As we enter 2021, the priorities for health and care systems across the globe remain centred on the need to manage the COVID-19 pandemic (Bourgeault et al, 2020). Although, of course, the unrelenting events taking place since early 2020 are things that we would not want to go through again, at the same time this has provided nurses and midwives with first-hand experience of the complex and dynamic nature of public health policy and practice.
Public health is classically described as ‘waves’ depicting the focus for health achievement (Figure 1). We are now in the ‘fifth wave’, the ‘culture of health’ where the aspiration is for people to see health as a value and interventions seek to create a culture and environment that promotes healthy behaviours above those considered to be unhealthy (Davies et al, 2014; Academy of Medical Sciences, 2016). Earlier waves from the 1830s focused on creating clean water and sanitation (structural, first wave), developing medicines and improving transport and communications (biomedical, second wave), creating evidence-based health care (clinical, third wave) and the emergence of the welfare state and universal education (social, fourth wave). As health and care professionals progressing in the fifth wave, we can learn from earlier waves and build our knowledge, understanding and resilience so that we can respond effectively to new health challenges. This means that, in the fifth wave, armed with our knowledge of the importance of clean water, immunisation, research, and evidence-based practice, we can engage and encourage people to be actively involved in their health and wellbeing. This will be essential in the coming months and years as the emergency moves into recovery and a focus on efforts to ‘build back better’.
As leaders of public health care and service delivery, nurses and midwives need to understand the global burden of disease, which will remain long after the urgency of the pandemic has passed (Elwell-Sutton et al, 2020). This systematic measure of health loss due to disease, injury and the presence of risk factors including age, sex, and geography will influence future priorities for public health. Defined by the World Health Organization (WHO) in 1990, the Global Burden of Disease requires the public health workforce to be capable of safe, effective, and quality service delivery (Murray and Lopez, 1996).
We know that during the ‘fifth wave’ many people will live long lives and will need to manage comorbidity to ensure those years are lived well. The rise in non-communicable diseases remains the greatest cause of ill health. It is imperative therefore that, alongside enough resources, health and care professionals also use their skills, knowledge and understanding of prevention and early intervention to help people achieve their health potential. They must be ready, able and willing, therefore, to influence people's health choices throughout their lives, not merely during episodes of illness. For example, if people are to avoid the need to manage the treatment and consequences of hypertension as adults, we should influence their food choices in childhood to reduce the likelihood of obesity; we must also support schemes that disincentivise cigarette smoking, making it increasingly unlikely for young people to see it as a normal lifestyle choice and in its place create a culture where daily exercise is commonplace, rather than something to do if time allows (Elwell-Sutton et al, 2020).
The All Our Health framework developed by Public Health England (PHE) is a call to action for all health and care professionals to embed prevention, early intervention, and health improvement in their day-to-day practice. Through educational materials, tools, and resources, All Our Health helps professionals make an even greater impact to preventing illness, protecting health, and promoting wellbeing (PHE, 2019). By collaborating with Health Education England (HEE), PHE has developed a package of 24 freely available and accessible e-learning sessions for all health and care professions. The bite-sized learning packages support practitioners to develop their skills, knowledge and understanding (PHE, 2019).
‘The All Our Health framework is a call to action for all health and care professionals to embed prevention, early intervention, and health improvement in their day-to-day practice
Case study
Shelley works as a registered nurse on a medical ward in an inner-city hospital. New to the area, she has noticed that a lot of 60-year-old men are admitted to the ward with previously undiagnosed high blood pressure. Many of them have their own business and describe themselves as ‘fit and healthy’. However, during further conversations, they tell Shelley that their work is all-consuming, they have increased their alcohol intake, reduced their exercise and have been smoking more, especially when feeling stressed. Shelley understands the medication and confidently explains how to take the different tablets, but feels lost when asked about other ways to reduce blood pressure.
Shelley decides to read through the cardiovascular disease e-learning package within the All Our Health suite of resources (PHE, 2019). Here she finds contextual information outlining the size of the problem and the rationale for prevention. There is also a section that gives her information about different topic areas. This is great, because she works full time and has limited time to study but wants to confidently answer people's questions about the difference that exercise can make to their blood pressure. She is surprised by the amount of information that she has gathered and after completing the self-assessment quiz, she finds she has understood more than she realised. The instant feedback helps her to see the areas where she could focus her reading another time.
The next time a person goes home from the ward, in addition to explaining the tablets, Shelley includes information about how a daily 10-minute walk can help them manage their health and wellbeing as well as their blood pressure. On reflection, the conversation flowed, and the person was keen to know more about the Active-10 App Shelley had found in the All Our Health package (https://www.nhs.uk/oneyou/for-your-body/move-more/active-10/).
By being inquisitive and challenging her everyday practice, Shelley made a small change to the information she shared with people starting to live with high blood pressure. Actively listening during opportunistic conversations gave her insight into lifestyle events that may have contributed to the diagnosis and subsequent hospital admission. Looking at the whole person, rather than the medical condition, also helped Shelley devise a plan to gather more information and deepen her understanding by using it in her practice.
As we go forward, in the ‘fifth wave’ the global burden of disease will be increasingly evident and collectively every small lifestyle change will make a big difference to a person's health and wellbeing. If health is to be a value and not merely the absence of disease or infirmity, the culture of health care must also move on. In this way, the education and training for those that follow Shelley will set them on a pathway that prioritises the foundations for creating health above treating illness. It will enable them to use data effectively to anticipate health and lifestyle concerns before problems requiring treatment arise and will allow their interventions to focus on engaging and enabling individuals, their families and communities to make healthy choices during their lives. In this way, nurses, midwives, and all health professionals entering the ‘sixth wave’ of public health, when it comes, will benefit from our experience and learning just as we have from those in the first five waves.
During 2021, PHE will continue working with the British Journal of Nursing to begin this process by putting a spotlight on key sections of the All Our Health framework. In turn, this will support our workforce to consider the changes required during the 2020s to ensure that nurses and midwives are leading our approach to preventing, promoting and protecting All Our Health.