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Citation for published version

Jenkins, Linda M. and Meade, F. and Beacham, S. (2002) Public health training in Kent - understandingthe needs of non-NHS staff with responsibility for health improvement. Project report. Centrefor Health Services Studies for the Kent Education Consortium

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http://kar.kent.ac.uk/8287/

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UNSPECIFIED

UNIVERSITY OF KENTAT CANTERBURY ••••

Public Health Training in Kent -understanding the needs ofnon-NHS staffwith responsibilityfor health improvement

Preparedfor the Kent NHS EducationandTrainingConsortium

by Linda Jenkins,FionaMeadeandSylvia BeachamCentrefor HealthServicesStudiesUniversityof Kent

April 2002

PUBLIC HEALTH TRAINING IN KENT- UNDERSTANDING THE NEEDS OF NON-NHS STAFF WITH

RESPONSIBILITY FOR HEALTH IMPROVEMENT

CONTENTS

Executivesummary 2

1.

2.

3.

4.

5

6

7

Background

Aims

Method3.1 Targetpopulation3.2 Surveyinstrument3.3 Questionnairedevelopment3.4 Questionnairedistribution3.5 Distribution timetable

Results4.1 Responserates4.2 Jobtitles4.3 Organisationsrespondentswork with4.4 Public healthworkload4.5 Agenciesrespondentswork with4.6 Understandingofpublic health4.7 Confidencein skills confidence4.8 Confidencein knowledgeareas4.9 Developmentof skills andknowledge4.10 Appraisalsandpersonaldevelopmentopportunities4.11 Barriers4.12 Furthercomments

Summaryof findings

Discussion6.1 Limitations6.2 Benefits6.3 Issues

Recommendations

5

5

556677

778891011121415161717

19

20202121

23

References

Annex A - Questionnaire

Annex B - Establishinga samplingframe

23

24

29

EXECUTIVE SUMMARY

The survey reported here wascommissionedby Kent NHS Education and TrainingConsortiumand was carried out by the Centre forHealthServicesStudies (CHSS), which ispart of the Universityof Kent atCanterbury.The fieldwork was carried outbetweenOctober2000 andFebruary2001, and its aim was toinvestigatethe levelof public healthknowledgeand skills among thoseinvolved in inter-agencyworking to improvehealth.

While staff in NHS posts with aresponsibilityfor improving healthwill have public healthqualificationsor access to public health training and advice, this is less likely to be the casefor non-NHS staff. For thisreasonthe survey targetednon-NHS staff working in publicsector and voluntaryorganisationsacross Kent whoseresponsibilityfor healthimprovementwould benefit from areasonableunderstandingofpopulationhealth.

Membershiplists were used forPartnershipBoards, JointPlanningBoards, HealthActionTeams and HealthImprovementPlan (HImP) Policy Boards.After excludingnamesof staffbased in health authorities andotherNHS organisations,all the remainingnames were sent aself-completequestionnaireby post. A similar survey wascommissionedand carried out byCHSS to assess the training needsofPracticeNurses. This has been reported separately.

The survey questions asked aboutpeople'sperceptionof public health, and about theirrelevant knowledge and skills. Thequestionnairewas developedfrom a templateprovidedby the Kent NHS Education and Training Consortium'sPublic Health Education Co-ordinator(Sylvia Beacham),and a surveyof practice nurses in Hampshire. While aiming toidentify public healthtraining needs, the survey wasadditionally expected toperform aneducational role in raisingawarenessof the function of public health and the rangeoftechniques used.

Relatively senior staff from a range of local authority departments and voluntaryorganisationsresponded to the survey, and said the timethey spent onpopulation healthvaried enormouslyfrom 0% to 100%of their time. Although non-NHS staffwere the focus,and staff in NHS public healthpolicy andstrategyroles hadbeendeliberatelyexcluded, onein sevenrespondentswere in fact based in NHS PCTs andotherNHS Trusts (although notnecessarilyin roles thatrequiredmedical qualifications). Responserates werebetween33and 55% for HImP boards. Two thirdsof the responses were from LocalAuthoritydepartments such as SocialServices, Community DevelopmentServices and Housing.Responsesfrom thevoluntarysector included sports clubs and charities.Respondentswereworking with several other agencies, and these almost alwaysincludedpartsof the NHS.

Respondents'definitions andunderstandingof public health in their own words were oftenquite limited - nine out of ten definitions of public health were rated as poor or limited.However, when prompted, most went on to say that all the keyresponsibilitieswithin publichealth that the survey asked about were important. Withregardto skills, respondentshadgreatestconfidencein their skills of leadership,communicationand working in partnership.They were leastconfidentin the useof statistics andpresentingdata. A small butsignificantproportion(20%) did not feel at allconfidentin halfof thepublic healthskill areas thesurveyasked about, even though themajority thought they were allhighly relevant to theirjobs.With regard to knowledge, abouthalf had none or basicknowledgein the areas thesurveyasked about.

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Although self-reportedknowledgeand skill levels were not high, asignificantproportionofrespondentsdid not identify any training needs. This may bebecausejust under a third ratedtheir opportunitiesfor personaldevelopmentno better than fair, and time was abarrier forvirtually all respondents. The next largestbarrier to developingskills and knowledgewasfunding, mentioned byhalfthe respondents.

The survey gives a snap shotof the perceptionsand needsof senior staff, a group notoftensurveyed (and an area in which there is little existingresearchof this type). Most studies havefocused onpractitioners'needs.

The survey hasidentified some public healthtraining needs. For example, two outof threerespondentsidentified specific areas in which theywantedto develop theirknowledgeandskills, and a similarproportionfelt they have goodopportunitiesfor personaldevelopment.The limited breadthof understandingof what public health covers indicates the need forsome education amongstaff involved in health improvementplans. Inter-agencyor sharedtraining opportunitiesmay be helpful here. Clearly time was abarrier for everyone,whichindicates that trainingbudgetswill need to beidentified and access to these clarified.

The survey foundsupportfor training that gives greateremphasisto economic, social andphysical influences on health. There also seems to be a need toclarify roles andresponsibilitiesof this group as well as helping them define the 'new public health' agenda.

The difficulty respondentshad in giving adefinition of public health needs to betakenintoaccount wheninterpretingthe results, and mayitself suggestthe need for general training.Itseems likely that thoseinvolved in health improvementprogrammeswould benefit from abroad education thatwould raise awarenessof the methodsandterminologyof public health.An examplesupportingthis statement is that when asked to rate theimportanceof topics,health impactassessmentwas at the topof people'slist for not knowing whether it wasimportant or not. Generallyrespondentswere lessconfidentwith their technicalskills, suchas handling andpresentingstatisticalmaterial, and useof specific public health methods.Again this agrees with skills theCMO's report identifies are in short supply, and poses achallenge to educators.

If public health training for this group of people is to be successful, it will have to bedesigned to overcome themajorobstaclesof lack of time and money.It will also haveto beseen to besufficiently relevantto their role to rise abovecompetingpriorities. Although thesurvey respondentsthoughtpublic health skills wereimportant,they wereactuallynot verygood at defining what thesubjectcovers. This mayhave lead todifficulty relating to thetopics that we asked about(hardly surprisingas by definition we were surveyingpeopleoutside NHS publichealthdepartments). This lackof familiarity with theterminologywouldalso account for therelatively low levelsof demand we found fordevelopingthe knowledgeand skills associated withmainstreampublic health responsibilities. Facing such abroadsubject, it may be that the first training objective should be to encourage sharedthinkingthrough shared training, then to raise awareness about public health issues and how to accessexpertise in them. Toprovide skills that people can use withconfidence may be aconsiderable way down this road.

3

Recommendationsfrom this survey are as follows:

• The mainpriority must be in raisingawarenessof the role of all the Local Authoritydepartments that areinvolved in Health ImprovementProgrammesin the broad publichealth agenda both within LocalAuthoritiesand within the NHS.

• More opportunities are neededfor joint appointments,joint training and educationthrough existing routes but maybe moreimportantly through shadowing,learning sets,mentoring and goodpartnershipsworking.

• There is clearly a need to providetraining/learningopportunitiesfor senior staff toincrease their skills and knowledge around public health issuesparticularly,healthneedsassessment, using statisticalprogrammes to interpret data, presenting data andundertakingresearchusing differentmethodologies.

• Learningopportunitiescould beintegratedinto existingprovisionto address theproblemof time pressures.

• Inter-professionaltraining andworking on Health Impact Assessmentwould move theagenda forward as this is seen as a need both from NHSstaffand from thoserespondentswithin this study.

4

1. BACKGROUND

This work wascommissionedby Kent NHS Education andTraining Consortiumand carriedout by the Centre for Health Services Studies at Tunbridge Wells. CHSS is partof theUniversityofKent at Canterbury.

Nationally, theChief Medical Officer's Project has worked to strengthen the Public HealthFunction (DOH, 1997 and 2001), andregionallythe NHS Executive South East has produceda strategic approach to developingcapacityand capabilityof the Public Health Function. Incommissioningthe survey reported here, the Kent EducationConsortium has raised theimportance of public health knowledge and skills existing in the wider arenaof localauthority and otherstaff involved in inter-agencyworking to improve health. The focusofthis study is thereforestaffoutside the main public health functions in the NHS, such as thoseon Partnership Boards and involved in HealthImprovementPlans.

2. AIMS

The study was carried out between October 2000 andFebruary2001 and aimed to:• identify those working in local authorities across Kent who hadresponsibilitiesfor health

or health improvement,• examine their perceptionofpublic health,• identify their training needs.

Given the target populationconsistedof people who were notworking in NHS public healthposts, it was envisaged that knowledgeof what public health consistsofwas likely to be veryuneven. As those being surveyed could notnecessarilybe expected to be familiar with therange of public health activities and skills, the survey was alsorequired to perform aneducational role in raising awarenessof these.

A similar survey was requested and carried out by CHSS to assess thetraining needsofPractice Nurses. The second survey covered all nurses in general practice in West Kent, andis reported separately.

3. METHOD

The first task was to describe the targetpopulationfor our survey more clearly, ie the widerclient catchmentpopulationfor public health training, and decide on anappropriatemeansofcollectinginformationfrom them.

3.1 Targetpopulation

We decided to include people who were involved in improving health for those living inKent, but who were not in NHS public health posts. They were likely to have'improvingpopulation health' as part of their jobs or responsibilities. Weexpectedto find themparticularly in local authorities - for example housing or social servicedepartments- but alsoin community groups, voluntaryorganisations,charities andprimary care organisations(PCG/PCTs).

5

3.2 Surveyinstrument

To get reasonablywidespreadcoverageof such a disparate group and enablecomparisonofthe responses, it was decided to use a fixed setof questions in aself-completedquestionnaire.This method had been usedbefore in a surveyof practice nurseselsewhere,and the PublicHealth EducationCo-ordinator(Sylvia Beacham)made available some preliminary workdrafting appropriate questions. Useof questionnairesenabled abroadcoverage atrelativelylow cost, and this coverage helped tomeetour secondaryobjectiveof raising awareness morewidely.

3.3 Questionnairedevelopment

A questionnairewas designed for the Kent wide non-NHS staff. The starting point was toreview concepts in apre-existingpracticenurse survey used inHampshire,and atemplateprovidedby the client in relation to thesurveyaims.

This resulted in an expanded listof skills and knowledge areas to cover the publichealthfunction in broad terms as would apply to thoseworking in local authorities. These two areaswereseparatedfurther so thatrespondentscould rate their skills by howconfidentthey were,and their knowledge by how good it was.

To gauge the potential demand fordevelopmentand trammg, we asked which areasrespondentswould like to develop their knowledge and skills, and what barriers they saw toachieving this. Additional questions were included aboutwhether staff had regularappraisals, and for an overallassessmentof the opportunitiesfor personaldevelopment.

A fundamental problem wasuncertaintyabout respondents'understandingof public health.It wasthereforedecided first to ask an open question about this, in order to rate the depth andbreadthof their conceptof public health. Insubsequentquestionswe used explicit lists, forexample rating the importanceof a list of responsibilitiesrelatingto public health. By givingthese functions explicitly, plus the skills and knowledge areas listed in following questions, itwas expected thatrespondentswould come to a similarunderstandingabout the topics thatare included in public health and be able to give a moreconsistentview about theirtrainingneeds.

The questionnairewas designed forself-completionand to take about five minutes to do.Itwas to be sent out under acoveringletter saying how thepersonhad been chosen and whohadcommissionedit.

There was little time for formalpiloting of the questionnaires,and we decided this was notnecessaryas the formatof the questionshad worked wellwhen used with practice nurses.However, a smallnumberof copies were sent to personalcontactsworking in local authoritypositionsin other counties, but no replies were received.

An exampleof the questionnaireis given in AnnexA.

6

3.4 Questionnairedistribution

Copiesof EastKent's and WestKent's Health ImprovementPlans (HImPs) wereobtainedand were studied in order to find the partnerorganisationssigned up to them and the keymulti-agencygroups set up to own and drive the HImPs. Local authority human resourcesdepartments were contacted and asked whichstaff had a public health role in theirjobdescriptions.

The client catchment within East Kent was basedprimarily on membersof partnershipboards with Social Services called Joint Planning Boards. These focused onlearningdisabilities, housing, transport, and so on. The namesof board members for sevenof thesewere obtained. The clientcatchmentwithin the West Kent area focused on the members whoare partofHealth Action Teams, HImP policy boards andpartnershipboards.

Getting complete and up to date listsofpeople onmulti-agencygroups was problematic. ThepublishedHImPs did not always reflect the currentsituationand, as board membership wassomewhat fluid, the names and addresses we did manage to get from health authoritystaffwere not always current. Detailsof this process are given in AnnexB.

3.5 Distribution timetable

The questionnaires sent to East Kent were distributed prior to Christmas 2000. The WestKent questionnaires were sent out in the first weekofJanuary2001. This staggeredapproachwas used to ensure that as fewquestionnairesas possible would get mislaid in theChristmaspost period, but that we would get as manyquestionnairesback as possible within thetimeframe. Thequestionnaireswere distributed to councils in the second weekof January2001.

Reminderquestionnaires were distributed to thosememberswho had not replied by thedeadlineof26th January 2001.

4. RESULTS

4.1 Responserates

In East Kent there were 29 responses, including three who felt the questionnaire was notapplicable to them andthereforedid not complete them. Valid response rate 26/68= 38%

In West Kent there were 45 responses,of which 4 people felt that the questionnaire was notappropriate for them to complete (either because they were 100% NHS based or because theywere voluntary) and a furtherrespondentstated that they did not have enough time. Validresponse rate 40/84= 48%.

Eight additionalquestionnaireswere received fromdistributions carried out for us by tenlocal councils. As we do not know how many were distributed, it is not possible to calculatea response rate for these, but it would appear to be lower than the other approaches.

7

In total there were 74 responses that could be used in the analysis. The results from thesurvey are given in thefollowing sections.

4.2 Respondents'Job Titles

A variety of job titles weredescribedby theparticipants.Many of thesejob titles appeared tobe senior posts. A totalof29 participantsincluded thewordingof 'Manager'in the title. Oneperson left this partof the questionnaireblank.

Figure I below shows thedistributionof the rangeofjob categories.

Fig I. Job titlesI 32

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".. 16..eｾ 12..".cS 8"Z

4

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c c § "0 " u " ｾ </l 0:0 E x 'c :;;u CD EJob Titles '0

<--- - - - -----------

4.3 Organisationswhererespondentsworked

The organisationsrespondentsworked for were coded into 12 separatecategories. Thesecategories are as follows, with Fig 2 showing howfrequentlythey occurred:

1. District Council, Chief Executive's office, service development,policy/planningdevelopment

2. Housing3. Communitydevelopmentservices(includingfamily support, youth)4. Leisure5. Environment(includingtransport,highways)6. NHS, CHC7. Voluntaryorganisations,EqualOpportunities,Racial Equality8. PCG/PCT9. Social Services10. Education,CommunityColleges11. Chemists, retailer,commerce12. Police,justiceservices.

8

About two-thirds of those respondingto our survey worked in LocalAuthorities, mainlysocial services,communitydevelopmentservices,housing,policy developmentandplanningdepartments. 15% were fromprimary care organisations(PCGIPCTs),CommunityHealthCouncils or other partsof thehealthservice. 11% worked in thevoluntarysector.

Fig. 2. Organisationswhererespondentsworked

1211 1%

10 1%

5%21%

918%

29%

87%

37 12%

11% 46 5 4%

8% 3%

4.4 Public Health workload

When asked whatproportion of their work was concernedwith the health of the localpopulation, 43% reported that over 70%of their work is related to this issue.Twenty onepeople (28%) stated that 100%of their work is concernedwith the health of the localpopulation. See Figure 3.

Fig. 3. Percentageof the respondent'swork relatingto healthof the localpopulation.

91-100%

81-90%

71-80%

6 J-70%

'"OIl

S 51-60%='"u 41-50%...'"'" 31-40%

21-30%

11-20%

0-10%

0 2 4 6 8 10 12 14 16 18 20 22 24

Number of res pondents

9

Figure 3 included some people who worked in the NHS even though we had tried to excludethem from the survey. Despite the fact that the NHSrespondents'workloadswere mainlyrelated tohealthissues, when they wereremovedfrom Figure 3 thepatternof workload wasrelativelyunaltered.

4.5 Agenciesthat respondentswork with

The survey asked what other agencies people were working with andwhetherthese workingarrangementswere formal or informal. Various agencies wereindicated, and these werecategorisedinto 10 groups as follows (Theserepresentthe key for figure 4):

I) Health Authorities, Healthpromotion, NHS Trusts, Community Health Councils,healthvisitors

2) Social services -includingyouth services, druginitiatives3) Education- schools and adulteducation4) Local Authority, KentCountyCouncil (includes: highways, water,energycentre, fire

service,environmentalagency, sport, leisure and housing)5) Police, probation, prison, youthoffending team, transport police, crimeprevention,

victim support, domestic violence.6) Voluntaryand community groups andorganisations- including YMCA, sports clubs,

MIND, charities, national governing bodies of sport, private sector, transportoperators

7) Multi-agencygroup8) PCG/PCT9) Others (such as KentRegistration,WHO, BTCV)10) Nursinghome,Independentsector, retail sector.

Fig.4 Other agencies with whomrespondentswere working

AgenciesWorked With

Although on averagerespondentswere working with four or five otheragencies, this maskedtwo main patternsof working, which were either to work with three to five other agencies or

10

at least nine. A quarter (19)of the respondentsidentified 9 or more agencies that they wereworking with. Of the 323 agenciesmentioned, the mostfrequently cited were healthservices,including Health Authorities, health promotion, NHS Trusts, Community HealthCouncils,Health Visitors, andPCG/PCTs(124).The distribution of these showed that most respondents areworking with staff in healthservices. The next most frequentotheragency to beworking with was nationalgovernment,local authoritylKentCountyCouncil (69), followed byvoluntarygroups (44).

Sixty six respondentsidentified that they were membersof inter-agencygroup/groups(this isnot surprisingas the mailout wasbasedon those involved inHealth ImprovementPlans).Threerespondentsdid not commenton this question.

Themajority ofrespondentsidentifiedthat work with theseotheragencies occurs on a formalbasis (54%), although anadditional 35% stated the work wasconductedboth formally andinformally.

When the NHS respondentswere removed from Figure 4, the pattern wasrelativelyunchanged.

4.6 UnderstandingofPublic Health

The survey asked whatrespondentsunderstoodby the term'public health'. The questionisrelativelycomplex due to itsmulti-facetednature and the way in which itincorporatesa widerange of disciplines, professions,skills and knowledge with abroad focus oncommunity/populationhealth as opposed totreatmentof individuals. Theresponsesranged from'thehealth of the wholepopulation' to rather more detailed answers. A simple scoring systemwasdevelopedto assess the replies. The system enables one mark to be allocated for eachofthe five dimensionshighlightedbelow. A further twodiscretionarymarks were awarded forthose answers which containedgreaterdetail. The five aspectsof public health we looked forwere:

• public health goals- improvinghealth, preventing disease, etc• organisationaland policyframework- eg strategic andmulti-sectoralapproach• public health skills- research,monitoring,needsassessment,etc• rangeofpublic healthprofessionals/workforce• disciplinesinvolved in public health.

The scoring of these results then fell into thefollowing categories 0, I=poor,2,3=limited/basic,4,5=quite good,6,7=excellentunderstandingof public health. Accordingto this scoring system 51% (38) had alimited/basicunderstandingof public health, 39% hada poorunderstandingand 10%appearedto have quite a goodunderstandingof public health.No answers received a scoreof excellent.

The resultsof the scoringappearto identify a lackof understandingwith regards to apublichealthdefinition. It is evident that further work in this area isneededto establish acommonunderstandingand shareddefinition ofpublic health.

The next question asked theimportanceof various activities to anyone with aresponsibilityfor public health. Three main areas were identified as beingof particularimportancewithin

11

public health. These were:health promotion, the reduction of inequalities and diseaseprevention. Environmentalhealth hazardsand studying patternsof diseasecame fourthgoing by the same criteria.

The percentagesandnumbersof responsesto each area can be seen in table 1. 90% ormorethoughtmost of the topics we listed were at least'fairly important'. The two areas with thehighestpercentagesin the 'not very important' categorywere: housingstock andconditionsand health and safetystandards. The percentagescan be seen in figure 5. The areawheremost respondentssaid 'don't know' was healthimpact assessment.Howeverone mustbearin mind that this is arelativelynew area for most people.

Table 1. Howimportantare thefollowing areaswithin public health.

Very Fairly Not very Don't knowImportant Important Important

Diseaseprevention 82% (61) 15% (11) 0% (0) 1%(I)Healthpromotion 80% (59) 19% (14) 0% (0) 1% (I)Reducinghealthinequalities 84% (62) 14% (10) 0% (0) 3% (2)Environmentalhealthhazards 64% (47) 30% (22) 1%(I) 3% (2)Diseasescreeningprogrammes 58% (43) 32% (24) 4% (3) 3%(2)Diseaseimmunisationprogrammes 68% (50) 24% (18) 4% (3) 1%(I)Clinical effectivenessofhealthcare 57% (42) 34% (25) 4% (3) 3% (2)Healthneedsassessment 58% (43) 31% (23) 4% (3) 5% (4)Healthimpact assessment 49% (36) 38% (28) 4% (3) 8% (6)Populationhealthmonitoring 54% (40) 39% (29) 4% (3) 3% (2)Housingstock andconditions 45% (33) 41% (30) 12% (9) 3% (2)Healthand safetystandards 45% (33) 38% (28) 9% (7) 5% (4)Hygiene 55% (41) 34% (25) 5% (4) 4% (3)Studyingof patternsofdisease 53% (39) 41% (30) 4% (3) 3% (2)

4.7 Confidence in skills

Respondentsrated themselveson their confidencein particularskill areas. Themain threeskills in which they felt 'confident' were: working in partnership(75%), using leadershipskills (53%) andcommunicationskills (61%). When those who are'fairly confident' areadded, thepercentagerises to around 100% feelingthey had somedegreeof confidenceinthese skills.

At the otherextreme,there are some areas whererelatively small numbersfelt 'confident'and these wereoutweighedby the numberwho ratedthemselvesas 'not at all confident' -both indicating potential training needs. Theseweaker areas were: usingstatisticalprogrammesto interpretdata,presentingdata,healthimpact assessmentskills, conductingahealthneedsassessmentsandundertakingresearchusingdifferentmethodologies.Skill levelratings are inTable2, which also shows thepercentagesof thosereplyingwho consideredtheskill irrelevantto their job. The data is showngraphicallyin Figure5, picking out skill areaswith the greatestpercentagessayingthey were'not at all confident'(20% or more).

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The greatmajority of respondentsratedthe skills as relevantto their jobs. Around half feltonly 'fairly confident' in each skill area. Respondentswere much more confident inleadershipand communicationroles and much less so in technical and methodologicalaspectsofdatahandling.

Table2. Skill levels.

Confident Fairly Not at all Not relevantconfident confident to my job

Knowing how and where to obtain45% (33) 48% (35) 7% (5) 1%(I)informationon populationcharacteristicsInterpretingpopulationdata 25% (17) 54% (37) 22% (15) 7% (5)Comparinginformationwith otherpopulations19% (12) 63% (40) 17% (11) 15% (11)Undertaking research using different 21% (12) 44% (25) 37% (21) 16% (12)methodologiesDevelopinginterventionsfor local situations 28% (17) 59% (36) 13% (8) 14% (10)Identifying methods to monitor progress32% (22) 54% (37) 13% (9) 7% (5)againstprojectobjectivesEvaluateresearchprojects 21% (14) 56% (37) 23% (15) 11% (8)Usingprojectmanagementskills 49% (36) 40% (29) 11% (8) 1% (1)Policydevelopment 42% (30) 46% (33) 11% (8) 4% (3)Critically appraisingresearch 24% (15) 52% (32) 24% (15) 12% (9)Working in partnerships 75% (53) 25% (18) 0% (0) 1%(I)Using leadershipskills 53% (37) 44% (31) 3% (2) 3% (2)Conductinga healthcareneedsassessment 10% (5) 42% (22) 48% (25) 28% (21)Engagingand involving the public 39% (28) 49% (35) 11% (8) 3% (2)Useof the intemetto obtaindata 25% (18) 46% (33) 28% (20) 3% (2)Useof the intemetto obtainliterature 27% (19) 46% (33) 27% (19) 3% (2)Statisticalprogrammeto interpretdata 8% (5) 29% (19) 63% (41) 11% (8)Presentingdata 14% (7) 43% (22) 43% (22) 14% (10)Facilitatinggroupwork 46% (33) 45% (32) 10% (6) 3% (2)Communicationskills 61% (44) 39% (28) 0% (0) 1% (1)Healthimpactassessment 13% (7) 38% (21) 49% (27) 23% (17)Accessingqualitativeinformation 28% (19) 54% (37) 18% (12) 5% (4)Accessingquantitativeinformation 28% (19) 52% (35) 19% (13) 5% (4)

13

Fig. 5 Levelsof confidencein specific skill areas

60

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'"...... 300

'"b.ll..-= 20'""..'"c.

10

o

Confidence in skills

.ConfidentDFairly confident.N ot at all confidentON ot relevant

2 3 4 5 6 7 8 9 10

Key:1. Interpretingpopulationdata2. Undertakingresearchusing differentmethodologies3. Evaluate researchprojects4. Critically appraisingresearch5. Conductinga health needsassessment6. Useof the internetto obtain data7. Useof the internetto obtain literature8. Statisticalprogrammeto interpret data9. Presentingdata10. Health impactassessment

4.8 Confidencein knowledgeareas

As shown in table 3, there are a numberof areas in whichindividuals feel they have no oronly basic knowledge. For all knowledge areas we asked about, substantialproportions(over40%) fell in the 'none'and 'basic' categoriesof knowledge. The fiveweakestareas (over60% with 'none' or 'basic' knowledge) are: population health status,screening andimmunisationprogrammes,systems forrespondingto environmentalhazards,communicabledisease control and clinical governance. Table 3 also shows that, apart from health status,over 20% felt theknowledgeareas they wereweakeston were not relevant to their job.

14

Table 3. KnowledgeAreas

None Basic Good Very Notlgood relevant

Populationhealthstatus 11% (7) 50% (33) 33% (22) 6% (4) 9% (7)HealthInequalities 8% (5) 37% (24)42% (27) 14% (9) 11% (8)Barriersto betterhealth 4% (3) 38% (26) 41% (28) 16% (11)7% (5)Use of healthand relatedservices 4% (3) 37% (25) 43%(29) 15%(10) 9% (7)Healthpromotioninterventions 8% (5) 47% (31) 33% (22)12% (8) 11% (8)Healtheducationinterventions 9% (6) 45% (29) 35% (23) 11% (7) 12% (9)Healthimprovement 7% (5) 34% (24) 37% (26) 21%(15) 5% (4)Screeningand immunisationprogrammes 21%(12) 57% (33) 19% (11)3% (2) 22% (16)Systems for responding to environmental32% (18) 54%(31) 7% (4) 7% (4) 23% (17)hazardsCommunicabledisease control 26% (15) 53% (30) 12% (7) 9% (5)23% (17)Clinical Governance 27% (14) 45% (23)24%(12) 4% (2) 28%(21)Local Agenda21 13% (9) 41%(29) 31%(22) 15%(11) 4% (3)Savinglives: OurHealthierNation 8% (5) 42% (27)31%(20) 19% (12) 9% (7)

Otherareas in whichindividuals felt knowledgewould bebeneficialare:CHD/Strokeprevention 1Communitysafety 4Neighbourhood 3Mentalhealth 1Healthat work 1Healthimpactof crime 1Housing 1NationalPlan 6VariousNSF's 6Urban regeneration 1

4.9 DevelopmentofKnowledgeand Skills

The surveyasked about the areas inwhich individualswould like to developtheir knowledgeand skills. Relativelyfew answersweregiven and these werespreadasshownin table 4. Atotal of 23 respondentsidentified that theywould like to developboth skills and knowledgein public health. A further 20respondentsstatedtheywantedto developtheir knowledgeofpublic healthand asurprising23 (31%)respondentsleft this questionblank, stated it was notapplicableto them or thatthey did not wish to developeither their skills or knowledgeinpublic health.

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Table4. Areasfor development

KnowledgeAreas Skill AreasPopulationhealthstatus 2 Knowing how and whereto obtain 1

informationon populationcharacteristics

HealthInequalities 4 Interpretingpopulationdata IBarriersto betterhealth 1 Undertakingresearchusing 3

different methodologiesUseofhealthandrelatedservices 2 Developinginterventionsfor local 2

situationsHealthpromotioninterventions 6 Usingprojectmanagementskills 1Healtheducationinterventions 1 Critically appraisingresearch 1Healthimprovement 5 Working in partnerships 4Screeningand immunisation 3 Using leadershipskills 2[programmesSystemsfor respondingto I Conductinga healthcareneeds 2environmentalhazards assessmentGovernmentpolicies 4 Engagingand involving the public 2Clinical Governance 1 Useof internetto obtain literature 1Local Agenda21 1 Statisticalprogrammeto interpret 5

dataOtherspecificknowledgeareas 14 Healthimpactassessment IGeneraltrainingareas 6 Accessingquantitative 1

informationStrategicplanning 1 Otherspecificskills 7SavingLives: OurHealthierNation 1 Generalneedfor PH skills 1

4.10 Appraisalsandpersonaldevelopmentopportunities

The majority of surveyparticipantsstatedthat they dohave regularappraisalsby their linemanagers.Only threepeoplesaid they did not and sixpeoplecommentedthey hadnot hadan appraisalrecently.

Opportunitiesfor personaldevelopmentappearto be goodon thewhole. Figure6 identifiesthe percentagesof thoseparticipantsrespondingto thequestionof: what are theopportunitiesfor your own personaldevelopment?

The resultsrelatingto staffappraisalsanddevelopmentopportunitiesweresimilar if the NHSrespondentswere excluded.

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Fig. 6. Opportunities for personaldevelopment

None

1%

Very good

24%

Good

45%

4.11 Barriers to skills/knowledge

Poor

1%

Fair

29%

Respondents were asked to outline any barriers todevelopingskills and/or knowledge. Thereplies were free text, and have been categorised as shown below. Clearly time was thegreatestbarrierfor everyone, and aroundhalfalsomentionedfunding as a problem:

No or limited time 73No or limited funding 38Not apriority/otherpriorities I1No guidance, support or help 8There are no barriers ITraining is not a need at the moment 2On training already 2No suitable courses IOther 8

4.12 Further comments

At the endof thequestionnaire,any other comments were invited. These have been arrangedinto the themes that emerged, as follows:

The importanceof joint or inter-agencytraining.

"Multi-disciplinary training is excellent. Modular training- practical approach. Training!awareness raisingofhealth and well being issues for council members is essential".

"More inter-agency training".

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"Mandatory joint traininglinduction for HP/PH/social care medical trainees and socialservices trainees. Tried to set this up locallyego through2 year project called Medical AndPublic Health Inter Agency group(MAPHIA) with 4 local GP's/CHC/socialservices/education/pharmacy/primarycare/KentUniversity. No funding. Hope toprogressthis in postgraduateeducationin 2001-2".

"There seems to be a need for moreopportunities for joint trauung and developmentinitiatives to engage seniormanagers/practitionersin othersectors".

"Joint health and SSDtraining (not oneoff seminars),opportunitiesfor secondmentacrossagencies".

"I am not involved with public health agencies asrecognised,although I believe that adulteducationcontributesto public health. We needjoined up funding to go withjoined upthinking".

"Need to keep looking athealthin its broadest sense(Joinedup thinking). Notjust in termsof disease or diseaseprevention".

"The ideaof inter-professional/inter-agencycourses are veryappealingto me. lts partof thenew govermnent agenda so whydon't we gettogetherand start trainingtogether- excellentopportunityto network".

Sharingof knowledgeand skills

"Training needs toexplorethe wealthof experienceand rolesof agenciesworking to addresscausesof ill health, whetherit be specific disease or generalinequalities,deprivationfactorsetc. In both statutoryand voluntary there is the need to explore links, thegovernmentagendas andmechanismsto make the impactsof interventions more effective andinnovative".

"The key area is for me to know how to access theknowledgeof others rather than for me tohave a more directknowledgeof the health agenda".

"There is scope for sharingknowledgeand skills within the public andvoluntary sector anddevelopingprogrammesparticularlyin the areasof working with andinvolving the public".

"Need to usepartnershipworking to share skills ie help some healthprofessionalsimprovetheir community development knowledge/skills so that people most at riskofdeprivation/inequalityactually get improved access toservices/opportunitiesand that theycan begin to makesupportedlife choices to improve theirlong-termhealth".

Feeling that thequestionnairewasinappropriatefor some respondents.

"I don't feel that thisquestionnaireis relevant to the work we do at our localvolunteerbureau".

"As a volunteer with theCommunityHealth CouncilI'm not sure that this form should applyto me",

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"My work remit only skims healthpromotion. It IS mainly dealt with by our healthdevelopmentofficer".

"My work as a planning policy officer does not have many directhealth related issuesinvolved in it - but there are many indirectconsequencesego location of development,needto travel, typesof development, facilityprovisionand planning etc".

Othercomments

"Needsand needsassessmentis an areacombinedwith ethics which are veryimportant inhealthpromotionand could beaddressedby looking at best practice".

"Too muchemphasison health care andcancerwith lessattentionnormally allocated to theeconomic, social and physicalinterventions."

"Importantneed to strengthenepidemiologicalresearch into newgovernmentaldirections inNationalNeighbourhoodRenewal Strategy".

"I feel more work in theeducationfield in schools andcommunity centres would bebeneficial. This could include living skillsprogrammesetc. Also Healthy Living Centres".

"Its essential to linkenvironmentand healthissues they aredivergingand spreading limitedresources".

"I have a greatconfidencein the developmentandopportunitiesto be gained by publichealthpractices. Theproblemlies in reachingotherpeople who should beinvolvedbut do not see itas their duty to become involved orownershipof identified problems".

'Thereare anenormousrangeof interventionsavailable to health workersif they had moretime and training to be equipped to do this".

"I think training in public health is veryimportantand should be widelyavailable".

"Recentlyattendedcourse at PublicHealthResourceUnit - Oxford - 'PuttingEvidence intoPractice'- excellentand practical. Would be a valuable resource to have a localprogrammeof training forprofessionals".

5. SUMMARY OF FINDINGS

• A survey instrumentwas developedand sent tostaff involved in partnershipand jointboardsassociatedwith improvinghealthin Kent and distributedwithin local authorities.

• Replies were received fromrelatively senior staff in local authority and otherpositionsbeyond the usualboundariesof NHS public health.

• Response rates were not high(between38% and 48% formembersofHImP boards, andlower whendistributedwithin local authorities).

• Respondentscame mainly from social services, community, housing andpolicy/planningdepartments, although a quarter were fromCommunityHealth Councils, PCGIPCTsorvoluntaryorganisations.

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• There was a wide spreadofpeople'stime spent onpopulationhealth, from 0-100%.• Most respondentshad formalworking relationshipswith severalotheragencies.• Respondents'definitions andunderstandingof public health were mostly quite limited.• Most attached importance to all the keyresponsibilitieswithin public health.• Greatestconfidencewasexpressedin skills of leadership,communicationandworking in

partnership.• Leastconfidencewas expressed in useof statistics andpresentingdata.• Aroundone in five did not feel at allconfidentin halfof the skill areas.• Halftherespondentsmentionedat least one skill area inwhich they wanted training.• Themajority thought the publichealthskills were relevant to theirjobs.• About halfhad none or basicknowledgein the areascontainedin the survey.• Overhalf therespondentsidentifiedaknowledgearea in whichtheywanted training.• Just under a third rated theiropportunitiesfor personaldevelopmentno greater than fair.• Time is abarrierto developingskills and knowledge forvirtually all respondents.• Fundingis a barrier to 50%.• Training needs will have to be assessed in the lightof the relevanceto jobs,availability of

time and attitudes to personaldevelopment.

6. DISCUSSION

6.1 Limitations

The survey has beendesignedto and appears to havebroadly achievedits aims, but it isworth noting, as in any design, there are anumberof potential limitations which should betaken into account wheninterpretingthe results.

First, the targetpopulationwas hard to find: healthauthorityand localauthority staffwerenot always able to respond to our requests for contact names;partnershipboards wereemergingand had changingmembershipswith no clearresponsibilityfor maintainingup todate lists. As a result we cannot be sure how well the survey hascoveredpeople with aresponsibilityfor public health.

Secondly, we used more than one methodof finding andcontactingthe targetpopulationandthesemethodsare likely to lead to a bias in favourof senior people onpartnershipboards setup to implementHealthImprovementPlans.

Thirdly, response rates were less than 50% and in some casesimpossible to calculate,creating some uncertainties about therepresentativenessof the response. For example, non-responders might bestaffwith little interestin public health ordevelopingtheir skills. Wealso know several peopleworking in voluntaryorganisationsdid not believethe surveywasrelevant to them.

A self-completedsurvey contammg questions, with a fixed range of responses, willinevitably limit the responses. In addition, respondents may not have shared ourunderstandingwhen answeringquestionsor may have given us the replies they think wewould want to see. Sincesimilar questionsand format had been used before andperformedwell, we have no reason to believe these would presentsignificantproblemsfor the survey.

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6.2 Benefits

The survey approach was chosenbecauseof the coverage that could be achieved atreasonablecost. By using anumberof open-endedquestionsit was possibleto pick upadditional views and comments. The survey approach ensuredrespondentswere presentedwith a consistentandcomprehensivelist of topicsrelatingto public health.

By choosing wide coverage and thequestionnaireformat involving explicit lists, it isanticipatedthat a second objectiveof the survey will have been met - to increaseawarenessof theresponsibilities,skills andknowledgeareas within thebroaderpublic health function.

6.3 Issues

The survey gives a snap shotof the perceptionsand needsof seniorstaff, a group not oftensurveyed (and an area in which there is little existingresearchof this type). Most studies havefocused onpractitioner'sneeds. Someindividuals did not answerthe questionnairefeelingthat it was not relevant to them. Methodsof addressing thisshouldbe explored.

In several ways the surveystimulateda positive response totraining opportunitiesin publichealth. For example,manythought the responsibilitiesthat public health covers were veryimportant, two outof three respondentsidentified specific areas in which they wanted todevelop their knowledge and skills, and a similarproportionfelt they have goodopportunitiesfor personal development.However,lack of time was abarrierfor everyone, and meeting thecostof training a problem for at least half. This indicates thatappropriatebudgetsneed to beidentified and access to these clarified.

Individual commentscan be used to shape trainingprogrammes. For example, there wassome consensuson the value of inter-agencyor joint training with staff involved inimproving health in partner organisations. This would help develop the public health'mindset' across health and localauthoritiesthat is recommendedby the CMO's report tostrengthenthe public health function. Induction courses weresuggestedfor council membersand social services trainees. There was also support fortraining that gives greateremphasisto economic, social andphysical influences on health. Onesuggestedthe networkingopportunitiesof training would allow access to skillswithout the need to learn themthemselves. Another said they would like training to bemodular and practical. Somespecific skills were wanted such as needs assessment andputtingevidenceinto practice.

Whilst respondentsare not clear on the overall conceptof public health' they know whatneeds to be done under thebannerof public heath but maybe not bywhom. There is a needto clarify roles andresponsibilitiesof this group as well asdefining the 'new public health'agenda.

The difficulty respondentshad in giving adefinition of public healthneeds to be taken intoaccount wheninterpretingthe results, and mayitself suggest the need for general training.Itseems likely that thoseinvolved in health improvementprogrammeswould benefit from abroadeducationthat would raiseawarenessof the methods andterminologyof public health.An examplesupportingthis statementis that when asked to rate theimportanceof topics,health impactassessmentwas at the topof people'slist for not knowing whether it wasimportantor not.

21

It is interesting that overhalf felt that 'housing stock andconditions' were only 'fairlyimportant' or 'not important' areasof public health.Almost as many felt the same about'health and safety'. Traditionally only environmental health has been seen to have aconnection with publichealth whereas public health is muchbroaderthan that andshouldencompass many otherdepartments.

Although many did not feelconfident in someof the skills listed they were not asking fortraining even though themajority felt that public healthskills were relevant to their roles.This could be due to a feeling that they had no time for morepersonaldevelopmentor thatcompeting demands tookpriority?

Respondentsfelt confidentin a numberof key skills that have been identified in theCMOs'report on strengtheningthe public health function - these were working inpartnership,communicationand usingleadershipskills. For this group, there appears little need fortraining in these skills. The areas people were lessconfidentwere technical skills, such ashandling andpresentingstatisticalmaterial, and specificpublic health methods.Again thisagrees with skills theCMO's report identifies are in short supply, and poses achallengetoeducators.

In many areas knowledge levels were described as basic,suggestinga widespreadneed fortraining. While there isclearlya benefit in gaining adetailedunderstandingof public healthmethods, training in these areas will need to take accountof occasionswhen people feel theknowledge is not relevant to their job.

Most respondentsfelt that theyhad satisfactoryopportunitiesfor developmentbut indicatedthat pressureofwork and lackof funding stopped these fromtakingplace. This mayindicateeither a need for morestaff or a need to examine andredefineroles? Thepriority given tofunding non statutorydevelopmentneeds to be explored.

This survey report will bedisseminatedto those agenciestaking part in order to gainfeedback as to theway forward. A conferenceto explore defining public health roles hasrecently taken place and a report is beingproducedwith recommendationsfor action. Thetwo reports willcomplementeachotherin supportingfurther action.

If public health training for this groupof people is to besuccessful,it will have to bedesigned to overcome themajorobstaclesoflack of time and money.It will also have to beseen to besufficiently relevantto their role to rise abovecompetingpriorities. Although thesurveyrespondentsthoughtpublic health skills wereimportant, they were actually not verygood at defining what thesubjectcovers. This may have lead to difficultyrelating to thetopics that we asked about(hardly surprisingas by definition we were surveyingpeopleoutside NHS publichealthdepartments). This lackof familiarity with the terminologywouldalso account for therelatively low levelsof demand we found fordevelopingthe knowledgeand skills associated withmainstreampublic healthresponsibilities. Facing such a broadsubject, it may be that the first training objective should be to encourage sharedthinkingthrough shared training, then to raise awareness about publichealthissues and how to accessexpertise in them. Toprovide skills that people can use withconfidence may be aconsiderableway down this road.

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7. RECOMMENDATIONS

• The mainpriority must be in raisingawarenessof the role of all the Local Authoritydepartments that areinvolved in Health ImprovementProgrammesin the broad publichealth agenda both within LocalAuthoritiesandwithin the NHS.

• More opportunities are needed forjoint appointments,joint training and educationthrough existing routes but maybe moreimportantly through shadowing,learning sets,mentoring and goodpartnershipsworking.

• There is clearly a need to providetraining/learningopportunities for senior staff toincrease their skills andknowledgearoundpublic healthissuesparticularly,healthneedsassessment, using statisticalprogrammes to interpret data, presenting data andundertakingresearchusing differentmethodologies.

• Learningopportunitiescould be integrated intoexistingprovision to address theproblemof time pressures.

• Inter-professionaltraining andworking on Health Impact Assessmentwould move theagenda forward as this is seen as a need both from NHSstaffand from thoserespondentswithin this study.

REFERENCES

ChiefMedical Officer's project to strengthen the public health function: reportof emergingfindings.DepartmentofHealth, 1997.

The Reportof the ChiefMedical Officer'sProject toStrengthenthe Public Health Function.DepartmentofHealth, February. 2001.

Developing public health in the South East region: a framework for action.Cornish Y,Christmas P, et al. NHS Executive South East, May 2000.

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ANNEX A. Questionnaire

Survey of Staff Involved in Health Improvement.

ITIIJ

This surveyis beingconductedby theCentrefor HealthServiceStudiesat TunbridgeWells, part ofthe UniversityofKent atCanterburyon behalfof the KentEducationConsortium. Answerswillbe treatedin confidence.

Job title:

Organisation:

Department:

TelephoneNumber:

I. Whatproportionof your work is concernedwith thehealthof the localpopulation?

ｾ ｾ ｾ ｾ ｾ ｾ ｾ ｟

2. What otheragenciesdo youwork with:

Agency Formally Informally

D DD DD DD D

3. Are you amemberof any inter-agencygroup? Yes No

(If yespleasespecify) D D

I PUBLIC HEALTH DEFINITION

4. Pleasedescribewhat youunderstandby the term'public health'

24

5. In your opinion does aresponsibilityfor public health include anyof the following? (pleasetick the appropriate box)

VeryImportant

FairlyImportant

Not veryImportant

Don'tKnow

a. Diseaseprevention

b. Health promotion

c. Reducinghealthinequalities

d. Environmentalhealth hazards

e. Disease screeningprogrammes

f. Diseaseimmunisationprogrammes

g. Clinical effectivenessofhealth care

h. Health needs assessment

I. Health impactassessment

J. Populationhealthmonitoring

k Housingstock andconditions

1. Health and safety standards

m. Hygiene

n. Studyingofpatternsof disease

I SKILLS AREA

D D D DD D D DD D D DD D D DD D D DDL-_--JDL---------.JDL--_DD D D DD D D DD D D DD D D DD D D DD D D DD D D DD D D D

6. Please indicate how skilled you feel you are in the following areas

Fairly Not at all NotrelevantConfident confident confident to my job.

a.

b.

c.

d.

e.

f.

g.

h.

I.

Knowing how and where to obtaininformationon populationcharacteristicsEg. Age profile,ethnic mix.

Interpretingpopulationdata

Comparinginformationwith otherpopulations

Undertakingresearch using differentmethodologies

Developing interventionsfor local situations

Identifying methods tomonitorprogressagainst projectobjectives.

Evaluate researchprojects

Using projectmanagementskills

Policy development

25

D

DDDD

DDDD

D

DDD

D

DDDD

D

DDDD

DDDD

D

DDDD

DDDD

Fairly Not at all Not relevantConfident confident confident to my job.

J. Critically appraisingresearch D D D Dk. Working in partnerships D D D DI. Usingleadershipskills D D D Dm. Conductinga healthcareneedsassessment D D D Dn. Engagingand involving the public D D D Do. Use of the intemetto obtaindata D D D Dp. Useof the internetto obtainliterature D D D Dq. Statisticalprogrammesto interpretdata D D D Dr. Presentingdata- eg graphs D D D Ds. Facilitatinggroupwork D D D Dt. Communicationskills D D D Du. Healthimpactassessment D D D Dv. Accessingqualitativeinformation D D D Dw. Accessingquantitativeinformation D D D D

I KNOWLEDGE AREAS

7. Pleaseindicatethe levelof knowledgeyou havein the following areasNot

Very relevantNone Basic Good Good to myjob

a. Populationhealthstatus D D D D Db. Healthinequalities D D D D Dc. Barriersto betterhealth D D D D Dd. Useofhealthandrelatedservices D D D D De. Healthpromotioninterventions D D D D Df. Healtheducationinterventions D D D D Dg. Healthimprovementprogrammes 0 0 0 0 0h. Screeningand immunisationProgrammes D D D D D1. Communicablediseasecontrol D D D D D1. Systemsfor respondingto D D D D D

environmentalhazards

26

NotVery relevant

None Basic Good Good to my job

D D D D DJ. Clinical Governance

D D D D Dk. Local Agenda 21

D D D D D1. Saving Lives: OurHealthierNation

m. Other policies: (please detail below)

D D D D DD D D D D

IDEVELOPINGKNOWLEDGE AND SKILLS

8. In relation to public health and healthimprovement,please indicatebelowthe areas inwhich youwould like to develop yourknowledgeand skills.

Knowledge Areas Skill Areas

9. Do you haveregularappraisals by your linemanager?

Yes D No D Haven'thad an appraisalrecently D

10. What are theopportunitiesfor your ownpersonaldevelopment?

None

DPoor

DFair

DGood

DVery Good

D

I BARRIERS TOSKILLIKNOWLEDGE DEVELOPMENT

I I. Please outlinebelowany barriers todevelopingyour skills and/orknowledge. Eg. Lackoftime, no funding available for courses etc.

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I FURTHERCOMMENTS

12. If you have any othercommentsregardingknowledge and skilltrainingwithin public healthplease write them in below.

Please return thequestionnaireby the 7th'hFebruary2001 to: Miss F.E. Meade,ResearchAssistant,CHSS atTunbridgeWells, Oak Lodge, DavidSa!omon'sEstate,Broomhill Road, Tunbridge WellsKent. TN30TG.

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ANNEX B. Establishing a sampling frame

Identifying and mailing out thequestionnaireto the targetpopulation was not a simpleprocess, and detailsoftheapproach thatevolvedare given below.

Methods

Lead staff in East and West Kenthealthauthoritiesresponsiblefor HImPswere telephonedand asked for contacts for all the keymulti-agencyboards or groupsinvolved in the HImP.

Within East Kent six key contacts wereidentified, although tenplanninggroups were in theHImP dated April 2000. On follow-upof these key contacts, four names were no longercorrect and we were given alternative names. The six key contacts were then sent lettersrequesting the board members names andcontactaddresses. All the key contacts replied,generating amailing list of 76 names.

In West Kent nine key contacts wereidentified and contacted. Four did not respond.Members for the specified HealthAction TeamsandPartnershipBoards wereobtainedfromthe remaining five key contacts. This lead to a totalof 84 namedpeople to whom aquestionnairewas sent.

All lists were checked to ensure there were no duplicates,which would result in a personreceiving two or morequestionnaires.Any duplicatenames were omitted.Namesof staffinNHS health authorities and trusts (apart fromPCG/PCTs)were also omitted. All the namesandaddresseswere then put into a database formailing purposes.

As an alternative approach, all fourteen localauthoritycouncils in Kent werecontactedbywriting to headsof Human Resources orPersonneldepartmentsand asking for names andnumbersof staffwith a public health remit in their job descriptions. Twocouncilsdeclinedthe invitation to participate in the survey. About 100questionnaireswere sent to theremaining twelve councils, who agreed to pass them on to relevant staff. At the outset, webelieved this might be the best way toidentify staff with public health training needs.However, theresponsefrom HR departmentswas patchy and so theapproachwas used tosupplementthe survey's coverage in local authorities. Adisadvantageof using HRdepartments was that thequestionnairesmight have reached the same people twice.However, apossibleadvantage is that it extended our coverage to lessseniorstaff(than thosewho weremembersofmulti-agencyboards).

We aimed to send aquestionnaireto all named and unnamed contactsderivedfrom the aboveprocess.

Questionnairedistribution

East Kent - Thequestionnairewas distributedto named persons.Forty two named peopleassociated with the JointPartnershipBoards in East Kent were identified. The last twonames were key people who wished to distribute thequestionnairesto membersof Children'sServices Board and the Mental Health Board. The membersof the Children'sServices Boardwere identified by the key contact after thequestionnaireshad beendistributed. The totalnumber of people on this board to which thequestionnaireswere sent was 13. Fifteenquestionnaireswere sent to the key contact for the Mental Health JointPartnershipBoard (the

29

actual numberof people on this board was not confirmed). This suggests an approximatetotal of 70 questionnaireswere sent out.

West Kent - Again thequestionnairewas distributed to namedpersonsidentified through thekey contacts. Four key contacts werennresponsiveandthereforecouldnot be included in thestudy. The total numberof named persons in West Kent to whom thequestionnairewas sentwas 84.

Councils in Kent - These were sentquestionnairesas an alternative approach to finding localauthority staff with a responsibility for public health, but who had not been sent aquestionnaire as a named person in the East and West Kent mailings.Questionnairesweresent to 12 councils. Previously two councils had declined theinvitation to participate in thesurvey.

Comments on sample

Finding staff in local authorities with a public healthcomponentin their job descriptionwasnot easy. In addition, healthauthority and local authoritystaff were not always able torespond to our requests for contact names. Partnership boards were emerging and hadchanging memberships with no clearresponsibilityfor maintainingup to date lists.

Peopleworking in voluntaryorganisationsand charitiessometimesreturned thequestionnairethinking that it did not apply to them.

It is thereforerecognised that there could be serious biases oromissionsin the contact nameswe were able to obtain.

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