With an ever expanding population and people living longer but not more healthily, the demand of healthcare is increasing. This, coupled with the fact that there is a big squeeze on the amount of money available for healthcare from central and devolved budgets, has meant that all four countries in the UK have decided to focus on ‘prevention’, public health and tackling health inequalities.
In the UK, there are currently not enough people working specifically in public health to tackle the major public health issues of our ever expanding population. This means that more people from a wider workforce need to be engaged so that more people can be reached (CfW! 2015). The wider workforce is defined as:
‘Any individual who is not a public health specialist but has the opportunity or ability to positively impact health and wellbeing through their paid or unpaid work.’ ( CfWI 2015)
AHPs are ‘early adopters’
Allied healthcare professionals (AHPs) have been highlighted as ‘early adopters’ in the wider workforce because they are already engaged with the public’s health, are active and interested in doing more.
Public Health England (PHE) has jointly worked with the Allied Health Professional Federation (AHPF) to produce a strategy to develop the capacity, impact and profile of allied health professionals in public health (PHE/AHPF 2015). In it there are 5 broad goals that seek to engage the hearts and minds of AHPs and equip them with the knowledge and skills to enable them to undertake a public health function as part of their everyday work.
A survey of a sample of all of the 12 AHPs conducted by PHE and RSPH in 2015 revealed that there is an appetite for AHPs to engage in lifestyle health promotion activities:
- 87% AHPs agree that their role should include prevention of ill health.
- 76% agreed that their role gives opportunities for healthy conversations.
- 81% said that they already incorporate health improvement into their daily practice e.g. healthy eating advice.
- 86% of the public said that they would trust health promotion advice if it came from AHPs.
These results are reinforced by the results of a national survey of the general public in which 86% said that they would trust health promotion advice if it came from AHPs (PHE/RSPH 2015).
76% of dietitians consider public health and health promotion as part of their professional role.
In early 2016, Public Health England conducted a survey of all Allied Health Professionals including dietitians. 171 dietitians (mainly from England) responded of whom 36% were from the acute sector. The survey showed that 76% of dietitians regarded health promotion and public health as part of their role. 43% of dietitians said that they were interested in becoming public health champions.
43% of dietitians said that they would like to be a ‘public health champion’
Dietitians are already having ‘healthy conversations’ and offering brief interventions about diet but want help with some public health priorities
Dietitians are already having ‘healthy conversations’ and offering brief interventions with their patients, but mainly about diet, malnutrition, weight management and alcohol. This is not unexpected as dietitians are trained to do this and many (but not all) have behaviour change and motivational interviewing skills. It is also not unexpected that fewer dietitians have conversations and offer brief interventions about the following public health priorities (in descending order of frequency):
- mental health
- social isolation
- smoking cessation
- falls prevention
- pain management
- substance misuse
- domestic violence
- developmental delay in children
Knowledge and skills training for dietitians is needed
Currently not many dietitians are not trained to have conversations and offer brief interventions about the above issues and dietitians cited the following as the types of support that they needed:
Knowledge about: mental health, social isolation, musculoskeletal disorders, smoking cessation, physical activity, alcohol, falls prevention and early years best start in life
Skills training in: initiating and managing difficult conversations, knowledge of current national guidance / recommendations, knowledge of local services, assessing risk behaviour, engaging and motivating people, behaviour change, prioritizing where to start with multiple priorities.
One of the most common barriers to having healthy conversations is time
Dietitians also indicated that there are a few barriers to delivering healthy messages and these including:
- Lack of time
- Lack of knowledge of local services
- Lack of knowledge and expertise
- Lack of access to patient education materials
- A perceived lack of interest by patients
Managers can help by including public health in job descriptions and appraisals
The results of the survey suggested that it would help if there was greater support from managers:
- Appraisals to include healthy conversations and public health objectives.
- Job descriptions to include healthy conversations and public health.
- NHS organizations can help by including public health in dietetic service contracts.
Although the survey found that 53% of organizations expected dietitians to focus on prevention only 37% wrote this into the dietetic service contracts. Organizations can help to embed public health in dietetic services if more were to include public health specifically in dietetic service contracts.
The results of the survey showed that most dietitians regard public health as part of their professional role no matter whether they are based in acute or community sectors. All of the dietitians in the survey are already having healthy conversations about diet, obesity and malnutrition but very much fewer dietitians are having conversations about the other public health priorities (mental health, smoking cessation, falls prevention, social isolation, alcohol, physical activity). Of the other public health priorities dietitians are talking mainly about alcohol and physical activity.
The survey highlighted knowledge and skills training needs that included knowledge of the national guidance for the other public health priorities and training in the skills of initiating and managing difficult conversations, behavior change, motivational interviewing and how to prioritise multiple health problems. Patient education resources are needed as well as up to date knowledge of local services to signpost patients to. Training in these areas would also help dietitian find the time to fit having these conversations into their contact time with patients. It is anticipated that the public health champions will help dietitians to overcome the barriers detailed in the survey.
Dietitians need more support from their managers to encourage them to have more healthy conversations and make every contact count. This support can come in the form of specific public health work objectives that are talked about at appraisals and the incorporation of healthy conversations and public health into the job descriptions of all dietitians. Dietetic managers also need help from their NHS organizations to include public health and healthy conversations in the dietetic services contracts. To help with this Public Health England is devising impact evaluation tools that can be used so that dietetic services can evaluate the impact of their public health work.
So what is happening in the other UK countries?
Each country has published documents that describe the commitment of the NHS to public health and these are briefly described below:
In Scotland: The ‘2020 Vision’ published by the Scottish government envisages that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting and, that the healthcare system will focus on prevention, anticipation and supported self-management.
In Wales: A paper called ‘Our Healthy Future’ (2010) sets out a new approach to help everyone live longer with better health. It wants to:
- Improve health and wellbeing in Wales
- Keep everyone healthier for longer.
- Get rid of the differences between social groups and areas.
- Get rid of the barriers that stop people leading a healthy life.
In Wales a network of ‘Allied Healthcare Professionals Public Health Champions’ is being set up.
In Northern Ireland: Transforming Your Care (2011) is, amongst a raft of other promises, focused on getting better at preventing ill health in the first place. ‘Making Life Better’ is a whole system strategic framework for public health 2013-2023 sets out to achieve better health and well-being for everyone and reduce inequalities in health generally.