Memorandum by The London School of Hygiene
and Tropical Medicine (PH 51)
1. The London School of Hygiene and Tropical
Medicine is the largest school of public health in the UK, with
over 350 research staff and almost 700 postgraduate students from
more than 100 countries. It is a research-led institution with
over 50 per cent of its activities in the UK and other developed
countries. Total annual research income is about £21 million,
of which 75 per cent is won competitively. Research at the School
on a wide variety of aspects of public health research covers
many subject areas, many countries and includes many disciplines.
We also play a major role in training specialists in all aspects
of public health practice.
2. We commend the Health Committee for initiating
an inquiry into Public Health since in our view public health
practice in the UK is in quite a parlous state, given the existing
potential both of expertise and of opportunities for increasing
health and well being.
3. The necessary conditions for effective
public health are key disciplines acting together in collaboration
and in partnership and various sectors collaborating to create
the conditions for effective public action. This can only work
when the groups being served are integral to the public health
strategies being proposed. In spite of the science of public health
being both highly complex and extremely diverse, any kind of paternalism
has no effective place, because proper and effective implementation
is intrinsically about empowerment.
4. There are two major problems, which bear
on most of your considerations, in the practice of public health
in the UK. The first is that public health lacks, a credible and
respected dedicated co-ordinating centre that embodies the elements
of excellent, evidence based, practice to enable an improvement
over time. The second concerns a divided and dissipated public
health workforce across sectors and disciplines.
5. The common feeling is that the NHS, the
MRC , the ESRC, the PHLS, the NHS Regional structure and NHS Research
and Development etc etc cater for all this. But precisely the
main deficiency in the contemporary public health function is
that it is marginal to all of these major responsibilities and
lacks a core national centre of excellence in public health practice.
6. Public health is complex and the knowledge
base extremely broad as well as intricate. It embraces a complex
common knowledge base but necessarily includes specialist understanding
and competence from several core disciplines.
7. The overriding feature of the specialist
practice public health currently is that it is essentially marginal
to clinical medicine. There is a clear double jeopardy for the
public health workforce as it is organised at present. Broadly
the accredited public specialists come exclusively from clinical
medicine, but have largely become health service managers and
are thus themselves considered to be marginal to medicine. Consequently
recruitment of ambitious candidates for specialist public health
practice from other disciplines, with no career structure open
to them, find the prospect of servicing a closed and marginal
profession particularly unattractive.
8. Public health is not clinical medicine
nor is it clinical management. As is often said "public health
is currently too close to health care and too far from health".
Environmental Health, HAZ, HIMPS and other strategies to bring
public health closer to health are thus perforce distanced from
the specialist practice of public health as presently constrained.
9. Medical training is clearly relevant
to improving well being among healthy people, but so are statistical
and social science training. It is clear that each of these base
disciplines requires considerable extra understanding to fully
understand public health issues; the particular mix depends on
the area of public health application.
10. As a consequence of an inappropriate
medical hegemony other public health specialists, such as, for
example, environmental health officers in local authorities, operate
quite independently from public health medicine. This is because
their responsibilities are consequently seen as very different
and hence separate.
11. Public health is highly complex because
it has to reconcile the short- and long-term interests of communities
in complex social systems with respect to various indices of wellbeing
and possible influences on them; all with much uncertainty. The
uncertainties derive from the intelligent combination of incomplete
biological knowledge with incomplete social and environmental
knowledge. Informed strategies for BSE, food deserts, HIV, salmonella,
fish, chips and salt reinforce this all the time.
12. The immediate implication is that, in
order to create a credible centre of excellence in public health,
there are several policy imperatives. Public health must assert
itself as mainstream and coherent in its own right, across its
sphere of effective influence. It must have the clear objective
of maximising the wellbeing of all of the people in the medium
to long term. The method of enabling this to happen is the responsibility
for the proper implementation of the White Paper "Our Healthier
13. This requires two things, both of which
are proposed in the White Paper. First appropriate training and
accrediting schemes for a highly qualified specialist workforce
from whatever relevant disciplines with clear equivalence of status
from rigorous criteria across disciplines and sectors. Secondly
a national centre of excellence to co-ordinate and encourage excellence
in public health practice across all sectors and determine sensible
and joined up public health policy with sensible priorities based
on what is achievable measured against clear outcomes.
14. This implies recognition and establishment
of expertise across disciplines and across sectors in which no
single discipline or sector is seen as pre-eminent. The world
of public health is concerned with the entire population and all
the influences on health and well being that bear on those populations,
from birth to death. Hence public health should be positioned
in a manner that is more analogous to the legal profession than
the medical professionwhose dominant concern is for the
15. The proper implementation of these necessary
policies requires strategies that are sensitive to the expectations
of the existing workforce and invoke intelligent upgrading of,
for example, the HDA, so that it can fulfil its clear function
described in OHN. But the nettle does now have to be grasped.
16. The essential requirement is an authoritative
and dedicated co-ordinating infrastructure in the UK for the effective
implementation of effective, exciting and imaginative disease
prevention strategies. Such an infrastructure ought to combine
several essential principles:
(a) authority and credibility based on scientific
(b) multi-disciplinary approaches;
(c) a culture that addresses the root causes
of healthnot disease;
(d) the ability to work effectively across
(e) respect for the contribution of all professionals
to health maintenance; and
(f) the proven ability to facilitate change
that captures the imagination of the ultimate beneficiaries.
17. The widening role of public health specialist
practice to PCGs and PCTs is visionary and a wholly appropriate
strategy and requires therefore a stronger co-ordinating public
health resource to assist and augment good practice at local level.
18. Similarly Health Action Zones, Employment
Action Zones, Healthy Living Centres, Education Action Zones,
Health Improvement Programmes and Community Plans all require
there to be centres of excellence in their territory, as a resource,
with credibility and reputation which understand and embrace current
knowledge in public health.
19. The model adopted for public health
infrastructure should stress research and standards. Thus the
research component must be at the forefront of facilitating a
coherent national and overarching public health strategy, from
which all the other organisations (some mentioned above) can take
their lead and augment as they see fit in their own context.
20. The establishment of an evidence base
is integral to that process. A possible Public Health Council,
like the MRC, should be responsible for developing and, possibly
implementing, such a strategy, with suitable infrastructure from
within the upgraded HDA. The HDA ought to become equal to the
MRC, in the terms in which it functions for medicine, for public
health. Overlapping interests can be dealt with by common and
21. From that can flow reasonable (and improving)
standards and strategies for implementation in a Co-ordinating
Hub in the above document. The role of successful NGOs in public
health ought to be harnessed in that process, as partner organisations
with the HDA, their role is essential to the process and again
must not be subservient to the HDA.
22. The model, for example, of the National
Heart Forum, is something to be emulated and enhanced across the
public health agenda. Such efforts ought to be integrated into
the work of the HDA with some commensurate executive responsibility
for the strategy of the HDA. In other words advise to Ministers
on the implementation of public health policy ought to evolve
from a coherent research strategy, and hence authoritative evidence
base, and the understandings and experience of the relevant NGO.
23. The developments of proper standards
for a new workforce currently being developed by Health Work UK
and work of the Tripartite agreement should be consolidated and
properly funded. Parallel specialist training schemes need to
be made available to graduates from public health degrees leading
to equivalent careers, based on public health needs, in all relevant
sectors, not just in the NHS.
24. An equivalent to the Chief Medical Officer
for public health needs to be established to oversee the Government
public health strategy. The public health responsibility of the
CMO should be transferred to this post.
25. The Minister for Public Health should
be of Cabinet rank and have responsibilities specifically for
public health strategy, that are not confined by Health Sector
26. Information strategies need to be enhanced
to monitor an enhanced public health function. This is particularly
true for cancer registries and disease registers. The Data Protection
Act requires amendment to allow monitoring and public health research
commensurate with clear safeguards on confidentiality and population
27. Public health opinion must see that
the whole of public health is lead by dedicated and knowledgeable
lifetime enthusiasts. This means that unless led by energetic
and authoritative practical and theoretical practitioners with
a clear record of excellence in public health research and practiceclearly
and at the forefront of knowledgepublic health will continue