House of Commons - Health

Select Committee on Health Second Report

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"[22] 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.[23] 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".[24] 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.[25] 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".[26] 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.

HEALTH INEQUALITIES

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.[27] Over the past twenty years, overall mortality rates have continued to decrease.

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 (see box).

"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 society".[28] 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 countries examined".[29]

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.[30] 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".[31] 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).[32]

Table 1: Life Expectancy at birth by social class England and Wales, selected years (from Health Statistics Quarterly 02, tables 1&5)[33]

Men

Social Class	Occupation Type	1972-76	1977-81	1982-86	1987-91	1992-6
I	Professional	72	74.7	75.1	76.7	77.7
II	Managerial/Inter-mediate	71.7	72.4	73.8	74.4	75.8
IIIN	Skilled non-manual	69.5	70.8	72.2	73.5	75
IIIM	Skilled manual	69.8	70	71.4	72.4	73.5
IV	Partly skilled	68.4	68.8	70.6	70.4	72.6
V	Unskilled	66.5	67	67.7	67.9	68.2
All men		69.2	70	71.4	72.3	73.9
Difference SCI-SCV		5.5	7.7	7.4	8.8	9.5

Women

Social Class	Occupation Type	1972-6	1977-81	1982-6	1987-91	1992-6
I	Professional	79.2	79.9	80.4	80.9	83.4
II	Managerial/Inter-mediate	77	78.1	78.5	80	81.1
IIIN	Skilled non-manual	78	78.1	78.6	79.4	80.4
IIIM	Skilled manual	75.1	76.1	77.1	77.6	78.8
IV	Partly skilled	75	76.1	77.3	77	77.7
V	Unskilled	73.9	74.9	75.3	76.2	77
All women		75.1	76.3	77.1	77.9	79.3
Difference SCI-SCII		5.3	5	5.1	4.7	6.4

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.[34] 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 health inequalities.

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%.[35] 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".[36] 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 amongst children.[37] 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.[38] 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

23 Ashton, op. cit., p.23. Back

24 June Crown, "The Practice of Public Health Medicine: Past, Present, Future", Perspectives in Public Health, p.214. Back

25 This was as a result of reforms set out in the White Paper National Health Service Reorganization: England, DHSS, 1972. Back

26 Public Health in England: the Report of the Committee of Inquiry into the Future Development of the Public Health Function, Cm289, 1988. Back

27 Health Inequalities: National Statistics Decennial Supplement, ed Frances Drever and Margaret Whitehead, London 1997, TSO, p3. Back

28 Tackling inequalities in health: an agenda for action, ed Michaela Benzeval, Ken Judge, Margaret Whitehead, London 1995, King's Fund, p.1. Back

29 A 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

30 Independent Inquiry into Inequalities in Health, p.24. Back

31 Q108. Back