Comment

Developing public health pharmacy

By Gary Boorman, Surinder Kalsi, Imran Khan and Hemant Patel

Public health is currently high on the political agenda. The Government's health strategy for England, “Saving lives: our healthier nation”, outlines an ambitious health improvement agenda. Effective delivery of this will require a number of agencies and professional groups including community pharmacy to come together, develop a common agenda and work toward agreed public health goals. So now is a good time to consider public health and public health pharmacy.

What is public health?

Public health is concerned with health and disease in populations. It complements, for example, pharmaceutical, medical and nursing concerns for the health of individual patients. It is about monitoring the health of a population, identifying its health needs, fostering policies that promote health and evaluating health services. Commissioning services based on needs of the local communities flows from this in a dynamic process. For example, medicines management, which is essentially about harm reduction, efficiency of service, and cost-effectiveness, needs to be promoted on that basis. Other issues are secondary.

Many health and regional authority departments of public health are undertaking local reviews of the public health function. They are considering how public health support can best be provided to primary care groups and trusts, mapping the need for public health skills development at all levels. For community pharmacy this means using pharmacists' new and traditional skills to meet the identified needs of various local communities. To facilitate this there needs to be:

• development of an integrated and responsive public health culture
• an understanding and agreement about what public health pharmacy skills can be accessed and what functions can be undertaken locally, as well as what needs to be accessed and undertaken centrally
• agreement about key priorities and accountability arrangements for relevant public health pharmacists
• identification of local pharmacists with relevant skills, who need to be empowered to undertake new roles, and whose training and development needs need to be supported
• identification of public health skills and other tasks that are shared with local authorities

New approaches are needed because the new environment, particularly implementation of the NHS Plan and modernisation agenda, requires new ways of managing and delivering the public health function that will span the whole health economy, including independent professionals, NHS trusts, and local government and other agencies. If pharmacy is to make a contribution and connect directly with the mainstream agenda of improving health and tackling inequalities. it will have to embrace key principles of good public health practice.

In any new co-ordinated multidisciplinary model, mechanisms will need to be in place to ensure professional issues for pharmacists are safeguarded and to ensure clinical governance and specialist training requirements are met and lines of accountability are clear. Pharmacists will be held clinically accountable for what they do by changes in clinical governance arrangements and by changes in the Royal Pharmaceutical Society's Code of Ethics. It may even be that a new NHS contract might specify certain public health functions, like health promotion and early detection of disease. Unless there is local understanding by all concerned of the breadth of skills required to deliver public health programmes, available expertise — for example, that of community pharmacists — might not be appropriately tapped to benefit the various populations served.

Engaging local government and other partners

Ways of getting pharmacists to be involved in sensitive needs assessment and implementation of locally sensitive plans (which include support for health improvement plans and performance management) need to be urgently explored. Local networks, including the pharmacy network, will need to work with specific local initiatives such as health actions zones, Sure-start schemes and education action zones.

A number of health authority public health departments have started to allocate staff, usually on a part-time basis alongside wider health authority responsibilities, to individual PCG/Ts or groups of PCGs. This can operate on a hub and spoke model and provides the basis for setting up a local public health team and could comprise public health specialist expertise (medical or multidisciplinary public health), health information analysts and health promotion specialists. The team will also need to include staff with relevant skills from the local community, such as pharmacists, health visitors, school nurses, GPs, environmental health officers and other local government officers and members of voluntary organisations. They can help support local health needs assessment and community development work, local HImP development, local implementation of national service frameworks and local work on health inequalities. Pharmacy has a direct and tangible interest and local representatives must ensure that public health directorates are made aware of pharmacy's contribution.

Public health activities

Public health covers a wide range of activities, which may be undertaken in conjunction with representatives from other disciplines both inside and outside the NHS. There is now a wider recognition that any policy change to improve the health must look at prevention, treatments and all the wider determinants of health, such as poverty, pollution, housing and education. Public health activities include:

assessment of the community's health care needs

• planning programmes and services to improve the provision of health care in the light of changing needs and to promote health, eg, emergency hormonal contraception, smoking cessation and diagnostic testing
• evaluation of health care services in terms of access, effectiveness and patient acceptance
• promotion of a healthy environment, including responsibility for the control of communicable diseases and physical hazards to health, eg, provision of treatment and advice on head lice, malaria and tuberculosis, and safe removal of unwanted medicines
• provision of comprehensive medical advice to health authorities and other agencies, including surgeries and hospitals
• research into the aetiology, incidence and prevalence of disease, and into the effectiveness of services to prevent, diagnose and treat ill health

Increasingly there is recognition that health impact assessment (HIA) of various policy decisions must be carried out. HIA is based on a holistic, social model of health that recognises that the well-being of individuals and communities is determined by a wide range of economic, social and environmental influences as well as by heredity and health care. Location of pharmacies in relation to surgeries and populations and services provided must be considered under this heading as closure of a surgery can lead to closure of a local pharmacy, which in turn could lead to the closure of an adjoining greengrocer and butcher leaving the community without any local amenities.

Pharmacists, by involving themselves in the wider health agenda can join the fight to improve the nation's health. Such involvement will guarantee a sustainable future for both community pharmacies and the communities they serve.