An evidence-culture shock for public health in local government
Gemma Phillips suggests that a fresh and appreciative understanding of how local government has improved public health over the past 40 years would be a fruitful approach following reorganisation.
The shifting of public health responsibility back into English local government, after 40 years as part of the National Health Service, has had an element of missionary zeal to it. Those of us who favour a ‘structural and social determinants’ approach to improving population health see the development as an opportunity for a step change in public health practice. Reflecting their time in the NHS, during the rise of evidence-based medicine and the standardisation of medical practice, public health professionals have a curriculum dominated by a medical model of health. Epidemiology is its core discipline, with a commitment to a hierarchy of evidence that holds the randomised controlled trial as an ideal, even if other types of knowledge are actually drawn on in practice.
Not surprisingly, many public health professionals have seen the world of local government as a threat to their work. They have tended to over-emphasise the influence of politics in local government and to present themselves as ‘evidence guardians’, positioning themselves as objective and neutral, unsullied by politics or ideology. Some have seen themselves as a force for enlightenment and rationality, tasked to convert to better ways those operating in the murky world of local government decision-making, educating them in the ways of evidence-based working.
However, the picture I have gained through observing local government officers at their work shows them operating in a sophisticated and complex manner that helps create the spaces in which health gain can be both advocated and achieved. They emphasise their accountability to multiple stakeholders: their local population, the requirements of good public administration, elected councillors. They must mediate and arbitrate between the needs of different sections of the public and integrate those groups’ needs with the financial and legal requirements imposed by central government. It is within this ever-changing context that the possibilities and options for action on the social determinants of health are decided upon.
Now, it would be naive to suggest that local politicians do not influence local services and programmes – indeed it is their job to do so – but I did not see dominant political ideology tainting every corner of the local authority in the way that has been feared by some in the public health profession. If politics is pervasive in the work of local government officers, it is in this everyday, interpersonal sense, not in the sway of party-political ideology.
For local government officers, local knowledge, expertise and their own particular experiences are key in shaping their decisions and for reassuring the public. Their work is constantly evolving, amid the fluid agendas of national and local politics as well as different sources of internal and external funding. Typically, their accumulating knowledge is embedded in practice and used to develop and adapt what they will do in the future, rather than to judge an approach as right or wrong, valid or invalid, as is the mantra of the controlled trial in public health.
These officers tend to have a strong sense of their locality’s unique character. This means that the notion of a generalizable ‘evidence base’ might not make a lot of sense to them. Their starting point is the locality and their understanding of it. So they have their own models of what the problems are and what might work and they test data and ideas from elsewhere against this knowledge.
It’s not that local government officers deliberately create barriers to the use of traditional public health evidence. It’s more that they have an entirely different framework for taking decisions that might impact on the social determinants of health. At its heart is a rather messy and multi-faceted notion of ‘wellbeing’. So there are lots of outcomes they value (such as reducing pollution, alcohol harm and road injury) that overlap with those of public health. This means that the different healths of diverse publics are brought into conversation with one another in decision-making. Within this complex of interests and agendas, public health professionals, and their particular conceptualisation of health and its promotion, emerge as simply one more interest group.
And I have to ask if maybe this should be the case? If the public health profession is really to embrace a social determinants approach, rather than just transfer its current approaches, will it not have to get involved in the politics of trading off different lives, livelihoods, needs and wants? Looking back to social medicine and the healthy public policy movement as the precursors to the ‘social determinants’ model might reinvigorate a taste for the political. Certainly, some Directors of Public Health have talked about trying out this approach. Perhaps, instead of decrying the ‘politics’ of local government, those newly arrived on the scene might also be wiser to explore what local government officers have achieved over the last 40 years without the organisational incorporation of medically-oriented public health specialists? They have been working over fields as diverse as food risks, refuse collection, transport safety and providing green space. In their actions, local government in England has been protecting, and sometimes improving, the wellbeing of its citizens.
And what about us public health researchers? Where will we fit into all this? We have talked at length about wanting to produce ‘better’ evidence to support public health work in local government. But whose definition of health are we choosing? And whose evidence? Is there a risk of irrelevance if we continue to operate within our current framework of epidemiological science with a sprinkling of qualitative methods to enlighten us as to what’s ‘really’ going on? There is certainly a market for it with Public Health England advocating greater use of traditional ‘evidence’ as a defence against political decision-making in the new world of public health. However, putting public health into local government was intended to harness the potential to work with other service areas and remodel public health around a social determinants approach. So we have some work to do to integrate two very different cultures of knowledge and evidence in order to support this new alliance for improving population wellbeing.
Dr Gemma Phillips is a Research Fellow at the University of Edinburgh, Centre for Population Health Sciences and a Research Associate at the University of Glasgow, MRC/CSO Social and Public Health Sciences Unit. She was previously a Research Fellow at SPHR@L.
Her SPHR@L presentation entitled ‘Politics, localism and epistemologies of practice: How will evidence-based public health fair in the world of local government?’ is on Thursday, 16 October 2014, 12:45 pm at Jerry Morris A, LSHTM, 15-17 Tavistock Place, London WC1H 9SH.