Abstract
Objectives
To develop and pilot an evaluation framework for assessing the engagement of local government public health teams in England on climate change and sustainability. These teams are uniquely positioned to address local health impacts of climate change and promote health co-benefits of mitigation. No statutory framework currently exists to support their engagement in this agenda.
Study design
Literature review and two cross sectional surveys.
Methods
A group of public health professionals conducted a literature review and agreed on criteria based on statutory responsibilities and remit of these teams, available information, and opportunities for local government action. With the resulting framework, this group evaluated all 11 local governments in the East of England region, and then conducted a follow-up survey to assess the framework’s impact and acceptability.
Results
An evaluation framework was developed with 21 criteria in two sections. The first assessed overall local government action and leadership in climate change and sustainability, to understand the context in which the public health team was situated. The second assessed the climate change related actions undertaken by the public health team.
All 11 local governments in the East of England region completed the evaluation. Results indicated inconsistencies in local public health team action on and engagement with climate change and health. Ten local governments completed the follow-up survey on acceptability and impact, reporting that the evaluation was easy to complete. Seven out of ten respondents found that the evaluation had influenced change or reflection within their organisation, for example through identifying gaps and prompting more collaboration between teams.
Conclusions
This evaluation framework is a useful and acceptable tool to assess local government public health engagement and leadership on climate change and sustainability. If used more widely, it could help to support public health teams to advance much-needed action in this area.
Keywords: Climate change, Public health, Local government, England, Climate crisis, Evaluation
1. What this study adds
- This framework offers a useful and acceptable tool for evaluating and promoting local government public health team leadership on climate change and sustainability
- Results from this region highlight variation in engagement of local government public health teams on the climate change and sustainability agenda
2. Implications for policy and practice
- If used more widely, this framework could support local public health teams to assess and strengthen their engagement with the climate change and sustainability agenda in a more structured and consistent way
3. Introduction
Climate change poses a rapidly growing and imminent threat to public health. Risks to health from climate change include the direct threat to human life and health associated with extreme heat and climate-related disasters; the risks posed by the changing profile of vector-borne diseases; the increase in heat and pollution related exacerbations of respiratory and cardiovascular diseases; and the mental and physical impacts of loss of housing, livelihoods, and disruptions to water and food supplies [1]. These effects are already being experienced in England [2], with an estimated 2985 excess deaths occurring during five heat episodes in 2022 [3]. Both national and local actions are necessary to minimise immediate and growing risks, and to take advantage of substantial opportunities to improve health via carbon reduction policies [4]. Despite this, climate change and environmental sustainability are not always seen as political or public health priorities.
In England, public health teams are based in local government (known as ‘local authorities’) [5]. While local government structures vary (they may be called ‘upper tier’ or ‘unitary’ depending on whether they have smaller councils beneath them), all have the same duty to deliver specific public health services under a grant from central government [6]. This co-locates public health alongside other teams such as planning, transport and housing, which shape the wider determinants of health. Therefore, public health teams are in a unique position to identify the local population’s health risks in the context of climate change, take action to reduce those risks, and see the benefits to health associated with those actions. Despite this, there is no published framework to guide or structure engagement in climate change and sustainability among public health teams in local government. Our aim was to develop an evaluation framework suitable to assess the engagement of local government public health teams in England in climate change and sustainability. We piloted the framework and investigated the acceptability, impact, and results within local governments in the East of England region, a region that is particularly vulnerable to climate-related health risks stemming from excess heat, flooding, and drought [7].
4. Methods
4.1. Designing the framework
To identify existing relevant criteria and frameworks, an exploratory literature search was conducted on PubMed using general search terms (see supplementary material). This was followed by a review of grey literature using broader terms via two Google searches, of which the first 100 results of each were reviewed (see supplementary material). Then, an informal national network of public health professionals interested in climate change was contacted to identify any relevant criteria not found in our searches.
A working group of eight public health professionals reviewed existing evidence, and proposed criteria which could be used as a framework for evaluating the action taken by a public health team on climate change. These were determined by considering the commissioning and statutory responsibilities for local government public health teams [5,8], public availability of information, opportunities for collaboration at local level, and using health to frame climate action [9].
In 2021, the framework of evaluation criteria was piloted with a single local government, to ensure criteria were within the public health team’s remit, were understandable, feasible to answer, and unambiguous. As a result of the pilot, we simplified some of the language of our questions to make them clearer.
4.1.1. Using the framework to evaluate local engagement in climate and health
Following the pilot, the framework was rolled out to all 11 local governments in the East of England region between 2022 and 2023 (which are a mix of unitary and upper tier councils). For each local government, the framework was completed by a member of the local government public health or sustainability team. This was followed by discussions with a member of each organisation’s public health team and sustainability team to review evidence provided alongside publicly available policies, address any information gaps and identify any work not yet finalised or published. Each criteria was finally marked as one of four options:
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Yes, clear action on this
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In the process of making changes towards achieving this/partial action taken;
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No action taken; and
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Unable to find evidence of action taken, further exploration needed.
Evidence for the chosen option was then recorded with links to public documentation wherever available.
4.2. Assessing impact and acceptability of the framework
In October 2023, all 11 local government organisations were re-contacted with a request to complete a mixed-methods survey, assessing ease-of-use, usefulness and impact of the service evaluation (supplementary material). Thematic analysis was performed on the free text elements of the survey.
5. Results
5.1. Design of the framework
The literature search returned 17 results, none of which matched the inclusion criteria after review of titles and abstracts. From the grey literature search, 8 resources were identified; 7 were items of grey literature published on the internet [[10], [11], [12], [13], [14], [15], [16]], and 1 was an unpublished work found via the professional network [17]. The majority of these mentioned health only in passing, and none were targeted at public health teams in particular, instead focussing on wider local government teams and responsibilities.
The relevant grey literature was reviewed and consolidated by the group of public health professionals, and additional criteria for public health teams were added. The resulting evaluation criteria were grouped into two sections (Table 1):
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1)
overall local government action and leadership in climate change and sustainability
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2)
climate change and sustainability actions in the public health team.
Table 1.
Criteria used for the climate and health evaluation framework.
| Criteria number | Criteria grouping | Criteria description |
|---|---|---|
| 1 | Overall local government action and leadership in climate change and sustainability |
Local government has declared a climate emergency. |
| 2 | Local government has assigned an elected member to lead for climate change. | |
| 3 | Local government has assigned an officer for climate change/sustainability. | |
| 4 | Local government has established a clear link with sustainability leads in public sector organisations locally, including the National Health Service Integrated Care Boards, and are exploring collaboration opportunities. | |
| 5 | Local government has calculated and accurately reports their carbon footprint. | |
| 6 | Local government climate change plan exists and is being monitored | |
| 7 | Local government has a policy not to invest in fossil fuels. | |
| 8 | Staff training on the importance of climate change on public health. | |
| 9 | Travel/commuting policies recognising the importance of sustainable travel/remote working. | |
| 10 |
Office factors (if relevant) – lights/computers off at end of day, recycling, use of renewable energy. |
|
| 11 | Climate change and sustainability actions in the public health team | One or more staff members within the public health team have a responsibility for promoting/considering environmental sustainability. |
| 12 | Process to consider environmental impact whilst developing new policies, strategies and programmes. | |
| 13 | Process to consider environmental impact in signing off new policies, strategies and programmes. | |
| 14 | Environmental impact considered in writing service specifications. | |
| 15 | Environmental policies of providers considered as part of commissioning processes such as mentioned within the social value statement. | |
| 16 | Specific mention of environmental sustainability or becoming carbon neutral as a strategic priority by public health and actions set to achieve this. | |
| 17 | Most important public health impacts of climate change for the local government area have been identified in strategy and links to other departments/services have been made. | |
| 18 | Public health taken action to raise profile of importance of climate impacts on health within local government | |
| 19 | Public health input into the local government climate change plan (if applicable). | |
| 20 | Public health represented on the local government climate change committee. | |
| 21 | Local government climate plan recognises and proposes actions on key impacts of climate change on health locally e.g. air pollution/transport/active travel, housing/insulation/fuel poverty, cold snap/flooding/heat waves. |
5.2. Local engagement in climate and health
5.2.1. Plans, representation and reporting
All 11 local governments with public health teams in the East of England region participated in the public health and climate change evaluation using the criteria above between 2021 and 2023 (Supplementary Table 3). Nine had declared a climate emergency, ten had assigned an elected member lead for climate change, while all 11 had assigned an officer for climate change or sustainability. Ten local governments had a climate change plan that was being monitored, and five reported that they had public health input into this plan. Eight local governments reported that their climate plan recognised and proposed actions on key impacts of climate change on health locally. Eight had calculated and accurately reported their organisation’s carbon footprint and seven had established clear links with sustainability leads in other local public health and care provider organisations.
5.2.2. Public health team engagement
Fewer than half of public health teams had contributed to their local government’s climate plan, while eight reported that their climate plan recognises and proposes actions on key impacts of climate change on health locally. There was variation in the leadership role of public health teams on the wider organisational climate agenda. Three local governments reported public health had taken action to raise the profile of the importance of climate impacts on health, and four had public health representation on the climate change committee.
Three local governments identified the most important public health impacts of climate change on their local population in a public health strategy and made links to other departments or services.
Six public health teams had one or more staff members with a responsibility for promoting or considering environmental sustainability, and three reported that environmental policies of providers are considered as part of commissioning processes. Five public health teams have specific mention of environmental sustainability or becoming carbon neutral as a strategic priority by public health and have actions set to achieve this.
5.2.3. Commitments and policies
Although many local governments had made broad commitments on climate change, specific policies to meet these commitments were less common. Seven had a policy concerning office factors, such as having lights and computers off at the end of the day, recycling and use of renewable energy. Comparatively, two local governments had a policy to divest from fossil fuels. Three local governments reported delivering staff training on the importance of climate change on public health. Three also reported having travel or commuting policies that recognised the importance of sustainable travel and remote working.
When considering public health policies, strategies and programmes, four had a process to consider environmental impact in developing and in signing off new policies, strategies and programmes. For commissioned services, three public health teams reported that environmental impact is considered in writing service specifications.
Full results for the evaluation framework are shown in Fig. 1, Fig. 2 (also Tables 4–5 in supplementary materials). From the process of completing the evaluation with local governments and from the findings, we also identified potential areas of good practice for public health teams working in climate and sustainability, which are shown in Fig. 3.
Fig. 1.
Results of the climate change and public health evaluation framework - wider local government criteria.
Fig. 2.
Results of the climate change and public health evaluation framework - public health team criteria.
Fig. 3.
Recommendations for public health team action generated from the evaluation discussions and findings Fig. 3 key:
Integrated Care System (ICS): sub-regional health and care partnerships set up in 2022 in England to ensure joined up health and care services. Greener NHS: a national NHS body (in England) that works on the mission ‘to deliver the world’s first net zero health service and respond to climate change, improving health now and for future generations’ UK Health Security Agency (UKHSA): UKHSA is an executive agency of the Department of Health and Social Care, responsible for preventing, preparing for and responding to infectious diseases, and environmental hazards (including climate change). Joint Strategic Needs Assessment (JSNA): these are assessments of the current and future health and social care needs of the local community, typically produced by local government public health team. Social Value Model: a model related to government procurement, under the Social Value Act 2012, which states that all public bodies must consider how what they are proposing to buy might improve economic, social and environmental wellbeing.
5.3. Acceptability and impact of the framework
Out of the 11 local governments who completed the climate and health evaluation framework, representatives from 10 responded to the feedback survey.
Five local governments reported finding the process of participating in the service evaluation easy or very easy, four found it neither easy nor difficult, and one did not respond. Five thought that an exercise like this should be conducted annually, whilst an additional four respondents thought that this should be conducted every other year. One respondent suggested repeating it every three years.
Seven respondents reported that the service evaluation had influenced change or reflection within their team or organisation. When asked to explain why they gave this answer, the most common themes among those who responded ‘yes’ included being useful to identify and reflect on gaps, that it prompted more collaboration between teams, that it highlighted the need for clarity on responsibilities for climate and health, and that it was helpful in light of a lack of national guidance.
Among those who did not think that the service evaluation had influenced change or reflection within their team or organisations, reasons given for this response included that they were already working on climate and health, and that they had also received other external requests (such as freedom of information requests) on this topic.
Finally, when asked what support their organisation required to better bring together climate and health work locally, the most common themes that emerged included the need for increased funding and resources and clear guidance and evidence documents. Other suggestions included the need for toolkits to support work in this area, the sharing of case studies and examples of good practice, improved access to timely and accurate data for monitoring purposes, and improved leadership and endorsement of climate and health work. Another proposal was to align these criteria with emerging work from UKHSA’s Centre for Climate and Health Security (a centre that was set up to support action on climate and health in England in 2022).
6. Discussion
This study reports the development, findings and self-assessed impact of a framework to evaluate local government public health team action on climate change and health. Results showed that no local governments found participation in this evaluation to be difficult and the majority reported that the exercise prompted action and reflection. Resources and guidance were two of the major barriers to further action. For the framework itself, we found that, while local governments are signalling leadership in responding to climate change, specific policies (particularly in relation to public health) to help meet these commitments were less common.
The level of climate change engagement within public health teams was variable, and public health teams were generally underrepresented in the activities and governance of wider climate change work within local governments. Despite being a significant funder of health services, (more than £3 billion per year in health services nationally [18]), local public health teams had not overall considered climate change from a commissioner’s perspective. Many lacked processes for considering the environmental impact during the development of new policies, strategies and programmes. This means there are likely to be missed opportunities to use health co-benefits as a lever to accelerate wider local authority action on mitigation and adaptation, and to meaningfully address the emissions created by public health commissioned health services.
To our knowledge, this is the first published use of a framework of this kind. In 2020, England’s National Health Service (NHS) published ‘Delivering a ‘Net Zero’ National Health Service’ [19], which sets net zero targets for the emissions the NHS directly and indirectly controls and emissions reduction trajectories across the health service’s sources of greenhouse gas emissions. Elements of this strategy are legislated through the Health and Care Act 2022 [20], which sets out duties in relation to climate change for NHS England and NHS trusts. Furthermore, all NHS trusts and integrated care boards have been required to produce a three year green plan, in line with the net zero strategy, following the Green Plan guidance produced by NHS England [21]. No equivalent guidance exists for local government, which has led to inconsistencies across the public sector and local government, which have been noted elsewhere [22,23]. This framework could therefore be a helpful starting point for assessing progress on climate change in this context in relation to public health specifically.
Despite climate change having been identified as the ‘biggest global health of the 21st century’ [1], this inconsistency in action by local government public health teams risks their omission from key local government discussions and decisions around climate change. The follow-up survey indicated a need for financial investment and resources, guidance and evidence to support public health teams in this area. Previous research has shown similar findings, highlighting the requirement for improved public health leadership and collaborative working in this area [[24], [25], [26]].
Public health expertise can help ensure the equity of climate mitigation and adaptation measures, but this angle may be missed if local government public health teams are not embedded in local responses to the climate crisis. Furthermore, public health teams may be able to use framing and co-benefits to bring about more immediate action to mitigate climate change. The shorter-term health benefits of active travel, for example, can be championed by public health teams, building local support and encouraging action sooner by framing climate action through a health lens [27]. This may be an essential lever for action in a context where outcomes such as carbon emissions are often perceived as remote and theoretical, lacking the incentives to drive immediate action.
Overall strengths of this framework include that it was piloted and its impact assessed directly with local government teams. This means we know it can be a practical, acceptable and feasible place to start, which is particularly important when it comes to advancing public health action on climate change in under-resourced local government contexts [28]. More broadly, this is a timely framework as climate change and health has a growing profile among local directors of public health across England [29]. The importance of local approaches to climate and health is also receiving greater attention globally, with several measures to support local health systems and governments in needs assessment, adaptation and response outlined in the recently published National Health and Climate Strategy from the Australian Government [30].
However, limitations include that the evaluation was completed with 11 local governments, all of which are in the East of England, and therefore may not be representative of other local government public health teams in England. Additionally, although framework evaluation criteria were scored collaboratively between our working group members and local governments, some criteria were more subjective than others, and the follow up survey was entirely self-reported. This means there may be variation in how local government representatives assessed the robustness of their action. Furthermore, many of the criteria concern the existence of policies and plans, rather than the content and implementation, so this framework only captures a first stage in what should be an ongoing process of assessment. Finally, we acknowledge that relationships between public health and other local government departments such as planning may be worth more specific exploration due to their importance, but we hope that some of these discussions can be kick-started by the generic question asked in criteria 17.
In conclusion, this framework is a useful and acceptable tool to assess and advocate for local public health leadership on climate change and sustainability. If used more widely, it could support improved engagement of public health teams in this important area, as well as potentially enabling comparison over time and between local governments. In addition, the findings and good practice recommendations (Fig. 3) from the completed frameworks in the East of England add to the limited knowledge on the extent of public health leadership on climate change and sustainability in local government, and illustrate the ongoing need to raise the profile of climate change in the public health sector.
Author declarations
Given this study was a service evaluation not involving any patient or individual level data, no ethical approval was required.
No specific funding was received for this work. However AMDN is partially funded through the NIHR Academic Clinical Fellowship (ACF-202-14-005).
We have no competing interests to declare.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We would like to acknowledge and thank all local authority teams who supported this work across the East of England.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.puhip.2024.100524.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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