British Medical Journal

August 29, 1998

Public health.(Recent Advances)

Author/s: Gabriel Scally

Identifying particular advances in public health is difficult because, in the final

analysis, success can be judged only by improvement in the health of a population.
Progress is rarely, if ever, a matter of developing a technical intervention and
applying it. Population health is determined by a complex mixture of genetic,
environmental, and social factors, as well as individual behaviour. Achieving progress
not only relies on altering a complex situation but is often something that can be
judged only over a period of years (or decades) rather than months. Clearer
understanding of the determinants of health and ill health, better control of hazards
to health, and earlier detection or improved treatment of established disease are the
building blocks of gains in public health. In keeping with the broadening scope of
public health practice, the skill base of the workforce is developing beyond medicine,
particularly in the applied social sciences.

Methods

This paper was based on personal experience in public health, the contemporary
public health literature, and the comments of respected colleagues. The literature
search had been undertaken during the preparation of a recent book.[1]

Life course epidemiology

The prime targets for preventive action in recent decades have been the chronic
diseases that are the major causes of mortality in developed countries. The approach
adopted has largely been based on the understanding of risk factors for these
diseases and has focused on changing the behaviour of adults, particularly in the
areas of smoking, exercise, and nutrition. A major challenge to this approach has
come from the work of David Barker and colleagues who have postulated that the
development of chronic disease in adulthood is programmed before or shortly after
birth.[2] As supporting evidence has emerged, the initially sceptical response to this
thesis has given way to an acceptance of the importance of fetal and early life
influences. Interest in long term cohort studies has been reawakened in the public
health research community, resulting in the disinterring of long neglected maternal
and child health records and in the recognition of the importance of contemporary
cohort studies.

The results emerging from this epidemiological endeavour may well have profound
implications for public health policy. The current concentration on reducing risk
factors in adults is likely to be tempered by a growing emphasis on the antenatal and
early life period.[3] This life course approach will not be without its difficulties.
Concern has already been expressed that promoting lifestyle change among adults
can turn into "nannying" At a time when women are increasingly seeking to have a
greater degree of control of the health care they receive during pregnancy, medical
concentration on antenatal interventions of various kinds aimed at the long term
prevention of adult chronic disease is now possible. However, it is also possible that
attention will be diverted from important problems, such as smoking and obesity in
adults, where much remains to be done.
Information

Information on the incidence and prevalence of disease in the community is crucial to

the practice of public health professionals. The importance of quantitative study of
population health was recognised by William Petty and John Graunt in the 17th
century,[4] and, if anything, this importance is increasing as we grapple with the
major non-communicable diseases such as coronary heart disease and stroke. The
backbone of public health information is the registration of life events, particularly
births and deaths, and these data continue to underpin much of our contemporary
understanding of population health. However, we have a strong tradition of
population surveys, of which the most important recent addition (1991) is the annual
health survey for England. This survey collects both questionnaire and clinical data
from those over 2 years of age in a random sample of households in England. The
large size of the sample (11 766 households in 1996) and the relatively high
response rate (79% in 1996), together with expert analysis, have made this survey
an outstanding innovation in public health intelligence.[5] Despite the coverage of
important health problems such as the prevalence and control of hypertension and
diabetes, as well as the collection of valuable data on the use of health services, the
health survey for England remains an under utilised resource.

The European dimension to public health activity is being increasingly recognised as

one of the major future influences on public health policy and practice.[6] Welcome
signs exist that the issue of the surveillance of non-communicable disease is being
taken seriously within the European Union. The Commission has identified the sum of
13.8 million ECU to establish a Public Health Observatory, which will undertake
disease surveillance across the European Union. This has enormous potential for
supporting the growing level of European involvement in public health issues.

Screening

The origins of population screening have been attributed to events at the beginning
of this century when, in the aftermath of the Boer War, steps were taken to improve
the health of British children and therefore, in due course, of recruits to the British
army. It was not until the 1960s that a satisfactory framework was developed for the
consideration of the ever growing number of propositions for screening tests and
programmes. The Wilson and Junger criteria, which cover key requirements--for
example, that the condition should be an important health problem with an accepted
treatment--have stood the test of time, although it has been suggested that they
need to be supplemented to deal with issues of resource use and opportunity cost.[7
8] The practical difficulties of applying the criteria, however, have highlighted the
necessity of developing a consistent and scientifically based approach to decision
making in relation to screening programmes. The formation in England of a National
Screening Committee to provide advice across the whole gamut of possible screening
programmes is an important advance. One of the first substantial products of that
initiative has been a recommendation that screening for prostatic carcinoma should
not be introduced.[9] Recent revelations in England of serious deficiencies in the
local provision of screening for both breast and cervical cancer have re-emphasised
the fact that the quality of these public health activities cannot be taken for granted
and must remain a key concern of public health doctors.

Tobacco control
The decision of the European Union Council of Ministers in December 1997 to support
a proposed directive banning tobacco advertising, promotion, and sponsorship has
been acclaimed as a major and long awaited breakthrough. Smoking remains the
single greatest cause of illness and death in the developed world, and tobacco
control should therefore be at the forefront of public heath endeavour. In recent
years, not only has progress in reducing tobacco consumption in the developed world
been disappointingly slow but the growth of consumption in the developing world has
been alarming.

It was as long ago as 1992 that an authoritative report from the Department of
Health concluded that advertising has the effect of increasing consumption and that
the introduction of advertising bans produced reductions in smoking.[10] The
previous lack of concerted effort at intergovernmental level in western Europe on the
important issue of tobacco advertising has been disheartening for many health
professionals and has been an obstacle to those activists seeking to build concerted
action.

While it is important to develop a comprehensive international strategy for tobacco

control, the next big battleground for anti-tobacco campaigners is likely to be in the
area of non-smokers' rights. The publication in late 1997 of conclusive research
evidence highlighting the powerful causal relation between environmental tobacco
smoke and ischaemic heart disease and lung cancer indicates that the further
restriction of smoking in indoor environments should be a major public health
priority.[11 12] The achievement of the right of individuals to work and enjoy leisure
without having to breath tobacco smoke is likely to be the most important advance in
coming years.

Management of clinical innovation

An important strand of public health activity has always been involvement in the
organisation and planning of personal health services. In his famous monograph,
Effectiveness and Efficiency, Archie Cochrane recounts being told by a very
contented crematorium worker that he was fascinated by the way in which so much
went in and so little came out.[13] Cochrane considered advising him to get a job in
the NHS, where this was even more true. The task of getting more improvement in
health out of the health service at a time of apparently ever more constrained
resources has, however, been the subject of a well constructed and impressive
strategy aimed at producing just the increase in effectiveness that Cochrane desired.
The development of a research and development programme for the NHS has been
the foundation of this strategy. As a result, increased priority and substantially
increased resources have been devoted to health services research in the United
Kingdom. This effort has engaged not just public health practitioners but many in the
wider clinical community. The "products" of this research effort are beginning to
appear and have the potential to change practice in important ways. The growing
field of health technology assessment has become recognised as an important skill
area and has, for example, helped marshal the evidence base to inform decisions on
screening. The days of new drugs, techniques, or equipment being sprung on an
unsuspecting and ill prepared NHS are now numbered, if not yet completely over.

Three important elements have underpinned the development of the move towards
more effective health care in the United Kingdom. Firstly, the growth of institutes or
centres with the academic skills to review systematically research evidence in order
to increase its accessibility and relevance to those making clinical and managerial
decisions. These have often been based on academic departments of epidemiology
and public health and undertake commissioned work for the NHS. The second
element is the various "effectiveness products" that flow from the different centres
and constitute the major source of information to the NHS on clinical innovation.
These products are usually based on careful synthesis of research evidence.
Typically, they cover not only clinical effectiveness but cost effectiveness, and inform
directly public health practitioners in health authorities and boards faced with difficult
and often politically sensitive commissioning decisions. The development of critical
appraisal skills among those considering research evidence has been the third
important advance in this area. While elements of these skills have always been
included in the training of public health professionals, skill reinforcement and
diffusion into the wider clinical community has been a central element of
developmental approaches in this area. The continuing growth in the emphasis on
quality of clinical services, along with the newly developing concept of clinical
governance, will ensure that public health practitioners continue to have an
engagement with personal health services as well as the broader social and
environmental agenda.[14]

Funding: None.

Conflict of interest: None.

[1] Scally G, ed. Progress in public health. London: Royal Society of Medicine Press,
1997.

[2] Barker DJP. Mothers, babies, and disease in later life. London: BMJ Publishing
Group, 1994.

[3] Kuh D, Ben-Shlomo Y. A life course approach to chronic disease epidemiology.

Oxford: Oxford University Press, 1997.

[4] Prescott-Clarke P, Primatesta P. Health survey for England. London: Stationery

Office, 1998.

[5] McKee M, Mossialos E. Public health and European integration. In: Scally G, ed.
Progress in public health. London: Royal Society of Medicine Press, 1997.

[6] Graunt J. Natural and political observations mentioned in a following index, and
made upon the bills of mortality. London: Roycroft, 1662.

[7] Wilson JMQ, Junger G. Principles and practice of screening for disease. Geneva:
World Health Organisation, 1968.

[8] Gray JM. Screening: challenge to rational thought and action. In: Scally G, ed.
Progress in public health. London: Royal Society of Medicine Press, 1997.

[9] NHS Executive. Population screening for prostate cancer. Leeds: NHS Executive,
1997. (EL(97)12.)

[10] Smee C. Effect of tobacco advertising on tobacco consumption. London:

Department of Health, 1992.

[11] Law MR, Morris JK, Wald NJ. Environmental tobacco smoke exposure and
ischaemic heart disease: an evaluation of the evidence. BMJ 1997;315:973-80.
[12] Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung cancer and
environmental tobacco smoke. BMJ 1997;315:980-8.

[13] Cochrane A. Effectiveness and efficiency. London: Nuffield Provincial Hospitals

Trust, 1972.

[14] Donaldson L. Clinical governance: a statutory duty for quality improvement. J

Epidemiol Community Health 1998;52:73-4.

(Accepted 6 May 1998)

RELATED ARTICLE: Recent advances

Large sample size and the relatively high response rate have made the annual health
survey for England an important development in public health intelligence

The European Commission is establishing a Public Health Observatory for disease

surveillance across the European Union

In England, the National Screening Committee will provide advice on possible

screening programmes

The recent European Union decision to support a ban on tobacco advertising,

promotion, and sponsorship is a major breakthrough

Development of a research and development programme for the NHS is the

foundation of a strategy to increase efficiency and effectiveness at a time of
constrained resources

Emphasis on the quality of clinical services and clinical governance is growing

Editorials by Alderslade, Palmer Education and debate pp 587, 592, 596

NHS Executive South and West, Bristol BS12 6SR Gabriel Scally, regional director of
public health

gscally@dohgov.uk

BMJ 1998;317:584-6

COPYRIGHT 1998 British Medical Association

in association with The Gale Group and LookSmart. COPYRIGHT 2000
Gale Group

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