THE ROCK CARLING FELLOWSHIP 1997 Public Health The vision and the challenge THE ROCK CARLING FELLOWSHIP 1997 PUBLIC HEALTH The vision and the challenge The pursuit of public health can have no finality... The problems of public health are changing rapidly with increasing medical knowledge and changes in social and economic conditions, the age distribution of the population and the outlook of the people. Sixth Annual Report of the Department of Health for Scotland 1934 Walter W Holland CBE, FRCP, FFPHM LSE Health, London School of Economics and Political Science London AND Susie Stewart DL, MA, HON MFPHM Department of Public Health, University of Glasgow Glasgow Published by The Nuffield Trust 59 New Cavendish Street, London WIM 7RD ISBN 1-902089-10-3 © Nuffield Trust 1998 Publications Committee Sir Derek Mitchell, KCB, cvo Professor John Ledingham, DM, FRCP John Wyn Owen, CB Designed by Benjamin Rowntree Reports Limited PRINTED IN GREAT BRITAIN BY BIDDLES & CO The Rock Carling Fellowship commemorates the late Sir Ernest Rock Carling for many years a governing Trustee and Chairman of the Medical Advisory Committee of the Nuffield Provincial Hospitals Trust. It was stipulated that each holder of the Fellowship will seek to review in a monograph the state of knowledge and activity in one of the fields in which Sir Ernest had been particularly interested, and which is within the purposes of the Trust. The arrangements provide that the monograph will be introduced by a public lecture given at a recognised Medical Teaching Centre in the United Kingdom. ii Public Health The vision and the challenge CONTENTS PAGE Acknowledgements iii Prologue — What is Public Health? v Chapter One 1 Updating the Poor haw — The foundations of modern public health Chapter Two 27 Between the Wars 1918-1939 Chapter Three 61 Towards the National Health Service 1940-1948 Chapter Four 95 Changing Names —from Public Health to Community Medicine 1948-1914 Chapter Five 126 Community Medicine in Turmoil 1914-1989 Chapter Six 145 The Health of the Nation 1989-1991 Chapter Seven 166 A Perspective on Public Health Past Chapter Eight 192 Where now for Public Health? — The art of the possible Annexe 1 222 Annexe 2 224 Index 237 iii Acknowledgements It would be impossible for us to acknowledge all the help we have been given in the preparation of this monograph. We are, however, particularly grateful to Sir Donald Acheson, Dr Michael Ashley-Miller, Dr Virginia Berridge, Prof Peter Burney, Dr Alan Bussey, Sir Kenneth Caiman, Dr Simon Capewell, Dr Gareth Crompton, Dr Cam Donaldson, Dr Michael D'Souza, Sir George Godber, Mr Peter Griffiths, Prof Andy Haines, Prof David Hunter, Dr Azim Lakhani, Dr Christopher Lycett, Prof James McEwen, Mr Gordon McLachlan, Dr Harold Markowe, Mr Douglas Mason, Dr Robert Maxwell, Dr Richard Mayon-White, Mr David Mead, Prof David Miller, Prof David Morrell, Prof Jerry Morris, Dr Michael O'Brien, Prof Stephen Palmer, Prof Peter Pharaoh, Dr Lewis Reay, Sir William Reid, Dr Geoffrey Rivett, Dr Sally Sheard, Mr Allan Stewart, Dr David Stone, Prof Michael Warren and Mr John Wyn Owen for their comments and constructive criticisms. The opinions we express are of course entirely our own responsibility. Miss Heather Lodge, Librarian UMDS, provided inestimable help as did the Research Unit and Library of the Royal College of Physicians, the Library of the Royal College of Physicians and Surgeons of Glasgow and the Library of the University of Glasgow. We thank also Mrs Cindy Mitchell for valuable help with picture and bibliographical research, Mrs Hilary Flenley for preparing the index and Mrs Patricia McKellar of The Nuffield Trust who oversaw the various stages of production with competence and calm. Mrs Fiona Holland and Misses Anna Hanson and Deme Nicolaou of LSE were of great assistance in deciphering our tapes and handwriting and typing the various drafts. Walter Holland Susie Stewart March 1998 iv Walter Holland CBE, FRCP, FFPHM Walter Holland qualified from St. Thomas's Hospital Medical School in 1954. His entire career has been in medical research. His interests in epidemiology were aroused by his involvement in investigations of the 1957 influenza pandemic while doing his national service in the RAF. After gaining experience at the London School of Hygiene and John Hopkins University School of Hygiene, he returned to St. Thomas's in 1962 where he remained until 1994. His major research interests have been in the epidemiology of chronic respiratory disease, blood pressure and the application of epidemiological principles to health services research. He has pubhshed widely, including editing the Oxford Textbook of Public Health. He was President of the International Epidemiological Association and the Faculty of Public Health Medicine. He has served on many national and international committees concerned with public health and has spent periods of time in Australia, France, Germany, and various parts of the United States. He has had experience of life at the 'sharp end' by being a member of a District Management Team, member and vice-chairman of a health authority and non-executive director of a health authority. Susie Stewart and Walter Holland have published together on several occasions including Screening in Health Care which was pubhshed by the Trust in 1990. V Susie Stewart DL, MA, HON MFPHM Susie Stewart graduated from St. Andrews University in 1962 and obtained a postgraduate diploma in Social Studies from Edinburgh University in 1963. She became an honorary member of the Faculty of Public Health Medicine in 1992. Her career began with a research post in mental handicap and genetic counselling. In 1971 she took up a research and editorial post with Professor Holland in the Department of Community Medicine, St. Thomas's Hospital. Following a move back to her home town of Glasgow in 1977, she was for ten years technical editor of two of the British Medical Association's specialist journals and technical editor for the Panel of Social Medicine and Epidemiology of the Commission of the European Communities. In 1990 she was appointed Executive Secretary of the Scottish Forum for Public Health Medicine and the subsequently established Scottish Needs Assessment Programme (SNAP). Work on the present monograph began in 1995 and she now has a part-time appointment as research manager in the Department of Public Health at the University of Glasgow and acts as an editorial adviser to The Nuffield Trust. vii Prologue WHAT IS PUBLIC HEALTH? The concept of public health was easy to define in the period before the Second World War. The major threats to life were the result of insanitary conditions such as a foul water supply and defective or absent sewage and waste disposal, inadequate or over-crowded housing, poor and adulterated food and thus poor nutrition, hazardous workplaces and little effective clinical care. Thus what was considered as public health was concerned with rectifying these conditions — largely through legislative and population policies. The tasks of our predecessors entailed identifying the malpractices of landlords, employers, the state and others and persuading these groups that improvements were essential and could lead to improvements in health status and better life expectancy. At the beginning of this century many of these ills had been tackled and we no longer had open sewers or child labour. The most dramatic event, however, was the finding that a very high proportion of young men needed to fight in the Boer War were incapable of doing so because of inadequacies in their physique and health. This provided a new focus for public health in improvement of health as well as prevention of disease and death. As a consequence, public health began to be involved far more actively in health surveillance and in identifying particular groups who needed additional help — pregnant mothers, for example, and infants and small children. These strands of public health activity were developed and strengthened in the period between the two World Wars. In 1911, Lloyd George introduced a health insurance system for the employed. With the creation of the Ministry of Health in 1918, analysis of the factors that influenced health demonstrated the need to include health services for populations and groups in the consideration of the public health responsibilities of central government. Over the past 80 years there have been major changes not only in our way of life, organisation of services, and the environment but also in the viii abilities of medical science to prevent as well as cure disease. Concomitant changes have occurred in our understanding and concerns in public health. Not only are we involved with the control of infectious disease but also with the control of other conditions which entail not only population/legislative control but also changes in individual behaviour. In this context, public health cannot be concerned only with the control of disease and the improvement of health. The factors that can contribute towards achieving these goals involve all aspects of our lives. Public health must, therefore, also mean involvement with a local community on two levels. Firstly, the public health professionals must work with representatives of the people in their community to find the best structure for what requires to be a reciprocal process of communication and a real partnership. Secondly, they must work with and guide those responsible for the planning and provision of those structures and activities which affect the health of a population — for example, housing, water and sewerage, education, social services, employment, transport and clinical services - since only by effective collaboration across departmental boundaries can health be maintained and improved. For this reason, we have tried in this monograph to look at the broad focus of public health over the years and how many factors interact in the pursuit of improvements in the health of the population.