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This reflected the impact of rapid industrialization and urbanization which led to poor neighbourhood and housing environments, occupational health risks in unregulated workplaces and heightened prevalence of communicable diseases, including tuberculosis, typhoid and cholera. Social reform came in steps. In , councils were empowered to appoint an MOH and improve urban hygiene; Public Health Acts in the s further strengthened local departments. In , Edwin Chadwick's report convinced many of the need for sanitary investment, even though the germ theory was not yet understood Fig.

From , civil registration of deaths gave local policymakers data on rates of mortality by age, sex, cause and place. By then, the social and health responsibilities of local government had expanded to include a wider range of actions than is covered by current NHS public health practice. London Sewer Construction in Bow, The public health service in its Victorian phase is associated with major capital projects, authorized and resourced by elected councils.

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Many factors, such as improved nutrition, female education and smaller families, also contributed to better population health. Yet evidence suggests at least some of this improvement should be attributed to the local public health service, with its broad range of environmental and medical services integrated under the MOH Fig. The local executive power of the MOH, the town's figurehead for public health, is projected here as paternalist reassurance.

Around him are represented health duties integrated with other municipal activities including housing, education, social care, regulation of commerce and business, as well as cure and prevention.


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With the establishment of the NHS, the size and scope of public health departments were substantially reduced, as Regional Hospital Boards took control of hospitals, and universal access to primary care was introduced. Between and , local government health departments typically retained a separate identity, with a staff of environmental and clinical medical officers, and health visitors and home nurses to supply community services.

The framework for local delivery outlined at the NHS's creation bore many similarities to that enacted for public health in Today, local public and environmental health departments continue to be involved not only in food and air quality, but also housing, urban planning, transport and other policies that affect environmental and social determinants of health. In both the early and current NHS, voluntary organizations were incorporated as providers of community services. Integration of local government with NHS functions has always been vital, and like earlier MOsH, the DsPH must ensure joint working, whether as representatives on NHS bodies, or local authority leads on joint processes, such as joint strategic need assessments.

Only public engagement, underpinned today by Local Healthwatch Organizations, differed, in that existing democratic processes were previously thought sufficient. Why then were these restructured local government public health departments so short-lived? Their abolition came in the NHS reform, with the creation of a hierarchy of regional and local health authorities and the disappearance of the MOH role.

Declining morbidity and mortality from infectious diseases meant that health concerns lost their importance within environmental and housing policy.


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Local government's public health role was also eroded by an expanding welfare state. Then, following the Seebohm Report of , social care was removed from public health's remit and conferred on Social Services Departments, staffed by a new profession: social workers. Another structural challenge faced by local public health was integration with the NHS.

Finally, historians suggest that local public health departments failed to establish a coherent philosophical and disciplinary underpinning for their work in an era of epidemiological transition.

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Most MOsH continued to focus on tackling communicable diseases and health service administration. Thus, the health advocacy and behaviour change agenda was increasingly set elsewhere. For example, local health education on tobacco consumption was limited, and the issue increasingly taken up by national government and voluntary organizations. So, what issues does this history raise for public health in local councils today?

A secure executive position independent of vested interests was the historic basis for MOsH in sustaining political and community relationships and the adoption, if necessary, of politically controversial positions. In the current transition, many factors will influence the impact of public health in councils Fig. Despite DH guidance that DsPH should be part of the senior management structure, examples already exist of DsPH appointed subordinate to other directors with public health teams part of other directorates including adult and children services.

Bevan's concern was that devolved power did not lead to virtuous localism but rather to spatial unevenness, with inadequate performance in poorly resourced areas. The current focus on localism makes this still a continued threat.

Public health budgets have been initially ring-fenced, with a recent increase in funding for those local authorities with the worst socioeconomic conditions. For the first time since , councils will be required to commission new public health services traditionally delivered by the NHS, including sexual health and individual health checks. Historically, local councils are well placed to commission and deliver these community services. DPHs will also need to ensure public health priorities remain embedded across other local organizations, such as primary care under the clinical commissioning groups CCGs , and improving the strategic coordination of commissioning across NHS, social care and related services through Health and Wellbeing Boards.

The main mechanisms to foster local joint working include the development of joint strategic need assessments and health and wellbeing strategies. DPHs also have a role in monitoring national bodies delivering PH services locally, for example, the role of Public Health England delivering screening and immunizations. The importance of these different mechanisms, and the scale of the coordination task for public health, needs to be acknowledged and prioritized by local council and health leaders if the failings of integrated working in the early NHS are not to be repeated.

In addition, public health practitioners face the challenge of developing or strengthening relationships internally, across a range of local government directorates, from housing, planning and transport, to alcohol licensing, to better tackle the health inequalities agenda within social and environmental policy. Historically, the annual report was the opportunity for MOsH to make public their review of local population health needs, and set the agenda for health policy, services and resources.

Since their post-Acheson reinvention, researchers have discovered both good and bad reporting practice. National politicians fully accept that prevention is a health priority Fig. This needs to draw together both public health practice and research, and provide a basis for political action to address today's priorities. This will require more relevant indicators to monitor local public health progress and success, which will need to respond to local political priorities as well as the DH's Public Health Outcomes Framework Fig. Public Health Outcomes Framework.

The aim is to increase transparency and responsibility. The Framework has a vision, two overarching outcomes and four domains as follows: Vision: to improve and protect the nation's health and wellbeing, and improve the health of the poorest fastest.

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Outcome 1: increased healthy life expectancy: taking account of the health quality as well as the length of life. Outcome 2: reduced differences in life expectancy and healthy life expectancy between communities: through greater improvements in more disadvantaged communities. Objective: improvements against wider factors that affect health and wellbeing, and health inequalities. Objective: people are helped to live healthy lifestyles, make healthy choices and reduce health inequalities. Objective: the population's health is protected from major incidents and other threats, while reducing health inequalities.

Objective: reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities.? Martin Gorsky was funded by a Wellcome Trust 5-year award, ref. Funding to pay the Open Access publication charges for this article was provided by the Wellcome Trust. National Center for Biotechnology Information , U. J Public Health Oxf. Published online Jan Author information Copyright and License information Disclaimer.

Address correspondence to Karen Lock, E-mail: ku. This article has been cited by other articles in PMC. Abstract This article uses history to stimulate reflection on the present opportunities and challenges for public health practice in English local government.


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Keywords: public health, government and law, health services. Public health before the NHS Health and social welfare functions in English local government extend back at least to Tudor times, when parishes were given responsibilities for poverty and the environment.

Open in a separate window. Public health in early NHS —74 With the establishment of the NHS, the size and scope of public health departments were substantially reduced, as Regional Hospital Boards took control of hospitals, and universal access to primary care was introduced. Implications for current local public health practice So, what issues does this history raise for public health in local councils today? Leadership A secure executive position independent of vested interests was the historic basis for MOsH in sustaining political and community relationships and the adoption, if necessary, of politically controversial positions.

Issues of public health leadership in transition to local government. Funding Bevan's concern was that devolved power did not lead to virtuous localism but rather to spatial unevenness, with inadequate performance in poorly resourced areas. Public health service delivery For the first time since , councils will be required to commission new public health services traditionally delivered by the NHS, including sexual health and individual health checks.