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The Origins and Development of Multidisciplinary Public Health in the UK

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The Origins and Development of Multidisciplinary Public Health in the UK “There was no plan!” - The origins and development of multidisciplinary public health in the UK Report of the witness seminar held at the University of the West of England on Monday 7 November 2005 Edited by David Evans Teri Knight University of the West of England, Bristol 2006 . “There was no plan!” – The origins and development of multidisciplinary public health in the UK Report of the witness seminar held at the University of the West of England, Bristol on 7 November 2005 Edited by David Evans and Teri Knight 2006 © University of the West of England, Bristol, 2006 Further paper copies of this report are available from: David Evans Reader in Applied Health Policy Research Faculty of Health and Social Care University of the West of England, Bristol Glenside Campus Blackberry Hill, Stapleton Bristol BS16 1DD E-mail: [email protected] Telephone: 0117 32 88750 A pdf file of the report is available at: http://hsc.uwe.ac.uk/hsc/index.asp?pageid=843 ISBN: 1-86043-395-2 and 978-1-86043-395-5 Acknowledgements We are very grateful to the Wellcome Trust for funding this witness seminar. Judy Orme did a superb job chairing the seminar, with particular skill in moving our conversations on so that we managed to cover the whole agenda for the day. Our thanks as well to Emma Griffin for her essential administrative support for the day, and to Leigh Taylor and her team of transcribers for producing the transcript - despite the multiple voices and poor sound quality of some of the recording. Jane Wathen kindly designed the cover and typeset the text. Finally, our deepest thanks to all the participants for their insightful contributions, both those who attended and those unable to attend who kindly supplied material which we have appended. Contents Page Introduction 1 David Evans and Teri Knight Participants 7 Transcript 8 Edited by David Evans and Teri Knight Biographical notes 54 Additional Comments 62 By those unable to attend and further reflections by participants Chronology 91 List of Abbreviations and Acronyms 94 References 95 Index 99 Introduction professional boundaries. The seminar David Evans and Teri Knight brought together key players to document and discuss the origins, The last twenty years have seen a sea context, and development of change in professional roles and multidisciplinary public health in the UK. boundaries in the practice of specialist We were particularly concerned to give public health in the UK (see Chronology voice to those activists whose often p. 91). In the 1970s and1980s specialist lonely work ‘banging on the door’ and public health was wholly medically creating ‘do-it-yourself’ careers, has to dominated. All senior public health posts date been little documented or analysed. in the National Health Service (NHS) The creation and development of the were restricted to those with a medical Multidisciplinary Public Health Forum in qualification, usually to members of the the mid 1990s was a key moment in the Faculty of Community Medicine development of multidisciplinary public (McPherson et al, 1997; Evans, 2003). health and several of the founding Public health workers from disciplines members were able to contribute to the other than medicine were restricted to seminar. ‘support’ roles (Somervaille & Griffiths, 1995; Smith & Davies, 1997). Even those Before discussing the seminar in more with high levels of skill and expertise in detail, it is important to briefly describe core public health disciplines such as the historical context and the current epidemiology and health promotion, fairly state of the literature on the development quickly experienced a glass ceiling in of multidisciplinary public health. There terms of their career development. From has been relatively little discussion of the the late 1980s and early 1990s an emergence of multidisciplinary public increasing number of such workers health in the UK within the wider began to question and challenge the historical and policy commentary on professional boundaries which excluded developments in public health. For them from senior public health roles. example, Lewis’ (1986; 1991) otherwise Although progress felt slow and difficult seminal work on the history of public at first, within a decade, a number of health medicine in the twentieth century quite significant changes were in does not discuss the development of process. The Faculty of Public Health multidisciplinary public health. Partly this Medicine gradually opened its is due to the relatively recent surfacing of examinations and membership to those multidisciplinary public health into the from disciplines other than medicine. policy arena. But this only partially Then senior NHS public health posts accounts for the silence. As Jefferys were similarly opened to public health (1997) and Warren (2000) illustrate, there specialists from other disciplines. Today, were tensions as long ago as the late there are a number of directors of public 1960s and early 1970s, around the health and specialists in public health establishment of the Faculty of working in the NHS from a variety of non- Community Medicine with quite heated medical disciplines, a situation hardly debates as to whether membership conceivable in the 1980s. would be restricted to registered medical practitioners or include others such as How and why did this change come social scientists from within the Society about? This paper reports on a witness for Social Medicine. Once the Faculty seminar designed to make sense of this was established, however, these rapid and arguably radical shift in tensions generally simmered under the surface and were not explicitly written 1 about until the mid 1990s when the policy provides a small number of other first debate re-emerged. hand stories of the development of multidisciplinary public health Public health policy documents of the complementary to the accounts reported 1980s and early 1990s did not often refer here. to multidisciplinary public health. A key document of the period, the report of the At the same time as these research Acheson inquiry into public health reports and policy commentaries, a (Secretary of State for Social Services, number of short articles and letters 1988), did refer to public health as a appeared in the professional press from ‘multidisciplinary endeavour’ but its the advocates and opponents of the discussion was essentially limited to the development of multidisciplinary public role of multidisciplinary training and health. Many of these exchanges took clearly conceived of other disciplines as place in the letters pages of the British limited to a support role to public health Medical Journal, and a noteworthy medicine. Other key public health example appeared in that journal’s documents such as The Health of the occasional series of ‘For and against’ Nation (Secretary of State for Health, debates (McPherson et al, 2001). 1992) and the Abrams Report (Department of Health, 1993) did not A national policy commitment towards mention multidisciplinary public health at the development of multidisciplinary all. public health was first articulated after the election of the new Labour government in The first significant publication May 1997. A first expression of the newly specifically focused on multidisciplinary emergent policy appeared in the interim public health was the report of a survey report of the Chief Medical Officer’s on the training and career development (CMO) project to strengthen the public needs of public health professionals health function in England (Department (Somervaille & Griffiths, 1995). This of Health, 1998). This was followed by a report demonstrated the extent of the much stronger statement in the White ‘problem’ – the large number of those Paper Saving Lives (Secretary of State working in public health from disciplines for Health, 1999). At the same time, the other than medicine who felt undervalued policy was given practical effect with the and disenfranchised, and acted as a first central guidance that senior public catalyst for much of the subsequent health posts in England (Primary Care activity described in the witness seminar. Trust (PCT) public health leads) could be There followed a steady stream of filled by non-medical professionals publications over the next decade, largely (Department of Health, 1999). The or wholly, on the development of following year saw a forceful statement multidisciplinary public health from the Secretary of State for Health (McPherson et al, 1997; Smith & Davies, (Milburn, 2000) decrying ‘lazy thinking 1997; Levenson et al, 1997;1999; and occupational protectionism’ and Cornish & Knight, 2000; Evans and calling for NHS public health to embrace Dowling, 2002; Evans, 2003; 2005; more multidisciplinary leadership. The Williamson, 2004; Abbott et al, 2005; pace of policy statements continued with Griffiths et al, 2005). Most recently (and further support for multidisciplinary public published subsequent to our witness health from the House of Commons seminar), the report of a Wellcome Trust Select Committee on Health (2001), the witness seminar on public health in the final report from the CMO project 1980s and 1990s (Berridge et al, 2006) (Department of Health, 2001a) and 2 further Department of Health guidance on for Specialist Practice in Public Health Shifting the Balance of Power (Lessof et al, 1999), the opening up of (Department of Health, 2001b; 2001c). public health training schemes and the The latter was a particularly significant Faculty of Public Health Medicine milestone, leading in 2002 to the examinations and membership, and the appointments of the first cadre of establishment of the Voluntary Register directors of public health from for Public Health Specialists. Change backgrounds other than medicine in was not of course linear or continuous. English PCTs (Evans, 2005). Wider UK As seminar participants discuss, some public policy also supported the wider policy changes such as the development of multidisciplinary public introduction of the NHS internal market in health. The two reports carried out by the 1990s had both facilitative effects Derek Wanless for the Treasury (e.g.
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