What is Public Health?

Author: Georgina Moulton (georgina.moulton@manchester.ac.uk)

Acknowledgements: HealthKnowledge syllabus and content

What is the first issue you think of when considering Public Health?

Is it the cholera epidemic in 1800s?  Or, the obesity epidemic in the noughties?

Public Health is something that we come into contact with every day of the week.  Just be reading the headlines of the newspapers we know what the current issues are with regards to the individuals and populations health; who will be affected, who and how it can be improved; and who disagrees.  In May 2011, the following headlines are around:

‘Five cups of coffee a day could beat breast cancer’

‘Caesarean risk: New research finds C-section babies are more likely to become obese in later life’

The newspapers and other published articles in journals, magazines and on the internet can influence our behaviour by how they are reported.

The foundations of Public Health start in 19^th Century. John Gaunt (the father of epidemiology) analysed statistics of the mortality data.  The bills of mortality were issued weekly for London parishes detailing the number and causes of death.  His epidemiological work laid the foundations for statistical writings that served the basis for the great sanitary reforms of the 19th century.  Epidemiology is the science that underpins public health.

One of the first public health was the cholera epidemic.  Many theories had been formulated for the cause of this including the ‘bad air’ theory, but in 1849 John Snow published the “The Mode of Communication of Cholera”, where he discussed that cholera was spread through contaminated water rather than bad air.   He proved his theory through the investigation of the Broad Street pump in Soho towards the end of 1854.  Eventually the pump was removed and the number of cases diminished.  This discovery was the end of cholera in Britain.

This work, plus many more in the 1800s, lead to a number of Government Acts that improved the quality of environment and health of the population.

Public Health Definition

The definition of health from the World Health Organisation changed between 1948 and 1984 from:

“A state of complete physical, mental and social well-being and is not merely the absence of disease or infirmity.” to

“The extent to which an individual or group is able to realise aspirations, satisfy needs and to change or cope with the environment “

Although quite aspirational, these definitions reflect that health is not just concerned with the healthy wellbeing of a person, but also their social-wellbeing; and in 1984 there is a move away from looking only at individual health, but also the health of the population.  In the UK particularly, we have developed a healthcare framework that provides services to address health and social care for the individual and population.  The NHS ranges from primary care to secondary care and community based.

Public Health has been defined by Chief Medical Officers as:

“The science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society” (Acheson 1988 in the Public Health in England report)

“Public health is concerned with improving the health of the population, rather than treating the diseases of individual patients.” (Chief Medical Officer)

Both statements highlight the importance of improving and not just treating the populations’ health, but also that this cannot be achieved alone and that society must share the responsibility.

The Faculty of Public Health sets to implement this through “assuring an effective public health workforce, promoting public health knowledge and advocating for the very best conditions for good health.”

How we view and the indicators we use to determine the health of an individual and the health of the population are highlighted in the table below.

	Individual	Population
History	Symptoms of illness	Indicators of population health
Examination	Signs of illness, bio- chemical tests	Surveillance, epidemiological information, Health Needs Assessment
Diagnosis	Label to describe what has gone wrong	Key health issues
Prognosis	Outlook associated with individual disease	Outlook associated with trends and disease patterns
Treatment	Individual interventions	Population based interventions, Health Protection, screening, Vacc & Imm, NSFs

Public Health Functions

The main functions as defined by the (Faculty of Public Health) of public health are: (1) health protection; (2) health and social care; and (3) health improvement.  Most people are familiar with the idea of public health professionals of helping improve the nations’ health through the promotion and encouragement of healthy lifestyles (e.g., stop smoking; 5-a-day or increase in exercise) through the consideration of individuals wider determinants of health (figure x). These include: lifestyle factors such as drinking and smoking; social and community influences (e.g., does the community feel safe?); living and working conditions, for example. If houses are damp this could exacerbate asthma; and socioeconomic factors such as air pollution, unemployment levels.

However, public health also focuses on managing environmental health and communicable disease, emergency planning and disease and injury prevention. As well as considering the effectiveness and quality of healthcare interventions and services.  It will investigate whether the deployed resources are the best to meet the population needs; ensure that clinical guidelines are in place; audit and evaluate the services; and service planning via the commissioning cycle.

A large part of the Public Health agenda revolves around decreasing inequalities in health.  In February 2004, the Wanless Report highlighted the effect of socio-economic inequalities on health outcomes in the UK.  He stated that the “Persistent socio-economic inequalities in the UK, combined with a greater severity of market failures affecting lower socio-economic groups, seem to have contributed to significant inequalities in health outcomes which, unless tackled, will present a significant barrier to many in society becoming ‘fully engaged’”.

There are targets to reduce the differences in Life expectancy and Infant Mortality rates. These are often closely associated with deprivation.  For example, in the  NW, the health of people in Stockport, Flyde and Cheshire East is better than the national average while the health of people in Manchester, Knowsley, Liverpool are generally worse. One of the biggest factors for inequalities is premature CHD deaths. This is often something Public Health teams will target in an attempt to reduce inequalities.

A number of actions can be executed in order to reduce health inequalities:

•         Working with parents and children to influence their future health

•         Improving access to care

•         Tackling major killers (e.g., CHD and cancer have a large influence on overall inequalities in mortality and ill health)

•         Tackling the wider determinants of health through partnership working

Key Policies that have Influenced Public Health

Along with Wanless, there are a number of key papers and policies that have influenced the focus and development of public health.  The figure above shows the key polices since 1976 to the present day.  Before the late 1990s reports and white papers where relatively infrequent. However, with the drive of improving the NHS from the Labour Government, the number proliferated in conjunction with the increase in financial resource.  These focused on improving the nations’ health by providing ..  In fact the Wanless Report stated that “in order to meet people’s expectations and to deliver the highest quality over the next 20 years, the UK will need to devote more resources to health care and that this must be matched by reform to ensure that these resources are used effectively.”

Each of these policies or initiatives had an impact on public health.  However, the largest change in the NHS and Public Health is yet to come with the publication of the Liberating the NHS White Paper (see article Changing Landscape in PHI).

All these white papers lead to a shift in how the NHS functions from a reactive service to a proactive service where the patient has responsibility for his/her own health and treatment is driven by the health needs of the local community and is delivered at the primary care level rather than the hospital (see table below).

Earlier decades	21st century
Treatment emphasis	Public Health emphasis
Demand led priorities	Needs-driven priorities
Hospital care centred	Primary Care Centred
Provider dominated	Consumer empowered
Professional opinion and therapeutic fashions	Evidence-based standards