Community Action

Professor George Morris worked as an EHO in local government before pursuing an academic career at Strathclyde and Glasgow universities. Between 1994 and 2004 he worked as an NHS consultant in environmental health in Scotland, later spending five years as scientific policy adviser to Scotland’s chief medical officer. He recently returned to the NHS, where he continues to advise on the implementation of Good Places, Better Health. He is a Fellow of the Faculty of Public Health and of the Royal Environmental Health Institute of Scotland and is now chair of the UK Public Health Register registration panel.

What led to Good Places, Better Health?

While environmental improvement is recognised as being vital for health protection, there has been much less emphasis on environmental factors within the health improvement agenda, particularly in relation to social inequalities in health.

In public health circles, it is recognised that health is the product of a complex interaction of social/behavioural, physical and genetic factors. In a very real sense “everything matters”, yet this complexity is often underplayed in shaping public health policy and action. For environmental health, this tends to perpetuate a hazard-based and compartmentalised approach.

The failure to match policy and action to a more complex reality means this perception has hampered action on the environment and stopped it from contributing fully to health improvement. Good Places, Better Health is a response to these concerns.

What other factors indicated a new approach?

How people feel about the places where they live can influence whether they choose or are able to adopt healthy lifestyles, for example, to take exercise. Another consideration was the recognition that stress, particularly the body’s inflammatory response to stress and feelings of hopelessness in which the environment can play a part, may be linked not only to a poorer sense of wellbeing but may also increase the likelihood of diseases such as cancers and heart disease and even accelerate premature ageing. There is a clear social pattern for many diseases, which is a sure sign that social and environmental factors are at work.

Has the failure to align EH interventions to the prevailing public health approach damaged EHPs?

Nobody can dispute that it is vital to secure and maintain environments free from toxic, infectious and physical hazards. The fact that EHPs are effective in delivering health protection in this area is a good news story for the profession.

However, it is evident that there is another narrative around today in public health where the language is less positive. The public health challenge has been redefined by reference to a growing obesity epidemic, low levels of physical activity, to concerns over excessive alcohol consumption, unacceptable levels of unintentional (but also intentional) injuries and, dominating the story, the stark differences in health by almost every measure between social classes.

If EHPs can gain a firm foothold here, they will straddle the health protection and health improvement agendas, raise their profile and thereby emphasise their relevance in any intervention.

Why will Good Places, Better Health be different?

At its heart is a new conceptual model, which illustrates the relationship between health, its environmental determinants, and equally important, the social, behavioural, demographic etc. context and how this impacts on the individual and community.

The model provides an overview of the wider issues and, once applied to particular environmental health issues, allows existing policies to be represented in the model. It also helps identify where there is poor understanding of a particular issue, encourages research into that area so that any data or policy gaps can be filled. The model also provides an overarching framework in which core systems can be placed to help deliver Good Places, Better Health.

What systems underpin Good Places, Better Health?

Three principal linking “systems” underpin the strategic approach to environmental health. We use the term “intelligence system” to describe the first system. It involves establishing and maintaining a flow of relevant information about the different areas of environmental health.

Stakeholder groups at the national and community level will come together to map selected environmental health problems using the conceptual model developed for Good Places, Better Health and described above. These problem maps are then passed to a consortium of academic institutions, led by the Institute of Occupational Medicine, which will ensure they are as comprehensive and as accurate as possible.

After this stage, another group collates data about environmental conditions, health and the relevant behavioural factors so that researchers can quantify where particular interventions will have a positive impact. A final and very important part of the intelligence system involves consulting local practitioners who identify barriers to health improvement and highlight good practice.

What are the other two systems you refer to?

The intelligence flow gathered within the intelligence system has to be properly evaluated and the second system covers this process then communicates its outcomes to policy makers. Good Places, Better Health takes an inclusive approach by involving various experts to provide an “evaluation system” that is both open and transparent but also robust.

However, because many of the issues are complex the evidence needs to be revaluated in a thorough yet pragmatic way. Through this process, recommendations for the government and others to take action are developed. In many cases, the recommendations will need to be taken forward by different policy constituencies across government in a co-ordinated approach.

The final system links closely to both the intelligence and evaluation systems and is called “levers of change”.

While “practice – what works” is about understanding intimately what is happening at the community level, the “levers or change system” helps us better understand what is effective and what the barriers are to health improvements at the national level.

How did you attract political interest?

Some real benefits have come about by underlining how a strategic approach to environmental health, which links evidence to policy through a robust process of evaluation, can inform other policy agendas.

Accordingly, Good Places, Better Health is promoted as a means of encouraging action on environmental improvements for better health and wellbeing but also to further other agendas, for example, around children’s health and wellbeing, inequalities and climate change.

How will you implement the policy without becoming overwhelmed?

Initially, we will focus on a limited number of priorities and set up our systems and structures around these. We consulted widely within government prior to agreeing the priorities for the first three years of the work. These are four child health outcomes – obesity, asthma, unintentional injury and mental health and wellbeing. To reinforce the cross-cutting relevance of our work within government, we have also undertaken to prioritise the links between sustainable homes, their immediate environment and health and wellbeing, with emphasis on our child health outcomes.

How important is the input of EHPs to its success?

We regard EHPs as key stakeholders. We have liaised closely with environmental health departments and representative bodies throughout the development of Good Places, Better Health. This is important because EHPs are uniquely placed to understand the issues and work in the community, where the most environmental improvements can be made to bring about greater equality in health. We recognise a desire among EHPs to become involved and lend their expertise to the health improvement agenda, particularly around inequalities.

How will you seek to involve EHPs further? 

There is an opportunity for EHPs to work at almost every level and we will actively seek that input. First, we aim to encourage EHPs’ involvement in many of the workshop groups to help map the environmental health territory around children’s asthma, obesity, mental health and wellbeing and unintentional injury. This is already under way.

Second, we are likely to enlist the support of environmental health departments to collate and provide data on the environment, health and behavioural factors, which is crucial to the success of the project. Again, there is a need for input from EHPs to develop the “practice – what works” area and we will liaise closely with EHPs in local government to help deliver this important strand of information.

We also plan to invite environmental health representation in other areas of the governance structures. EHPs’ insights are needed if the project is to succeed.

For references, contact George Morris.

Email: george.morris@nhs.net