Discussion Paper - (2008) Volume 16, Issue 3
Lecturer in Public Health, Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, UK
Received date: 25 November 2007; Accepted date: 19 February 2008
The World Health Organization’s Ottawa Charter for Health Promotion has been influential in guidingthe development of ‘settings’ based health promotion.Over the past decade, settings such asschools have flourished and there has been a considerable amount of academic literature produced,including theoretical papers, descriptive studies and evaluations. However, despite its central importance, the health-promoting general practice has received little attention. This paper discusses: the significance of this setting for health promotion; how a health promoting general practice can be created; effective health promotion approaches; the nursing contribution; and some challenges that need to be resolved. In order to become a health promoting general practice, the staff must undertake a commitment to fulfil the following conditions: create a healthy working environment; integrate health promotion into practice activities; and establish alliances with other relevant institutions and groups within the community. The health promoting general practice is the gold standard for health promotion. Settings that have developed have had the support of local, national and European networks. Similar assistance and advocacy will be needed in general practice. This paper recommends that a series of rigorously evaluated, high-quality pilot sites need to be established to identify and address potential difficulties, and to ensure that this innovative approach yields tangible health benefits for local communities. It also suggests that government support is critical to the future development of health promoting general practices. This will be needed both directly and in relation to the capacity and resourcing of public health in general.
general practice, health promotion, nursing, settings
How this fits in with quality in primary care
What do we know?
The World Health Organization’s Ottawa Charter for Health Promotion has been influential in guiding the development of ‘settings’ based health promotion in sites such as schools. The application of the concept to the health promoting general practice has received little attention.
What does this paper add?
This paper discusses the concept of the health promoting general practice where staff undertake a commitment to create a healthy working environment, integrate health promotion into practice activities and establish alliances with other health promoting institutions and groups within the community.
The World Health Organization’s Ottawa Charter for Health Promotion (see Box 1)[1] is a seminal document of the new public health.[2–4] The charter was influential in guiding the development of the settings approach. This moved interventions upstream away from merely focusing on individuals who are ill and towards organisations, systems and the environment that can be used to prevent ill-health and promote health. The UK public health strategies have all commented on the importance of certain settings.[5–9] For example, Our Healthier Nation[9] emphasised communities and healthy schools and Choosing Health[8] devoted a whole chapter to the workplace and a health-promoting NHS.
Internationally, examples of a wide range of settings can now be found including:
• healthy cities
• healthy islands
• health promoting schools
• health promoting workplaces
• health promoting prisons
• health promoting hospitals.
For some of these, for example health promoting schools and health promoting hospitals, a considerable amount of academic literature has been produced, including theoretical papers, descriptive studies and evaluations. However, despite its crucial importance, the health promoting general practice has received little attention. This paper will attempt to rectify this situation by discussing: the significance of this setting for health promotion; howa health promoting general practice can be established; effective approaches; the nursing contribution; and some challenges to be resolved.
Although the settings approach was given a substantial boost by the Ottawa Charter,[1] it was at an earlier World Health Organization global meeting at Alma- Ata,[10] where primary health care was adopted as the principalmechanism for healthcare delivery.[10] The conference called for urgent national and international action to develop and implement primary health care throughout the world. It should be noted that here the World Health Organization was using the primary healthcare concept in its broadest form. In a later ambitious strategy they were explicit that primary health care should be the hub of the healthcare system, with secondary and tertiary levels placed in a supporting role.[11]
It is almost 30 years since Alma-Ata and there is now considerable agreement among leading academics, international organisations and many governments about the importance of primary care as the key to an effective and efficient health service.[12–17]
In England, Shifting the Balance of Power created primary care trusts (PCTs) to lead the NHS in assessing needs, planning and securing all health services and improving health.[18] In essence they were given both the public health function and the majority of the NHS budget. The latest strategy Our Heath, Our Care, Our Say signalled a further shift of care towards primary and community care settings and away from acute hospitals.[19] It also indicated that there was to be a move towards an emphasis on prevention.
In his succinct document A Dozen Facts About General Practice, Professor Pereira Gray clearly highlights some of the main reasons why general practice is considered to be a key setting in the UK.[20] For example, in terms of reach, there are about 250 million consultations between patients and general practitioners (GPs) every year, and about 15% of the entire population has contact with their GP in a two-week period.[20] However, behind these statistics it is important to remember the doctor–patient relationship. Registration with a GP provides an important link with an individual that can last many years, including those where significant health events occur. There are, therefore, many opportunities for maintaining and promoting the health of individuals and their families. For those who have a long-term condition, and this is nearly one in three people,[19] continuity of care by someone who knows and understands the individual’s problems, is particularly important.
With a sound knowledge of individual patients, GPs in this setting are well placed to perform their decisive gatekeeper function; here they are functioning as agents of their patients and, Starfield suggests that this offers protection from unnecessary procedures.[21] Besides knowledge about individuals, practitioners have an intimate knowledge of their local community including information about local factors that may influence health. This presents opportunities for practices to play more roles in tackling certain public health issues.[15]
In addition, general practice is consistently well rated, and GPs are accorded a high status and credibility, [20,22–24] so also providing them with the potential to act at an individual and community level on public health matters.
There are many opportunities for promoting health in this setting. However, it is necessary to differentiate between a ‘health promoting general practice’ and health promotion in general practice. The latter may merely involve certain aspects of health promotion that are carried out as part of the normal dealings with patients, whereas the former is a more comprehensive and co-ordinated approach. The health promoting general practice is essentially the gold standard. Baric suggests that to become recognised as a health-promoting general practice the staff must commit to fulfil three conditions (see Figure 1).[25]
Figure 1: Three criteria for a health promoting general practice
The workplace can have a powerful effect on the health of employees, and a number of authors have written about the costs of ill-health to organisations, and the benefits of creating a healthy workplace.[26–29] The benefits include fewer injuries and accidents, improved productivity and performance, and improved employee morale and staff retention.[29] If a practice were to create a healthy working environment, it could also be used as a model to encourage other workplaces to follow.
For health promoters, the workplace provides access to a target group that is to a certain extent a ‘captive audience’. It is noteworthy that in terms of access, around 160 000 GPs, nurses and others work in and alongside general practice,[19] and thus there is a gateway to a significant population. In addition, the staff in general practice, in common with other employees, spend a considerable amount of time at work. Therefore, long-term effective interventions can be planned.
Kristenson and Weinehall, in their national report entitled Towards a More Health-promoting Health Service, recommend that the health service, whose very ‘business idea’ is health, should be a pioneer in creating optimum working conditions for staff.[30] They also suggest that this approach is important for the patient’s health as the staff ’s own experiences will then be reflected in their approach to disease prevention and health promotion initiatives.
The Faculty of Public Health has fairly recently produced a practical guide to support employers to improve the health and well-being in the workplace.[29] It covers major areas to make the workplace conducive to health, including: mental well-being and minimising stress; musculoskeletal disorder; physical activity; and recruitment, retention and rehabilitation.
The comprehensive and co-ordinated nature of health promotion in a well developed health promoting setting has been described succinctly by Tones and Green:
A key feature of the settings approach is that it involves ensuring that the ethos of the setting and all the activities are mutually supportive and combine synergistically to improve the health and wellbeing of those who live or work or receive care there.[31]
Although one of the criteria for the health promoting general practice includes the words ‘integrate health promotion into all practice activities’, this should be seen as a long-term goal rather than a starting point. In the early phases it is advisable to have consultations with a public health/health promotion specialist so that time scales, planning, potential obstacles, resource requirements and effective approaches can be discussed. [25]
Lessons from a review of the literature on the health promoting hospitals movement have indicated that in reality there can be a variety of interpretations of the meaning of a health promoting setting.[32] At one extreme some hospitals do little more than provide health information and education to patients, whereas, at the other, health promotion becomes integrated into staff roles throughout the organisation. For the re-orientation of the hospital to occur and be sustainable, the research indicated that there had to be strong organisational commitment to change, supported by strong policy and leadership. Similar levels of commitment and support will be needed in general practice.
It is important to highlight that general practice is one, but only one, key setting for health promotion activities, and alliances with other settings and groups will be needed for the benefit of patients as well as staff.[25,33] In accord with this, the Royal College of General Practitioners’ recent ‘roadmap’ for the future direction of general practice suggests that primary care professionals and public health physicians should provide leadership and take the health promotion agenda forward in schools and workplaces.[15] Advocacy and direct action in different settings will make general practice an even more potent force for health.
Although in the past there has been a dearth of information about the effectiveness of health promotion in the primary care setting, health promotion theory provides a number of frameworks that should be used to guide action.[31,34,35] In addition, the World Health Organization’s Ottawa Charter provides clear direction.[1,36] More recently, there has been a growing number of articles and books that highlight opportunities, especially in the priority areas identified in Choosing Health.[8]
In relation to smoking, for example, recent Cochrane reviews have indicated that fairly brief advice from doctors and nurses can have an effect on cessation rates.[37,38] However, the review by Rice and Stead also indicated that the challenge now will be to incorporate smoking behaviour monitoring and smoking cessation interventions into standard practice, so that all smokers are given an opportunity to be supported.[38] A further systematic review and metaanalysis that has clear relevance to this setting assessed the effectiveness of brief interventions delivered in general practice to reduce alcohol consumption.[39] Here, brief interventions were again shown to be effective and consistently produced reductions in alcohol consumption.
Another major public health problem that is linked to national strategies concerned with diabetes, coronary heart disease, stroke, chronic kidney disease and the health of older people is hypertension. It should be noted that for this issue there was sufficient evidence for the Faculty of Public Health and the National Heart Forum, to jointly produce a detailed toolkit to support health professionals (including those in general practice) in producing effective strategies.[40]
Looking further afield, a number of high-income countries including Canada,[41] the Netherlands[42] and Sweden,[30] have recently carried out major reviews of their health systems and have elicited some similar findings, particularly in relation to health promotion. In Canada, for example, the evidence was compelling enough to recommend that one of the directions for change should be:
Integrate prevention and promotion initiatives as a central focus of primary health care targeted initially at reducing tobacco use and obesity, and increasing physical activity in Canada.[41]
Similarly, in the UK, the independent review carried out by Sir Derek Wanless found evidence of effectiveness. [43] His final report stated:
An NHS capable of facilitating a ‘fully engaged’ population will need to shift its focus from a national sickness service, which treats disease, to a national health service which focuses on preventing it.[43]
Although he did comment on the lack of research in the past, he concluded that resources should be made available to ensure that successful initiatives are rapidly ‘rolled out’.[43]
For those in general practices who are seeking details about effective public health approaches, a valuable national source is the National Institute for Health and Clinical Excellence. One of its key functions is to produce guidance on the promotion of good health and the prevention of ill-health for those working in the NHS, local authorities and other sectors. For example, a recent relevant production presented a set of generic principles that can be used for behaviour change at the population, community and individual levels.[44] At a PCT level, effectiveness information can be found in the annual reports of the Director of Public Health and in multi-agency health strategies. These documents should be used to guide the development of health promotion in general practice.
For practices that have studied different health promotion approaches,[31,34,45–47] it will have become apparent that there are certain key components of effective programmes (see Box 2).
One such component, needs assessment, is included as the first stage in at least two influential planning frameworks.[34,47] Enlightened practices will draw on the needs assessment skills of community nurses and health promotion/public health specialists.[48,49] These groups could help to broaden the perspective and approaches taken.[50] Additionally, individuals may also have very useful longstanding networks with key people and members of the public that could be drawn on to aid the needs assessment process. Practical guidelines on how to assess needs and set priorities, have been clearly and concisely described by Ewles and Simnett.[34] At the primary care level, there have also been documented examples of good practice.[51,52]
After needs assessment and the setting of priorities, a systematic strategy should be developed linking the skills and expertise of all relevant staff to the unique needs and characteristics of the target community. The strategy should cover: priorities; target groups; interventions; and quality control. In addition, it should also take account of the support needed, including training needs. A useful starting point in developing a strategy is to scrutinise similar or broader strategies that may have been produced at different levels including PCT, regional and higher levels.
Evaluation is also an integral component of effective health promotion,[28,53] and it is not merely a process for documenting the past or judging performance; it also offers an opportunity for learning and directing the way forward. A range of methods should be used, each carefully matched to and built into the particular stage, element and level of the programme. Both quantitative and qualitative designs may be needed, and staff who are involved should draw on their research skills from their feeder disciplines.[54]
Teamwork is a prerequisite of effective health promotion, [34,55] and increasingly professionals will have to work as members of multidisciplinary teams. The make-up of teams in general practice will vary widely depending on the task to be accomplished. A hypertension team, for example, may include: GP and/or practice nurse; patient or carer; practice manager; public health specialist; and a pharmacist.[40] There may also be other members depending on the specific focus of the team.
Looking beyond the health service, it must be remembered that a primary care team on its own may have a limited impact on health. Key people, for example from schools, workplaces, the local authorities and the media, all have roles to play in effective health promotion campaigns, and they may already be working together on specific topics. In most districts multi-agency groups exist for certain topic areas such as accident prevention and heart health. In general, these groups co-ordinate activities, act as champions for the topic, and research and evaluate activities. It is important that doctors, nurses and other members of primary care teams are represented on these groups so that they can maximise their impact at both an individual and a community level.
The amount of support available is a significant factor in determining the level and quality of health promotion in general practice.[28] At a local level, health promotion/public health specialists may be available to facilitate some teams, whereas, at a national level one type of support that is available is the Quality Team Development (QTD) scheme, which is specifically designed to assist general practices in improving the quality of their services. It has already been used by over 2000 practices to review their own performance.[19] The QTD criteria cover health promotion, giving and recording of lifestyle advice, and working in partnership with other organisations.
The importance of team cultures and team climate theory to quality in general practice has recently been succinctly described by Edwards and Langley.[56] At a time of considerable change within the NHS, it is essential that teams have a constructive ethos so that they can face the challenges positively and adapt to the many new demands and opportunities. An understanding of motivational theory is crucial for many who work in general practice, both in relation to helping patients develop healthy lifestyles and in relation to the performance of individual team members. [57] High-performing teams will be ‘learning teams’, tapping the potential of all the members, and characterised by high levels of commitment and motivation. [57–59]
The World HealthOrganization’s Munich Declaration recognised the unique roles and contribution of nursing as a ‘force for health’ and states:
WE BELIEVE that nurses and midwives have key and increasingly important roles to play in society’s efforts to tackle the public health challenges of our time ...[60]
Within the UK, NHS policies and initiatives have emphasised the development of the public health roles of nurses.[7,19,61–64] Supporting this, the Royal College of Nursing in alliance with a number of other organisations such as the United Kingdom Public Health Association has recently produced a paper describing how nurses can influence the health of communities.[65] Key roles include individual and population needs assessment, community development and partnership working. They also provide some concrete examples of innovative initiatives.
In the primary care setting, distinctive contributions are made to improving health from different nursing disciplines including health visitors, school nurses, practice nurses and district nurses. In addition, in response to national policy, new contracts, increasing service demands and shortages in the medical workforce, new nurse-led first-contact roles have developed.[66,67] A recent national study found that most PCTs reported having nurse-led services for a range of important public health issues (e.g. asthma, coronary heart disease, diabetes and hypertension).[66]
Some nurses working in primary care have significant clinical elements to their role and focus on individual care and treatment, whereas others, for example health visitors, have considerable potential to develop broad health-promotion approaches in line with the Ottawa Charter. Moreover, successive government policies have introduced supportive statements for such developments.[7,8,63] For example, Saving Lives: our healthier nation highlighted the need to strengthen the public health role of health visitors in order for them to work in new ways.[8] It stated that they are in the future to be encouraged to develop a familycentred public health role.
Although over the last two decades there has been considerable literature encouraging nurses to take on more health promoting roles, there has also been a growing body of research illuminating the reality and describing barriers inhibiting them.[68–76] If nurses in primary care are to develop their health promoting roles in line with the Ottawa Charter, then they will need extensive education, time, support and effective leadership.[71–73,76,77]
On paper at least, primary health care has been highlighted as a key setting in both national and international declarations, strategies and other documents. However, not all are fully convinced that primary care is fully in the ‘driver’s seat’.[78–80]
There are challenges and opportunities for all those working to promote health in this setting. Five of the challenges are:
• structural changes
• new roles and methods of working
• high workload
• capacity and resourcing of public health
• balancing the needs of individuals with the needs of the population.
Over the last decade the NHS, including general practice, has been subjected to successive policy and structural changes,[78] and is currently undergoing unprecedented reform. In relation to general practice, the introduction of the new GP contract and the Quality and Outcomes Framework, for example, have radically altered working practices.[15] At a PCT level, the changes have also been dramatic, and some commentators have suggested that the boundary changes and the pressures to develop commissioning have meant that it is difficult to also meet public health objectives.[78] Considerable support will be needed, including that from public health professionals, if health improvement responsibilities are to be met.
Moreover, although a national public health strategy was produced and funding was allocated for tackling important public health issues, many parts of the NHS are using the funding to pay for financial deficits.[81,82] This will seriously limit the ability of many staff to deliver on vital areas such as obesity, smoking, sexual health and long-term conditions. In the future, the government will need to ensure public health money is ‘ring fenced’ so that effective health promotion programmes can be instigated in different settings, including general practice.
Balancing the needs of individuals with the needs of the population is another important challenge that needs to be considered. An approach based on the whole population will achieve the greatest reductions in morbidity and mortality for key areas such as heart disease and hypertension.[28,40] However, complementary to this is the individual approach that can be targeted at high-risk subjects. It is important to highlight that these two approaches are not mutually exclusive and both will be needed in any comprehensive strategy.[40] As staff in this setting will be more focused on individualistic approaches and many will be less familiar with broader public health ones, training will be needed so that they have the skills and competencies needed to be effective. For some topics, multidisciplinary and/or multi-agency training that includes a range of professionals may be appropriate.[40]
The overall direction for the future of health promotion was made clear in the conceptual scheme of the Ottawa Charter for Health Promotion.[1] Settings such as schools have flourished as they have had the support of local, national and European networks.[31] Similar technical assistance and advocacy will be needed if we are to expect general practices to achieve the gold standard.
Aseries of high-quality pilot sites that are rigorously evaluated should be established to demonstrate that this innovative approach yields tangible health benefits for local communities. This research could also be used to identify and address potential practical and organisational difficulties, and ensure that all staff, including nurses, participate fully.
Crucial to the future development of health promoting general practices is government support. This will be needed both directly and in relation to the capacity and resourcing of public health in general.
Finally, it is important to state that for most practices, achieving gold will not be easy nor will it be resource neutral; however, there will be benefits for patients, staff and the local community.
