HC 1048-III Health CommitteeWritten evidence from the Centre for History in Public Health (PH 99)


This memorandum describes the history of public health within local government.

This involvement extends back to the 19th century, when local authorities included health committees and appointed Medical Officers of Health (MOHs).

The historical record of public health within local government is disputed. While it is important not to idealise the pre-NHS period as a “golden age” for public health, its location within local government had major advantages. Initially this facilitated sanitary reform, and subsequently aided integration of preventative and curative services.

Successful MOHs were high profile figures in their communities and those who were skilful leaders and capable of negotiating local political realities could raise population health.

Public health departments in local government oversaw an expanding range of health and environmental services before 1948 and were widely expected to become the lynchpin of the NHS. However this did not happen.

Primary health care has historically been disputed territory between the general practitioner (GP) and local public health departments.

Present proposals to reassign public health to local government cannot replicate the situation from the past, but they offer the opportunity to resume the community focus of public health prior to 1974 and to some extent prior to 1948.

Introduction: An Historical Perspective on Public Health

1.1 There are several aspects of current proposals for health service reorganisation which will affect public health:

The location of public health within local government, with responsibilities for appointing a director of public health, promoting healthy living and providing preventive services.

The allocation of responsibility for service commissioning to consortia of GPs, which will also have duties of health improvement and disease prevention.

The appointment of local Health and Wellbeing Boards to ensure integration of local authority health work with other NHS bodies.

The establishment of Public Health England, which will hold a ring-fenced budget to fund local government public health activities, and provide “national support for local delivery”.

1.2 These are not new entirely developments. Within the British health system, public health had been a local government duty since the mid-Victorian period. It was only with the 1974 NHS reorganisation that this long-standing relationship ended, presaging a period widely considered one of decline for public health. The problems of co-ordinating GP services with public health needs and of balancing central objectives with locally sensitive delivery also have a long history, long predating the inception of the NHS in 1948.

1.3 This memorandum provides an historical perspective on the Committee’s interest in the future role of public health in local government. It will discuss these earlier experiences and present the views of historians. It will show that the general verdict on the impact of public health within local government is a mixed one, but that there are aspects worthy of positive development.

2. Before the NHS: the Medical Officer of Health

2.1 The role of the MOH as leading local public health officer developed in Britain in the mid-19th century. Medically qualified officials were at first attached to temporary Boards of Health in periods of epidemic crisis. Their appointment became compulsory in London districts in 1855 and in all local government areas in the 1870s.

2.2 Their responsibilities were wide and included the removal of “nuisances” (ie refuse, sewerage), the regulation of overcrowded lodging houses, building standards, and monitoring of bakeries, dairies and slaughter houses. From 1889 they enforced prevention of infectious diseases through notification and isolation and by the early 1900s they increasingly supervised local services such as health visiting.

2.3 The greatest legacy of the MOHs and the health committees of Victorian and Edwardian local government was the infrastructure they built. This included drainage systems, waterworks, public baths, wash-houses and refuse collection, and a nationwide network of municipal isolation hospitals. Central government played some role in setting the policy course. Early supervisory efforts by Edwin Chadwick and the General Board of Health are well-known; the Local Government Board (the Department of Health’s distant antecedent) also issued advisory memoranda and used its loan sanction powers to influence capital projects. Ultimately though, it was local taxation and initiative which drove policy.

2.4 Although a postgraduate diploma (1870s) established public health as a discrete specialty, its status was low within the medical profession. It was distrusted by GPs, who feared an expanding salaried medical service would diminish opportunities for private practice, while hospital consultants considered it inferior to curative medicine for acute diseases. Nonetheless, MOHs with leadership capacity could operate effectively to enhance population health. The example of Arthur Newsholme as MOH in Brighton in the early 1900s shows how a skilful actor could negotiate local political and medical systems to improve areas like food safety and housing conditions.

2.5 Appraisal of the achievement prior to 1914 is broadly favourable, because from c 1870 life expectancy rose and mortality from infectious diseases fell. Historical epidemiologists caution that this was driven largely by improvements in living standards and nutritional status. However there is a consensus that public health interventions mattered too, particularly to falling mortality from cholera, typhus, typhoid and other enteric diseases.

2.6 Conclusion: The initial focus of public health was environmental improvement, and local government was the appropriate location for these activities. MOHs were potentially influential figures, but from the start a tension existed between private medicine and the salaried local bureaucrat.

3. Before the NHS: Public Health and Health Services

3.1 By 1939, the public health duties of local government had expanded far beyond the original environmental remit. Now they included maternal and child welfare services; a school medical service; dentistry; school meals and milk; tuberculosis schemes including sanatorium treatment, clinics and aftercare; health centres; “mental deficiency” (learning disability) institutions; venereal disease clinics; and regional cancer schemes. MOHs were also key figures in slum clearance and council housing programmes. From 1929 local authorities were empowered to take over the administration of Poor Law institutions, and many developed these into publicly funded general hospitals untarnished by the stigma of pauperism. In large, prosperous authorities like the London County Council this array of preventive and curative services meant local public health departments were running an embryonic NHS.

3.2 Central government now exerted policy influence through Treasury grants, initially supporting specific health services, then after 1929 through a block grant determined by local needs indicators. A new Ministry of Health (formed 1919) had principally an advisory role.

3.3 There is much historical debate about how well this system operated. Many in the public health field later saw it as a “golden age”, when their powers and achievements were at their height. Infectious disease mortality was firmly in decline, with rates falling from around 350 per 100,000 in1917, to 150 in 1937, to c 10–20 in 1957. Public health was a clearly identifiable aspect of public life, with many MOHs well-known local figures heading amply-staffed departments, including health visitors, clinicians, bacteriologists and sanitary inspectors. Their tenured appointments conferred some political independence in dealing with elected councillors and their annual public health reports presented local health statistics and helped set policy agendas.

3.4 The “golden age” interpretation is open to criticism. Despite central grants, disparities in local taxable wealth meant there was consistent variation between places in resources for health, and hence quality of services. Integrated working between the public sector and voluntary agencies was also poor in many areas.

Arguably too, public health failed to meet the challenge of the 1930s’ depression. Most MOHs were silent on poverty’s impact on ill-health, ignoring the emergent literature on malnutrition, and were conservative in their approaches to prevention, for example failing to adopt diphtheria immunisation despite international evidence of its efficacy. Tragically high levels of maternal mortality represent another failure. There were risks of “overstretch” imposed by responsibility for curative health services, and the loss of public health’s once distinctive advocacy role, as MOH activities increasingly overlapped with those of GPs.

3.5 More recent interpretations strike a balance between these views. Analysis of local financial statistics reveals rising real investment in public health in many areas despite national economic difficulties, albeit many poorer places remained disadvantaged. Variations were not solely determined by rateable wealth, but could also reflect local expenditure choices made by council politicians working alongside MOHs The extent to which health policy was directly determined by local electoral preferences remains uncertain.

Against the charges of “overstretch” can be set the benefits of integration of preventive and curative services, for example in the school medical service and in infant and maternal welfare. Moreover, new municipal clinics and general hospitals advanced equity of access, with health increasingly understood as a right of citizenship. Examples can be found of innovation (eg in health education), active vaccination policies, and concern for the sick poor. Often MOHs were constrained both by limited local resources, uncooperative politicians, and hostility from doctors in the private and voluntary sectors towards collaborative working. Their failures must also be attributed to the weak Ministry of Health, which provided little vision or leadership and was “a career backwater”, unattractive to civil service high-fliers.

3.6 The terrain of public health remained a contested one, with conflict over who had lead responsibility for primary health care, MOHs or the general practitioner. Such tensions were famously fictionalised in A.J.Cronin’s 1935 depiction of Dr. Finlay, the GP, and, Dr Snoddy, the public health doctor, later dramatised in Dr Finlay’s Casebook. This caricature underlines the cultural prejudices of British medicine against the doctor as “local government bureaucrat”.

3.7 Conclusion: The interwar period was the zenith of municipal medicine and the MOH’s public health “empire”. Historical verdicts are mixed, perhaps inevitably, since a permissive, decentralised system was bound to lead to variations in expenditure and quality. The commitment to local choice must be set against this geographical unevenness, which, in one historian’s words, “... mattered in terms of life and death”.

4. Public Health and the NHS

4.1 In debates preceding the NHS Acts many policy-makers and politicians (particularly Labour) argued that a comprehensive, universal service could best be achieved by building on existing local government arrangements. This would have kept public health at the core of the health service. However, in 1945 Aneurin Bevan argued that most local authorities lacked the financial and managerial capacity to meet national health goals, and had a track record of uneven provision. His solution was to create separate regional bodies administering hospitals and primary care, leaving public health in local government but with drastically reduced functions. Herbert Morrison’s counter-argument, that this would instil a democratic deficit, was over-ruled. Bevan’s model was also a political compromise needed to reconcile the medical profession to the NHS.

4.2 This left public health with limited duties (maternal and child welfare, vaccination programmes, community care for older people and psychiatric patients) and administratively distinct from hospital services. Bevan initially planned a network of health centres (polyclinics) to link public health with primary care. However, economic retrenchment in the 1950s and Conservative rejection of the policy meant this did not happen.

4.3 Conclusion: The NHS settlement left public health in local government but with much reduced powers and responsibilities. This was due both to political expediency and legitimate concerns about the capacity of local government to meet health goals deemed nationally optimal.

5. Public Health in Local Government, 1948–74

5.1 Public health after the war was forced to search for a new identity. Local government was rigid and unreformed and major developments in public health mostly took place away from the local level. GPs began to develop their role as providers of primary health care.

5.2 The rise of chronic disease led to an increased focus on “lifestyle” and individual behaviour as determinants of ill health. Evidence on, for example, the connection between smoking and lung cancer, brought an emphasis on “risk” and on prevention. Increasingly public health operated through national advertising campaigns, mounted by a central agency established at arms length from government. This was the Health Education Council founded in 1968, then refounded in 1973, and renamed the Health Education Authority with the advent of HIV/AIDS in the 1980s.

5.3 A gulf opened up between public health as an academic, research-based, professional activity and public health in local government. Public health developed as a professional set of institutions, for example with the establishment of the Society for Social Medicine in 1956 and the Faculty of Community Medicine in 1972. The ideas of social medicine, envisaging amalgamation of preventive and curative approaches to health, developed academically but bore little relationship to practice on the ground within local government.

5.4 A key deliverer of the public health message became “single issue” groups or organisations which focussed on one public health issue. Action on Smoking and Health (ASH) founded in 1971 is a notable example. There was no representation of MOHs on the Royal College of Physicians committees on smoking in the 1960s and 70s. Such new developments in public health had little of a local dimension.

5.5 Nonetheless it would be incorrect to conclude that public health within local government achieved nothing in these years. A dynamic MOH with a clear vision could still achieve a great deal. For example, Dr Paddy Donaldson (father of the former CMO), as MOH in Teesside in the late 1960s and early 1970s began to inaugurate screening clinics and to work closely with local G.Ps. Similarly, Dr Ian McQueen, MOH in Aberdeen during the 1964 typhoid outbreak, used the media in an innovative way.

5.6 Conclusions:

(a)Public health post war lost its local focus and emphasised the national level with advertising campaigns, mounted by a central agency, and single issue pressure groups commanding most attention.

(b)G.P.s began to play a more prominent role in primary health care.

(c)Nevertheless public health continued to operate at the local level and there are examples of innovative MoHs who were able to take new initiatives despite the difficulties of the post 1948 local government system.

6. Public Health Outside Local Government, 1974–Present

6.1 In the 1974 NHS reorganisation public health was renamed “community medicine”, taken out of local government and integrated into the NHS. The MOH post was abolished and replaced by “community physicians”, who were intended to be both community advocate and NHS technician/manager. Other factors in this change were the desire for parity and consultant status among public health doctors, and the emergent professionalism of social work and environmental health, both of which were removed from the public health umbrella within local government.

6.2 It is widely acknowledged that this transfer from local government was a disaster. Community physicians became preoccupied with health service matters and administration and little time was spent on prevention. The location within NHS authorities meant that they were remote from services such as housing and environment, while their population focus was at odds with the individualised interest of clinicians.

6.3 Part of the problem was the absence of a clearly articulated vision of what public health meant, and the tensions within the profession between different conceptions of their role - as technician manager or community activist.

6.4 The community physicians’ expertise in epidemiology and population health was expected to make them the lynchpin of NHS consensus management teams, at area, district and hospital level. But the advent of general management in health services in the 1980s undermined this potential public health role. Community medicine failed to achieve the promised status within the NHS and recruitment declined.

6.5 The discipline revived only with the advent of HIV/AIDS in the mid 1980s. This led to the establishment of a committee of enquiry into the public health function chaired by the CMO, Sir Donald Acheson at the same time as he was actively involved in the fight against AIDS. The new syndrome seemed to presage a revival of epidemic disease and thus provided a model with which public health felt comfortable. The resultant report published in 1988, did not propose a return to local government, but helped to rejuvenate the profession.

6.6 Subsequent developments saw changes within the composition of the public health workforce and a greater recognition of multi disciplinary public health (MDPH). Further outbreaks and crisis events (BSE, 9/11, salmonella, pandemic influenza) saw parts of public health organised as an arms length agency, the Health Protection Agency, (HPA), while the mass advertising function declined and the related agency (HEA, later HDA, then NIHCE) lost this responsibility.

6.7 Conclusions:

(a)Public health lost its local government role in 1974 and thus its contact with local communities.

(b)The local government system replaced by the NHS consultant role was not especially vigorous but was capable of development.

(c)Public health became remote from local communities and over dominated by the health service location.

(d)Its ethos and workforce were both uncertain and fragmented.

(e)Central arms length agencies assumed a key role in carrying out public health activities.

7. Overall Conclusions

7.1 The historical record of public health within local government is disputed. It is important not to idealise its location there as a “golden age” but it did have major advantages. Initially it facilitated sanitary reform and subsequently aided integration of preventative and curative services.

June 2011

Prepared 28th November 2011