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In a speech on 13 November 2001 to the Royal College of Physicians and Faculty of Public Health Medicine, Lord Hunt described the Government's vision of the future of public health in England. His talk was well received by many in the audience, but not by all. In this age of evidence-based medicine it is important to consider whether the proposals are soundly based and are likely to achieve the goal desired by all—health improvement of the population.
The proposals for public health need to be considered within the context of other proposals by the Government in the NHS Plan1, Health Inequalities2 and Shifting the Balance of Power in the NHS3. The underlying aspiration is stated to be to devolve greater power to frontline staff and communities. Primary care trusts (PCTs) are to be the most local NHS organization, ‘led by clinicians and local people’.
It is envisaged that each PCT will be responsible for a population of about 100 000. There will be about 300-500 PCTs in England, though the actual number does not yet seem to have been decided. Each PCT will have a director of public health and a support team. The directors will be board-level appointments. It is envisaged that ‘the focus of their activity will be on local neighbourhoods and communities, leading and driving programmes to improve health and reduce inequalities’. They will also have to forge partnerships and influence local agencies to ensure the development of health improvement and healthcare programmes.
Lord Hunt acknowledged that local action will need to be underpinned by specialist expertise and skills in public health that cannot be provided in every PCT. Public health networks will be established to ‘pool expertise and skills’ and act as a ‘source of learning and professional development’. This network is not to be an additional tier of management and will not adhere to a rigid geographical boundary. It is intended that the design and composition will be decided locally, and managed from the bottom up. Development of these networks is seen as crucial; therefore the ‘regional directors of public health will co-ordinate dicussion to design the new networks’. Regional directors of public health represent (and are employed by) the Department of Health in each of the nine regional offices of government. They will be responsible for addressing the wider determinants of health in their regions and will have ‘a lead role for health protection and some responsibilities in relation to the NHS’. Since local authorities are regarded as key partners, the case is made for PCT directors of public health to be appointed jointly by the PCT and the local authority. In the longer term it is envisaged that links between public health and environmental health will be ‘further strengthened and enhanced’.
In addition to the regions and PCTs there will be strategic health authorities (StHAs)—28 of them, covering an average population of 1.5 million. They will be co-terminous ‘with an aggregate of local authorities’ but ‘cut across government office boundaries’. The major functions of the StHA will be to create a coherent strategic framework for the development of NHS services and to consider how these can be delivered area-wide. The regional directorates and the StHAs will be accountable to the Secretary of State. The StHAs will ‘manage performance across organisational boundaries and networks’ and ‘will lead on the creation and development of public health networks’.
Lord Hunt emphasized that PCTs would be the key foundation for public health, underpinned by the expertise of the public health networks. At StHA level he indicated that there would be a doctor with ‘the appropriate strategic management skill to undertake this function as a member of its executive team’. It is not clear whether this individual will have any public health medical background.
In addition there was reference to public health surveillance, and tribute was paid to the work of the Public Health Laboratory Service (PHLS) and local consultants in communicable disease control. Lord Hunt, unfortunately, did not elaborate on the configuration or relationships of this extremely important activity to PCTs, StHAs or regions. Proposals have now been published by the Chief Medical Officer4.
Lord Hunt's analysis of the public health function emphasized the need to address inequalities in health and to tackle the major care areas identified in government policy—namely cancer, coronary heart disease and child health. Presumably this also includes mental health and the elderly, for which National Service Frameworks have already been promulgated.
This brief outline demonstrates the challenge facing the public health function, but several issues need closer scrutiny.
Some of the propositions put forward are reminiscent of the situation in England before 1974. Lord Hunt emphasized that he considered this to be a ‘glory time’ by recounting how effective public health was in Oxford where he was a local authority councillor. It is correct that the medical officer of health (MOH) for Oxford at that time, John Warin, was an outstanding individual and Oxford had an excellent public health department. It had achieved a very high level of success in its programme of immunization through the close relationships Warin had built up with local general practitioners and through his success in extending the role of health visitors, whose responsibilities were widened to include the whole family. He pioneered the attachment of health visitors to group practices5. However, the situation in other parts of England was not as rosy as in Oxford. It is thus important, when looking at the current proposals, to recall the difficulties experienced between 1948 and 1974.
Before the First World War, public health flourished and had great impact on social policies5. The main focus was on surveillance, containment and prevention of infectious disease. Matters changed between the two World Wars with the introduction of, for example, chemotherapy, insulin, liver extract and vitamins and a widening of the possibilities open to clinical medicine. Moreover, general levels of health were beginning to improve despite much unemployment. The ability of public health to influence wellbeing was not as great as in the previous century. There were fewer ‘heroes’, with exceptions such as McGonigle of Stockton-on-Tees who showed how rehousing of people in new premises with higher rents led to inadequate nutrition through loss of disposable income. The major interest of public health practitioners was in the governance of hospitals, which were transferred to local authorities from the Poor Law Administration in 1928. An example of the failure of public health practitioners in the period 1930-1940 was the lack of drive to introduce universal diphtheria immunization, which resulted in about 20 000 preventable deaths. Nonetheless, Godber6 has pointed to the great strengths of some MOHs who were moving from the sanitary revolution to the development of personal health services, ‘though with some friction with the general practitioners and not a great deal of help from the paediatric and obstetric hospitals’.
It had been expected that the NHS would be introduced through the expansion of the services provided by local authorities. Seeds of antagonism, however, had long been evident in the relationships of local authorities with the powerful voluntary hospitals and with general practitioners. Public health, not for the first time or the last, failed to grasp the political reality. Thus when the NHS was introduced local authorities became responsible only for a range of environmental and personal health services (including maternity and child welfare clinics, health visitors, midwives, health education, and vaccination and immunization). They were also in charge of the ambulance service. The MOH was still the key local authority health officer, and funding for public health services provided by local authorities came from central government grants and local rates.
With the separation of public health from the NHS there was a gradual decline in the capability of public health doctors to have a major impact on health services. Similarly their status within local authorities, and thus their ability to influence local policies, declined especially when social work and environmental health were separated from the MOH in 1970 and 1972, respectively.
The period 1948-1970 also saw a decline in the attractiveness of the local authority public health service as a career option. There were conflicting views on the role of public health doctors, but by the time of the Todd Report on medical education7 there was a majority opinion that change was needed. Morris8 was first to define the role of the community physician, as the individual responsible for community diagnosis and as such for providing the information required for efficient and effective administration of health services. He emphasized the importance of cooperation. His views were endorsed by many leading public health practitioners, but as Lewis9 makes clear, MOHs accepted the concept mainly because ‘they understood it to mean a substantial rise in status for the specialty—a move at last away from the public health with its undertones of drains and sewerage’. Another very important development at this time was the foundation of the Faculty of Community Medicine (now Public Health), which has been fully documented by Warren10.
The need for change in the structure and organization of public health had become increasingly obvious since the introduction of the NHS in 1948. The ideas and concepts put forward by Morris and others provided an enormous incentive for many to enter the field. The separation from control by local government was also greeted with general relief. While a few authorities, particularly counties, treated public health as a professional activity, many local councillors interfered in public health activities and subverted necessary actions for ‘political reasons’—e.g. on housing, education and the environment.
The period 1974-89 was one of great turmoil for public health physicians. Community medicine was regularly ‘reorganized’ and its practitioners had to reapply repeatedly for their positions. The one tangible gain was the establishment of a sound system of education, training and professional development both in the universities and in the NHS, aided and supervised by the Faculty of Community Medicine.
Elsewhere I have outlined the critical requirements of public health as follows:
‘An effective public health service must identify and be responsive to major public health problems, and be efficient in promoting strategies to combat them. If no well-attested solution is available, an effective service ensures that appropriate investigation is mounted in order to develop the body of knowledge and define the means of solving it, and thus to identify suitable methods of protecting the public's health. The intelligence system maintained by the service should provide appropriate mechanisms in order to undertake these public health tasks’11
Examples of the problems that need to be addressed are inequalities in health outcomes in different places for patients treated for cancer, appropriate transport strategies to deal with local road accident hot spots, or an outbreak of salmonella in a school.
If this is accepted as the main principle underlying public health activities then a diagnostic surveillance system is essential to assess situations and devise appropriate actions. Ideally public health should influence all sectors of society. Public health must have the ability to initiate action through the mobilization of resources, or the ability to influence those responsible for executive action to undertake corrective or preventive activities. It permeates through all social, environmental and other activities of populations, whether it is farmers producing food or growing tobacco, or water engineers devising a clean water supply, or doctors providing preventive or curative services. Here are the major issues facing public health practitioners (PHPs).
These are the skills and functions identified by the Faculty of Public Health Medicine as the key activities and standards for PH practice14. It is thus necessary to examine how the tasks considered important by the Department of Health can be fulfilled by the proposed organizational structure.
Lord Hunt, in his address to the Faculty of Public Health Medicine and the Royal College of Physicians15, and Shifting the Balance of Power within the NHS: Securing Delivery3, outline the Department of Health's expectations of what public health should do. The major task identified is to tackle health inequalities. Specific examples of action are mentioned, such as smoking cessation clinics, rapid access to chest pain clinics, promotion of screening in minority ethnic communities and improving the diet of young people. Of course, the prevention and control of infectious disease is included, but details of this are still awaited.
Shifting the Balance3 outlines the organizational framework. The intention is that front-line staff should have the power and influence to meet local needs ‘within the context of clear national standards and a strong accountability framework’. There will be decentralization and ‘empowerment’. There will be close cooperation and coordination between health and local government authorities. Appointment of chairs and non-executive directors of the new authorities is to follow ‘procedures of the appointments commission’; chief executives are to follow guidelines laid down by the Department of Health and the Leadership Centre while directors will be appointed by the chairs and chief executives.
Before considering the tasks public health is expected to take on, let us examine whether the organizational structure will enable PHPs to perform effectively.
Relationships and staffing at the different levels within the proposed new structure are ill defined. The proposals, despite the rhetoric, imply far greater central control and less ability to be concerned with local conditions than we have at present. The lack of input by democratically elected representatives (a problem since 1974) into decisions at PCT and StHA level is bound to reduce ability to improve levels of health in relation to local needs, because of lack of ‘ownership’ by the authorities responsible for education, environment or employment, all of which influence health. There continues to be confusion between the provision, planning and management of health services and clinical services.
The lack of detail about the staffing and relationships of public health at PCT, StHA and regional levels is worrying. Although it is suggested that the PCTs and the networks of public health specialists at other levels will not work hierarchically but be established by ‘organic, bottom-up approaches’, this does not seem to comprehend the difficulties the various organizations are likely to face, nor how priorities will be established when help is needed in the face of competing demands—for example, to solve a routine problem or to deal with an outbreak. Of even greater concern is how the necessary training and support will be organized and linked to established academic institutions.
If the proposals were regarded as developmental, then it would be feasible to experiment—to evaluate various different structures and then choose the most appropriate. But, as with so many current political initiatives, structures are likely to be imposed, and to be based not on evidence but on the ideas of advisers and politicians who lack knowledge of what worked and did not work in the past.
Even at the start of public health activity in the 19th century, public health was subservient to bureaucratic domination. It is extremely difficult to devise an independent public health system capable of influencing the activities of health, social, educational and other authorities at all levels. Only where public health has been set to tackle major individual problems—as with tuberculosis or smallpox—has it been able to act effectively. An example of a successful method of organization was the US Public Health Service, which was accountable for overall achievements rather than specific activities. PHPs must be part of an independent authority not beholden to any specific interest group, but with input into both strategic and operational decision-making in all forms of policy with an impact on health. Only if the PHP is able and willing to provide uncomfortable, unwanted, advice is the public health function likely to be adequately performed.
As long as public health remains enveloped within a bureaucratic and administrative structure, the conflicts and difficulties are likely to be too great. However, there is a danger that, if removed from the structure of the National Health Service, public health would become even more remote. The past separation of provider and purchaser authorities did offer a chance to circumvent the difficulties outlined, but unfortunately was never completely realized. The proposed structure of PCTs, networks, strategic health authorities and regional departments is likely to lead to even more confusion and to more conflicts between authorities, individuals and their responsibilities and tasks.
There is little disagreement about the major challenges facing public health. One solution would be to separate the public health function and create an independent organization capable of influencing the activities of all authorities—e.g. health, education, social services. Such an organization, however, was rapidly dismantled in New Zealand5 in the early 1990s when it began to give uncomfortable advice on tobacco control. For effective action public health must be able both to investigate and to intervene in the activities of all sectors of society. Experience indicates that there are several levels at which public health policies must be able to act. Since we are part of the European Union and diseases do not recognize boundaries there must be a suitable presence at supra-country level. This is important even within the UK, since we have separate administrations in England, Northern Ireland, Scotland and Wales. Differences in structure, organization and methods are already beginning to emerge. It would be unfortunate if we did not build upon the strengths of uniform professional standards and training within the UK in coordinating national policies for such hazards as smoking or air pollution. Within England it is envisaged that there will be regional directors in the outposts of government at the regions. The public health problems of regions will differ; for example, the environmental-health concerns of the north-east and north-west will differ from those of the more affluent south-east. Thus a strong regional public health presence is crucial. The difficulties arise at the lower levels—the proposed StHAs and PCTs. It is unlikely that there are sufficient experienced, able PHPs for an adequate cadre in each of the proposed authorities. As with all other professional activities, the individuals in charge must not work in isolation; they must be exposed to peer judgment, critique and control.
In the period 1974-1989 public health physicians were called community physicians. There was confusion about their role. Some considered them to be providers of health services within the community; some regarded their major role as more strategic. With the main focus of the provision and commissioning of health services, including clinical services, shifting to the primary and general practice level, advantage of this should be taken.
For at least the past century public health services have had dual roles. One is the provision of community health services; the other, activities such as the planning of services in relation to need, and the investigation and control of infectious disease. This duality of function generated ambiguity about whether PHPs were ‘advisory’ or executive. The opportunity of basing the health service ‘building block’ on the PCTs should be seized. General practice should be encouraged and trained to deliver appropriate preventive and protective health services—i.e. become responsible for community medicine with their associated nurses and therapists. PHPs should become more concerned with the development of systems of surveillance, devising methods for the prevention and control of disease and methods for the promotion of health in the population for which they are responsible.
For effective activity in public health, local knowledge is crucial. Thus PHPs must not be remote figures. But it is also important that sufficiently wide specialist expertise is available locally. One individual is unlikely to be expert, say, in the prevention and control of infectious disease, programmes to discourage children from smoking and planning clinical services for stroke. Thus PHPs will need to work in teams. 300-500 teams (the possible number of PCTs in England) is far too many; 28 teams, the number of StHAs, is too few. The exact number should depend on geography and human resources. If there are about 150 teams and 9 regions it is questionable whether the StHAs provide a suitable level for public health activity.
There are several prerequisites for effective PH activity in such a structure.
If we wish to improve population health, to reduce the burden of disease, to lessen the inequalities in health outcome and health status, and to meet the challenge of global threats to health, the structure of the PH function must be radically reformed. We must not repeat the errors of the past or neglect the successes. Critical scrutiny in the light of past experiences and future needs is required. It is unfortunate that the proposals put forward by the Government have not been subjected to scrutiny. This essay suggests a way forward.