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Popay, Jennie; Mallinson, Sara; Kowarzik, Ute; MacKian, Sara; Busby, Helen and Elliott, Heather (2004).Developing public health work in local health systems. Primary Health Care Research and Development, 5(4) pp.338–350.

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Developing public health work in local healthsystemsJennie Popay, Sara Mallinson, and Ute Kowarzik Institute for Health Research, Lancaster University, Lancaster,UK, Sara MacKian Department of Geography, Manchester University, Manchester, UK, Helen Busby and HeatherElliot Formerly of the Institute for Public Health Research and Policy, Salford University, Salford, UK

Current government policy aims to create a wider ‘community of public health prac-

tice’ within local systems, working in a coherent and coordinated way in partnership

with local people to reduce health inequalities. However, for this to happen policy-

makers and practitioners across the public sector have to reconsider boundaries, role

definitions, professional identities and responsibilities. On the basis of documentary

analysis and fieldwork involving interviews with individuals from various sectors and

nonparticipant observation of public health nursing and primary care organizations

within two local health economies in England, the paper explores the ways in which

these processes of reconfiguration have been developing in local health systems. It

illuminates new exclusions and tensions emerging from inherent contradictions in

national policy and from difficulties individuals have thinking beyond existing spa-

tial, conceptual and organizational boundaries and divisions. Paradoxically, there-

fore, rather than opening up new spaces for public health practice these tensions

may ‘force’ some people back into narrower more traditional roles or ultimately out

of public health altogether. The paper also uses the notion of communities of prac-

tice to explore issues of ‘agency’ in professional practice � that is the way in which

individuals reflexively construct their practice and in so doing engage with or resist

the relevant policy imperatives. The research illuminates some of the boundaries that

are operating to discourage people from engaging with public health. This analysis

suggests people may need more time and support to respond constructively to the

new public health agenda. Without this, potential members of the wider public

health workforce may respond defensively and resist alignment to public health

goals in order to protect their embattled workspaces.

Key words: communities of public health practice; health inequalities; primary care;

public health; reflexive communities

Introduction

In recent years, the nature and scale of the policyand practice change agenda facing those workingwithin primary care and public health has beenevolving rapidly. Internationally, there has been amajor resurgence of policy interest in thereduction of health inequalities and a renewedcommitment to involve patients and the publicmore directly in policy and practice decisions that

affect their lives. In the UK, there has been averitable flood of policy documents setting thisagenda (see for example Acheson, 1998; Depart-ment of Health, 1997; 1999; 2001a; 2001b; 2002;2003; Wanless, 2004; and a forthcoming WhitePaper on public health in the summer of 2004).Perhaps most importantly from the perspective ofthis paper, the key role for primary care organ-izations and practitioners in delivering improve-ments in population health and reducinginequalities has been reiterated by key inter-national agencies (Busby et al., 2000; WHO,2003). In the UK reflecting this trend, leadresponsibility for public health activities in local

Address for correspondence: Jennie Popay, Institute forHealth Research, Lancaster University, Alexandra Square,Lancaster LA1 4YT, UK. Email: [email protected]

Primary Health Care Research and Development 2004; 5: 338–350

#Arnold 2004 10.1191/1463423604pc224oa

health economies has been located within newprimary care organizations � primary care trusts(PCTs) � which are required to work in partner-ship with local government, local people andother stakeholders to improve population healthand reduce health inequalities.

Parallel modernizing trends have been underwaywithin local government including the extension ofthe local government brief to include the promotionof population social well-being and the establish-ment of overview and scrutiny committees (with aremit including oversight of health-related develop-ments) and local strategic partnerships. Majorurban regeneration initiatives involving the activeengagement of disadvantaged communities are alsobeing implemented in many areas, including NewDeal for Communities.

The overall aim of these policy initiatives at thelocal level is to create a wider ‘community ofpublic health practice’ � including policymakers,managers and front-line service providers withinprimary care, other NHS organizations, localauthority services and the voluntary and com-munity sectors � working in a coherent and coor-dinated way to address agreed local priorities toreduce health inequalities and connecting up localservices to provide easier access to high qualityservices for those most in need. Public sectorinstitutions and service providers are required tobe ‘flexible and responsive’ to the diverse needs ofconsumers and communities who are to be activeparticipants in policy development and implemen-tation. In principal, at least, these changes areopening up new spaces within local systems forpublic health work aimed at addressing healthinequalities to be ‘practised’ in new ways by newwider communities of practitioners. However, forthese new institutions, practitioners, communitiesand practices to develop there will have to be areconsideration of boundaries, role definitions,professional identities and responsibilities.

In this paper we summarize the main results ofresearch funded by the Department of Health inthe UK which aimed to explore the ways inwhich these processes of reconfiguration havebeen developing in local health systems and toilluminate the factors that are acting to promoteand=or constrain new ways of working in publichealth. More details of this research are providedelsewhere (see for example, MacKian et al., 2003;Mallinson et al., 2004; Popay et al., 2004a;

2004b). In the following section the researchmethods are described and then the results of thetwo main strands of the work are reported.Finally, we briefly explore some of the implica-tions of the research for future policy.

The research design

The research reported here was based in two innercity localities in Greater Manchester and London:both have significant levels of socio-economic dis-advantage, but one is culturally very diverse,whilst the other is overwhelmingly white. Thischapter presents findings from work conductedduring this project concerned to develop anunderstanding of the factors shaping public healthpractice and policymaking across professionalgroups and agencies within localities. Two wavesof fieldwork were conducted � one wave in1999=2000 and the second in the autumn=winter2001=2002. The fieldwork involved nonparticipantobservation, in-depth interviews with a purposivesample of public and voluntary sector workersand document analysis. In both localities the in-depth interviews involved 21 individuals drawnfrom the health sector (London (L) 11 andGreater Manchester (GM) 14), local government(L 2; GM 6) and the voluntary=community sector(L 5; GM 3). The interviews lasted around anhour on average and most (38=42) were taperecorded and then fully transcribed � detailednotes were taken on the other four. A topic guidewas used to ensure that interviewees reflected onsimilar issues in all the interviews. The key head-ings in the topic guide were: perceptions of publichealth, people’s roles in relation to public health,their views on partnership working, the relevanceand impact of national and local policy initiativeson daily work, and the barriers and=or facilitatingfeatures of various policies for effective joint workto tackle public health issues.

The interview transcripts were content analysedand thematically indexed (Spencer and Ritchie,1994). The different strands of work involved dif-ferent types of data and therefore differentapproaches to analysis. Only the analysis of inter-view transcripts is described here. This indexingprocess involves identifying key themes from aninitial read of all transcripts, constructing a seriesof categories with which to label the data, and

Developing public health work in local health systems 339


then systematically analysing all transcripts. Threemembers of the team read all the transcripts andagreed the categories for the indexing system. Toensure that our analysis processes were trans-parent two transcripts were independently indexedby two researchers and then compared. During thecourse of the analysis, we reflected upon thestrength of the categories we developed by con-sidering if they were able to capture the full rangeof views, experiences and theories expressed byour diverse sample and amended them wherenecessary. The fieldwork also involved the col-lation and analysis of various local and nationalpolicy documents and this material provided ageneral context or background to the accountsgiven by individual research participants.

The research results

Understanding the dynamics of change in localsystems

The development of new institutions and prac-tice in public health requires changes in under-standings of roles, identities and responsibilitiesat the level of individual workers and agencies.Some insights into the processes and=or factorsshaping these changes are provided by theoreticaland empirical exploration of two concepts fromthe social sciences � ‘reflexive communities’ and‘communities of practice’.

‘Reflexive communities’: a frameworkfor studying policy implementation

The idea that we inhabit an increasingly ‘reflex-ive’ society in late modernity is gaining currency(Beck, 1992). It is argued that individuals are nowfaced with a wider range of options and decisionsthan in the past and that there is an opening upof possibilities for individuals to reflect criticallyon the changes impacting on them and potentiallyinfluence these changes. This is an interestingproposition in the case of public health activity inthe UK where government policy has sought tobreak with familiar delivery structures and createmore possibilities for public health practitionersto make choices and exert influence.

From this perspective interpretation andimplementation of policy is a highly situated pro-cess � spatially, temporally and socially � aslocal actors perceive and respond to the wider

forces around them. Central policy directives canonly provide possible route maps for the reflexivecommunities who inhabit the world of publichealth to colonize and in so doing shape to maketheir own. Thus the local implementation of pub-lic health policy and practice is shaped bynational and local policy initiatives and structuralarrangements � both historical and contempor-ary � as well as by the reflexive construction ofroles and relationships in the minds of peopleoperating in the system.

In attempting to reveal these reflexive processesat work our analysis has drawn on the longstanding tradition within public health of usingmaps and mapping techniques. It has sought tomap how different groups (from central govern-ment to individual public health practitioners)reflexively construct less tangible relationships intheir minds and how the resulting multidimen-sional conceptual maps influence their under-standing of public health roles and the routineday-to-day work they do. The results, brieflydescribed below, are discussed in more detailelsewhere (MacKian et al., 2003).

Our empirical analysis traces one recurring anddominant concept in the rhetoric of public health,that of ‘partnership’. This empirical journey takesus from the vision of partnership coming fromcentral government; through the perspective of aprimary care group (the transitional organiza-tional form that preceded primary care trusts); tothe day-to-day operation of less formally struc-tured partnerships between individuals in theirworking lives.

Looking at the language and discourse of part-nership in central government documents thereappears to be an almost universal belief thatpartnership is ‘a good thing’ and there have beenincreasing efforts to provide structural oppor-tunities for such partnerships to develop includ-ing the establishment of interagency localstrategic partnerships and public health networks.This partnership drive is indicative of an attempt,at least in rhetoric, to move away from a central-ized, hierarchical model of government (Figure 1),towards a more flexible, responsive process oflocal governance (Figure 2) in which responsibilityfor policy formulation and delivery is, theoret-ically, increasingly handed over to networks ofpublic and private sector actors, working to meetshared goals (Stoker, 1999). However, despite this

340 Jennie Popay et al:


rhetoric of devolution and community empower-ment, public health policy documentation com-bines a mixture of strong central direction andmonitoring, suggesting ‘vertical’ control, with thesoftening of old boundaries ‘horizontally’ (Dixonand Preker, 1999). The resulting conceptual map(Figure 3) is almost a hybrid of the two, with some fluidity allowed through the generation of

partnerships and iterative learning being squeezedby forces of regulation, set through targets andmonitoring mechanisms.

Having mapped the new spaces of public healthsign-posted in central policy discourse we turn tothe local, as it is the work of reflexive communi-ties in particular places which will have the great-est influence on how those spaces will materializein practice. As others have argued, shifts inpower relationships at all levels within the publicsector and with service users are key to the evol-ution of effective partnership working (Nelsonand Wright, 1995; Petersen and Lupton, 1996).However, as one of our study sites illustrated,there are powerful constraints on agencies andindividuals challenging old relationships of powerand control, despite facilitative structural change.During the collaborative development of the

Figure 1 Hierrarchical policy design. Here there is alayered implementation, with the drive coming from‘above’ at central level

Figure 2 Fluid policy design. Here policy implemen-tation is a discursive process with numerous partnersworking together on a more level playing field

Figure 3 Integrating the vertical and horizontal?Using key words from relevant policy documentation, inthe centralized map there is a tension between theelement of vertical control, and the drive towards amore horizontal, enabling framework for public healthworking. Devolution and greater local integration enablea more reflexive form of learning through day-to-dayoperations, but constant monitoring and control act asforces of restraint, squeezing the increased fluidity



annual health improvement programme (HImP)in 2001 involving the local health authority, thePCG, local government and voluntary=community groups, the PCG board saw its roleas central. It was therefore concerned at anapparent criticism ‘from above’, at the HealthAuthority level that local agencies were actingalmost independently of the content of the HImP.The PCG was very keen to change this perception� they saw themselves and their work with part-ners operating as the ‘engine house’ of the HImP,rather than independent of, or passively subjectedto it. Their understanding was that they held acentral role in a discursive process � involvingjoined-up working across national, regional andlocal partnerships. This is very much in line withthe ‘fluid map’ of modernized governmentdepicted in Figure 2. However, in their own doc-umentation they continued to portray their pos-ition at the bottom of a distinctly vertical mapwith three clear layers � national, regional, local� much more indicative of the layered map ofpolicy implementation (Figure 4). Contrary to themessage they wanted to portray, this inevitablysuggested a hierarchy and a certain detachment,rather than the more fluid discursive playing fieldthey were keen to emphasize.

Despite apparent opportunities for an increas-ingly reflexive approach, the PCG was limited byexisting systems of knowledge and power. Thusestablished power-laden processes, practices andlanguage have the potential to perpetuate existingpatterns despite well intentioned attempts to fos-ter change (Christie and Mittler, 1999). How farthis situation was the result of central control andpurposeful design, or the inability of participatingagencies to think beyond existing spatial, concep-tual and organizational boundaries and divisions,remains an important empirical question. Theway in which this PCG depicted its role reflectedthe long established conceptual models of theactors involved. Vertical centralized control con-tinued to dominate the way in which ‘horizontal’partnerships were conceptualized, experiencedand represented. Although this may not directlyprevent horizontal linkages, it could potentiallyprevent any real breaking of the mould.

Finally, individual workers will of necessity beinvolved in the frontline of partnership oper-ations both formally through, for example, theorganization in which they work and on a more

informal basis with the people they work along-side. Figure 5 was developed from shadowing twohealth visitors working with refugee and homelesspopulations. They told how their public healthfunction was being expanded and they wereencountering difficulties in managing the bulgingboundary around this role. They both noted thatthey acted as advocates for their clients arguingthat this meant they had to liaise with numerousother professionals and services. Building trustwas seen as an essential part of that process, andthey believed they worked effectively ‘in partner-ship’. However, they found this role demandedboth a professional and a personal input whichthey felt exceeded that which was reasonable andwas not taken into account in their job training,nor recognized and acknowledged by fellow pro-fessionals. They therefore found themselves hid-ing the true extent of their partnerships fromcolleagues, whilst feeling increasingly isolatedfrom a profession that on the whole did notengage so extensively with the wider world ofpublic health. They felt official recognition fortheir public health work was not available withintheir profession, and therefore used their relation-ships with people outside their profession �including for example, welfare benefit(s) or hous-ing staff, interpreters, or even clients � to givethem the support they needed. These were inhab-itants of the same reflexive place, with a sharedunderstanding of how that space was constituted.

These health visitors were engaging whole-heartedly with the expanding territory of publichealth, carving out a supportive core for theirinvolvement. Their self-reflexivity was enablingthem to visualize themselves at the centre of afluid world of intense relationships, emerging outof the changing policy climate. However, therewere tensions in the wider reflexive community ofwhich they were a part, yet to be resolved. In anattempt to deal with these tensions they hadtaken additional training, and sought support inunusual places. Nonetheless for both these healthvisitors, the strain was becoming overwhelming,and each harboured plans to move on in the nearfuture, either to a health visiting position with amore bounded public health role, or outside thefield of public health altogether. For them,the uncertainties associated with the fluidity oftheir public health role represented an almostunmanageable risk. The daily job of crossing



professional boundaries was developing strongworking relationships and a sense of partnership,but it was also destabilizing a sense of pro-fessional identity. Their working relationshipsoutside their profession had developed into rela-tionships of support, but this way of working wasalso causing an unsustainable burden of internalstress and feelings of professional inadequacy anddisillusionment, with the ultimate threat ofmigration from the service.

Far from the aim of bringing ‘empowered’people together to share workloads and developreflexive communities of understanding to carveout a meaningful role in the expanding territoryof public health, the shifting boundaries of thehealth visiting role would seem to be leading to

secrecy within the profession and increased levelsof individual stress. Partnership in this examplewas therefore having some of the complex knock-on effects in the wider system that are given rela-tively little recognition in a literature that almostexclusively promotes and supports this way ofworking (Medd, 2001).

A ‘communities of practice’ perspectiveon developing the public health workforce

A second conceptual vehicle for unpickingsome of the factors shaping change in publichealth within local health systems is the notion ofcommunities of practice. (Wenger, 1998) Like thenotion of reflexive communities Wenger’s workfocuses attention on to issues of ‘agency’ in pro-

Figure 4 Cutting across the map: understanding local actions. The PCG combined their own sense of beingin the driving seat for change, with the hangover of a vertical framework for public health policy design andimplementation. Thus, although there is a space for reflection and fluidity, this is distinct from the ‘upper layers’where decisions are made. They were creating their own reflexive community to interpret vision and strategy, ratherthan influence it. Reproduced from MacKian, S., Elliot, H., Busby, H., Popay, J. 2003. Health and Place, 9: 219–229.Copyright Elsevier Science.



fessional practice � that is, the way in which indi-viduals reflexively construct their practice and inso doing engage with or resist the relevant policyimperatives. In particular, this concept provides aframework for looking at the collective andorganizational context for practice change anddevelopment � on the relationships throughwhich knowledge is shared and practicedeveloped amongst people sharing a commitmentto a task or goal. As Wenger argues, oppor-tunities for learning and development are at theirrichest within the context of a community ofpractice (CoP).

According to CoP theory, how individualswithin specialist public health services and=or inthe various agencies and organizations they aretrying to connect with manage the new agendaaround multidisciplinary and multi-agency work-ing will depend to a large extent on the way they

define their identity. CoP theory suggests thatidentities are developed through participation andnonparticipation � in other words, what people‘choose’ (although choices are not entirely uncon-strained) to devote energy and interest to andwhat they do not. People may be members of sev-eral communities of practice at any one time (e.g.as a health visitor, school governor, hockeyplayer), but it is always necessary for an individ-ual (consciously or unconsciously) to define thelimits of relevance of different areas of practiceby creating boundaries. Once defined, theseboundaries determine openness to or resistance toactivities at a personal and professional level.This has a direct impact on engagement � theactive process of involvement � with a com-munity of practice.

Throughout the interviews we explored aspectsof work practices that had some relevance to the

Figure 5 Health visitors’ world of partnership and public health. This map represents the process of reflex-ivity of two health visitors who were trying to reconcile the wide remit of public health with the challenges of theirown day-to-day work. The expanding world of public health had an intensely supportive core. The key anchor ofadvocacy and trust, together with support from certain partners and clients, kept them ‘afloat’. However, beyond theworld of partnership, that was not designed to support this inner core, negative forces detracted from that core.These negative forces were working to erode their enjoyment of the job, and there was a clear sense that the futuremay lie outside public health all together. Reproduced from MacKian, S., Elliot, H., Busby, H., Popay, J. 2003. Healthand Place, 9: 219–229. Copyright Elsevier Science.



health inequalities agenda, regardless of whetheror not these practices were explicitly defined aspublic health work. Analysis of these reflectionson the nature of public health practice and peo-ple’s relationship to this area of work revealeddifferent types of engagement with a ‘communityof public health practice’ amongst our inter-viewees � an analysis that is described in moredetail elsewhere (Mallinson et al., 2004). These‘types’ of engagement with public health workmirror the three layers of CoP form identified byWenger � a core membership, a peripheral=marginal membership, and nonmembers beyond.Additionally, however, as we discuss below ouranalysis points to important subdivisions withineach ‘type’ of engagement.

Core membership: engagement and practicein public health

At the heart of the local public health systemswe explored there are, as one might predict,people whose organizational and professional his-tories seem fully aligned with current publichealth strategy. These are mostly people whohave been public health consultants and non-medical specialists in public health departments inthe NHS or have been part of these departmentsin some other capacity. Their interest in andengagement with the core activities of publichealth is therefore well established. Accounts ofpublic health work given by these respondentstended to reflect the contemporary discourse onpublic health within government documents, aca-demic literature and amongst senior leaders in theservice. Their talk was of the wider determinantsof population health and inequalities, of localaction to improve health and reduce inequalitiesand of delivering health improvement throughpartnership with local agencies. There was astrong suggestion amongst this group that recentpolicies and government strategies were facilitat-ing engagement because they encouragedthe widening of public health vistas.

At the periphery: pragmatic engagementwith public health

Some respondents acknowledged the connec-tion between their perception of public healthgoals and their current work role, but did notidentify themselves as public health practitioners.

Our analysis suggests that there were two mainreasons for their detachment: first, some individu-als were already fully committed to other interestsand activities and this precluded a more activeinvolvement; secondly, some appeared to value aposition ‘outside’ the community of public healthpractice because of the freedoms they felt it gavethem. The accounts given by ‘peripheral’ mem-bers suggest that maintaining a connection withlocal public health practitioners was valuablebecause they had knowledge=interests that theywanted taken into account by local decision-makers or because they had a pragmatic interestin funding sources within the primary caregroups=trusts that public health practitionerscould help them access.

An important feature of the accounts of inter-viewees who we define as at the periphery of localcommunities of public health practice were theexpressions of discontent with the way new publichealth strategies were being developed. This con-trasted with the more positive tone of core mem-bers. There was more discussion amongst thisgroup of restrictions operating to exclude a widerworkforce from actively engaging with publichealth practice. These included concerns thatstrategic direction was not being appropriatelytranslated into local action and concerns that themessages about the wider focus of public healthpractice were not understood by people outsidethe management structures of the newly estab-lished primary care trust. In essence then, thisgroup adopted a more critical stance and ques-tioned the extent to which ‘old’ public health wasreally widening its scope and softening its bound-aries to encourage new partnerships and engagenew knowledge pointing perhaps to some of theborder restrictions operating to constrain moreactive participation in the public health agenda.

Nonmembership: misunderstanding and exclusionA third and final group of interviewees posi-

tioned themselves as entirely separate from publichealth practice. However, two somewhat differentprocesses were seemingly contributing to this‘excluded’ identity.

First, amongst this group of respondentsdefinitions of public health practice effectivelyestablished a boundary that excluded them fromthis terrain. In contrast to accounts in other



groups, most of the people in this group oftenfocused their definition of public health on medi-cal and=or environmental issues. One social ser-vice worker, for example, characterized publichealth as being about ‘sanitation’. Throughoutthe rest of her interview this respondent talkedabout the interrelationship between health andsocial care and strategic links with what are read-ily defined as ‘public health’ practices aroundsocial inclusion, tackling crime and managingsocial need. Nevertheless, while she linked toNHS colleagues in the PCT and general practiceshe regarded this as separate from ‘public health’.Whilst it might be expected that people fromnonhealth organizations may have difficulty see-ing a connection between what they are doingand public health practice, accounts of publichealth as ‘marginal’ to an individual’s work werenot confined to non-NHS respondents. Forexample, two of the GPs interviewed were verydismissive of the idea that public health waspotentially part of their role as frontline NHSpractitioners.

A second strand in these narratives of exclusionfocused on the difficulties people had penetratingthe ‘health circles’ they perceived to be control-ling public health practice locally. In some instan-ces this was linked to the particularly turbulentperiod in which the research took place withnewly formed primary care trusts getting to gripswith new policy, new roles and new faces. Thelack of continuity in personnel was argued to beputting strain on existing partnerships and mak-ing the pursuit of new connections more difficult.Respondents described what was, in effect, apause in the development of local relationships ashealth sector employees caught their breath.However, outside the NHS there was some frus-tration expressed at not being able to gain entryto areas of interest.

The new public health nurse

Observational research with health visitors in oneof the two study areas � a group given a centralrole in public health policy in the new nationalagenda � reveals how the new public health pol-icy agenda is reflexively constructed at the levelof individual public health practitioners and illu-

minates the processes that operate to constrainthe development of new ways of working. Twomain themes have emerged from this strand ofour research: first the way in which communitynurses narratively construct themselves as publichealth practitioners with a key role to play inreducing health inequalities and secondly, theproblematic way in which they experience thisrole on a day to day basis.

Nurses’ perceptions of their public health roleand the tensions within it

There was widespread acceptance among com-munity nurses that they had a key public healthrole in relation to the wider social causes ofpopulation health and health inequalities. Parti-cular dimensions of this role were highlightedincluding: health promotion, planning care,communicable disease control, community devel-opment, work as an advocate for clients andidentifying and responding to ‘hidden’ socialproblems such as domestic violence and childabuse. Additionally, for the nurses involved inthis research although tackling health inequalitieswas a long standing element of their practice �eroded during the 1980s but now coming to thefore again � it was also an aspect of practicearound which there was some ambiguity, a recur-rent theme in previous research on the role ofcommunity nursing professionals (Edwards andPopay, 1994). There appear to be two aspects tothis ambiguity.

First, far from being cohesive, various aspectsof the public health nurse role could competewith each other for limited time and resources.For example, at the time of the research schoolnurses and health visitors were involved in anintensive immunization programme, which madethe delivery of other public health tasks difficult.In such situations there was a feeling that themore clinical=medical aspects of the role weregiven priority by managers. Secondly, communitynurses are uneasy about the difficulties inherentin measuring the impact of the wider publichealth aspects of their roles compared with therelative ease with which the volume, if not theimpact, of work on immunizations and develop-mental checks could be measured. Because of thedifficulties involved in judging the effectiveness ofthe less tangible aspects of community nursing it



was widely felt that these activities were less likelyto be acknowledged and valued by managers whowere also perceived to be ill informed about thenature of the wider public health work in com-munity nursing.

During the observational fieldwork, the ten-sions and contradictions inherent in three keyaspects of the wider public health nursing rolewere revealed: tackling social exclusion, advocacyon behalf of clients and nursing involvement inthe planning of services.

Tackling social exclusionCommunity nurses encounter a great deal of

social exclusion in the course of routine work anddemonstrated considerable initiative, creativityand determination in their responses. The starkestexamples in this study came from observation ofspecialist teams working with the homeless andrefugees. One nurse, for example, described howshe had seen one of her clients ‘walking funny’. Ittranspired that he had had a minor stroke buthad been discharged from hospital after only onenight because he was homeless and there wereconcerns that he would block a bed indefinitely.The nurse had had to return him to the hospitaland insist that he was readmitted. Other nursesdescribed clients being extremely wary of services,often exacerbated by bad experiences of trying toaccess care. Nurses responded to these difficultiesin a variety of ways including: working on a long-term intensive basis with individuals; findingpractitioners who spoke the same language as cli-ents; and matching patients with providers whohad experience of working with particular clientgroups.

Advocacy on behalf of clientsBeing called upon or pro-actively volunteering

to act as advocates for clients would appear to bea common aspect of routine public health nursingamongst the groups involved in this research.There was potential for almost limitless involve-ment with clients, smoothing access to services;intervening with other public services includingthe benefit agency, housing departments, immi-gration and legal services, as well as mediatingbetween clients and other family members.

The intensity of involvement was a matter forthe consciences of individual professionals. For

some it was presented as a core part of theirwork, motivated by personal conviction as muchas by the way in which they constructed theirprofessional roles � though these workers oftenkept their level of involvement in advocacy workhidden from colleagues and managers as they feltit would not be seen to be a legitimate use oftheir time. Others were more hesitant to getinvolved in advocacy work. A variety of factorswere important here. In some instances, clients’requests were seen as extravagant or inappropri-ate. There were also concerns that by gettinginvolved they would raise clients’ hopes of successor waste time on cases they knew to be hopeless.Some requests for help were seen to be beyond arespondent’s competency � particularly inrelation to benefits advice. There were also con-cerns about being drawn too far away from coreclinical and health promotion competencies.

Public health nursing input to service planningThe newly revitalized public health nurse role

in the UK includes a contribution to the planningof services through the management structures ofthe new primary care organizations � the ration-ale for this is that it will bring their specialistknowledge of localities and clients ‘on theground’ into the policymaking processes. Asalready noted in the UK reforms, primary caregroups were initially established and these movedover time to become primary care trusts. Nurseshad a planning role in both organizational formsbeing represented on the board of primary caregroups (PCG) and on the professional executivecommittee (PEC) of the newly forming primarycare trusts (PCT). However, at the time of theobservational fieldwork in the London localityproposals for transfer to trust status were at anearly stage so the potential role for communitynursing on the PEC was not raised. More signifi-cantly, however, neither did there seem to bemuch interest amongst community nursing staffin the strategic role they could play on the boardof their primary care group. Perhaps not surpris-ingly, at this early stage of their development pri-mary care groups and trusts were generallypresented as external policy initiatives with littlerelevance to routine practice, rather than as apotential vehicle for revitalizing the public healthnurse role.



Nurse members of PCG boards commented onthe lack of interest in their role amongst their col-leagues on the ground and at more senior levelswith one board nurse describing the PCG as ‘thegreat unmentionable’. This situation started tochange in the course of the fieldwork and as thepace of change towards PCT status accelerated amore active interest in the implications for nurs-ing practice began to develop, albeit onlyamongst senior nurse managers. Even if there hadbeen wider interest in their role, nurse membersof the PCG board felt that there would have beenlittle of relevance to report as concerns from andabout general practice and acute sector issuesdominated board=committee business. As a resultmembership of management groups within pri-mary care organizations was described as an iso-lating experience by the nurses involved.

Conclusion

The research reported here has highlighted someof the more subtle but still significant factors thatare operating to constrain the engagement withpublic health work amongst a wider workforce.These findings have important implications forfuture policy concerned to address the widersocial determinant of health inequalities and todevelop the multidisciplinary public health work-force this requires. In particular the research sug-gests that action is needed to support thedevelopment of a public health ‘work view’ in thewider workforce relevant to public health and toprovide more support for the public health nurs-ing role.

Fostering a public health ‘workview’ in the widercommunity of practice

Getting local ‘buy in’ to public health practiceis a complex process. Although it is important toget the structure and location of public healthright, it is also recognized that the most impor-tant imperative is to ensure that the culture andmindset of those working in and around publichealth shift in appropriate ways (House of Com-mons Select Committee, 2001).

Our research suggests that organizational andprofessional ‘work views’ were leading to resist-ance to, rather than engagement with the public

health agenda within local systems. There arenow major initiatives underway within the publicsector in the UK to improve opportunities fororganizational and professional developmentwhich have the potential to contribute to a newpublic health ‘workview’ amongst the wider prac-tice community. However, the challenges for suchinitiatives are:

. To provide more ‘spaces’ within organizationaland professional development for the reflexivereconstruction of public health practice and the‘unlearning’ of old ideas about professionaland organizational boundaries, as well as thedevelopment of new skills and competencies topractice with.

. To invest more resources in the development ofa wider understanding of the ‘rationale’ under-pinning the new public health agenda.

. To develop within performance managementsystems a greater sensitivity to, and=or moreexplicit recognition of, the wider public healthaspect of organizational and professional roleswithin local systems.

Developing the public health nurse roleOur research has highlighted a serious mismatch

between the rhetoric in policy concerning the piv-otal role for public health nursing in addressingthe wider social determinants of health inequalitiesand the daily experience of individual publichealth nurses. Either strategies to increase thelegitimacy and hence the visibility of the wider ele-ments of this role � tackling social exclusion,advocating on behalf of clients, and contributingto policy development � need to be developed andthe support and resources required to deliver theseneed to be clearly delineated, or the expectationsplaced on community nurses working in the publichealth sphere should be reduced.

The public health nurse role encompassesa wide canvass ranging from involvement withstrategic management structures, through activi-ties focusing directly on the social causes of illhealth, such as community development andadvocacy to the more ‘clinical’ aspects of publichealth nursing. Ensuring that this wide rangingand ambitious vision for an enhanced publichealth role for community nurses is delivered inpractice is a complex and challenging agenda



both for individual professionals and the organ-izations in which they work. Our research hasrevealed how contradictions embedded in policyat both a rhetorical and operational level nation-ally and locally combine with limitations in thepractical options open to individual nurses asthey seek to meet clients needs to severely restrictthe way in which this role can develop. There isevidence that the wider public health work aimedat addressing the social causes of health inequal-ities continues to lack legitimacy and is thereforedone ‘on the side’ in an ad hoc fashion, a situ-ation that creates intolerable burdens for the indi-vidual professionals involved and reduces theeffectiveness of these responses. Similarly, whilstpublic health nurses have now been given a placeat the strategic table within new primary careorganizations, at the time of our fieldwork theimperatives coming out from the centre and thecontinuing imbalances in power between doctorsand other health professionals were severelyrestricting the contribution they could make.

On the face of it the current policy climateappears to allow public health practitioners totransform their working practices and providemore locally sensitive solutions. In theory at leastthis opportunity to negotiate the new territory ofpublic health within a local context allows for thedevelopment of reflexive communities, developingshared or unique ways of ‘being in the world’.However, our data suggest that beneath this pic-ture of fluidity and reflexivity, there remain majorpolitical, structural, professional and personalbarriers to successfully changing public healthpractice creating new exclusionary processes.These, in turn, exert strong influence over theemerging reflexive communities. If these are notaddressed then there will in practice be relativelylittle scope for new spaces to open up within localsystems in which public health work aimed ataddressing health inequalities can be ‘practised’ innew ways by new wider communities of practi-tioners. Perhaps the most important messagefrom our research and that of others is thatdespite these difficulties there remain manypeople willing � if not yet enabled � to populatewhatever spaces become available for new practi-ces. There is therefore much to be gained fromopening up these spaces more effectively thanwould seem to have been the case when ourresearch was conducted.

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