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Analysis Building Health Communities

Lowering hospital walls to achieve health equity

BMJ 2018; 362 doi: (Published 20 September 2018) Cite this as: BMJ 2018;362:k3597

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Rapid Response:

Re: Lowering hospital walls to achieve health equity

The Institute of Health Promotion and Education fully agrees with Matheson and colleagues, potentially hospitals have pivotal roles in promoting health and tackling health equity.(1) However we do need a paradigm shift in the way we think about hospitals. Currently hospitals are mainly focused on providing services for patients that are sick, but they could also develop their positive health promoting roles.

The World Health Organization’s Ottawa Charter proposed a positive empowering view of health and was influential in guiding the development of the settings approach.(2,3) This moved interventions upstream away from merely focusing on individuals who are ill and towards organisations, systems and the environment that can be used to prevent ill-health and promote health.

Globally, examples of a wide range of settings can now be found including healthy cities; health promoting schools; health promoting workplaces; and health promoting hospitals. In order to become a health-promoting setting, those involved should undertake the commitment to three conditions:
(1) creation of a healthy working environment
(2) integrating health promotion into daily activities
(3) reaching out into the community.(3,4)
Health-promoting hospitals should not just be for the patients but also for staff and community members.

Hospitals are institutions with a large number of workers and service users and potentially they can reach a large section of the population including patients and relatives. The staff are highly skilled but their current focus is to mend patients and then send them back into social conditions that made them ill in the first place.(5)

It is important to note that hospital staff have high status and more of them could act as advocates for health both at an individual and population level. In addition, hospitals have tremendous assets in relation to all NHS resources and their substantial daily purchases could be changed to assist healthy choices.

For example, in relation to the obesity epidemic, hospitals have an opportunity to promote healthy eating to their patients, visitors and staff through the availability of healthy foods on their premises.(6) As an organisation, hospitals could be role models for other workplaces.

In some parts of the country hospital emergency departments are reaching out into the community. The Injury Minimization Programme for Schools (IMPS) is an innovative health education programme being delivered jointly in schools and local emergency departments.(7) Its aim is to teach children how to recognise potentially dangerous situations and prevent injuries. The programme also equips children with first aid skills, helping them to respond effectively if an incident does occur.

Also in relation to accident prevention, some A&E departments have small-scale initiatives to share data with a range of external professionals, which is important for developing local initiatives. The data can be used for assessing need, planning activities, raising awareness and programme evaluation. However, there is a need for better data collection and aggregating at a national level.(8)

Although throughout the UK small-scale projects such as these can be found covering different topics there is little evidence that a re-orientation of health services has occurred systematically and comprehensively.(9-11)

Public health staff in local authorities have the skills to be able to support the development of health promoting hospitals. However, they will need to be given the resources appropriate for the scale of the tasks.(12,13) Crucially, what is also needed is inspirational and transformational leadership at a national level: government action is needed.

Finally, it is important to state that for most hospitals, becoming health promoting will not be easy nor will it be resource neutral; however, there will be benefits for patients, staff, the local community and the NHS.

1) Matheson A. et al. Lowering hospital walls to achieve health equity. BMJ 2018;362:k3597

2) World Health Organization. Ottawa Charter for Health Promotion. Copenhagen: World Health Organization, 1986.

3) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.

4) Baric L. Health Promotion and Health Education in Practice. Module 2. The organisational model. Altrincham: Barns Publications, 1994.

5) Middleton J. Managing public health – health dividends and good corporate citizenship. Int. J. Management Concepts and Philosophy 2010;( 2): 154-176.

6) Watson M and Lloyd J, 2013 It’s time to ban junk food on hospital premises. BMJ Rapid Response 1st July 2013.

7) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health. 2016; 26(5), 194-199

8) RoSPA. Safe and active at all ages: a national strategy to prevent serious accidental injuries in England. Birmingham: RoSPA, 2018

9) Wise M., Nutbeam D. Enabling health systems transformation: what progress has been made in re-orienting health services? Global Health Promotion 2007,14, 23-27.

10) Ziglio E, Simpson S, Tsouros A. Health promotion and health systems: some unfinished business. Health Promotion International 2011, 26(2),ii216–ii225

11) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018,56(2), 73-84.

12) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.

13) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.

Competing interests: No competing interests

12 October 2018
Michael Craig Watson
Associate Professor in Public Health.
Sylvia Cheater, MBE (President, Institute of Health Promotion and Education,
University of Nottingham, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham. NG7 2HA.