THE HISTORY OF PUBLIC HEALTH
23. The influence of public health has waxed and
waned over the past 150 years. In the latter years of the Nineteenth
Century and in the first half of the Twentieth Century, public
health measures led to substantial improvements in health status
in the UK. The past few decades have seen a decline in the importance
of the discipline as research and technology based clinical medicine
has increased in influence and importance.
24. Public health has its origins in the social reformer
Edwin Chadwick's report The Sanitary Conditions of the Labouring
Population of Great Britain published in 1842. With the spectre
of cholera "stalking the slums of the great towns"
he concluded that the most important measures which could be taken
to improve the health of the public were "drainage, removal
of all refuse from habitations, streets and roads and the improvements
of the supplies of water". Water companies were reluctant
to take measures to ensure the purity of their product but as
a result of public pressure, the first of the Public Health Acts
was introduced in 1848 to enable local authorities to take control
of their environment. The first Medical Officer of Health (MOH),
Dr William Henry Duncan, was appointed in 1847.
According to one authority, "the best of the Medical Officers
of Health fully understood the breadth of their task. They ensured
that their localities had safe water supplies and sewage systems;
they pressed their authorities to replace slum housing; and they
influenced education departments and introduced preventive and
school health programmes".
By the end of the Nineteenth Century, a central government Department
of Public Health and local departments of public health in every
local government district had been established.
25. The Public Health Department headed by the MOH
flourished during the first half of the Twentieth Century. The
school health service was formed in 1907 and arrangements for
improving antenatal and postnatal care were developed. The first
centre for prenatal care was set up in Edinburgh in 1915. Public
provision of health care was extended by the introduction of the
National Insurance Act 1911 and by the 1920s and 1930s Medical
Officers of Health occupied a pivotal role in the provision of
health care to the population. They had responsibility for monitoring
water supplies, sewage disposal, food hygiene, housing and control
of infectious diseases. In addition, they had responsibility for
health visitors, midwives and the school health service. In 1929
they also took on the task of administering municipal hospitals.
The Medical Officer of Health occupied a central role in the public
provision of health care as well as in the prevention and monitoring
of ill health.
26. After the Second World War, the NHS Act 1946
set up three distinct controlling bodies for health care. NHS
hospitals were administered by Regional Hospital Boards, public
health services became the responsibility of local authorities
and local executive councils administered general medical services
which provided primary medical care to the population. Reorganisation
of the late 1940s was the first of many over the past 50 years
which have led to radical changes in the relationships between
public health, local authorities and clinical services.
27. The post of MOH was abolished in 1974 and the
responsibility for monitoring environmental determinants of health
passed to Directors of Environmental Health who were employed
by local authorities.
Doctors trained in public health medicine became Community Medicine
Specialists employed by health authorities to monitor the health
status of the population and advise health authorities on how
best to tackle the health problems of their community. Before
1974, the MOH had responsibility for the provision of some personal
health services and in addition, was able to influence, as an
officer of the local authority, social and environmental aspects
of health. These functions were lost as a result of the transfer
of the MOH into the Health Service. Community Medicine Specialists
fulfilled three basic functions: they were medical administrators
who assisted in planning and managing clinical services; they
were advisers on the medical aspects of environmental health to
the local authority and they continued to have a role in epidemiology
and the evaluation of health status and programmes of health care.
28. The specialty of Community Medicine failed to
fulfil expectations and in 1988 a committee of inquiry into the
future development of public health medicine was set up under
the chairmanship of Sir Donald Acheson. This found that Community
Medicine had failed to meet expectations as a result of blurred
definitions of roles whilst the need for community physicians
to take the long term view of events "often conflicted with
short-term pressures on health authority management".
The Acheson Committee recommended a return to the name Public
Health for the specialty. Since then, public health doctors have
been involved in reshaping health services as purchasers within
the internal market and are now being increasingly involved in
the development of evidence-based healthcare within the NHS.
29. Over the course of the Twentieth Century, health,
as measured by life expectancy, has improved for the population
of Britain to a remarkable extent. Life expectancy in England
and Wales has increased from 52 years for men and 55 years for
women in 1910, to 74 years and 79 years respectively in 1994.
Over the same period infant mortality has fallen from around 105
per thousand to six per thousand.
Over the past twenty years, overall mortality rates have continued
30. However, health indicators such as mortality
and morbidity rates have not improved at the same rates for everyone,
with the result that health gap between the healthiest groups
and the least healthy groups has now widened and is widening further
- "if all infants and children up to age 15 enjoyed the same survival chances as the children from classes I and II, then over 3,000 deaths a year might be prevented ... in addition, bringing all adults aged 16-64 up to the mortality experience of class I would mean 39,000 fewer deaths per year" (Whitehead, 1992, cited in Tackling Inequalities in Health: An Agenda for Action, ed Michaela Benzeval, Ken Judge, Margaret Whitehead, 1995, London, p.17)
- "In the early 1970s, the mortality rate among men of working age was almost twice as high for those in class V as for those in class I. By the early 1990s, it was almost 3 times higher" (The Independent Inquiry into Inequalities in Health, Acheson et al, p.11)
- "people in Black (Caribbean, African and other) groups and Indians have higher rates of limiting long-standing illnesses than white peoples. Those of Pakistani and Bangladeshi origin have the highest rates. In contrast, the Chinese and 'other Asians' have lower rates than the white population" (The Independent Inquiry into Inequalities in Health, p.23)
This is not just a problem for Britain, it is a problem
for all developed countries, but "what is particularly worrying
... is the suggestion that one of the most significant indicators
of disadvantage - economic inequality - appears to be growing
more quickly in Britain than in any other advanced industrial
A review conducted in 1994 of international trends which looked
at most of the countries of western Europe and Australia, Canada,
Japan, New Zealand and the USA, commented that "the UK stands
out for the sharpness of the rise in recorded income inequality
in the second half of the 1980s. This was unparalleled in the
31. Indicators of inequalities include gender, race,
age and geography - for instance, at each age in childhood, and
on into adulthood, the age-specific mortality rates for boys is
higher than for girls.
However, the health gap in Britain now is most consistently and
starkly demonstrated across a social class gradient. The latest
data for the mid-1990s indicates that life expectancy at birth
for a baby boy born into social class V is over nine years less
than for a boy born into social class I. In the mid-1970s the
difference was one of five and a half years. The difference is
not quite so extreme for a girl: the girl in class V now can expect
to live over six years less than a girl born into class I; twenty
years ago the difference was just over five years (see Table 1).
Sir Michael Marmot told us, however, "what we have seen is
not that things have got worse in mortality terms for people at
the bottom, but that things have improved for people at the top
and they have improved much faster, depending on where you were
in the hierarchy".
The health of those at the bottom of the social pile has improved
over the last twenty years, but not as quickly as has that of
those above them in the social order. Moreover, the problem is
not simply a polarisation of the most and least advantaged ends
of society: health indicators show a stepwise relation to social
position in a gradient which correlates higher social class with
increased health throughout the different social groups. This
implies that health is predicated on an individual's position
in society at every level. There is also evidence to suggest that
bad health results not only from absolute poverty but also from
relative poverty - one becomes unhealthy if one perceives oneself
to be poorer than others (see paragraph 52).
Table 1: Life Expectancy at birth by social class
England and Wales, selected years (from Health Statistics Quarterly
02, tables 1&5)
32. The first step towards attempting to tackle such
health inequalities, is to establish why they exist at all: what
it is about the behaviours of the classes which creates this social
gradient of health. Sir Michael Marmot explained to us that for
different diseases, causal factors are different; some will be
determined by health status in childhood or even earlier, others
will be affected by risky behaviours and life events.
Moreover, it appears that less tangible factors such as the amount
of control one feels over one's environment, which is related
to one's position in society and at work, affect physical and
mental health (see below paragraph 53). It is a complex picture
which requires more research. However, it is also true that social
and economic inequalities have increased over the last twenty
years, and it would be hard not to see a causal link of some kind
between the increase in these inequalities and the increase in
33. The epidemiological trends are not disputed.
What is less easy to establish is what can be done to improve
the situation. Although there is a lot of evidence about the existence
of health inequalities, there is very little evidence about the
effectiveness of interventions to tackle health inequalities.
As a result, governments have pursued policies based on vague
ideas of plausibility. The problem with this is not only that
they might turn out to be ineffective and a waste of public money,
but that such policies may inadvertently increase health inequalities:
uptake tends to be much better amongst the advantaged sectors
of the population than amongst the deprived populations which
are the target population. As a result, the advantaged sector
becomes even more advantaged and the deprived population is unaffected,
leaving the gap between the two wider than before.
34. A problem with government initiatives targeted
at deprived groups, such as Sure Start, is that the group targeted
is often too small. Given that health inequalities follow a social
gradient, rather than being the problem of a small polarised group
distanced from the rest of society, to target only the bottom
10%, for example, is to miss where the bulk of the problem lies,
which is in the bottom 20-40%.
As Sir Donald Acheson told us, "health policies should be
drafted in such a way that they favour the less well off; not
the least well off".
We recommend that health policy should benefit the less well
off on a sliding scale rather than targeting only the small group
who are the most deprived.
35. We see great potential for health inequality
targets to give real bite to the HImP/Community Plan and to provide
a yardstick for Directors of Public Health, Local Authorities
and Health Authorities. We welcome their recent publication and
were particularly pleased to see a focus on health inequality
We also recognize that inequalities targets will only make a difference
if effective strategies are put into place to achieve them. This
should include developing appropriate "baskets" of intermediate
targets for each of the headline targets.
Intermediate targets may usefully take account of some targets
set out in The Health of the Nation, as well as locally-determined
targets that are relevant to local conditions.
HEALTH IMPACT ASSESSMENTS AND HEALTH
INEQUALITY IMPACT ASSESSMENTS
36. Health Impact Assessments and Health Inequality
Impact Assessments offer an opportunity to put a health equity
perspective into every government department and every government
policy which has a bearing on the health of the population. They
would provide a methodology for assessing the likely impact on
the population's health of any government policy. However, they
must not degenerate into a theoretical exercise or be simply another
piece of 'box-ticking' paperwork; an assessment of the positive
or negative impact upon health and health equity should result
in action to change the policy if it is expected to have a negative
impact on health or health equity. We recommend that every
Government Department has a Public Service Agreement to conduct
health audits and health inequality audits of relevant policies
and to work towards policies which have a positive effect on health.
We also think the Government should consider the advantages of
the establishment of a Parliamentary Health Audit Committee to
assess whether or not departments deliver on this along the lines
of the Environmental Audit Committee. Whilst this is a matter
for Parliament, not Government, we would welcome the considered
views of DoH on such a suggestion.
22 John Ashton "Past and Present Public Health in Liverpool"
in Griffiths S and Hunter D eds, Perspectives in Public Health,
Abingdon 1999, p.23. Back
op. cit., p.23. Back
Crown, "The Practice of Public Health Medicine: Past, Present,
Future", Perspectives in Public Health, p.214. Back
was as a result of reforms set out in the White Paper National
Health Service Reorganization: England, DHSS, 1972. Back
Health in England: the Report of the Committee of Inquiry into
the Future Development of the Public Health Function, Cm289,
Inequalities: National Statistics Decennial Supplement, ed
Frances Drever and Margaret Whitehead, London 1997, TSO, p3. Back
inequalities in health: an agenda for action, ed Michaela
Benzeval, Ken Judge, Margaret Whitehead, London 1995, King's Fund,
Atkinson (1994) Seeking to Explain the Distribution of Income,
Welfare State Programme Discussion Paper 106, Suntory-Toyota International
Centre for Economics and Related Disciplines, London School of
Economics, London, cited in Tackling Inequalities. Back
Inquiry into Inequalities in Health, p.24. Back
31 Q108. Back
32 Q187. Back
34 Q130. Back
35 Q119. Back
36 Q131. Back
press notice 2001/0108 (28/02/2001). The new national health
inequalities targets are:
- By 2010, to reduce by at least 10%
the gap in infant mortality between manual groups and the population
as a whole.
- By 2010, to reduce by at least 10%
the gap between the fifth of areas with lowest life expectancy
at birth and the population as a whole. Back
evaluation of Health of the Nation showed that merely having
targets is insufficient to ensure action. Hunter, DJ et al (1998)
Investing in Health? An assessment of the impact of the Health
of the Nation, in The Health of the Nation: a policy assessed,