The origins of local government and public health
Dr John Ashton, Joint Director of Public Health for NHS Cumbria
Thirty-six years ago the British public health system, which had been rooted in local government for more than 100 years and copied around the world, was taken apart in a wholesale reform programme.
How that system evolved and why it was so important for it to be based within the remit of local authorities has been poorly understood by its NHS custodians in the intervening years. They have too frequently neglected to pay attention to the wider determinants of health and have concentrated too little on the preventive medical transactions which should be part of the bread and butter of decent modern healthcare. As a result, we have no robust and responsive public health system which we can depend upon to make any significant difference to the inequalities in health, life chances and wellbeing. This failure blights this country's claim to be a modern, progressive democracy.
The origins of Victorian public health lie in the slums of Liverpool and other industrial towns of the north. In the 1840s, the cholera outbreaks not only killed thousands but were bad for business, and the disease also affected the more salubrious areas. Until this point, the town council in Liverpool had been little more than a gentleman's club, elected by an urban elite of property-owning males, meeting in the splendour of their Palladian villa town hall to discuss the price of cotton, tobacco and corn. It had few civic powers over the conditions of life, health and wellbeing of the proletariat.
The cholera outbreak changed this dynamic in Liverpool and in towns and cities across the nation over the next 20 years. Civic leaders, including business, the church, and typically the local press, became involved in mobilising local assets and resources for sanitary reform. Water, sewers, paved streets and refuse collection were followed by a focus on housing and town planning.
The success of local government in defending the health of its citizens not only led to enhanced legal and fundraising powers but to enhanced credibility. Over time the range of local government provided services became formidable - from public wash houses to parks and gardens; from corporation housing to museums and libraries; from running markets to supplying gas, water and electricity and providing tramways; from schools, social services, health visiting to abattoirs, hygiene inspection and bacteriological analysis. Even in some places municipal hospitals. So successful were local authorities in providing direct services that many have come to think that that is the core business of local government losing sight of its role in providing leadership and mobilising and enabling communities.
Fortunately the recent publication of the Marmot report and the Local Government (LG) Improvement and Development (formerly IDeA) report on 'Social determinants of health and the role of local government' provide us with a route map of the way back.
I believe it is time for local government to step up to the mark once again and show what it is capable of. However, in doing so it must do what it often finds hardest: to set aside its institutional self-interest in favour of that of its public. We desperately need reform and a strengthening of local government so that good people with a range of experience put themselves forward for office and it is seen again as a highly desirable way of putting something back and making a difference.
Decentralisation must now take place but the appropriate levels for action need to be made explicit. It is my view that all strategic public health functions need to be brought together at the county level (policy, intelligence, specialist expertise, health protection, environmental health, health and safety, research and development) with the operational level being embedded at the district and neighbourhood levels. Primary health and community care need to broker very strong partnerships with citizen-led associations in much the same way that we need local accountability through the ballot box.
We have face significant challenges ahead. It is my guess that future generations will judge us by whether we are as effective at responding to an ageing population and the increase of dementia as the Victorians were at responding to an exploding population and the outbreak of cholera. Surely local government is once again the key.
23 November 2010