Health services for health promotion and disease prevention

The importance of social and environmental factors in determining the health status of a population provides the context for the role of health services in health promotion and disease prevention. Health service providers play important roles as advocates, leaders, and partners in disease prevention and health promotion strategies. The initial sections of this chapter discuss the definition of prevention, levels of prevention, and the place of population-wide and high-risk approaches. It then discusses some of the public health skills that are required in prevention programmes, including assessing needs and priorities, evidence of effectiveness, the role of behavioural and implementation sciences, and the importance of evaluation. The chapter illustrates these principles using examples from communicable and non-communicable disease control.

Access to healthcare

Access to healthcare is concerned with the processes of gaining entry to the healthcare system. Analysis of access focuses on inequality and inequity in the availability and use of health services. In order to address global inequalities in access to healthcare, international organizations have promoted access to healthcare as a human right. This is linked to the ideal of universal health coverage, with shared funding of some or all healthcare for everyone, as a key strategy for achieving this. At a national level, rational strategies for resource allocation and priority setting are used to promote equity of access in terms of equal access for equal need, but historical inequalities based on the ‘inverse care law’ have been resistant to change. In health systems led by primary care, access to a general practitioner (GP) tends to reduce inequalities in ‘entry’ access to the health system, but the gatekeeping role of GPs may contribute to the development of inequalities of ‘in-system’ access. Wide variations in the utilization of both primary and secondary care services are indicative of access inequalities, but these variations may sometimes reflect clinical uncertainty or poor-quality care. Access inequalities may also arise from personal, social, and cultural barriers experienced by patients in accessing healthcare. These barriers typically represent more severe obstacles for marginalized groups in the population. Promoting equity means ensuring that services are responsive and acceptable to all groups, including those with stigmatized conditions.

Concluding remarks

Demographic change and economic constraints are likely to drive change in healthcare systems over the next few decades. It seems inevitable that both the amount and the shape of healthcare systems will be stretched by increasing numbers of old people, even as the definition of ‘old age’ is itself stretched. Concepts of ‘disease’ may need to change; such changes will need to be mirrored in coding systems. As healthcare becomes more specialized, pathways become more complex. This will disadvantage people who lack the cognitive, physical, and financial resources to navigate complex systems. Specialists in healthcare public health will need to adapt their knowledge, skills, and attitudes.

Perspectives on healthcare quality and safety

This chapter offers an introduction to the recently developed applied health science fields of patient safety, improvement, and implementation sciences. Healthcare is a high-risk activity because of the complexity of its systems and processes. Errors arise frequently and these can impact negatively on patients by causing adverse events. Errors and adverse events are generally attributable to defective systems for organizing care, which create conditions in which errors arise. This represents a failure of risk management. Patient safety science takes a scientific approach to understanding why errors occur and how to prevent their occurrence or minimize their impact. Learning from analysis of patient safety incidents, through root-cause analysis, enables an organization or service to learn and avoid repeating similar failures in the future. Patient safety incidents represent one aspect of the wider problem of poor-quality care. Improvement science offers standardized tools and measurements that can be used to monitor and improve healthcare delivery. The Model for Improvement employs repeated Plan–Do–Study–Act (PDSA) cycles to quantify problems and to develop and test potential solutions. Engagement with stakeholders is an essential part of this process. Implementation science can contribute by providing methods to promote the uptake of new research evidence into healthcare practice. It can address the second translational gap by facilitating the widespread adoption of strategies for improving health-related processes and outcomes, and advancing knowledge on how best to replicate intervention effects from trials into real-world settings. These new scientific fields provide well-established approaches to addressing some of the key problems arising in healthcare. Modern public health needs to reap the benefits of these newly emerged sciences to address the burden of adverse events and harm that arises in the delivery of healthcare and to promote evidence-based practice.

Healthcare needs assessment

Healthcare needs assessment is an evaluative process that aims to quantify population needs for healthcare. Need is defined as the capacity to benefit from healthcare. It is characterized by a deficit in health linked to the potential for effective healthcare intervention. The epidemiological approach to needs assessment considers the burden of illness in terms of the incidence, prevalence, and mortality of a disease or health condition. This approach also draws on estimates of clinical and cost effectiveness from systematic reviews of well-designed studies. These estimates can be mapped to existing patterns of service utilization to identify potential gaps in services. Needs assessment should evaluate inequalities in health needs and access to services in key population subgroups. The comparative approach to needs assessment contrasts locally derived estimates with data from comparator areas as well as national benchmarks and other normative data. The corporate approach engages with stakeholders, including service providers and patients, to understand their perspectives and concerns. Epidemiological, corporate, and comparative assessments of need should be summarized to make quantified recommendations for changes to existing services, informing the development of a business case, and being integrated into service commissioning.

Populations, values, and health

This chapter explores some of the philosophical and ethical presuppositions of population healthcare; it investigates the implications for how we should understand the jurisdiction, aims, and evaluation of population healthcare. The jurisdiction of population healthcare is primarily within the healthcare system but necessarily extends beyond the walls of clinics and hospitals, given the need for social coordination to bring about healthcare access at the population level. The dual aims of population healthcare in maximizing population benefits of healthcare and reducing health inequalities are clearly moral in nature, but they can give rise to conflicting goals that the ethics of population healthcare should seek to resolve. While population healthcare’s aim is to advance a value-based approach to healthcare, which seeks to promote what is called technical, allocative, and personalized value, there are a number of questions that remain unanswered: in particular, the justification and evaluation of personalized value, and why the satisfaction of individual preferences in relation to health outcomes should be a population-level concern alongside promoting health and health equity.

Digital healthcare public health

New digital technologies are having important impacts on the practice of public health and the organization and delivery of healthcare. Developments in information technology ensure that public health information is now available in more timely and accessible formats; data linkage has enriched public health information by making it possible to analyse multiple data sources simultaneously; and the use of smart devices and smart cards is generating even larger data resources that may be utilized for public health benefit. Computationally intensive approaches, derived from machine learning and artificial intelligence research, can be employed to develop algorithms that may efficiently automate healthcare-related tasks that previously relied on human analytical capabilities. Prediction modelling and risk stratification are being developed to promote precision public health. Increasing population coverage, with smartphones and other smart devices, makes it possible to deliver health-related interventions remotely, blurring the distinction between healthcare and public health. The availability of social media makes the exchange of knowledge and opinion more open, but this may also contribute to the propagation of false information that may be detrimental to public health. Public health needs to embrace and understand these developments in order to be at the forefront in harnessing these new technologies to improve population health and reduce inequalities. This must be accompanied by awareness of some of the ethical challenges of big-data analysis, the potential limitations of new analytical techniques, the relevance of behavioural science in understanding the human–machine interface, and the importance of critical evaluation in an era of rapid change.

Population screening

This chapter outlines the concept and definition of population screening. It identifies key challenges and considerations in converting the simple concept of early identification of disease into population screening programmes. Ethical considerations are important in evaluating the potential benefits and harms of screening programmes. These inform the criteria used to determine whether it is appropriate to introduce screening. Screening tests must usually be sensitive to maintain public confidence in a screening programme, but specific tests are also required because false positives may often outnumber true positives in a population screening context. Assessment of screening programme effectiveness usually requires randomized controlled trials that minimize the potential effects of lead time and length bias. The chapter concludes by discussing policy decisions involving starting, stopping, and changing programmes, as well as how screening programme performance can be measured.

Knowledge management

Knowledge management is the process of identifying, appraising, and synthesizing evidence to inform healthcare organization and delivery. This chapter summarizes the role and use of evidence in healthcare. Evidence identification, appraisal, and synthesis are described, and the use of evidence to inform the development of healthcare guidelines is discussed. The challenges of guideline implementation are explored and potential solutions are outlined. The future direction of knowledge management is complex and may involve individualized risk scoring and new approaches to analysing large datasets. Knowledge management should be used to guide more coherent care across healthcare systems; evidence and knowledge management must also promote appropriateness in healthcare.

Involving patients and publics in healthcare

Patients and patient organizations, and other members of the public and communities are widely recognized as important stakeholders in processes through which healthcare systems and services are designed, delivered, and monitored. Their involvement in these processes is promoted not only as a strategy to enhance the quality of systems and services, but also as an act of democratic participation. Yet putting involvement into practice is not straightforward. This chapter outlines the field of involvement in healthcare, focusing on some of the key areas of debate. These include definitions of involvement, the rationales put forward, involvement as represented in policy, and the methods used. The chapter summarizes some current key debates in relation to questions of who is involved, power, and evidence of effectiveness.