In this Step we discuss the removal of public health services from local government in 1974 and their re-location within the NHS. We explore the reasons why public health services were moved in to the NHS, and some of the problems and opportunities that this presented.
Public health within the NHS: the 1974 reorganisation
In the early 1970s, a major reorganisation of the NHS took place. The structure of the health service was reconfigured at the local and regional level, with new bodies being created to oversee hospitals and community care. Responsibility for public health services was removed from local authorities, and instead incorporated within the NHS. It was hoped that this would create a more integrated health system, with public health services working more closely with the rest of the health service. This seemed especially pertinent in the light of the rising costs of health care, and a desire to shift resources away from the expensive, acute sector and towards disease prevention. The post of Medical Officer of Health was scrapped, to be replaced with that of the Community Physician. The Community Physician worked within the NHS, instead of local government.
The development of community medicine
The creation of the post of Community Physician was representative of more than just a change of name and reporting structure. The idea of ‘community medicine’ had been around since at least the 1960s. From this time, there had been moves within academic public health to try and develop a more coherent philosophy for public health practice and enhance its status. The epidemiologist Jerry Morris helped develop the notion of ‘community medicine’ and of the public health doctor as the ‘community physician’. It was hoped that the community physician would act as the lynchpin of a new, integrated NHS by bringing services together, evaluating the effectiveness of these and coordinating preventive services.1
For many, though, the reality was far from the vision. The post of Community Physician was a difficult position to occupy for many practitioners, as they had to balance three distinct roles: that of health service manager, planner and specialist.2 Moreover, power in the health service lay elsewhere. The service was still dominated by the acute sector and hospitals, where the consultants held sway. Disease prevention continued to be a poor relation.
It was also unclear as to exactly what ‘community medicine’ meant. Was this about the health of the community, or the whole population? Or was it about the provision of all health services that were based in the community (i.e. everything but hospitals)? Or, should the community physician act as a spokesperson for the public and their health? Alternatively, was the community really an object of study, with little role for the public themselves in determining health goals and outcomes. None of this was clear, and this lack of clarity hampered the development of public health services and thinking.
Yet, there were also developments that presented opportunities for public health services and helped to enhance the status of the field. New challenges to public health in the 1980s and 1990s led to new approaches and structures, helping to spark off a revival of public health practice and provision. The AIDS crisis, for example, powerfully demonstrated that there was a continued need for public health services and approaches. Other apparently new diseases like Creutzfeldt-Jakob Disease/Bovine Spongiform Encephalopathy (or mad cow disease) also pointed to the importance of public health authorities and their need to communicate more effectively with the public. At the same time, older challenges also received new levels of attention. The relationship between social inequality and health was highlighted by a series of reports and inquiries, indicating the importance of public health services not only in improving health, but also in a wider social, political and economic context too.3
Public health services began to develop some novel approaches to such challenges. These were rooted in three inter-related strands of thinking and practice that developed in the UK and globally from the late 1970s: what was called the ‘new idea of public health’, health promotion, and primary care’. These separate, but to some extent overlapping, philosophies held in common an emphasis on involving individuals and communities in maintaining and improving public health.
But, the greater involvement of the public in public health could not be achieved without strong leadership within public health services and structures. The Acheson report on the future of the public health function, published in 1988, envisaged a revitalised role for public health medicine at the local and national level. Community physicians were to be replaced by Directors of Public Health, who amongst other things, would be required to produce an annual report on the health of the public in their region.4
So, what we have by the end of this period is a profession and set of services, that, although they faced considerable challenges, were perhaps clearer in their role and purpose than they had been in the past.
© London School of Hygiene & Tropical Medicine