The development of public health policies

Emma Spencelayh, Senior Policy Fellow at the Health Foundation, reflects upon the fascinating history of public health.

‘Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year… We must also consider the qualities of the waters … and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labour, and not given to excess in eating and drinking.’  On Airs, Waters and Places by Hippocrates translated by Francis Adams .

The text above was written by Hippocrates in 400 B.C.E and not only was it ahead of its time, it is still applicable today. The Policy Navigator timeline on public health doesn’t stretch quite as far back as Hippocrates, but it charts the development of public health in this country from the Middle Ages onwards. All of the team involved in the project unanimously felt that this was their favourite timeline to work on. Unlike some of the other system-focused timelines, it is clear to see the advances and continual developments that have taken place which have had an impact on all of our lives. The diversity of issues which public health comprises is fascinating and one of the challenging aspects has been deciding where to stop researching.

The Policy Navigator timeline on public health focuses predominately on system issues rather than on practice, and focuses mainly on domestic issues rather than on international development work in low-middle income countries. This was necessary to narrow down the scope of the work.

While public health has in recent times been seen by some as of secondary importance to other aspects of the health service, it is arguably developments in areas such as sanitation, vaccination and the development of antibiotics which have contributed most to the health of our population.  Broadly speaking, it is now non-communicable diseases such as diabetes which are threatening the health of the population rather than diseases such as cholera or small pox. That said, the emergence and spread of Ebola shows that areas of the world are still highly vulnerable to the spread of infectious diseases.

Within the UK context, there are three things that particularly jumped out for me: the changing local government, structural instability and health inequalities.

Local government

During the 19th century, local government played an increasingly important role in protecting the health of the population. During the early 20th century local government ran and managed local hospitals, which had formerly been administered under the Poor Laws. Indeed, the 1944 White Paper on the National Health Service was produced on the assumption that the hospital service would be administered by local government. The National Health Service Act 1946 adopted a different approach. However, many people today may not realise that local government was a key pillar of the NHS from its inception as part of a tripartite system. It was directly responsible for the delivery of ‘personal health services’ which included maternity and health visiting services and vaccination programmes.

It was the National Health Service Reorganisation Act 1973 that created a unified NHS administration function and transferred public health functions from local government (with the exception of environmental health) to the NHS. These administrative functions were subject to considerable change over the decades which followed but it was the Health and Social Care Act 2012 which returned health improvement functions to local government. The rational was that many determinants of health are out of the NHS’s control and are more closely aligned with local government functions.

Structural reorganisation

I saw first-hand the impact of structural re-organisation when I worked on the legislative provisions on public health in the 2012 Act. While the return of health improvement reforms to local government was broadly welcomed, the abolition of the Health Protection Agency and the transfer of its functions to the Secretary of State for Health provoked more concern. In practice, the Secretary of State’s functions are carried out by Public Health England (PHE) as an executive agency of the Department of Health, leading to questions about the degree to which PHE is able to operate independently from government. Against the backdrop of wider controversy on NHS reform, the debate on public health was not quite as potent. However, as the Policy Navigator timeline on public health will demonstrate, public health bodies have been subject to considerable change over the last few decades.

In many respects, administrative structures have been a distraction from the core issues. Health inequalities are still rife in this country with the Office for National Statistics finding that males in the most advantaged areas can expect to live 19.2 years longer in ‘good’ health than those in the least advantaged areas and females 19.5 years. This is not a challenge that is unique to the UK nor is it a new phenomenon.

Failure to make progress in tackling health inequalities

The Working Group on Inequalities in Health known as the Black Report, published in 1980, outlined the fact that while health care had an important role to play in reducing health inequalities, it was broader influences (such as employment and social factors) which had a greater impact on health inequalities . In short, there is a limit to how much any health system can impact on health. The government at the time could not accept the recommendations given the considerable costs attached to them. However, the issues that Black identified did not go away. In 2010 Professor Sir Michael Marmot published ‘Fair Society, Healthy Lives’ and described a social gradient in health. Essentially, the lower a person’s social position, the worse his or her health, and that action to reduce health inequalities would have broad economic benefits for society .  In the current economic climate where there is a policy of austerity and of cuts, it is difficult to see that much progress will be made in tackling the endemic inequalities within our society. The first Chief Medical Office for the City of London, John Simon, made the following statement in his report on the sanitary condition of the City of London in 1848-9:

‘Ignorant men may sneer at its [sanitary science] pretensions; weak and timorous men may hesitate to commit themselves to its principles so large in their application: selfish men may shrink from the labour of change, which its recognition must entail; wicked men may turn indifferently from considering that which concerns the health and happiness of millions of their fellow-creatures.’

While the challenges today are quite different to those of the 19th century, it is a message that is still eerily current today. The Health Foundation has traditionally focused on health service delivery and we will be building on our work in this area to start developing work programmes on population health.