The Public Health Act of 1848

The 1848 Public Health Act is 150 years old. Its context, origins, content, and compromises are extensively reviewed in this issue by Hamlin and Sheard (p 587).¹ It was an exercise in effective politics, technically remarkably well informed, yet also an imaginative legislative attempt to deal with some still very current issues. How can the best technical public health competence be created in both the essential aspects of the public health discipline—knowledge and action? How can this technical competence be allied to effective combinations of central and local governance and administration? What is the role of law, and enforcement? How can the multisectoral content of public health be addressed? How can communities and individuals best be involved? How can private and corporate influences be brought on board? Above all, how can public health be made to count? These are formidable questions, yet the act shows what can be achieved with imagination and determination. We need to find these same qualities today if public health is to move centre stage.

There is no doubt that it needs to do so. Internationally health is improving, but not enough.² Although average life expectancy has been increasing throughout the 20th century, three out of four people in the least developed countries today are dying before the age of 50. Within Europe a great divide has opened between western and eastern European countries³: in the Russian Federation average life expectancy for men is now below 60 years—that is, below the age of retirement. And in western Europe too, deep economic and social divisions exist in health: in the United Kingdom a child born today in the highest social class can expect to live five years longer than a child born in the lowest.⁴

Within a UK context, Our Healthier Nation clearly identifies the determinants of health—genetic, social, economic, environmental, lifestyle, and health services.⁵ The challenge for public health is to affect these influences to promote health. The globalisation of information and economic activity has made these influences more complex and more removed from a purely national frame of reference than was the case in 1848.

Both internationally and nationally public health strategy and leadership are required. Both need to be more effective than hitherto, particularly in creating and sustaining effective actions that result from public health knowledge. Often there has been much analysis, but little change. Internationally, for example, the effectiveness of the World Health Organisation’s health for all strategy⁶ certainly needs reinforcing. And in the UK the public health function,⁷ initially full of promise, has often become preoccupied with NHS management and the cost effectiveness of clinical services. Both are important but have limited impact on public health because health services are probably one of the least powerful of the determinants of health in any society.⁸

Today it is clear that health improvement must be set within an arena much wider than health services—namely, the sustainable development of societies, for which health is a prerequisite as well as one of the most important consequences. Health is therefore intricately related to political, economic, social, environmental, and institutional circumstances.⁹ This concept is at the heart of the new global health for all strategy endorsed by the World Health Assembly earlier this year.¹⁰ A new European health for all strategy will be considered by the WHO European Regional Committee in September. Both focus on promoting equity and solidarity for health and unlocking resources and promoting accountability for health consequences across the whole range of societies. The aim is to give a more powerful strategic thrust to health improvement and act as a backcloth to national strategies such as Our Healthier Nation.

Public health leadership will be crucial. Promoting education and practice in public health is seen as a key European regional priority and a vital prerequisite for achieving realisable improvements in health. Within the UK the chief medical officer’s project to strengthen the public health function¹¹ has begun to identify ways to achieve this goal. Public health surveillance and information; a strong evidence base; and strengthened education and research are all vital elements.

Yet perhaps something remains missing—namely, coherence and a common sense of purpose among all the many practitioners of public health. A unifying concept is important. One that has been proposed is that of public health management: the concept of mobilising society’s resources, including those of the health service, to improving the health of populations.¹² Such a concept provides the necessary multidisciplinary focus and link between all public health practitioners, rather than simply those who are medically trained. It is a functional concept, relevant to all societies, irrespective of their administrative and professional structures.

What of a new public health act? Or a public health commission? On the former there is probably now agreement that in certain areas of public health practice, notably infectious diseases, environmental health, and food safety, some legal amendments are necessary, as Kenneth Calman points out in his article (p 596).¹³ Beyond that there is as yet no clear sense that new national or even European legislation will help us reach where we want to be—namely, with public health policy and practice that is comprehensive and effective within societies.

Similarly, the idea has been mooted (among others by Sram and Ashton (p 592)¹⁴) of a commission for public health, independent of government, to advise on all relevant issues and evaluate the public health implications of the policies and actions of all public bodies. It is an appealing notion and may have a role. Yet it is not sufficient.

Ultimately the objective is to make the public health function count at all levels of societal governance and influence, public and private. This implies making the public health function more comprehensive and coordinated, better focused, more skilful, and above all more effective. Some ideas are worth considering: firstly, separating public health practice from NHS management; secondly, linking public health practitioners to structures such as local government that are properly multisectoral and rooted in communities; thirdly, requiring the production of public health reports which are regular, comprehensive, and biased towards action by politicians, professionals, and the public alike; and, finally, protecting again the independence of public health practitioners.

Two new public health technologies will be of great importance. Strategic health programming should provide the local unity and inclusiveness of purpose required to achieve multisectoral change. Health impact assessments will promote the inclusion of health in policy thinking, as well as accountability for health consequences.

Perhaps, however, the most powerful influences for health lie with the public themselves. Informing them about health determinants, risk and uncertainty, and options for policy and action may be the most constructive role that public health practitioners can play. Such a view puts public health back where it belongs—and where the 1848 act positioned it: technically expert, but rooted in functioning democracies at both central and local levels.

Editorial p 550, Recent advances p 584, Education and debate pp 587-98