Public health is "the science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society".2 In essence it is about the way in which the totality of a country’s resources can be brought to bear to increase the level of health of the population.3
The health of Scots is unacceptably poor and significantly worse than it could be if current knowledge was applied through a strong public health approach. The route to improved public health in Scotland is clearly laid out in the recent White Paper Towards a Healthier Scotland. Leadership, authority and responsibility for this task have to be clearly apportioned if we are to make significant progress.
The current national policy context offers an unparalleled opportunity to create a "health improvement service", not vested in any one organisation but born out of the co-ordinated and sustained efforts of all stakeholders, including the public at large. Central to success is a strong "public health function", that is, a robust, adequately resourced endeavour that can secure and sustain the public health, address health policy issues at a population level, and lead a co-ordinated effort to tackle the underlying causes of poor health and disease.
The purpose of public health has not changed radically over recent decades. However, the public health function has developed significantly due to:
the greater complexity of organisations and their increasing need for good information upon which to base decisions;
the changing nature of organisations as they evolve and adjust to a changing political and societal climate;
heightened public expectations and wider public access to information, specifically informing views about the risk to public health from various hazards.
Given this context and the need for a strong public health function for the next century, the major challenges are to:
improve further our understanding of health and well-being;
clarify the role, responsibilities, authority and accountability of sectors, organisations, professionals, communities and individuals in health improvement;
ensure that the professional public health workforce has the capacity and capability to respond appropriately to the expectations placed upon it, and react flexibly to continued contextual change;
make the very best use of Scotland’s public health professionals by providing appropriate context and support to enable them to play a leading role in the effort to improve Scotland’s health;
work in partnership in a concerted effort to tackle health inequalities and develop a common public health agenda at national, regional and local level, making "the effort count" in achieving tangible improvements in Scotland’s health.
To ensure that Scotland has a robust public health function, the Minister for Health, in the autumn of 1998, invited the Chief Medical Officer (CMO) to lead a comprehensive review. While the review is focused on public health medicine and public health dentistry, the wide range of individuals, organisations and agencies contributing to the public health function is reflected in the detail of its remit and in the membership of the Steering Group charged with taking it forward (Appendix 1).
The remit of the review is "to re-assess the role, relationships and locus of public health medicine and public health dentistry to ensure the optimal use of all available resources in the drive to safeguard and improve Scotland’s health".
Within this remit it was anticipated that the review would address the following issues in relation to the public health function:
The implications of the Green Paper Working Together for a Healthier Scotland and the White Paper Towards a Healthier Scotland including reference to the importance of joint work with local authorities;
The implications of the White Paper Designed to Care with particular reference to the role of public health medicine in the working relationships between Health Boards and the new National Health Service (NHS) Acute and Primary Care Trusts, its involvement in the work of the Trusts and Local Health Care Co-operatives (LHCCs), and the lines of accountability and performance management;
The implications of the Acute Services Review, with its emphasis on managed clinical networks;
The implications of the changing NHS environment for public health dentistry;
The linkages, inter-communication and working relationships between various elements of the public health network in Scotland, including The Scottish Executive Health Department (SEHD), Directors of Public Health (DsPH), Consultants in Public Health Medicine (CsPHM), Consultants in Dental Public Health (CsDPH), Office of Public Health in Scotland (OPHIS), the Chief Scientist’s Office (CSO) and relevant CSO units, the Scottish Centre for Infection and Environmental Health (SCIEH), the Information and Statistics Division (ISD), Academic Departments of Public Health and Dental Public Health, the Health Education Board for Scotland (HEBS) and other health promotion agencies;
Linkages and working relationships between NHS and non-NHS bodies and agencies, with particular reference to the context established by the White Paper Towards a Healthier Scotland and the involvement of all individuals, organisations and agencies concerned with safeguarding and improving Scotland’s health;
The use of health-related information for surveillance, the deployment of information technology and the development of epidemiology in Scotland, so as to capitalise on existing databases and registries, population surveys and research strengths, including consideration of the genetic correlates with health and disease;
The strength of the academic base in Scotland and the full realisation of the research and development potential provided by collaboration between Academic Departments of Public Health (and other relevant academic departments), HEBS, Medical Research Council (MRC) units, CSO and related units, the Clinical Resource and Audit Group (CRAG), ISD and the other relevant elements within and outwith Scotland;
Prioritisation of the research and development agenda in Scotland so as to identify and address needs and capitalise on strengths;
The implications of current and emerging concerns relating to transmissible disease (e.g. variant Creutzfeldt-Jakob Disease, E-Coli O157, immunisation programmes, HIV/AIDS, antimicrobial resistance);
The training, recruitment and development needs of the public health workforce and the extension of multi-disciplinary team working;
The relationship between Scotland, other parts of the UK and the wider international community in terms of public health organisation and development.
To discharge this wide-ranging remit and inform its considerations, the Steering Group decided to consult as widely as possible, seeking the written views of all those with public health interests. The 133 written responses proved exceptionally helpful as did the overview, commissioned from the York Health Economics Consortium. The report of the York group will be available separately. The Steering Group took oral evidence from key groups and individuals at its meetings (see below) and its exploratory seminar in Stirling on 15th January 1999 was attended by individuals with a wide range of relevant interests.
Members of the Steering Group accompanied the CMO in the following series of regional and specialist interest meetings with public health professionals:
23 April 1999 – Edinburgh - representatives from the University of Edinburgh, Lothian Health, Fife, Forth Valley and Borders Health Boards
23 April 1999 – Dundee - representatives from Grampian and Tayside Health Boards;
12 May 1999 – Hamilton - representatives from Argyll and Clyde, Greater Glasgow and Lanarkshire Health Boards;
20 May 1999 - Inverness - representatives from the Primary Care Trust, Grampian, Highland, Orkney, Shetland and Western Isles Health Boards;
21 May 1999 - Ayr - representatives from Argyll and Clyde, Ayrshire and Arran, and Dumfries and Galloway Health Boards.
In addition, the review benefited from meetings in which the CMO and members of the Steering Group met the following groups and interests;
1 March 1999 - SCIEH - communicable diseases and environmental health interests.
15 March 1999 - Aberdeen – academic, research and training interests.
28 April 1999 - St Andrew’s House - public health trainees.
30 April 1999 – Edinburgh - Scottish Affairs Committee of the Faculty of Public Health Medicine (FPHM).
12 May 1999 – Glasgow – non-medical public health professional groups drawn from Health Boards, SCIEH, dentistry, health promotion, pharmacy, nursing, economics, epidemiology and generic management
14 June 1999 – St Andrews House – HEBS.
17 June 1999 – SCIEH – consultants in communicable disease/environmental health.
Themed meetings of the Steering Group considered consumer views, the White Paper Towards a Healthier Scotland, and the CMO England’s Project to Strengthen the Public Health Function. The Review also heard presentations from the Chief Executive of the NHS in Scotland, the Chairman of the Consultants in Dental Public Health group, and representatives of local government, ISD and the Scottish Committee for Public Health Medicine and Community Health.
Finally, the Office for Public Health in Scotland (OPHIS) hosted meetings in Stirling Royal Infirmary to discuss evidence for submission to the Review (4 March 1999) and consider the national public health infrastructure (11 June 1999).
The early years – public health and local authorities
The statutory origin of the public health function in Scotland lies in the Burgh Police (Scotland) Act 1892, which required the Commissioners of Burghs to:
"Appoint a Medical Officer of Health, who shall be a registered medical practitioner, registered on the Medical Register as a holder of a diploma in sanitary science, public health, or state medicine"
It was the duty of the Medical Officer of Health (MOH) to:
"ascertain the existence of disease within the limits appointed to him, especially of all infectious diseases, and to point out any local causes likely to occasion or continue such diseases, or otherwise injure the health of the inhabitants, and to point out the best means of checking or preventing the spread of such diseases, and from time to time, as required by the Commissioners, to report to them upon the matters aforesaid, and to perform any other duties of a like nature which may be required of him, as well as all duties pertaining to medical officers under the Public Health Acts".
The Public Health (Scotland) Act 1897 was a further milestone in the evolution of the public health function, giving the clear public health lead to local authorities. Based on the principle of "protection from nuisances" the Act was framed to provide the local authority with a wide range of functions to protect and improve health, and, among other things, developed the powers and responsibilities of the MOH. Until 1948, the MOH in the local authority was responsible for the isolation and treatment of people with infectious diseases in fever hospitals and for the care and treatment of indigent people in poor houses and their associated hospital wings. In addition, legislation to protect the health of mothers and children gave the MOH and local authorities considerable responsibilities for public health and well-being. This period saw the evolution of separate professional groups such as health visitors, and social workers, and the development of new services, including the school medical and dental service. After the NHS formed in 1948, public health professionals separated into employment by Regional Hospital Boards and Local Authorities. Within these arrangements, successful public health measures included the growth of integrated maternal and child services, and projects that linked primary health and social care. Public health retained responsibility for preventive services such as immunisation, health education, communicable disease control and environmental protection.
The NHS (Scotland) Act 1972 - Public health and the National Health Service
The National Health Service (Scotland) Act 1972 and the Local Government (Scotland) Act 1973 radically altered the structure of the health service and local government in Scotland. Local authorities lost their responsibility for the provision of community and public health services and the post of MOH was swept away. At the same time there was a professional convergence of "population clinicians" in local authorities, medical administrators of regional and local hospital boards, and members of academic departments into a single specialty, then known as "community medicine". Nevertheless, the importance of joint working was emphasised in the National Health Service (Scotland) Act 1978 which required Health Boards, local authorities and education authorities, in exercising their respective functions, to co-operate with one another in order to secure and advance the health of the people of Scotland.
The 1972 Act also introduced the concept of the Designated Medical Officers (DMO). Every Health Board was required to designate a medical officer or officers for the purpose of exercising assigned functions on behalf of the local authorities. The DMO, unlike his predecessor the MOH, was based in the health service rather than a local authority where his roles and responsibilities were integrated with those of the medical administrators from the former Regional Hospital Boards and Hospital Boards of Management.
But with changes in legislation came uncertainties. After 1974, separation of "community medicine" from many of the conventional levers of influence in protecting and improving health resulted in an influential group of professionals being employed in the running of the Health Service, a group whose wider role was often misunderstood. Community Medicine Specialists had varied backgrounds and experience and their corporate effectiveness and numbers dwindled in the early 1980s, as the first of a series of NHS reforms re-orientated public health resources.
The Acheson Committee of Inquiry
Prospects brightened in 1988 when the Acheson Committee of Inquiry redefined public health (Para 1). The Committee of Inquiry was established because of loss of skilled manpower from the specialty of community medicine in England and public concern following two major outbreaks of infection. The Acheson definition reflected a holistic view of health improvement and began explicitly to focus public health on the wider determinants of health. The Inquiry also signalled development of the specialty of public health medicine, its role being to prevent ill health by minimising and, where possible, removing adverse environmental, social and behavioural influences; promote health and well being; and ensure provision of effective and efficient services to restore the sick to health. The Faculty of Community Medicine of the Royal Colleges of Physicians (founded in 1972) changed its name to the Faculty of Public Health Medicine (FPHM) in December 1989.
In Scotland, NHS Circular No 1988(GEN)15 set parameters for the speciality of community medicine. It asked each Health Board to establish a Department of Community Medicine, headed by the Chief Administrative Medical Officer (CAMO) "who should have authority to ensure that an appropriate range of community medicine skills are developed, maintained and deployed effectively". The CAMO and community medicine specialists were asked to provide medical advice on public health matters to local authorities. Importantly, the circular led to the re-introduction of Annual Reports on the health status of the population of the area. The Scottish Council for Postgraduate Medical Education was commissioned to review the content of post-graduate education and training in community medicine and review the facilities available.
The effective practice of community medicine was seen as requiring broad medical knowledge, experience of epidemiology and the principles of health promotion, and an understanding of how these principles may be applied to allow health and other public authorities to discharge their health and health service responsibilities. The circular identified the following tasks for community medicine specialists:
determining and interpreting the health status of the population and the factors which have a bearing upon it;
identifying the requirement for health care as a basis for promoting and planning health service provision;
monitoring and improving the efficiency and effectiveness of the service;
developing medical information services to help determine the health status of the population and support service planning and management;
promoting health through health education, vaccination and immunisation, screening services, and preventive measures generally;
identifying and controlling outbreaks of communicable diseases in co-operation with others;
identifying the effects on the population of adverse environmental factors; and
providing advice on medical manpower planning, postgraduate medical education, and the planning of health service buildings.
The specialty of public health medicine, as it became known throughout the UK, had the same terms and conditions of service as other medical specialties, and accredited practitioners were designated "Consultants in Public Health Medicine" (CPHM). In Scotland the CAMOs also took the title of "Director of Public Health" (DPH) and from 1994 most were appointed by the Secretary of State to be Executive Directors of Health Boards.
Dental public health
The first recognised reference to dental public health in the UK was a paper by William Macpherson at the annual conference of the British Dental Association in 1885 on "Compulsory Attention to the Teeth of School Children" which described the appalling epidemiological evidence of childhood dental decay. He advocated establishment of a school dental service and initiated the first working group on children’s oral health. School dental services were the responsibility of the local authority, dental staff being responsible to the MOH.
It became widely recognised that dental decay had reached epidemic proportions in the UK. Not only did many children exhibit rampant dental disease, many of the young potential recruits for the Boer war were rejected due to "loss or decay of many teeth". The war office made dental public health recommendations saying that oral hygiene instruction should be given in schools, daily cleaning should be enforced by parents and teachers and that there should be a systematic inspection (screening) of children’s teeth by dentists and school authorities.
Dental public health continued to develop within the school dental service and within dental schools. In 1974 following restructuring of the local authorities and the NHS in Scotland, all dental staff were transferred from the local authority to the Health Service. The post of Chief Administrative Dental Officer (CADO) was created in each Health Board to advise health boards on planning of services, dental public health, and to manage the community dental services. This was not a recognised specialist post but heralded the clear intention to move towards that position. In 1992 Consultants in Dental Public Health were first appointed as specialists in parts of the UK, a change which occurred in 1997/98 in Scotland. Initially they managed the community dental service, becoming the dental public health advisers to Health Boards with the purchaser-provider split. The CADO posts were slowly phased out except in the Island Health Boards where postholders have a role to manage the community dental service and advise the Health Board on dental public health matters.
Public health in the 1990s
The importance of action for health was given a further boost with the publication in 1991 of Health Education in Scotland: A National Policy Statement, followed in 1992 by Scotland’s Health – A Challenge to Us All. These documents laid unprecedented emphasis on promoting good health and preventing illness and disease and recognised the influence which lifestyle behaviours had on health. The importance of multidisciplinary working in public health became clear; for instance, the drive for cost-effectiveness in the Health Service signalled the need for health economics input.
Following the white paper Working for Patients Scotland’s public health doctors and dentists worked within the context of the NHS purchaser-provider split. The Shields Report Commissioning Better Health (1996) set out the roles of Health Boards and, effectively, the context in which public health medicine and other public health specialists should undertake the functions described in 1988(GEN)15. The Report also provided the basis for including public health medicine in management costs, giving rise to persisting controversy in Scotland about effects on the discipline. It did not specifically cover dental public health or the role of consultants in dental public health in Health Boards.
The 1997 shift of government policy to reflect increasing awareness of the importance of the nation’s health and well-being provides real prospects for driving significant improvement. The White Paper Towards a Healthier Scotland reaffirmed the crucial role of public health medicine in health improvement. This document, together with the White Paper Designed to Care and the Acute Services Review, provides the backdrop for this review of the public health function.