MEMORANDUM BY ASSOCIATION OF DIRECTORS
OF PUBLIC HEALTH (PH 64)
Modern Service Public Health Practice consists
of three parts:
(1) The competent discharge of statutory
functions such as communicable disease control and child protection
and the discharge of duties under relevant legislation on public
health matters eg AIDS, Port Health etc.
(2) Providing Health Authorities/Boards with
independent medical and epidemiological advice on how to review,
plan, manage and evaluate healthcare services in order to meet
a population's health needs.
(3) Preventing disease and promoting good health
on a wide canvas by working with other disciplines and multiple
organisations; including local authority departments of social
services, housing, environmental health and education, voluntary
organisations and non-governmental organisations, private industry
and individual members of the public.
Public Health Service Departments are headed
by a Director of Public Health. These individuals will have spent
five or six years at medical school, will have done at least three
years clinical medicine (and often much, much more); have spent
five further years in higher specialist training in Public Health
Medicine before their appointment as a DPH.
Public Health Medicine is officially defined
"The art and science of preventing disease
and promoting health through the organised efforts of society".
All this is quite a challenge and a formidable
responsibility. Of course, fortunately, we do not work alone.
We manage a department of medical, nursing and other professional
and administrative staff. We also work with many other professionals
both within and without the NHS to promote and assist in improving
health. Health improvements will only come from a wider combined
push on improving NHS services and tackling the wider determinants
of ill health like poverty, education and housing.
Our core business combines medical management
with the science of epidemiology. Unlike other doctors we don't
generally see patients on a one-to-one basis. Our patients are
the 500,000 or so people who live in our area. However, just like
other doctors we:
recommend treatment (usually develop
a service or introduce a new one);
check that the treatment/service
Doctoring for a population, make up of a large
number of people, needs some different skills than for the usual
one to one doctor-patient relationship. Epidemiology and statistics
are key to making a population diagnosis and evaluating the effectiveness
of health services and non-health service interventions. Epidemiology
is the study of the distribution of disease in populations. We
generally look at:
who is most likely to suffer from a certain health
where will a health problem be most prevalent
when is it most likely to occur (time).
We also study and try to identify the likely
cause or causes of a disease or health problem (netiology).
Looking at the:
effectiveness of health care interventions is
also a frequent pastime (patient outcome).
In these ways we can find out what the major
health problems are for our area, their likely causes and design
effective strategies to prevent or cure health problems. If neither
of these is possible then services to care for people with chronic
disease are needed.
This approach is best explained by looking at
People who are poor are more likely to die prematurely
from heart disease and stroke than more affluent people. In contrast,
more affluent women are more likely to get breast cancer.
People from Asian subcontinent are more likely
to suffer from heart disease and TB and people from Africa and
the Caribbean are more likely to suffer from diabetes and hypertension.
Teenage pregnancy is much more common in some
local areas. Children living in urban areas are more likely to
be admitted to hospital with chest infections. Cryptosporidium
infection and Salmonella Typhimurium DT 104 food poisoning are
associated with private water supplies and farming in rural areas
Flu and childhood chest infections are more
common in the winter whilst certain gastrointestinal diseases
are more common in the summer eg Salmonella Typhimurium DT 104
and E. Coli 0157.
Looking back in time, many diseases are on the
decrease like heart disease, cervical cancer and tuberculosis.
Some diseases or health problems are on the increase such as HIV,
malignant skin cancer and teenage pregnancy. Treatments change
this pattern eg less people now die of AIDSmore live long
term with HIV or combination therapies.
The definitive causes of diseases and health
problems need to be evaluated by thorough research which connects
cause and effect. A good example here is Sir Richard Doll's sentinel
work, which showed that smoking caused lung cancer.
Deaths and serious injury from road traffic
accidents are high in county areas compared with elsewhere. Human
error is a causative factor in over 90 per cent of all road accidents.
High levels of sulphur dioxide air pollution
in London in the early 50s clearly contributed to increasing the
death rate. This was known as "Winter Smog". The deaths
were largely due to chest and heart disease.
Knowing a lot about the diseases which afflict
local people is little help to them unless we can put in place
effective health services and/or other interventions which will
combat these health problems. The increasing enthusiasm for evidence-based
clinical practice will do much to contribute to this goal. Research
studies can help clinicians convert good intentions into treatments
with proven benefit. A particularly good example of this is the
ISIS II trial of thrombolytic drugs (clot busters) and asprin.
These drugs combined dramatically improve survival after a heart
attack. A Duty study showed that influenza vaccination halved
the incidence of influenza in the elderly.
Science is all very well in Public Health but
it isn't worth doing unless we can persuade health care and other
professionals to do things differently. Therein lies a key skill
and personal attribute which is essential for all Directors of
Public Health and their staff. Therein also lies a source of unpopularity.
Other professionals and opinion leaders can understandably resent
our perpetual enthusiasm for changing what they do. In striving
to influence others we spend a lot of my time talking to them
in meetings or one to one.
Sometimes a solution with a scientific basis
is not what people want. It is often important to combine a rational
model of decision making with the views and convictions of key
stakeholders and the public. There are an infinite number of health
problems on which we could focus our attentions. We choose which
issues to focus on according to two parameters:
(1) The size of a health problem paired with
an effective intervention to alleviate it (the science).
(2) The degree of stakeholder and public
support for a change (the art).
The FPHM/ADPH believe that my population focus
on health adds an important perspective to that gained through
one to one patient contracts. This contribution is delivered through
a continuation of skills which include: medical, epidemiological,
management, sociological and psychological.
We hope we have fired your enthusiasm to improve
health and health services through the organised efforts of society
and brought to your attention the role that our organisations
can play in that regard.