Chapter Three. Innovation and change in public health
David Fone, Shantini Paranjothy and Rhianwen Elen Stiff
Introduction
This chapter provides a framework for understanding recent innovations and change in public health practice. It explores the history of public health from the pioneering days in Victorian times to the pressures for change that have led to the redefinition of the functions of public health and the development of modern public health practice.
A case study of innovation in local collaborative public health practice highlights how modern public health can work to improve community health and reduce health inequality.
What is public health?
Public health is about understanding and improving the health of populations or communities, rather than the health of individuals. The key feature is of a geographically defined population, such as a country or region, or at smaller levels, the local authority or the electoral ward. Within these, public health practitioners may focus on people with a particular illness, such as coronary heart disease, or a client group such as children or the elderly.
Population measures for health improvement include population screening programmes for breast and cervical cancer to identify disease at an early stage for treatment, health promotion activities aimed at the underlying determinants of poor health, such as smoking cessation programmes, and health protection which may include, for example, preparation for and managing outbreaks of infectious disease, non-infectious hazards such as threats to the health of the public from chemical spills, and measures to improve environmental safety, such as reducing danger from unfenced ponds or measures to improve traffic-calming.
The scientific basis of public health practice is the discipline of epidemiology, which is often described as the study of the distribution of diseases in populations. In fact, the science of epidemiology is broad ranging and of fundamental importance to everybody who is working towards improving the health of the population. Epidemiological methods can help us understand the aetiology and natural history of disease, measure the size of health problems to inform planning for action and evaluate the effectiveness and cost-effectiveness of interventions to improve health.
One of the fundamental principles of epidemiology and public health is that the subject of interest must be defined. The most commonly used definition of public health was suggested in the Acheson Report (1988), which reviewed the public health function: ‘the science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society’.
This definition makes it clear that public health is not the responsibility of one professional group or organization, but is a process which involves the whole of society. In a report on strengthening the public health function, the Chief Medical Officer for England (Department of Health 2001a) considered that ‘this definition is still widely used because it reflects the essential elements of modern public health’ (Beaglehole and Bonita 2004). The UK Faculty of Public Health recognizes the public health approach as:
• population based
• emphasizing collective responsibility for health, its protection and disease prevention
• recognizing the key role of the state, linked to a concern for the underlying socio-economic determinants of health as well as disease
• having a multidisciplinary basis, which incorporates quantitative, as well as qualitative, methods
• emphasizing partnerships with all those who contribute to the health of the population.
What are the public health functions?
Much consideration has been given to defining the public health functions required to move towards a better understanding of how to improve population health through public health practice. Ten public health core activities have been defined by the US Health and Human Services Public Health Service (1995). They are shown in Box 3.1.
Box 3.1
The ten public health functions
1. Preventing epidemics
2. Protecting the environment, workplaces, food and water
3. Promoting healthy behaviours
4. Monitoring the health status of the population
5. Mobilizing community action
6. Responding to disasters
7. Assuring the quality, accessibility and accountability of medical care
8. Reaching out to link high-risk and hard-to-reach people to needed services
9. Researching to develop new insights and innovative solutions
10. Leading the development of sound health policy and planning
The UK Faculty of Public Health defines three overlapping domains in which public health specialists practise. These are health improvement, improving services and health protection (see: http://www.fphm.org.uk/about_faculty/what_public_health/3key_areas_health_practice.asp). The range of activity within each domain is given in Box 3.2.
Box 3.2
Public health domains (UK Faculty of Public Health)
Health improvement
• Inequalities
• Education
• Housing
• Employment
• Family/community
• Lifestyles
• Surveillance and monitoring of specific diseases and risk factors
Improving services
• Clinical effectiveness
• Efficiency
• Service planning
• Audit and evaluation
• Clinical governance
• Equity
Health protection
• Infectious diseases
• Chemicals and poisons
• Radiation
• Emergency response
• Environmental health hazards
The UK Faculty of Public Health core values are that public health practice should be equitable, empowering, effective, evidence based, fair and inclusive. Together with the three domains, these inform the Faculty’s nine key areas for public health practice:
1. Surveillance and assessment of the population’s health and well-being
2. Assessing the evidence of effectiveness of health and healthcare interventions, programmes and services
3. Policy and strategy development and implementation
4. Strategic leadership and collaborative working for health
5. Health improvement
6. Health protection
7. Health and social service quality
8. Public health intelligence
9. Academic public health
See: http://www.fphm.org.uk/about_faculty/what_public_health/9key_areas.asp.
The UK Faculty of Public Health core values are that public health practice should be equitable, empowering, effective, evidence based, fair and inclusive. Together with the three domains, these inform the Faculty’s nine key areas for public health practice:
• surveillance and assessment of the population’s health and well-being
• assessing the evidence of effectiveness of health and healthcare interventions, programmes and services
• policy and strategy development and implementation
• strategic leadership and collaborative working for health
• health improvement
• health protection
• health and social service quality
• public health intelligence
• academic public health
The functions of public health show that everyone, both public and professionals, has responsibilities for improving public health. Public health is clearly not just one activity but requires a broad multidisciplinary team to implement the defined public health functions. The functions will be discharged by many people working for a variety of different organizations in different settings, but all with the same aim of improving the health of the population.
Who practises public health?
It became increasingly apparent that in order to respond to the health inequalities agenda, new modes of multidisciplinary collaborative teamwork were required. A broader view of the different roles and scope of public health practitioners necessitated a careful consideration of training and professional standards of public health practice. An important debate on the need for appropriately trained and accredited public health specialists who are not medically qualified developed and the question of leadership in public health was aired in the British Medical Journal (McPherson et al 2001).
A national tripartite project between the Faculty of Public Health, the Multidisciplinary Public Health Forum and the Royal Institute of Public Health and Hygiene redefined the three levels of public health practice as generalists, practitioners and specialists. This was reflected in the report of the Chief Medical Officer for England on strengthening the public health function (Department of Health 2001a), where he identified three broad categories of people who work to improve public health:
1. Specialists: those whose primary role is maintaining and improving the public’s health. They come from a variety of professional backgrounds and experience including social science, public health science, environmental health, public health medicine, pharmacy, nursing, health promotion and dentistry. They will have completed specialist training in public health. Specialists will lead public health programmes across organizational boundaries to manage change at strategic and operational levels.
2. Practitioners: those for whom public health is part of their role. Public health practitioners include people whose role includes (but not exclusively) furthering health by working with communities or groups. They include health visitors, health promotion specialists, community development workers and environmental health officers. As well as their core professional training and qualification, public health practitioners may have had more specific training in the public health sciences and practice, for example taking a Masters in Public Health degree.
3. Generalists: those whose roles have an influence on the wider socio-economic and environmental determinants of health and whose role would benefit from an awareness of public health issues. This may be either at a strategic or policy level, such as government officials or managers in the NHS or those working with communities or individuals, such as voluntary workers, teachers or housing officers.
The Faculty of Public Health has outlined the nine key areas as the basis for standards of specialist practice (see above). Training schemes, to the standards required to achieve the core competencies as defined by the Faculty and to become a ‘specialist’, are now available to both doctors in specialist training and to graduates from non-medical backgrounds. In addition, trainees are required to become Members of the Faculty of Public Health by examination. Having achieved membership and satisfactorily shown that they have gained all the skills required by the curriculum, a trainee is eligible for specialist registration, either with the General Medical Council Specialist Register, or the UK Voluntary Register for Public Health Specialists for non-medical graduates. At this point all are eligible for consultant in public health or equivalent posts within the NHS.
An alternative route to ‘specialist’ status is available to people with experience of working within the field but who have not participated in a dedicated training scheme via a process of ‘retrospective recognition’. Those applying are required to demonstrate their experience and capabilities through completion of a portfolio of work. Currently, this allows people to be granted specialist status only in the defined area of public health in which their experience lies, for example pharmaceutical public health or health promotion.
The UK Voluntary Register for Public Health Specialists is currently working on establishing a framework for public health practitioners. Further information may be obtained from the Faculty of Public Health career guidance website: http://www.publichealthconferences.org.uk/careers/ and the UK Voluntary Register for Public Health Specialists website: http://www.publichealthregister.org.uk/.
Local job descriptions will vary, but the key principle of the role of public health specialists is to take a local leadership role, facilitating and leading partnership working between the statutory organizations with a public health remit, such as primary care organizations and the local authority, with links into wider public health networks. A new cadre of well-trained and enthusiastic public health specialists is the key with which the door to modern public health practice is being opened.
History of public health
As medical science developed in the 19th century, a growing awareness that the major causes of epidemic infectious diseases, such as cholera, were preventable through ensuring a clean water supply and safe disposal of sewage led to growth of the public health movement. Edwin Chadwick, a lawyer and engineer and secretary to the Poor Law Commission, was one of the pioneers of the day and the architect of the first Public Health Act of 1848. This was a defining moment in the history of public health. It established a General Board of Health and local boards were set up which became the forerunners of local government. The 1848 Act gave the boards of health permissive powers to monitor and enforce control of the environment, through activities such as inspecting drains. It recommended the appointment of Medical Officers of Health to advise on matters relating to the health of the community. These appointments were not obligatory until the next major Public Health Act of 1875, which obliged local health boards to improve a range of sanitary and environmental provisions.
But what was the role of the Medical Officer of Health? One of the most perceptive comments on this subject was made by P.H. Holland Esq., the General Board of Health inspector sent to assess the condition of Merthyr in 1853. In a letter to C. Macauley Esq, the secretary of the General Board of Health, dated 15 December 1853, he recommended the appointment of a Medical Officer of Health and believed that:
the labour of such officer will do much to remove the ignorance which has permitted such evils to arise, to arouse the apathy which allows their continuance, and to overcome the opposition which impedes their removal. Such officers would show the fearful amount of suffering disease and death produced for want of means for bringing pure water into the town, and for taking foul water out of it. They would prove that the losses occasioned by avoidable sickness and its consequences reduce a well paid population to poverty.
A sequence of four public health activities was envisaged to carry out these duties. These are shown in Box 3.3.
Box 3.3
Four public health activities for the Medical Officer of Health, 1853
1. Epidemiological investigation of disease prevalence and incidence (to show).
2. Evidence-based assessment of the socio-economic impact of the disease burden (to prove).
3. Dissemination of knowledge about disease and their causes (to remove ignorance).
4. Advocacy for changing environmental conditions (arouse the apathy).
Local authorities continued to provide these public health services until the 1974 NHS reorganization. After 1974, the Medical Officer for Health role became the responsibility of health authorities and the medical specialty was renamed community medicine. This fragmented the public health service and removed the focus for public health doctors away from public health and their colleagues in nursing and environmental health to a more medical administrative role. This ‘new’ specialty of community medicine further lost its way in successive NHS reorganizations and in 1988 the Acheson Report (1988), taking stock of the ‘crisis’ in public health, suggested renaming the specialty back to public health medicine. He recommended the appointment of Directors of Public Health as an executive director and member of the health authority board. The professional role of the Director of Public Health was to assess the health needs of the health authority resident population, to publish an annual independent report on the health of the population and play a key role in organizing the necessary multisectoral and multidisciplinary links to implement change to improve the health of the population.
However, despite this role, the specialty of public health medicine in health authorities became increasingly isolated in the 1990s from the wider practice of public health. Public health physicians were increasingly drawn into the commissioning of secondary and tertiary hospital services within the NHS purchaser/provider split. The health service reforms of 1990 brought in by the NHS and Community Care Act 1990 established an ‘internal market’ healthcare system in which health authorities and some GP fundholding practices acted as purchasers of healthcare, setting up contracts for provision of services with hospitals, the providers of healthcare. Despite the rhetoric that services should be commissioned on the basis of healthcare need and interesting theoretical frameworks for healthcare needs assessment (Stevens and Raftery 1994, see: http://hcna.radcliffe-oxford.com/introframe.htm), there was little evidence that assessment of health need actually drove the process; contracting for healthcare within the internal market was essentially a financial accounting process, with small marginal shifts in provision over time.
This was the situation up until as recently as 1997. Since then, modern multidisciplinary public health practice has continued to evolve in response to the pressures for change that are described in the following section.
Pressures for change
The fundamental pressure for change has been the refocusing of the public health agenda back to its core purpose of improving the health of the population and reducing health inequalities through action on the wider societal determinants of health. An understanding of social exclusion, which refers to individuals living in communities on the margins of society as a result of a cycle of problems such as low educational achievement, unemployment, poor health and crumbling community infrastructure, was made possible through societal change which included an increasing awareness of these issues and a greater individual and community involvement in solutions. All those practising public health realized the need to move away from the traditional medical model of public health practice to a multiprofessional approach in order to rise to the challenges posed by health inequalities. The newly elected Labour government in 1997 provided the necessary policy frameworks for change.
Inequalities in health
The fundamental pressure for change has been the awareness of increasing evidence for health inequalities within the UK and the need for action to address them. Although absolute levels of health have improved in the UK over the last 20 years, the effect has been simultaneously to widen the health divide between affluent and deprived populations (Shaw et al 1999).
In the late 1970s, the Labour government established the Black Committee on Inequalities in Health, chaired by Sir Douglas Black. Their report published in 1980, the Black Report, has since become a landmark in the history of understanding inequalities in health (Department of Health and Social Security 1980, Townsend and Davidson 1988). The report highlighted the substantial variations in health that existed in the UK, arguing that these inequalities were caused by inequality in material well-being and poverty. However, the report was rejected by the Conservative government of the day on the grounds that implementation of the recommendations was financially unrealistic. The report was effectively suppressed as the government restricted the number of copies published to a few hundred and there was no official publicity.
Although increasing evidence on health inequalities was published during the 1980s (Whitehead 1987), it was not government policy to explicitly address them. Eventually the overwhelming research evidence that was being published did lead the Conservative government to establish a Health Variations Group in 1994 (the word ‘inequalities’ was never used), chaired by the Chief Medical Officer for England. Their comprehensive and enlightened report (Department of Health 1995) identified that although some activity within the NHS was addressing the so-called ‘variations’ in health, it was taking place at the margins of health authority business. The report reinforced the need for ‘alliances’ with local government, voluntary and community organizations to make progress, and made a series of recommendations that paved the way for change later in the decade.
Following the election of the new Labour government in 1997, an independent inquiry into inequalities in health was commissioned, chaired by Sir Donald Acheson. Their report (Department of Health 1998a) made 39 recommendations for action. A detailed examination of the evidence presented to the inquiry was published a year later (Gordon et al 1999), summarizing the evidence base for each recommendation.
The three areas considered by the independent inquiry to be crucial to reducing inequalities in health are shown in Box 3.4.
Box 3.4
Three areas crucial to reducing inequalities in health
1. All policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities.
2. A high priority should be given to the health of families with children.
3. Further steps should be taken to reduce income inequalities and improve the living standards of poor households.
Source: Department of Health (1998a).
What innovations and change are happening?
Innovation and change will be considered under the three domains of health improvement, improving services and health protection.
Health improvement
Surveillance and assessment of the population’s health and well-being
Growing acknowledgement of the need for a greater understanding of inequalities in health at a local level, for local planning, has given a new focus to public health practitioners in the surveillance and assessment of the population’s health and well-being. This focus has moved away from large population areas to geographically defined small areas (such as administrative local government units of the electoral ward, population of around 5000 people). At this small area level, information on disease and health status is usefully displayed in maps. Maps of disease will highlight areas of greatest risk and reveal patterns of local geographical variation that may not be suspected from inspection of the same data as numbers in tables. Maps are an important source of information for local planners, as well as generating hypotheses on causal mechanisms that can be tested in further research studies.
There is a long history of geographical public health and the use of maps of disease to highlight health inequality. The first example is that of John Snow and the Broad Street pump in Soho, London in 1854 (Donaldson, Donaldson, 2003 and Donaldson, Donaldson, 2003). The increasing availability of information at a small spatial level, coupled with the growth in computer technology and geographical information systems (GIS), small area statistical methods and advances in disease-mapping techniques, has led to a much wider use of geographical information in health needs assessment. These techniques have greatly enhanced the presentation and analysis of information as a basis for strategic planning to address health inequality.
New Internet-based interactive GIS technology has resulted in the wider availability of small area data for planning. For example, the Office for National Statistics Neighbourhood Statistics website (see online: http://www.statistics.gov.uk) has a wide range of multiagency data at electoral ward and unitary authority for England and Wales that can be downloaded and used to calculate local rates for presentation in tables and maps.
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