Feature

Public health in decline

Has public health medicine really moved centre-stage in the wake of the NHS reforms? Charles Webster consults the historical record — and charts the slow decline of the public health function

When viewed from a historical perspective, the 1988 Acheson Report and subsequent changes in public health medicine seem like a desperate exercise in crisis management, attempting to breathe life into a medical specialism which seemed to be entering a terminal decline.

Better understanding of the current dilemmas of public health medicine will perhaps be helped by reflecting briefly on longer term trends. The crisis afflicting public health is deep seated. Ironically, the arrival of the NHS created almost impossible conditions for optimising public health, while almost every subsequent reform of the NHS has rendered meaningful survival of the public health function ever more precarious.

The difficulties of public health stem from its inevitable and inextricable association with the political process. Although all medical activity is implicated with social and political affairs, the public health specialism has been directly associated with national and local politics since its inception. Achieving its basic objectives has depended upon ability to influence policy-making. Similarly, incompetence in influencing policy, passive complicity with policies subversive to the interests of public health, or facile pretence that the specialism can be isolated from direct political involvement, have represented ever present obstacles to public health’s success and credibility.

As I argued in The Public Health Legacy (Public Health Alliance 1990), the Victorian pioneers of public health were successful because they were frank about the political nature of their function. The public health specialism emerged as the result of a fervent political campaign waged by leaders who overtly utilized every resource at their command to propagate the public health message. They succeeded in elevating public health from a position of almost total neglect into one of the major political issues of the day.

Their leaders, such as Chadwick, Farr, Nightingale and Simon, anticipated that the new cadre of medical practitioners, professionally engaged in public health, would project sanitarianism to a new level of importance and permanent influence. For a time it looked as if Britain would lead the world in combating threats to health caused by industrialisation, urbanisation, environmental degradation and epidemic disease. The 1871 Report of the Royal Sanitary Commission envisaged a vital strategic function for the public health professionals. Their ‘staff of sanitary officers guided from a central office by the highest scientific knowledge, and collecting facts from every town and village in the kingdom’ would promote sanitary knowledge and determine ‘all questions relating to public health’ (Report, p.15). The alliance of strong central leadership and independent local officers was thought sufficient to overcome local inertia and vested interests, and exercise effective political influence in central government.

Superficially, the public health mission seems to have been eminently successful in the century between the first Public Health Act of 1848 and the start of the NHS in 1948. This golden age of public health is now looked upon with a degree of nostalgia. But despite the superficial success of the Medical Officer of Health and the great expansion of municipal health services, the seeds of its demise were already sown, especially during the interwar period.

The very opportunities for expansion of public health administration deflected the specialism from its basic responsibilities. In the decades before the NHS, the MOH became increasingly absorbed with hospital administration. Extravagant institutional provision was adopted as the favoured solution to health problems, often to the neglect of more economical and humane methods of control and treatment.

The public health profession took on the characteristics of an insensitive bureaucracy, which failed to command the respect of the public and was treated with a mixture of contempt and resentment by the rest of the medical profession. Public health doctors displayed all the signs of intellectual bankruptcy. They were, for instance, insensitive to the problems of health stemming from unemployment, poverty and adverse social conditions, endemic during the Depression. They were therefore not at the forefront of nutritional studies, demography, epidemiology, medical sociology, social administration or social medicine as these disciplines developed during the interwar period in response to the social catastrophe affecting the western economies.

This phase of public health medicine is critically important because it demonstrated the ease with which the specialism could be manipulated by retrenchment-minded governments, determined to minimize the scale of social problems. The idea of ‘social medicine’ was evolved by socially aware groups as a means of confronting the apathy of the public health elite. Initially at least, social medicine encapsulated the political activism of the Victorian pioneers. John Ryle, for instance, firmly included in his definition of social medicine ‘as its main purpose the education of professional and lay thought and the direction of legislation on behalf of national health and efficiency’.

It is not surprising that the administrative system adopted for the NHS reflected the lack of confidence in the MOH. The public health empire was dismantled and the MOH left with a small rump of miscellaneous, Cinderella services, and no guiding philosophy with which to mount a revival. The elite of the profession became split between the small, fortunate group who joined the Regional Hospital Boards, and the remainder who were left with the local authorities. This meant there was no coherence among the leadership, and the task of revitalising the traditional public health function was delegated to the depleted and dispirited ranks of the Medical Officers of Health.

The patent unattractiveness of this office ensured that public health medicine was starved of able recruits. University departments of social medicine, designed to provide the academic training for public health professionals, were generally accounted a failure, which exacerbated the problem of recruitment. Despite its superficial claims of attachment to preventive medicine, health education and health promotion, the NHS became an essentially curative service.

Virtually all changes between 1948 and 1974 further weakened the position of public health medicine. The health centre programme was scrapped even before the inception of the NHS. In this and other services, the MOH was dependent on the willing compliance of other medical professionals. In general this support was intentionally withheld. Former areas of importance such as tuberculosis after-care, maternity and child welfare clinics, or the school health service, were reduced or replaced. The opportunities to develop environmental health, health education or community care were not effectively grasped. The public health profession made little attempt to resist the loss of involvement in social services which resulted from the Seebohm reforms. It was not appreciated that this seemingly insignificant reduction in commitments would throw doubt on the viability of local government public health departments.

By 1970, the sole possibility for restoring the fortunes of the MOH lay in reversion of the NHS to local government administration, a possibility encouraged by the 1969 Report of the Royal Commission on Local Government. But the 1974 NHS reorganisation reinforced the negative judgement on public health medicine by eliminating the Medical Officers of Health and splitting their residual functions between local government environmental health departments and Regional Hospital Boards, renamed Regional Health Authorities. Consequently the decayed residue of public health doctors constituted a second wave of migration into authorities basically concerned with hospital administration.

Of course, on this occasion a positive attempt was made to provide public health doctors with a new image and establish a role for the new ‘community physicians’ in the labyrinthine administration of the reorganised NHS. But in the atmosphere of instability and relentless reorganisation which has been gathering pace since 1979, public health medicine has failed to take on a settled and clearly defined role. The 1980s were marked by disorientation and internal dissent. Yet this decade also witnessed the emergence of grave new challenges to health, and the intellectual revitalisation represented in the New Public Health.

In many respects, events since 1979 have repeated the 1930s. The Black Report and Margaret Whitehead’s The Health Divide are directly inspired by the pioneering analysis of class and regional inequalities in health undertaken by Richard Titmuss. Also, as in the 1930s, much of the impetus for the New Public Health has emerged from outside the ranks of public health organisations, initiatives in other western nations, or lay and scientific pressure groups. The Acheson Report seems like a belated response to these pressures, and an act of damage limitation provoked by an increasingly embarrassing sequence of public health scares.

Notwithstanding its progressive posturing, the report gives little encouragement to the kind of radical leadership envisaged in the 1871 Report of the Royal Sanitary Commission. Although the Acheson Report is a step towards reinventing the Medical Officer of Health, the investigative and reporting role proposed is likely to be of no more than marginal relevance. It is clear public health doctors occupy only a minor niche in the NHS bureaucracy. They are incapable of reframing health service priorities, or deflecting resources according to priorities dictated by criteria of objective need because they possess neither the power nor the independence. The checks and balances of professional and political control are likely to suppress effective expression of initiative or disaffection. The prospect of a unified, planned, and appropriate system of health care, first developed by the Victorian Sanitary Commission, must now be regarded as a Utopian fantasy.

The public health doctor, even more than the Medical Officer of Health in the 1930s, is likely to become preoccupied with hospital administration, joining the army of bureaucrats needed to convert the NHS hospital system into a market economy. Public health medicine in Britain is therefore set to enter the next millenium without the essential equipment of independence and leadership required to give meaningful expression to the New Public Health.