Public health and English local government: historical perspectives on the impact of 'returning home'

Abstract

This article uses history to stimulate reflection on the present opportunities and challenges for public health practice in English local government. Its motivation is the paradox that despite Department of Health policy-makers' allusions to 'a long and proud history' and 'returning public health home' there has been no serious discussion of that past local government experience and what we might learn from it. The article begins with a short resumé of the achievements of Victorian public health in its municipal location, and then considers the extensive responsibilities that it developed for environmental, preventive and health services by the mid-twentieth century. The main section discusses the early NHS, explaining why historians see the era as one of decline for the speciality of public health, leading to the reform of 1974, which saw the removal from local government and the abolition of the Medical Officer of Health role. Our discussion focuses on challenges faced before 1974 which raise organizational and political issues relevant to local councils today as they embed new public health teams. These include the themes of leadership, funding, integrated service delivery, communication and above all the need for a coherent vision and rationale for public health action in local authorities.

Keywords: government and law; health services; public health.

Fig. 1

London Sewer Construction in Bow, 1859. Copyright Illustrated London News/Mary Evans Picture Library, ref 10010475. The public health service in its Victorian phase is associated with major capital projects, authorized and resourced by elected councils. In Thomas McKeown's famous account of the modern rise of population, he calculated that 33% of the mortality decline between 1848/54 and 1901 was attributable to water-borne diseases amenable to such interventions.

Fig. 2

‘Hints from the Health Department’, Leaflet, nd. Wellcome Library, London, reference CMAC SA/SMO/R.4/13. The local executive power of the MOH, the town's figurehead for public health, is projected here as paternalist reassurance. Around him are represented health duties integrated with other municipal activities including housing, education, social care, regulation of commerce and business, as well as cure and prevention.

Fig. 3

Issues of public health leadership in transition to local government.

Fig. 4

Public Health Outcomes Framework. Local data will be submitted to the DH and areas will be assessed on this basis. The aim is to increase transparency and responsibility. The Framework has a vision, two overarching outcomes and four domains as follows: Vision: to improve and protect the nation's health and wellbeing, and improve the health of the poorest fastest. Outcome 1: increased healthy life expectancy: taking account of the health quality as well as the length of life. Outcome 2: reduced differences in life expectancy and healthy life expectancy between communities: through greater improvements in more disadvantaged communities. DOMAIN 1: improving the wider determinants of health. Objective: improvements against wider factors that affect health and wellbeing, and health inequalities. DOMAIN 2: health improvement. Objective: people are helped to live healthy lifestyles, make healthy choices and reduce health inequalities. DOMAIN 3: health protection. Objective: the population's health is protected from major incidents and other threats, while reducing health inequalities. DOMAIN 4: healthcare public health and preventing premature mortality. Objective: reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities.?>