Select Committee on Health Appendices to the Minutes of Evidence


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 Nation" (OHN).


  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 profession—whose dominant concern is for the sick.

  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 evidence;

    (b)  multi-disciplinary approaches;

    (c)  a culture that addresses the root causes of health—not disease;

    (d)  the ability to work effectively across organisational boundaries;

    (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 mutual representation.

  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 boundaries.

  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 involvement.

  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 practice—clearly and at the forefront of knowledge—public health will continue to fail.

July 2000

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