role into one of the 15-minute consult and prescription. Surveillance information gives GP the tools to take up the mantle of community leadership and, in the process, broaden their professional interest and reclaim community status.

Surveillance offers secondary care services a similar view from the bridge. Hospitals are data rich but analysis poor, with few links or ‘thinks’outside their own walls. Surveillance systems offer clinical planners the opportunity to view trends and act in a timely manner. They also offer managers new scope to analyse those investments made outside the hospital that are designed to manage demand. Examples of such investments are the Auckland influenza surveillance system, which provides weekly updates of influenza levels to clinicians and hospital mangers, and a recent call by South Auckland Health for more investment in the wider community health sector to reduce hospital admissions.


Applied Epidemiology
Epidemiology is the study of the distribution and determinants of disease.

The science of the epidemiology has generated the methodologies that determine causal associations, such as case-control studies, cohort studies and randomised controlled trials and the methodologies that support population screening programmes. Epidemiology is at the core of evidence-based practice and the development of clinical pathways that reflect best practice.

Unfortunately, the wider brief that epidemiology provides to problem identification and analysis is often missing from the primary and secondary care sectors. One strength of epidemiology is its ability to maintain a robust scientific approach while scoping from a whole population focus to a particular intervention. Evidence-based practice at the level of clinical intervention is able to be rationally aligned with a population view which looks at the cost-benefit ratio of that intervention in the wider scope of overall disease management. Epidemiology, therefore, has the ability to create the common language for the whole health sector. It also fits cleanly with economic analysis, providing a point of intersection for clinicians, managers and policymakers.

Epidemiology also has a role in public communications, reducing complex issues to simple concepts such as ’Numbers Needed to Treat’, thus allowing lay people to compare risks and interventions, and make decisions about value for money.


Health Risk Analysis and Applied Health Risk Assessment
Health risk analysis is an emerging science internationally and is still immature in New Zealand. However, health risk analysis is the cornerstone of the proposed new Health Act. The Bill supports a more explicit application of health risk methodologies at a central government and local government level. Health impact assessments could become as commonplace as environmental impact assessments, when looking at policies and development proposals. A health risk assessment quantifies the risk posed by a hazard. It is applied mainly in the areas of environmental hazards but could also be used to analyse social and economic hazards. Health risk methodology helps to develop a systematic approach to the prioritisation and management of risk. This methodology would be a key part of any strategy in which budget-holding and management of population health is aligned at the provider level. It would help to focus all providers on how to proactively manage risk and to prioritise investment in disease prevention.


Public Communications
Stephen Palmer, Professor of Epidemiology and Public Health at the University of Wales, said it best in a recent BMJ issue focussing on 150 years since the original Health Act: ’In the new information age it is the public themselves who will drive the agenda. The one thing that will sustain the momentum is providing open access to individuals to comparative information about their own health, environment and health care.’  ¹  

One of the reasons for infecting the entire health sector with the public health virus is to develop multiple champions for presenting health information to the people. Personal health care organisations rightly come from a culture of confidentiality, but this culture does not support a public mindset where health decisions are based on evidence. The health sector has demonstrably failed in supporting the population to make decisions that support good health. The alternative therapies industry is very proficient at motivating proactive health action. Unfortunately, that action is often misguided and ineffective, however, they have shown that it can be done.

Public health providers are the only place within the health sector where the culture and skills for proactive public communications reside. The communications agenda should focus not only on personal health issues but also on the wider risk factors inherent in communities and technological urban environments. The communications ’competency’ links closely with the need for strategies to shift health surveillance and information management from being a series of data museums into focussing on information-for-action.


Health Programme Management
Public health programmes start with a needs analysis, build strategies in consultation with stakeholders, project manage programme activities over space and time and end with a formal evaluation. This process is fundamental to project management, however, it is rare to see programme development and management undertaken competently within the wider health sector. Hospitals are getting better at it but programme development and evaluation are not skills that GPs have been trained in. However, health programme delivery is fundamental to the any strategy that aims to manage population health status or modify risk factors.

The rigours of formal programme management methodologies, as understood in public health, would provide the platform for operationalising the other four competencies in primary and secondary care, for example through surveillance systems, public communication programmes or evidence-based screening programmes.

Summary

Transplanting public health competencies into the wider health sector will have broad ranging positive effects on the ability of the sector to contribute to health gain. But before the public health competencies can be exported into other parts of the health team they must be nurtured and grown within public health. New Zealand always suffers from a lack of critical mass when it comes to issues of technical expertise and public health is a prime example.

Public health services in Auckland have only just achieved the critical mass to support, develop and export these competencies. Services in Wellington and Christchurch are struggling to develop their specialist skill sets. Other parts of the country simply do not have the staff numbers to support the specialisation necessary to maintain skill sets and knowledge in a manner that would define them as ’competencies’.

The public health sector requires a process of consolidation or the development of virtual teams, which would support expansion of its unique skill sets and marketing these capabilities to the wider health sector. The Ministry of Health also needs to review its own function and expand its horizons towards blurring the historic bureaucratic boundaries between public and personal health and allowing the public health competencies to become the new common language and base note for sector development.