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- 1. Public Health –the Vision and the Challenge SHAZIA HAYAT SOCIOLOGIST NISHTAR HOSPITAL MULTAN
- 2. Learning Objectives • Toexamine the development and major issues in public health in the last 100 years • To consider what we believe needs to be done for the future • To emphasize our own personal analysis of the issues, and possible solutions
- 3. Public Health inthe 19th century - overview • Firm foundations were created for public health in this country by giants such as Chadwick, Simon, Farr, Snow, Duncan, Budd and many others. • Manifested by 1. the Poor Law Institutions 2. the Public Health Act of 1875 3. sanitary issues (control of cholera in urban areas) 4. concern with the provision of unadulterated food.
- 4. Public Health inthe 20th century • The initial part of this century was dominated by public health – concern with the health and fitness of young men, the health of the school child, introduction of the Lloyd George National scheme for the employed • First World War – cataclysmic event consuming all energies • 1918 – creation of the Ministry of Health, also responsible for housing • Interwar period between the two world wars – use of the MoH’s Annual Report to highlight particular problems of poverty, unemployment and so on.
- 5. Public Health inthe 20th century - continued • During the Second World War – Beveridge report led to improvements in health, education, housing, pensions and employment, and rationing of food ensured availability of nutritious diet for all. • 1948 – NHS introduced • 1948 – 1972 – Social and Environmental services became independent from public health • 1972 – change in title to community medicine
- 6. Public Health inthe 20th century - continued • Past 25 years – Return to the title of public health and numerous reorganizations • Major landmarks: 1. Concerns with management 2. Black Report on Inequalities in Health 3. Health of the Nation Initiative 4. Purchaser-provider split
- 7. Major issues inpublic health that have recurred time and again
- 8. Issues affecting health •Housing – The move to demolish unsanitary slums – The Garden City Movement – Destruction wreaked by the Second World War, led to a need to rebuild and improve housing. • Nutrition – Under-nutrition before 1939 – M’Gonigle - demonstrated deleterious effects of an inadequate diet on health, despite improved living conditions – Rationing during World War II was an important impetus to change – Recently there is an increasing tendency towards overweight and obesity http://www.tcpa.org.uk/downloads/1899-1999.pd
- 9. Morbidity and Mortality •20th century decline of infectious disease mortality - most important cause of increased life expectancy • Problems of antibiotic resistant organisms, and new conditions such as AIDS and Legionella • Decline in mortality due to respiratory diseases, and major declines in mortality due to diseases of the digestive, genito-urinary and nervous systems. • Dramatic reduction in maternal, infant and child mortality. • Increases in mortality for circulatory diseases and cancer
- 10. The environment Source –The London Smog Disaster of 1952. Days of toxic darkness. http://www.portfolio.mvm.ed.ac.uk/studentwebs/session4/27/greatsmog52.htm
- 11. The environment • Dramaticenvironmental change has been the improvement of air quality. • Clean Air Act of 1956 • Problems of air pollution are still a matter of considerable concern - in the form of nitrogen dioxide and carbon monoxide • new issues have arisen - lead in the environment, in paint, in petrol, in food or in the soil; the impact of the use of pesticides in farming; the content of some animal feeds; the sitting of waste dumps, or the building of houses and schools on sites formerly used for industrial waste disposal.
- 12. The cons ofprogress • Increase is cigarette smoking • Less physical exercise - increase in diseases as coronary heart disease, stroke and arthritis • Recent advances in reproductive medicine and treatment of infertility, have vast ethical implications yet to be fully addressed by the profession, politicians and society at large.
- 13. The cons ofprogress - continued • Mental illnesses have been a continuing concern. • Life expectancy has increased - issues of long- term care, dementia, arthritis and multiple diseases • Rise in the side-effects for drugs • Poverty - inequalities in levels of health between the various social groupings
- 14. Organizational issues • SinceVictorian era - friction between the ideas and methods of medical practitioners concerned with public health and those with other qualifications, conflict of state authority and libertarian principles, conflict between the view of public health practitioners who demonstrated the need for sanitary reforms which reduced the profit of landlords and unscrupulous employers • In the Victorian era - Most public health doctors combined clinical practice with part-time, salaried public health duties.
- 15. Organizational issues -continued • Change from the Poor Law administration of hospitals in 1929-30, to local authority control - first major change • Major drawback - those involved became more concerned with the problems and minutiae of clinical/hospital administration, became medical superintendents and thus directed clinical care
- 16. Organizational issues -continued • The introduction of the NHS in 1948 changed this picture radically • PH was separated from clinical practice and remained under Local Authority control • The 1974 reorganization integrated all health authorities • One of the most effective tools for the PHP - the public annual report of health
- 17. Education, Research, Manpower •PH over the last 80 years - search for its sense of identity, was perceived both by the profession and by society in general as searching for a role and tending towards bureaucracy and administration • It is only in recent years that progress has been achieved - academic departments of public health in every medical school, structured post-graduate training • Research, in general has been neglected
- 18. Where Now? Concerns • Roleof PH in the control of communicable diseases - the law currently lags behind the reforms of both the health service and Local Authorities • Directors of Public Health now have authority in areas of clinical concern in which they are not expert • The public health function is now frequently labeled as “health policy”, responsible for contracting for clinical services
- 19. • Once againtherefore, public health is being seduced into assuming responsibility for large budgets which must be spent on clinical services, and once again public health practitioners believe that they can use this power to improve health • The Director of Public Health’s position as an Executive Director and budget-holder has tended to become a constraint in freedom to speak freely and deliver if necessary a critical, unpopular or controversial public health message.
- 20. Public Health ResponsibilitiesToday • Major public health problems – Outbreaks of disease caused by infective or toxic agents – Problems arising from social and environmental issues – Behavioral concerns – Health service issues • Public health should not become involved in the management of clinical services
- 21. Public Health ResponsibilitiesToday - Continued • Public health practitioners must develop their skills in handling outbreaks of disease • Training in epidemiology is crucial to this • It is important for the effective monitoring of health needs and outcome that data collected about patients are linked to individuals, and not merely based on events • Appropriate epidemiological and other studies are necessary to determine the factors responsible for ill-health
- 22. Health Risks • Avariety of biological, behavioral, social and environmental factors play a part in the development of diseases in individuals or populations • If public health is to fulfill its proper function - to improve and maintain health - the specialty must secure the necessary means and freedom both to identify and to disseminate knowledge of the factors that lead to ill-health and possible means of solution.
- 23. Risk Communication • Riskperception and communication - extremely complex process , central to any modern public health function and structure • Ability to communicate with the media, pressure groups and the public on the concept of health has enormous implications for any future public health structure
- 24. Possible Solutions • Thereremains at present, confusion between the role of public health in the management of clinical services and its primary role in the management of public health services. • Public health can influence the priorities and distribution of health service resources to improve the health of the population for which it is responsible.
- 25. Options for abetter structure • Return of the MOH • National Commission of Public Health • Modification of present structure with re- creation of Institutes of Public Health - most realistic way forward and the one that is most likely to be both practicable and productive
- 26. What Next • Anessential ingredient for progress is clarification of the role of individuals required to perform the public health function and thus has implications for staffing and personnel • It is essential that the interdisciplinary nature and working of the discipline is established more firmly than at present. • Public health physicians must accept fully that they must work on equal terms with other qualified health professionals of similar.
- 27. Conclusions • Public healthhas made massive inroads into diseases within a relatively short period. • Public health is now at a cross-roads where it can either accept the status quo or confront realistic change and challenge and seek to regain its former independent voice. • The specialty has a duty to inform the public responsibly on public health matters. • We perceive public health as the central medical specialty of the future.
Editor's Notes
- #2 The structure/organisation of public health described in this lecture refers to the UK, although the principles of PH are the same everywhere.
- #4 In the 19th Century firm foundations were created for public health in this country by such giants as Chadwick, Simon, Farr, Snow, Duncan, Budd and many others. These were manifested by the Poor Law Institutions, the Public Health Act of 1875, sanitary issues such as the control of cholera in urban areas, and concern with the provision of unadulterated food.
- #5 The first 14 years of this century were dominated in public health, by concern with health and fitness of young men, the health of the schoolchild, and the introduction of the Lloyd George National Insurance scheme for the employed. The First World War was a cataclysmic event, and all energies appeared to be consumed in its pursuit. There was little concern for what would happen after the end of the War; in contrast to the 1939-45 conflict, and attempts to provide equitable food distribution were rudimentary, and only introduced towards the end of the War. 1918 was marked by the creation of a Ministry of Health, also responsible for housing. The concerns for public health in the inter-war period were largely on the effects of poverty and unemployment on health, linked to attempts to improve housing and nutrition. Organizationally, this period saw the change from the Poor Law Administration of institutions, to Local Authorities and the use of the MoH’s Annual Report, to highlight particular problems of unemployment, poverty, and so on.
- #6 The lessons of the First World War had been learnt by the Second. Even during the darkest hours, the Beveridge Report was commissioned, reported and accepted, and thus offered major prospects of improvement in health, education, housing, pensions and employment to those who would survive and thus a reason to fight for a better future. The rationing of food, introduced almost from the start of the war, ensured that there was an equitable, affordable, nutritious diet available to all - arguably it can be said that this measure was responsible for a greater effect on improving the health of the population than any other in the previous 50 years. Certainly the problems of under-nutrition, such as rickets, almost disappeared. For public health the introduction of the NHS in 1948 meant that it remained under local government and was no longer responsible for the management of Local Authority hospitals. The period between 1948 and 1972 saw a further erosion of public health responsibilities, when social and environmental services became independent under their own directorates. 1972 heralded a new era with a change in title to community medicine.
- #7 In the past 25 years there have been numerous re-organizations, and a return to the title of public health. Perhaps the major landmarks for the specialty during this period, have been concerns with management, the Black Report on Inequalities in Health, the Health of the Nation initiative, and the purchaser-provider split.
- #9 (a) Housing as a health issue first claimed attention in the mid-i 800s. In recent times the topic has once again come to the forefront of concern. The Ministry of Health in 1918 recognized the important influence of housing on health. The 1920s saw the move to demolish insanitary slums, the Garden City movement, and the involvement of Neville Chamberlain, who chose to become Minister of Health rather than Chancellor of the Exchequer in 1925 as he could contribute more in that post to national policy. After the Second World War, housing need was again paramount in view of the destruction wreaked by the War, and the need to re-build and improve. In more recent times major problems in this area remain, both in terms of quality, availability and affordability. (b) Nutrition is one of the major influences on the health of any population. Before 1939, under-nutrition was the main problem. M’Gonigle, among others, in his study in Stockton-on-Tees, demonstrated the deleterious effects of an inadequate diet on health, despite improved living conditions. With the beginnings of the school medical service and better surveillance of health in school children, improvements were made. The major impetus to change, however, was the introduction of rationing in the course of World War II as I have already stated. The effect of nutrition on health however, has not disappeared. Rather, it has changed direction, with an increasing tendency towards overweight and obesity, particularly among the poorer sections of the community.
- #10 During the 20th century, the decline of infectious disease mortality has been the most important cause of increased life-expectancy. Infectious disease as a cause of illness and death in the 1920s and 1930s was of huge importance. Although the introduction of immunizing agents, suiphonamides and antibiotics have had an enormous impact, new problems have arisen, such as antibiotic resistant organisms, and new conditions such as AIDS and Legionella. The decline in respiratory mortality was second in importance. There have also been major declines in death rates for the diseases of the digestive, genito-urinary and nervous systems. One of the most dramatic changes over the years in the question has been the reduction in maternal, infant and child mortality. As against these declines there have been increases in mortality for circulatory diseases and cancers.
- #12 The most dramatic environmental change has been the improvement of air quality. Until the Clean Air Act of 1956, most of our urban areas were covered by a pall of dirty black smoke in the winter months. This resulted in many episodes of so-called “smog”. But in spite of this major improvement in air quality, and thus in the frequency of respiratory illness in both young and old, problems of air pollution are still a matter of considerable concern - in the form of nitrogen dioxide and carbon monoxide rather than sulphur and soot. Past problems with both domestic and public hygiene in terms of adequate sanitation, sewage and water supplies have largely been rectified. But new issues have arisen - lead in the environment, in paint, in petrol, in food or in the soil; the impact of the use of pesticides in farming; the content of some animal feeds; the siting of waste dumps, or the building of houses and schools on sites formerly used for industrial waste disposal.
- #13 Not all the changes that have occurred in this century have been good for health. The most obvious of the health-damaging behavior that have shown an increase is cigarette smoking. Changes in society with improved transport systems, more advanced information and industrial technology, increased leisure, and very widespread possession of televisions and videos in homes has led to less physical exercise being taken, and thus an increase in risk for such diseases as coronary heart disease, stroke and arthritis. Abortion and fertility are also issues of public health, as well as ethical concern. In the past abortion was illegal, and practiced illicitly with undocumented consequences. It has been legal since 1968, with a sharp increase in the first 4 years. Whether it is now more common than in earlier years we know not. Other methods of contraception, such as the Pill have been introduced, and have revolutionized this area of health care and society. Recent advances in reproductive medicine too have opened possibilities in the treatment of infertility, which have vast ethical implications yet to be fully addressed by the profession, politicians and society at large.
- #14 Throughout the period covered by this work, mental illnesses have been a continuing concern. Whereas in the early years most of the mentally ill were cared for in institutions, often isolated deep in the countryside; few of these asylums still exist, and most patients are looked after in the community. But the trend may now be changing back to some extent. Along with the reduction of infections, life expectancy has increased with a rapidly growing population at the upper end of the age spectrum. This has coincided with increased population mobility, and the weakening of family bonds. Issues of long-term care, dementia, arthritis and multiple diseases have to be considered alongside other priorities for health care. Violence, whether towards children, partners or in the streets, has been present over the years and there is little evidence of any profound change in incidence or effective means of prevention other than reducing alcohol consumption, a difficult step to achieve. With the increase in the availability and use of effective drugs, there has also been a rise in the side-effects they can cause. From the public health point of view, they have underlined the need for an adequate system of surveillance. Poverty stands out as a factor of major impact on health throughout the whole period. There has been an indisputable improvement in standards of life in state provision for those in need. The change from the old Poor Law to the present welfare and benefits system has improved life for many. But even with these changes, inequalities in levels of health between the various social groupings have remained to the detriment of the deprived and are unacceptable at the end of the 20 century.
- #15 For public health, organizational issues have loomed large in this time period. Since the Victorian era, there has been friction between the ideas and methods of medical practitioners concerned with public health and those with other qualifications. In the 19th century this was exemplified by the conflict between Chadwick, a lawyer and Simon, a doctor, and between Simon and Florence Nightingale, a nurse. The Victorian era also provided an exemplar of the conflict of state authority and libertarian principles, and the view of public health practitioners who demonstrated the need for sanitary reforms which reduced the profit of landlords and unscrupulous employers. It is within this context of both inter-professional, intra-professional and professional versus governmental rivalry that these issues have to be viewed. In the Victorian era public health tasks were clearly defined. Most public health doctors combined clinical practice with part-time, salaried public health duties.
- #16 The change from the Poor Law administration of hospitals in 1929-30, to local authority control was the first major change in this arrangement. Local authorities gave public health practitioners authority to manage and control these newly acquired facilities. Medical Officers of Health responded to this challenge in varying ways, many took this opportunity to improve services, while others took a more relaxed attitude. The major drawback to this new responsibility for public health was that those involved became more concerned with the problems and minutiae of clinical/hospital administration, became medical superintendents and thus directed clinical care. This often gave rise to unease. Clinical consultants on the one hand, did not respect Medical Officers of Health whom they considered divorced from “real medicine”. MOHs on the other hand saw this as a means of acquiring power, authority and status. At the same time they were charged with, and developed, community services for pregnant women, infants, children and school health services, particularly in poor areas where the population could not afford to use GP services. Thus public health and general practice found themselves in competition and tensions resulted.
- #17 The introduction of the NHS in 1948 changed this picture radically. PH was separated from clinical practice and remained under Local Authority control. This was a profound disappointment to many PH practitioners. Some PH doctors became full- time medical administrators. Between 1948 and 1974 PH in many areas began to acquire new roles and identify gaps that had occurred as a result of the radical changes. Perhaps the most important of these was the co-ordination of services between GPs and hospitals for example for maternity and child health. Despite advances in some parts of the country, this was a period of turmoil and uncertainty for PH. The differences between Local Authorities became greater - in some, such as the counties, MOHs were treated as professionals and given freedom, while in many urban areas elected councilors played a far more active and interventionist role. At the same time social workers and environmental engineers (sanitary officers) became restive and achieved independence under their own directorates. The 1974 reorganization integrated all health authorities. The Todd Commission of 1968 had suggested a change in name - community medicine - and the creation of a unifying faculty, responsible for education and standards. This has not been the end of reorganizations. In 1982, the area tier was abolished, and in 1989/9 1 the number of districts and regions was reduced, and the purchaser/provider split introduced. In 1995/6 regional directors of public health effectively became civil servants as employees of the NHSE. A common concern over this period has been the difference in relationship between trained medical practitioners. Once the position of consultant or partner has been achieved practice is essentially controlled only by themselves. Historically PH has worked within a hierarchy, with the MOH or DPH as leader. One of the effects of the 1974 reorganization was the gradual disappearance of this hierarchical relationship. A major contrast between PH and clinical practice is that the former is usually concerned with the health of populations, whereas the latter with the health of an individual. To influence the latter requires diagnosis and prescription of treatment. To influence the health of a population also requires diagnosis - but the provision of a remedy is more complex. It is rare for a public health remedy to be administered by an individual. It is essential to recruit the help and resources of others. One of the most effective tools for the PHP is the public annual report of health, which can highlight problems, possible solutions and assess progress. The requirement for these annual reports was abolished in the 1974 reorganization but reintroduced in 1988. After a generally poor start, these reports have improved greatly, but in more recent years have become less effective. One major organizational issue involving PH as a key player continues to demand skilled attention - how to allocate limited resources within the context of exploding demand for health care.
- #18 One of the difficulties that has bedeviled PH over the last 80 years has been a search for its sense of identity as illustrated by its change of names. The specialty of PH was perceived both by the profession and by society in general as searching for a role and tending towards bureaucracy and administration. Perceptions do not have to be true to be powerful and PH allowed itself to be seen as confused and to become something Of a second class citizen in the medical field. Over this time-span the teaching of PH in medical schools and elsewhere gradually deteriorated and in some places disappeared altogether. In spite of repeated attempts for example by the Goodenough Committee in 1944, it is only in recent years that progress has been achieved. There are now recognized academic departments of public health in every medical school and the Faculty has enabled structured post-graduate training and development to be introduced. Recruitment to the specialty has been variable over the years, both in quality and quantity. Only in recent years has it settled down in a most encouraging way. Research, except perhaps in epidemiology, has followed a variable course - but in general has been neglected.
- #19 It must be obvious to all of you that in the time available I have only been able to highlight a few of what I consider to be the major issues. I would now like to bring this all together to look at the major issues that confront public health now, and suggest how the application of PH knowledge can be applied more effectively to improve the health of the population. The first concern is the role of PH in the control of communicable diseases. The law currently lags behind the reforms of both the health service and Local Authorities. No one has a duty to control infectious disease. As public health is in the purchaser authority, relationships have also have to be established between them and providers in the form of general practitioners and hospital trusts, in a similar way to what happened before the National Health Service but with one major difference. There now exists a Public Health Laboratory Service, and the microbiologists in these and other laboratories are no longer under the control of local authorities. Although co ordination is possible and occurs in many instances, clear lines of responsibility, accountability and relationship need to be established if proper control and prevention of infectious disease is to be possible. The second major problem is that usually the only medically qualified executive director of a Health Authority or Board is the Director of Public Health. He or she is able to offer advice and provide knowledge of clinical matters which the other executive and non-executive directors do not have. This is a powerful role. Directors of Public Health now have authority not only in matters concerned with public health, but also in areas of clinical concern in which they are not expert, such as establishing clinical priorities and monitoring services. The public health function is now frequently labeled as “health policy” with public health practitioners made responsible for the management of contracting for clinical services. Some authorities also have executive directors of primary health care development and this too can increase the tension because so much primary care now impacts on public health.
- #20 Once again therefore, public health is being seduced into assuming responsibility for large budgets which must be spent on clinical services, and once again public health practitioners believe that they can use this power to improve health. Where this is linked to appropriate means of considering the total expenditure and development of preventive, curative and rehabilitative services, as for example in the Health Care Program developed by O’Brien and his group for the Medical Royal Colleges, this is to be welcomed. Otherwise there are obvious dangers. Thirdly, although public health is theoretically independent and capable of producing independent reports, it is inhibited by nature of the structure within which it works from enunciating and propagating messages contrary to the views of management or the employing health authority. This issue was covered previously by the special position of the Medical Officer of Health. Currently, the Director of Public Health’s position as an Executive Director and budget-holder has tended to become a constraint in freedom to speak freely and deliver if necessary a critical, unpopular or controversial public health message. The doctrine of the collective responsibility of the whole executive team can be an inhibiting factor in plain speaking. Although medically qualified consultant grade public health physicians have the same security of tenure that other consultants have, they are bound by similar rules of public disclosure. For DPHs to review progress and highlight deficiencies annually is a daunting task and for some an irreconcilable conflict between their roles as independent advisers and as members of executive teams with collective responsibilities. Even more subtle in its hostility is the relationship between the Director of Public Health and public health physicians and the Chief Executive of a Health Authority or Board. The salary of the Director of Public Health is based on a nationally agreed scale, that of the Chief Executive, and other non-medical senior staff, is assessed annually, and depends on a performance review which considers achievements in the past year against a set of agreed objectives. These are usually concerned with the development of services, financial control, waiting lists and other process measures. Chief Executives in Health Authorities are accountable to the Executive of the National Health Service, and will not wish to report any deterioration in the health services, the health status or the risk factors of their population. The Director of Public Health is a member of a corporate health authority team and will prefer not to undermine the Chief Executive. Thus, although in theory the Director of Public Health is free to publish an honest and if necessary critical Annual Report on the health of the local population or on deficiencies in particular services, there are many human and career factors working against complete candor. In the past 22 years service, public health practitioners have also had to reapply for their positions with each re-organization - that is, in 1974, 1981, and 1989 - and on other occasions when districts have been amalgamated or boundaries changed. This continuous turmoil and insecurity has not been conducive to the development of properly critical attitudes of the public health professional nor to the willingness of individual practitioners to speak out on issues of public health importance.
- #21 Major public health problems have tended to recur continuously over the years, sometimes in slightly different guises or with modifications. There are four broad areas of concern: i) Outbreaks of disease caused by infective or toxic agents - for example smallpox, typhoid, food poisoning, BSE, radiation and so on; ii) Problems arising from social and environmental issues such as inadequate housing, unemployment, poverty, abortion, fluoridation of water; iii) Behavioral concerns such as smoking, excessive consumption of alcohol, drug-taking, absence of exercise; iv) Health service issues including assessment of health care needs and outcomes, and the effectiveness and efficiency of particular services. Given that these types of problem will continue to be faced in the future, how can the practice of public health be improved to address them directly and try to find solutions for the modern age? Public health, as a discipline, should not become involved in the management of clinical services whether in the community or within institutions - it lacks the expertise essential for this task. Its prime responsibility is to promote health and to prevent and control disease. It should thus have responsibility for surveillance and for the planning and co-ordination of measures which promote and maintain health. It should be involved in the planning and distribution of clinical services in accordance with measures of need and demand and the assessment of effectiveness. Since the major academic disciplines of public health, epidemiology, medical statistics and some aspects of the social sciences including economics, are the unique bases of training in public health, their contribution to the inter-disciplinary work required to develop clinical services in accordance with criteria of need, effectiveness and resource availability are required, and accepted, by the other disciplines involved.
- #22 Public health practitioners must develop their skills in handling outbreaks of disease and the law must be updated to clarify these responsibilities and ensure that they are accompanied by the necessary powers to act. Training in epidemiology is crucial to this. They need to develop the essential links with microbiology and toxicological laboratories, so important in this task, but must also be appropriately trained in these disciplines to be able to assess and use this expertise to best effect. Defined responsibilities in this require explicit organizational links and adequate powers to investigate and control any outbreak. For this function, appropriate methods of disease surveillance, including notification are essential. Thus public health has key needs in the collection, analysis and dissemination of accurate information. It follows that it should have a major role in the design and establishment of appropriate information systems. It is important for the effective monitoring of health needs and outcome that data collected about patients are linked to individuals, and not merely based on events. Methods of record linkage which respect confidentiality pioneered in Oxford and Cumbernauld should become the norm, as they are in countries such as Sweden and Denmark. Although unique patient numbers were promised for introduction in the United Kingdom in 1996, they have yet to become a reality, apart from in Scotland where linked data in the form of CHI numbers is in routine use. Their information is central to more effective use of data systems in health care. Responsibility for the assessment of health and its maintenance implies the requirement to determine the factors responsible for ill-health. Public health must be involved in appropriate studies, whether epidemiological, sociological, psychological, or statistical, which enable hypotheses to be tested and solutions implemented for the control of ill health. Its major role is in the identification, and planning of appropriate methods of intervention, to correct deficiencies and prevent the occurrence of disease. This must be a multi-disciplinary activity. In purely medical terms however, roles can and should be distinguished. The role of public health in the surveillance, identification, planning and co-ordination of measures to prevent, if possible, the occurrence of disease, and to deal with it if it does occur, is central to the specialty. The implementation of appropriate preventive, curative and rehabilitative measures is the responsibility of clinicians, in both hospital and general practice. There is thus a clear distinction in the roles of public health and clinical medicine in this context. Public health identifies a problem and co-ordinates the service; general practitioners or hospital clinicians provide whatever treatment or management is appropriate. If these distinctions are recognized many of the factors causing friction will be removed or at least modified. The different knowledge and expertise of different medical specialties - and their inevitable overlap - must be acknowledged and respected if effective collaboration is to be achieved.
- #23 The importance of infectious and toxic hazards in the causation of disease is universally accepted. But not all individuals exposed to a particular hazard succumb. There are a variety of biological, behavioral, social and environmental factors which play a part in the development of diseases in individuals or populations. In chronic diseases such as cancer of the lung, coronary heart disease, diabetes, or stroke, multiple factors are involved in the development of illness. And although we accept that certain forms of treatment should be given for particular conditions and certain outcomes expected, there are wide variations within both these parameters. The main determinants of ill-health are associated with social factors such as unemployment and deprivation, risk-taking behaviors such as cigarette smoking and over-consumption of alcohol, environmental factors such as housing and fluoride in the water supply, genetic predisposition and the availability and quality of clinical services. The role of public health in finding a way through the jungle of determinants of disease is an extremely complex one. Many of these factors are related inextricably to political, professional and economic realities. Their identification may well antagonize one interest group or other. Public health physicians therefore, require diplomatic, political and persuasive skills to achieve the most positive results. These qualities are in short supply in any field of endeavor and, although public health tries to fulfill its role, it has not always been successful either in describing dangers to health clearly and forcibly enough or in proposing workable and acceptable solutions. This has become no easier in the past few years when little meaningful attention has been paid to the indisputable relationship between deprivation and ill-health. If public health is to fulfill its proper function - to improve and maintain health - the specialty must secure the necessary means and freedom both to identify and to disseminate knowledge of the factors that lead to ill-health and possible means of solution. This may on occasion involve pointing the finger at particular groups - for example, tobacco manufacturers, farmers, butchers, even clinicians - and it is obviously of the utmost importance that such knowledge is based on incontrovertible evidence and is presented responsibly - and where possible without the hysterical media reportage that has been all too common in recent times. Put plainly, public health must regain an independent voice and use it. Health Authorities have a responsibility to do everything in their power to prevent ill- health and to provide clinical services to those who need them. But many of the factors which cause ill-health are under the control of other Local Authority departments or central government and the opportunity for public health to intervene may be limited. Some important public health messages are uncomfortable and unpopular politically and others may have unwelcome resource implications.
- #24 Public health’s ability to communicate with the media, pressure groups and the public on the concept of health is one that also has enormous implications for any future public health structure and one which - whether it sits easily with training in the specialty or not - is unlikely to disappear. Some health risks are the result of deliberate decisions of individuals consciously trying to get the best deal possible for themselves and those important to them, such as the wearing of bicycle helmets and seat belts. Others involve social issues, such as the sitting of hazardous waste incinerators, whether to vote for or against fluoridation of public water supplies or whether to support sex education for primary school children. In some cases, single choices can have a large effect on individual risk - buying a car with air bags, for example, or becoming pregnant. In others, the effects of individual choice are small but can accumulate over multiple decisions - adding salt to food and using butter rather than margarine. In some cases, choices tend to affect health risks, do nothing at all, or achieve the opposite of what is intended - for example, the adoption of quack treatments. Thus risk perception and communication of the risks of particular behaviors, environments and events is an extremely complex process but one that is central to any modern public health function and structure and requires greater attention to communication skills than has previously seemed necessary.
- #25 The skills and concerns of public health are agreed. But there remains at present, confusion between its role in the management of clinical services and its primary role in the management of public health services. Its present service structure is as part of the corporate team that contracts both public health and clinical services from National Health Service providers for a defined population in a defined geographical area. Public health can thus influence the priorities and distribution of health service resources to improve the health of the population for which it is responsible. However, as the health authorities are appointed by the Secretary of State for Health, they have no powers to influence the policies or activities of other departments with responsibilities which impact on health and disease, such as housing, environment, social services or education, which are controlled by locally elected representatives of local councils and their officials. The only way these can be influenced, at local level, is by formal and informal consultative mechanisms or partnership arrangements. Although theoretically, some transfers of resources between the two types of authority are feasible, they only occur rarely, and the amounts transferred are usually relatively very small. At central government level, the Chief Medical Officer of the Department of Health is also the Chief Medical Officer to other Departments of State - Education, Home Office, Social Services, Environment. In addition there are formal (and informal) inter Departmental committees, including at Cabinet level, to try to develop relevant central governmental policies, for example in support of the Health of the Nation targets and program. But it is at this level that the problem for the public health is particularly stark. Although Chief Medical Officers, since the first incumbent John Simon, have been willing to enunciate publicly about health hazards such as inadequate housing or the dangers of cigarette smoking, both their public pronouncements and actions have been circumscribed by their political masters. Recent Chief Medical Officers have had their powers reduced, their resources cut, and their ability to influence policies further constrained. The difficulties for public health to influence policies or events are even greater at lower levels. We have already referred to the constraints on the annual reports produced by Directors of Public Health and the possibility of influencing resource allocation policies outside the health sector, at local level, is very restricted or non existent.
- #26 In order to fulfill their role effectively, public health practitioners have to do certain things: • They have to be forthright in the advocacy of programs that improve health and to state clearly and openly the dangers and consequences of some actions, clinical, environment or political. • They have to be able to influence the budget for public health activities and to ensure long-term public health issues are considered on a separate dimension from short-term clinical and practical issues which will otherwise always take precedence. • they have to assume a clearly identifiable role in helping to influence and guide the policies not only of health authorities but also of schools, environmental agencies, housing departments, microbiological laboratories and practicing clinicians in hospital and general practice. To be able to fulfill these tasks public health must work in close co-operation with other relevant disciplines and must take responsibility for the development, maintenance and operation of the information systems required to maintain first-class intelligence on the health needs of the population, disease control, including prevention and the outcome of public health and clinical policies. As we have already seen, the present structure does not fulfill these important requirements. Public health practitioners have no control over the required information systems and do not have the practical freedom to report on the health of the populations for which they are responsible. Their power to influence and guide the activities of bodies other than health authorities is either absent, or rudimentary and informal. Change is needed. The present structure and powers of public health physicians are inappropriate and inadequate to fulfill the essential tasks. There are, in our view, three possible options for a better structure: Return of the MOH There is a view that, since many of the factors that influence the health of the population are administered by local government, public health practitioners should be employed by local government, and their coordinating and guiding duties to Health Authorities, hospitals and general practice carried out on an agency basis. There are two major obstacles to this solution. Firstly, most health information systems are administered by Health Authorities. Since appropriate guidance has to be based on accurate data and responsibility for information systems is essential if they are to be in a position to deliver that guidance, it is most unlikely that Health Authorities would be willing or indeed permitted to relinquish these functions. Secondly, although clinical interventions are only one part of the way in which health is maintained and achieved, the role and authority of doctors is vital both in understanding, knowledge, and communication. One of the most important roles of public health is in the surveillance, prevention and control of disease, whatever its cause. It is important that highly qualified medical doctors are attracted to public health not only to cope with the public health problems, but also to communicate with the public, policy-makers and other practitioners. They play a central role in the planning of health services. If public health were not considered as a mainstream health activity, it is likely that the status of the subject and its attraction for medical graduates would diminish and public health and the health service in general would be the poorer. National Commission of Public Health This option envisages a Commission which would include the Public Health Laboratory Service, a central Toxicological Laboratory, the National Poison Centre and perhaps even the National Radiation Protection Board. The Commission would have a budget agreed not only for the expenses and staffing of these laboratories but also for the cost of all of the service public health practitioners throughout the country. Although the appointment and payment of public health practitioners would be undertaken by the Commission, most would be located in Districts or Boards. Each Health Authority would continue to have a Director of Public Health and several consultant posts as well as trainees. But all public health practitioners would be on the staff of the Commission and those at local level seconded there for fixed, renewable periods. Directors of Public Health would continue as members of Health Authorities, but would be ultimately accountable to the Director of the Commission and not to the Chief Executive of the District. At all levels of staffing the need for multi-disciplinary working would be paramount. Consultant level appointments would be needed not only for those with a medical qualification, but also for statisticians, social scientists, health economists and so on. For all disciplines it would be essential to have a proper education and training program and not merely a university degree. For some posts, for example communicable disease control, medical training would obviously be essential. For others, this might be helpful but not mandatory. The obvious advantages of this model are the independence that public health practitioners would have in both their action and reports, the recognition of the importance of a multi-disciplinary approach, and an acknowledgement of the clear differences between clinical services and the public health services. There are however, various problems with this solution which effectively preclude its adoption as a practicable proposition. The most obvious of these are firstly that the establishment of a free standing commission, controlling not only action but also staffing and training might stifle initiative and secondly, it would be a bold and imaginative government who would be prepared to grant the commission the wide remit proposed or meet the full cost implications of the equivalence of salaries of all staff whether medically qualified or not. The experience of such an organization for public health in New Zealand has demonstrated how easy it is to relegate public health functions and abolish independence when uncomfortable decisions have to be made. Modification of present structure with re-creation of Institutes of Public Health A more realistic modification of the full Commission of Public Health option might be to reinforce the role of public health at district or board level - whether in health or local authorities - by the re-creation of expert regional institutes with a national institute, including micro-biological and toxicological laboratories. For public health to function effectively it needs access to expertise. This can be provided to a large extent through universities and research units, but there is also a need to have an identifiable practical resource with service responsibilities. This option would retain a Director of Public Health and consultant grade public health practitioners in each District or Board. The function would be that of coordinator, with access to and responsibility for all public health information services as defined and the duty to guide with advice, not to direct, except in special circumstances. Public health physicians should once again have specially secured positions as Medical Officers of Health had before 1974. Public health physicians should again be involved at both central and local level in the discussions of bodies concerned with the environment, social services, education, nutrition, and housing so that the influence, for example, of housing policy on health is fully recognized. By requiring public health at local level to participate in and influence the decisions which in turn influence health, the wide diversity of different parts of the country could be recognized and a positive sense of local ownership encouraged. If this option were to be introduced Local Authorities would again need to become involved in the appointment of public health physicians. This option emphasizes the fact that public health should be concerned largely with its own issues rather than with clinical service management and contracting. This model could also be used to promote involvement with general practice and hospitals locally and remove or reduce many of the current conflicts and difficulties between different specialties. At central level, the ability of the Chief Medical Officer to guide policy of tobacco, food, transport, education and so on should be strengthened and public health expertise consulted in policy decision-making.
- #27 An essential ingredient for progress is clarification of the role of individuals required to perform the public health function and thus has implications for staffing and personnel. Many of the interdisciplinary tensions within public health arise from lack of clarity about the nature of expertise and false beliefs about the abilities of different professional groups. As we have already emphasized, to fulfill some of the service requirements medically qualified public health physicians are needed. Medical knowledge and skills are essential, in particular, in the control, surveillance and prevention of diseases, both infectious as well as chronic. Medical expertise is also required in the assessment, evaluation and planning of clinical care requirements, and is helpful for the co-ordination of activities and policies with hospital and general practice clinicians. If public health is to play the wider role envisaged, it is essential that the interdisciplinary nature and working of the discipline is established more firmly than at present. In the investigation of an outbreak of infectious disease for example, the consultant in communicable disease control has to work with microbiologists and with environmental health officers trained in environmental investigation and control. To devise appropriate programs of health promotion for a school, public health workers must be trained in education, psychology and sociology. Medical statisticians are important for design of investigations and the successful analysis and interpretation of data. Only if public health physicians accept fully that they must work on equal terms with other qualified health professionals of similar status will it be possible to achieve the crucial development and application of policies that can improve the population’s health. The proposals also have implications for the often uneasy interface between service and academic public health. Part of this is a result of the different emphasis of these two branches of the specialty. Academics can seem indifferent about the practical application of findings and some appear to consider that some service preoccupations are mundane in comparison with the development of knowledge. Similarly, the service side has sometimes seemed preoccupied with day-to-day problems and unwilling to invest in research efforts without an immediate pay-off.
- #28 Public health has come a very long way and made massive inroads into diseases within the relatively short period covered by our book. It has progressed through the vision and commitment of the public health giants of the past. It has also suffered disappointments, reversals and missed opportunities. We would argue that a return to the era of the Medical Officer of Health would risk another sidelining of the specialty at a time when it must be at the centre of the health scene. The radical option of the establishment of an independent public health commission is of course attractive, but it does not seem feasible that any government of whatever political complexion would be willing to fund and support such a body persistently at an adequate level. We therefore, favor the third option of modifying and extending the present structure, powers and functions of public health within Health Authorities and boards but with the addition of a national, and several regional institutes. Public health is now at a cross-roads where it can either accept the status quo or confront realistic change and challenge and seek to regain its former independent voice. It is more than time, for example, to nail the “libertarian” myth that individual freedom and the right to choose are worth more than an improvement in the health of the population as a whole. Public health does not and should not seek to patronize, nanny or coerce the population into “health”, as is sometimes suggested by powerful critics with vested interests. But the specialty surely has a duty to inform the public responsibly on public health matters, to fight the active promotion of products such as cigarettes, which have a well proven and damaging effect on health, and to seek vigorously the introduction of simple public health measures, such as fluoridation of public water supplies, which would provide enormous benefits, particularly in more deprived sectors of the population. We perceive public health as the central medical specialty of the future. It now has a clear and workable definition of its proper functions and we hope it will find the courage and unity to face the challenge of realistic change in pressing for the return of its independent voice. Of course this is a personal view. But the political climate now seems right for such a move to lay the foundations for a real improvement in the nation’s health in the next century. The Labor Government, elected in May 1997, has in principle accepted the central importance of public health in its creation of the new post of Minister of Public Health. And public health has surely learned from the lessons of history the real power of political expediency, opportunism and realism. This we hope will be the new vision and challenge for public health.