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Public health - England

Key Points

Public health has been defined as "the science and art of preventing disease, prolonging life and promoting health through organised efforts of society" by the Faculty of Public Health.(1)

Public health falls into three main areas: health improvement, health inequalities, and health protection.

Physiotherapy has the scope to play a key role in each of these areas, especially with the growing emphasis on prevention, chronic disease management and health inequalities.

  • The CSP is running a long term 'Move For Health' programme and is working to engage members and the public more widely in the prevention of illness and promotion of good health, particularly by encouraging regular physical activity.
  • Public health seeks to understand and address the determinants of, and trends in, health across a population. It is well established that our health is affected by a range of factors, including where we live, our gender, income, education and social status. Public health is about promoting physical, mental or emotional well-being by inspiring, educating and empowering the public to stay healthy. Physiotherapists can play a key role in improving public health.
  • Over the past 50 years, there have been impressive social economic and health improvements in the UK. People from every class and region are healthier, and living longer than ever before. However, not everyone is able to share the benefits of these improvements. Inequalities in health start early in life and persist not only into old age but through subsequent generations.
  • A major aspect of public health involves tackling social inequalities in health. The major killers, such as stroke and chronic heart disease, are linked to socio-economic inequality, with risk factors such as smoking being much higher among people in deprived areas. An estimated 30 per cent of cases of coronary heart disease in under-65s, and 25 per cent of all cancers, could be prevented through public health measures to encourage healthier lifestyles.(2)
  • Key public health issues include physical activity, childhood obesity, work health, and the health of older people. Physiotherapists can play a key role addressing many of these issues – for example, by raising awareness of the links between a musculoskeletal condition such as back pain and contributory factors such as poor diet, lack of exercise and obesity, and helping people set goals and follow-up advice.
  • Public health initiatives draw on epidemiology – the branch of medical science that studies the factors that affect the health and wellbeing of populations – for their evidence base. This area of research investigates how specific health conditions may feed into wider health concerns (for example, how wider access to physiotherapy for lower back pain can affect overall levels of obesity).
  • There is a general acceptance that the NHS must play a greater role in preventing ill-health and maintaining and promoting good health if it is to be sustainable in its current form 
  • There is a growing emphasis on the need for all health practitioners to contribute to the public health agenda. Physiotherapists, as allied health professionals are key members of the wider public health workforce.

Implications

  • Public health involves education, preventing illness, empowering individuals to make health choices, and redesigning services to support all of these. Individual physiotherapists and practice managers can embrace these principles within every aspect of their daily practice.
  • Physiotherapists need to be aware of the latest advice on lifestyle issues that affect health. The most obvious issues within the physiotherapy scope of practice include obesity, levels of exercise, diet and injury prevention. But it is also important to be well informed about other factors, including smoking, diet, drug and alcohol misuse, and to offer motivation in these areas where appropriate.
  • Physiotherapists should engage with the epidemiological findings within their area of work to ensure that they are following the latest evidence-based practice.
  • Working with patients to set up activity programmes (such as the activity action plans set out in Choosing Activity), can help patients address a range of issues relating to their health and well-being. It can also help improve musculoskeletal health, decrease the risk of osteoporosis and back pain, and reduce the effect of arthritis.
  • A key part of the work for physiotherapists is to educate, encourage, inspire, and lead by example on ways of promoting well being and preventing ill health. This should be complemented by work to adapt services to respond to the challenge – not only within primary care, but also within secondary care and specialists' centres too.

News & Comment

Background

Physiotherapists have not traditionally identified strongly with public health. However, the philosophy of care of physiotherapy (and the other allied health professions) is a biopsychosocial model underpinned by enabling service users to learn how to manage their own health and sustain new positive health behaviours more effectively. In this way physiotherapists have in fact been contributing to this area of work for some time.

In recent years, there has been a growing emphasis within England on the importance of promoting public health and recognising the contribution of the wider public health workforce, including allied health professionals within that agenda. As a result, physiotherapists have been developing a growing understanding of the role they have to play within this area of work.

In the 2002 report Securing Our Future Health(3) and the follow-up review on investing in public health Securing Good Health for the Whole Population(4) (both commissioned by the then Chancellor of the Exchequer rather than the Secretary of State for Health), Wanless concluded that the health service must focus on prevention in order to be sustainable. Linked to this was the need for increased self-care, in which:

the health services can support a pro-active public… for example, helping people to empower themselves with appropriate information, skills and equipment or supporting people to take a more active role in the diagnosis and treatment of a condition followed by rehabilitation and maintenance of well being.(5)

These measures have already been taken up within physiotherapy, through initiatives such as self-referral.

Two years later, the Department of Health published the White Paper Choosing Health(6), which set out a strategy for improving public health. It had two supplementary sections – Choosing a Better Diet(7), and Choosing Activity(8) setting out specific guidance and targets for these areas.

In 2008, the Department of Health review High Quality Care for All(9) argued that the NHS should transform itself from an 'illness service' into a 'wellbeing service', and acknowledged the ability of all health professionals to help prevent ill health. Regional priorities were set out in ten-year vision documents, produced by each strategic health authority (for details, see the CSP's SHA Vision Synopsis). In 2009 the Department launched the physical activity care pathway Let's Get Moving(10), which set out NICE-recommended methods of promoting physical activity.

The Department of Health's public health programme is supported by national support teams that work directly with senior colleagues in PCTs and local authorities to help them deliver their public health priorities. They have dedicated teams working on a range of issues including childhood obesity and health inequalities.

Public health plays a major role in the commissioning process. Since 2008 each local authority has been required to produce a joint strategic needs assessment (JSNA), fed in to by a variety of statutory and non-statutory partners, to identify 'the big picture' in terms of the local population's health needs and any inequalities. This information is then used to inform primary care trust plans, in order to improve health outcomes and reduce inequalities. This process underpins a number of the world class commissioning competencies.

This process runs alongside local area agreements (LAAs), which set out the local priorities as agreed between central government and a local area (including the local authority, local strategic partnerships and other partners). Through these structures, local health priorities are focused on both improving the health of the local population and addressing health inequalities.

The Department of Health has released a series of health profiles for local authority areas, produced by the Association of Public Health Observatories, highlighting the health issues for each local authority across England.

The CSP has its own public health initiative, our Move for Health campaign, which complements the government's Change4Life campaign by promoting messages about physical activity and the expert advice that physiotherapists can provide on exercise and movement.

Sir Liam Donaldson, the Chief Medical Officer, in his Annual Report for 2009 states that the harm caused by inactivity has been ignored for too long and it is now time for action. He states that up to 70% of adults in England do not do the recommended minimum amount of physical activity and child fitness is falling by up to 9 per cent every decade.

In the report, On the State of Public Health, England's Chief Medical Officer calls for action to help reverse the nation's trend towards physical inactivity, including recommending that the Government undertakes a pilot of fitness assessments for every secondary school pupil. Sir Liam is calling for a major change to get the population active, whatever their age.

He says, "Inactivity pervades the country. It affects more people in England than the combined total of those who smoke, misuse alcohol or are obese. Being physically active is crucial to good health. If a medication existed that had a similar effect on preventing disease, it would be hailed as a miracle cure. Studies indicate that approximately 61 per cent of men and 71 per cent of women over the age of 16 years failed to meet the minimum adult recommendation for physical activity.

"Inactivity increases the risk of more than six chronic diseases. This is of grave concern. Improving physical fitness in children helps build a lifelong habit of participation in physical activity. We must get our children moving to improve their future health."

In addition to a pilot of comprehensive physical fitness testing in secondary schools, Sir Liam has also called for:

  • New recommendations on the minimum physical activity requirements to be built into public health programmes.
  • Recommendations for minimum physical activity requirements to be consistent across the United Kingdom.
  • Further research to be undertaken to establish the most effective interventions to increase physical activity within specific age groups.

Action Points

  • Take some time to understand the key drivers in this field and how they impact on physiotherapy in your area:
  • Read up on the epidemiology in your area of work. See, for example, the Association of Public Health Observatories website (http://www.apho.org.uk/) which has live data on various health issues and the Journal of Epidemiology and Community Health – the official journal of the society for Social Medicine.
  • Help your clients to make their own informed decisions about the choices that affect their health, drawing on the recommended targets for physical activity, calculating their Body Mass Index, and using the 5aday web tool.
  • Improve awareness of wider public health messages by promoting government targets for healthy lifestyles – for example, by displaying leaflets around your practice.
  • Educate and promote exercise and activity in programmes to patients with long-term conditions. Enable patients to manage their condition and to improve their fitness levels and their overall quality of life.
  • Find out about local health promotion projects or services and refer individuals, or make recommendations, if appropriate.
  • Collect key data about health inequalities in your area, and think about how you can address them through the way you promote your services and enable access to them.
  • Follow the nationally agreed standards to support your practice around the public health agenda set out in the National Occupational Standards for the Practice of Public Health. These will help you follow the same benchmarks as other healthcare workers, and can be a useful tool to sit alongside the National Service Frameworks and NICE guidelines.

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