Making Sense of Public Health Medicine

Jim Connelly, Chris Worth

• Publisher: CRC Press
• Year: 2018
• Print ISBN: 9781138449374
• eBook ISBN: 9781315348896
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This book presents an introduction to modern public health seen from the perspective of practitioners of public health medicine. Written for non-practitioners interested in public health and as an essential introduction for those considering a career in public health medicine, the book uses illustrative case studies to demonstrate the practical application of public health techniques. In demonstrating the value of this approach, the book argues for the adoption of a realist health policy and radical reform of clinical medicine - to achieve public health. The skills of public health physicians are central to planning health services, purchasing effective and cost-effective treatments, and improving the quality of services. It is vital that those who plan and deliver health care understand their work and appreciate their contribution. This book describes that contribution, and provides a powerful analysis of the challenges the NHS and the wider community face in improving health.

1

What is public health medicine?

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The history of public health in the UK is largely the history of changing ideas about how disease is caused and what can be done to reduce it and improve health. The British cholera epidemics of 1832-33, 1848-49 and 1854-55 were the spurs to a wide-ranging set of actions captured by the term ‘sanitary reform’. This sanitary reform period saw the consolidation of a number of social movements that were united in their belief that poverty and insanitary conditions were dependent upon each other. Public health thus took on an unmistakably social and political agenda, which, however, seemed to be weakened and even lost as the nineteenth century wore on. The institutional history of public health medicine is the subject of this chapter and so we must, for the moment, leave this wider context. The connection between public health and social, economic and political factors, however, figures largely in the remainder of this book.

For present purposes, an important landmark occurred when the City of Liverpool appointed Dr William Duncan as the first Medical Officer of Health (MOH) in 1847, and other towns and cities subsequently followed this lead. The rationale and duties of the MOH were first set out in the Liverpool Sanitary Act, 1846, as follows:

And whereas the health of the population, especially of the poorer classes, is frequently induced by the prevalence of epidemical and other disorders, and the virulence and extent of such disorders, is frequently due and owing to the existence of local causes which are capable of removal but which have hitherto frequently escaped detection from the want of some experienced person to examine into and report upon them, it is expedient that power should be given to appoint a duly qualified medical practitioner for that purpose; Be it therefore, enacted, that it shall be lawful for the said Council to appoint, subject to the approval of one of her Majesty’s principal Secretaries of State, a legally qualified medical practitioner, of skill and experience, to inspect and report periodically on the sanitary condition of the said borough, to ascertain the existence of diseases, more especially epidemics increasing the rates of mortality, and to point out the existence of any nuisance or other local causes which are likely to originate and maintain such diseases and injuriously affect the health of the inhabitants of the said borough, and to take cognisance of the fact, of the existence of any contagious disease and to point out the most efficacious modes for checking or preventing the spread of such diseases ...

In the Local Government Board Act, 1871, appointment of an MOH was recommended for every local district and in the following year the Public Health Act, 1872, made such appointments compulsory. These Acts did not, however, lay down specific duties for the MOH. Attempts to define these duties came from a variety of subsequent sources, all of which, in practice, were in place well before the turn of the century. Perhaps the clearest written statement came in 1910 in the Sanitary Officers (outside London) Order:

He shall inform himself, as far as practicable, respecting all influences affecting or threatening to affect injuriously the public health within the District ... He shall inquire into and ascertain by such means as are at his disposal the causes, origin and distribution of diseases within the District, and ascertain to what extent the same have depended on conditions capable of removal or mitigation.

The work of public health doctors was therefore concerned with investigating the origins and causes of disease and taking actions to prevent them. The Sanitary Officers (outside London) Regulations of 1935 added to these duties the significant duty ‘and be prepared to advise the local authority on any such matter’ (affecting, or likely to affect, the public health of the district). Thus the official view of the work of public health doctors was clearly in place by 1935.

The Committee of Inquiry into the Future Development of the Public Health Function

The Royal Commission of 1871 was the means of coming to terms with a number of administrative deficiencies in the fledgling Public Health Service (PHS). Its recommendations essentially were to form the basis of the PHS until 1974. The second major review of the organizational arrangements for public health were reported in 1988. The chairman of this Committee of Inquiry, the Chief Medical Officer, Sir Donald Acheson, stated his hope that:

[the Committee’s] recommendations will improve the surveillance of the health of the nation, clarify roles and responsibilities, show how each particular skill may be brought to bear at the appropriate point in the National Health Service within the framework of general management, and taken together, will provide a structure conducive to better health for all.

The definition of public health adopted by this Committee is currently the one most favoured by public health practitioners. Public health is defined as:

the science and art of preventing disease, prolonging life and promoting health through organised efforts of society.

The committee explicitly stated the public health responsibilities of various institutions, including central government, local authorities and regional and district levels of the National Health Service (NHS). The responsibilities of district health authorities (DHAs) were considered to be:

• to review regularly the health of the population for which they are responsible and to identify problems. To define objectives and set targets to deal with the problems in the light of national and regional guidelines
• to relate the decisions that they take about the investment of resources to their impact on health problems and objectives so identified
• to evaluate progress towards their stated objectives
• to make arrangements for the surveillance, prevention, treatment and control of communicable disease
• to give advice to and seek co-operation with other agencies and organizations in their locality to promote health,

and the tasks of public health doctors within districts were:

• to provide epidemiological advice to the District General Manager and the DHA on the setting of priorities, planning of services and evaluation of outcomes
• to develop and evaluate policy on prevention, health promotion and health education involving all those working in this field. To undertake surveillance of non-communicable disease
• to coordinate control of communicable disease
• generally to act as chief medical adviser to the authority
• to prepare an annual report on the health of the population
• to act as spokesperson for the DHA on appropriate public health matters
• to provide public health medical advice and link with local authorities, family practitioner committees, and other sectors in public health activities.

Consequently, the tasks of DHAs and public health doctors (directors of public health and consultants in public health medicine) were seen to be almost identical, with the public health doctor being the means through which the DHA’s public health tasks were to be performed. The principal recommendations of this Committee of Inquiry were accepted by government and the renaissance of public health medicine seemed to be beginning.

The fall and transformation of public health medicine

‘Renaissance’ means a re-birth and it is used here because the practice of UK public health by doctors during the twentieth century had, in the opinion of many, become marginal and irrelevant. The Committee of Inquiry report was therefore seen as providing a rationale, a professional renewal and a framework for a re-birth of the specialty.

The basic charge against public health doctors was that throughout the twentieth century they had busied themselves with the administration of the very diverse parts of the emerging PHS and had consequently failed to develop a coherent philosophy of public health practice. Before the NHS was inaugurated in 1948, health services were fragmented. Medical Officers of Health (MOsH) worked in local authorities and had, from 1929, assumed the responsibility for the former poor law (now municipal) hospitals in addition to a variety of community health services (e.g. health visiting, school medical services, health services for mothers and children, health clinics, TB sanitoria and services for the treatment of venereal diseases).

Critics of the MOsH and their ways of working were found both inside and outside the medical profession. General practitioners (GPs), during the 1920s to 1940s, complained bitterly of ‘encroachment’ by public health doctors into what they saw as their domain, the treatment of individual patients. Others, who drew upon the accumulating knowledge of the central role of economic and social factors in causing ill-health, condemned public health doctors for failing to develop a philosophy of practice that adequately encompassed these factors. Jane Lewis, in her book What Price Community Medicine? (1986) writes:

The public health departments added to their domain without questioning what was distinctive about public health. New thinking about health as opposed to sickness, and about the determinants of both, came not so much from the public health practitioners as from privately-funded experiments, like the Peckham Health Centre; pressure groups, such as the Women’s Health Inquiry and the Children’s Minimum Council ...

(Lewis 1988, pp. 16-17).

And apart for GPs, the criticisms of another group of doctors, academics, gathered pace during the interwar years. These academic criticisms were too diverse to represent a coherent alternative, however a dominant critique can be identified in the shape of social medicine.

Social medicine was seen as a distinctive development of clinical medicine, concerning itself with the range of influences that individuals and communities encounter in relation to health and disease. It was, in the view of some of its most influential proponents, concerned with a much larger set of issues than public health. The latter’s traditional concerns were environmental conditions, such as sanitation, housing, water, infectious diseases and community health services. These concerns were considered to have been largely determined by the preoccupation of sanitary reformers during the nineteenth century and had been consolidated via numerous Public Health Acts. The new discipline, however, proclaimed itself as distinctive and would consider genetic, social, economic and other causes of disease and would explicitly draw upon the findings of social science. Perhaps not surprisingly, the MOsH became rather unhappy with this ‘new’ way of understanding health and disease. Social medicine was born within universities and showed little interest or understanding of MOsH work. The MOsH criticisms ranged from viewing social medicine as ‘nothing new’ to seeing in its wide-ranging concerns an absurdly empty, because over inclusive, set of preoccupations. The distancing of academics, who in the main did see something useful in social medicine, and practitioners therefore increased. This distancing was indeed one motivation, among others, for subsequent educational and professional developments such as the Todd Commission report on medical education (1968) and the Committee of Inquiry report on the public health function (1988).

The MOsH between the wars were powerful actors in local government. They had acquired, through an admittedly rather disjointed and unplanned development of the state’s concern for health and welfare, a professional interest in the administration of a range of community and hospital services. Certainly they saw this PHS as a model for a coming NHS. The Second World War had shaped the public mood for such a service and it had become a question of what form the service should take rather than whether an NHS would be created.

In the event, the architects of the NHS adopted an organizational form that dismantled the PHS and left the MOH with a reduced staff and influence, working still from a local authority base. Moreover, though the postwar development of social work had occurred within the local authority public health department, there was a strong lobby to end this arrangement and allow social workers greater professional autonomy within their own social services departments. This became a reality after the Seebohm Committee report (1968). The role of the MOH was therefore in need of radical reassessment.

Community medicine within the NHS

The reassessment of the role of the MOH became a central issue in the 1974 reorganization of the NHS. This reorganization ended the position of MOH and created the medical specialty of community medicine. This specialty, like others, would be employed within the NHS and it was envisaged that MOsH would become specialists in community medicine. In 1972, the Faculty of Community Medicine was founded to enable the training of specialists, set standards for knowledge and competence and examine trainees in their attainment.

The faculty’s view of the role of the Specialist in Community Medicine (SCM) differed from the role envisaged by the promoters and key officials who had devised and steered through the reorganization of the NHS. Whilst the faculty placed central importance on the uses of public health sciences, in particular epidemiology, in assessing the health needs of a population, advising on service development, evaluating the effectiveness and efficiency of services or treatments and promoting health, these functions were seen as less important to government compared with achieving change in the NHS within budget constraints. A consensus management approach formed the centrepiece of a reorganized NHS administrative structure, and the SCM was seen as the mediator between the administration and the consultants, working to achieve the organizational goals of the health authority. The faculty’s view, however, was heavily influenced by academics, in particular by Professor Jerry Morris. His book, Uses of Epidemiology, was first published in 1957 and became a profound influence on the self-understanding of public health doctors. It offered, and still offers, a coherent ground for public health practice, seeing clinical medicine as, in effect, a branch of public health.

Morris identified and discussed seven uses of epidemiology, defining the discipline as: ‘The study of health and disease in populations in relation to their environment and ways of living.’ These uses were:

1. The study of the history of the health of populations ...
2. To diagnose the health of the community ...
3. To study the working of health services ...
4. To estimate from the group experience what are the individual risks and chances, on average, of disease, accident and defect.
5. To complete the clinical picture of chronic disease, and describe its natural ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Preface
• Acknowledgements
• 1 What is public health medicine?
• 2 Why has health improved?
• 3 What determines health?
• 4 What is wrong with medicine?
• 5 How should medicine develop?
• 6 Is the NHS a success?
• 7 A policy for health?
• 8 Where now?