Select Committee on Health Appendices to the Minutes of Evidence


Letter from the Secretary of The Nuffield Trust to the Clerk of the Committee (PH 59)

  I note that you are conducting an Inquiry into Public Health. I enclose a copy of:

    —  an editorial written by myself, published earlier this year; and

    —  the proceedings of a meeting which The Nuffield Trust organised in Oxford to consider whether we need a new Public Health Act.

    I hope that this material will be of interest to the Committee.

10 July 2000


Challenges to public health in the new millennium

  Of all the medical specialities, it is public health that by its very nature is most affected by political, social and economic changes. Therefore the challenge to public health in the new millennium will be deciding how to adapt to the simultaneous changes in all these areas created by the forces of globalisation. Diseases will travel faster than ever before, as will the information (and misleading pseudo-information) about how to treat them. Information and mobility will bring great wealth to some and the troubles of the very poor, especially their health problems, closer to all of us. Existing political power structures will be challenged by the power of big business and, perhaps, small organisations, ranging from legitimate and well-meaning pressure groups to terrorist organisations, newly empowered by modern information technology. International organisations such as the European Union, will develop as an attempt by nation states to rescue their power by sharing it.

  The last great paradigm shift in social development was the industrial revolution of the 19th century. The transformation of an agrarian, socially stable society with little political or physical mobility into an urban society on the move in every sense, which was most noticeable in the United Kingdom but was mirrored throughout much of the world, shares many parallels with the impact globalisation will have. Back then the UKs 1848 Public Health Act and its successors were the finest examples anywhere of public health helping to shape a social transformation in a humane direction. The UK can once again take a lead in this by asking "do we need a Health of the People Bill?" Despite the gathering pace of globalisation, nation states still for the moment have the capacity for meaningful action and leadership.

  The approach to public health established by the 1848 Act, as well as by other Acts introduced in the last century, certainly led to dramatic improvements in the health of the people. These Acts have continued to be effective in both preserving and promoting health even though there have been major changes in the structure of central and local government, the introduction of an NHS and the privatisation of such fundamental public health provisions as water supply and sewerage. But with devolution, European law and changes in disease occurrence and demography, the laws governing public health need updating and tidying up. In a democracy it is actually important to know who is responsible for what. No one should be able to avoid blame and no one should be required to accept blame for matters that are beyond their control. We have come close to that on recent occasions.

  The determinants of health had, on the whole, little to do with the health service, and public health has been over medicalised in many countries. Local authorities in particular play a crucial part. The assessment of the lessons from The Health of the Nation are that local authorities were undervalued and marginalised and it is clear that these lessons have been learned by the present government. A positive health approach with local strategies, locally owned, offers a way of getting local government and local people more actively engaged in a public health agenda.

  To improve and maintain health requires international and national co-ordination because the factors that influence health know no boundaries and although the needs of different areas, for example, urban and rural, will vary, central co-ordination and leadership is crucial.

  Furthermore, devolution in the United Kingdom—a feature of many other countries—has led to the establishment of a Scottish Parliament and a Welsh Assembly with significant devolved law-making powers and in Scotland "including overall responsibility for the NHS in Scotland and public and mental health". Beef on the bone has already been raised as early business in the Assembly and the Parliament and different practices may be adopted on either side of the English borders. These developments have important public health implications, and Canada and Australia—countries with a federal structure—can provide examples of how to tackle the problems that will certainly arise.

  In his Annual Report for 1998 the CMO for England said "The 1848 Act has a Board of Health, a high-level committee to oversee the changes proposed. Perhaps something similar would be useful now". Perhaps it would. Those attending the Nuffield Trust Christ Church workshop in July 1998 certainly thought so.

  In the United Kingdom it may also be necessary to strengthen the role of ministers—especially that of the Secretary of State for Health—in relation to those matters for which they do have direct responsibility, such as international negotiation and maintaining a broad policy overview. It is their job to ensure, whether through legislation or otherwise, that the responsibilities of the key players are clearly defined and to satisfy themselves that effective structures are in place for improving the health of the people. The Secretary of State, as the public health minister in the United Kingdom cabinet, will need clarity about their role and that of ministers responsible for public health in the nations of the United Kingdom. A high level advisory council of experts and representatives of countries and regions is needed to provide the necessary authoritative advice to the secretary of State so that he is able to give the necessary leadership. This Council must have the ability both to devise and collect the appropriate information that is crucial for the execution of policies. It must also have the power to publish and disseminate information, which may be uncomfortable for ministers, to influence public knowledge and behaviour. Recent concerns about, for example, BSE and genetically modified foods demonstrate the need for ministers to have access to public health experts and for the public to be reassured that the advice they receive is sound and independent. None of this is new and much of what we advocate returns us to the position that public health had at the end of the last century

  It is also important to distance ministers from certain matters, such as the collection and dissemination of information and statistics about the health of the people and the factors that affect it. An independent body—a commission or board acting as the champion for the health of the public and operating at arms' length from central and local government—could do much to meet those two needs, and strengthen public confidence in the public health function.

  The European Union has now firmly put its badge on public health as a subject but there is a lack of overall co-ordination of public health across the different directorates of the Commission. We also need to work out how institutions such as the WHO European Regional Office, which possesses significant resources and expertise, can be harnessed successfully to the benefit of Europe as a whole and in a way that would be both helpful and effective. If in the next few years the United Kingdom successfully develops its own public health function, achieving the right balance of harmonisation and subsidiarity in the context of Europe, devolution and the renewal of local government, it would be well placed to take the initiative and provide a lead on public health in Europe as well.

  Reprinted from Journal of Epidemiology and Community Health, January 2000, Vol 54, No 1, p 2-3.

John Wyn Owen, Nuffield Trust



Report of a workshop held at Christ Church, Oxford, on 14-15 July 1998

  (The workshop was held under the Chatham House Rule, so these notes, while recording the main points of presentations and discussion, do not mention individual participants by name.)


Background and objectives of the workshop

  The Nuffield Trust has a long standing interest in public health, the most recent evidence of which was the award of the 1997 Rock Carling Fellowship to Professor Walter Holland. Professor Holland reviewed the history and considered the challenges currently facing public health; his monograph, Public health, the vision and the challenge, written jointly with Susie Stewart, was published by the Trust in June 1998. At a seminar to discuss Professor Holland's conclusions, held at the Trust in December 1997, it was noted that 1998 would mark the 150th anniversary of the original 1848 Public Health Act, and this raised the question: what advice should be given to parliamentary counsel on drafting a possible Health of the People Bill.

  In 1998 there were a number of influences at work which the authors of the 1848 legislation did not have to take into account. Most obviously, the issues arising from the government's programme of devolution raised questions of potential for diversity and the need for co-ordination across the United Kingdom; and at the same time, the wider European dimension of public health should not be ignored. Here experience in other countries could provide useful pointers. In Australia, for example, agreement had been reached on a commonwealth Public Health Law, which the individual states had then had to find ways of accommodating, looking at local and national issues, drivers of change, human rights and ways of commonwealth and state governments working together.

  The objectives of the Christ Church workshop were:

    —  to examine the current legal framework;

    —  to consider possible improvements to this framework;

    —  to consider the need for a mechanism to co-ordinate and monitor public health policy; and

    —  to consider proposals for reform.

  The workshop was divided into two main sessions: on day one the framework for discussions was considered, with the help of expert overviews of the United Kingdom and European legal positions; on day two problems and the need for change were discussed in groups, whose conclusions were presented in plenary sessions before a final summing up discussion.


  The workshop was considering the question: how might parliamentary counsel address drafting a new Public Health Act; but underlying this was the wider question: is new legislation the most appropriate way forward? In approaching these questions, a number of areas were explored:

(i)   How is Public Health law defined at the present time?

  From the papers circulated for the workshop, it was clear that there was no currently generally agreed definition of "public health"; equally the term "law" is used with a range of meanings in different contexts; and there is no single code to refer to in resolving legal matters. Instead, law can be defined in a number of overlapping ways:

  Law defined by subject matter:

  A review of the tables of contents of Halsbury's Statutes and Halsbury's Laws showed clearly that in statute law there is no coherent recognition of public law.

  Law defined as a particular institutional form:

    Usually thought of as:

    —  legislation: primary and delegated;

    —  judicial: common law and wider judicial principles;

    —  quasi-legislation: circulars, codes of practice, guidance notes, which, though without formal legislative status, may in practice be extremely influential.

  Within this framework there are overlapping powers: for example, the public planning system includes a public health dimension.

  Law defined as powers to act:

  For public authorities, the power to act is limited by the ultra vires doctrine: in the narrow sense, this is concerned with whether a body has the power to act; in the wider sense, though a body may have a prima facie power, it may offend judicial principles to use it. For private individuals, and organisations, there is a general freedom to act unless prohibited from doing so, or limited by other private interests or by regulatory law.

  Law as the substance of what can be done:

  This is not limited to what is laid down in formal documents, but may be based on administrative practice, or what commonly happens and is defensible.

  Law as the procedures to be used:

  Procedures may be explicit in statute or quasi-legislation, or implicit in judicial principles.

  Law as control or accountability:

  Law in the public sphere is seen by some as primarily concerned with controlling public bodies and holding them accountable.

  Law as a set of values:

  A range of different values has been incorporated into the law, but there is a particular emphasis on individual rights, which will be made more explicit with the passing of the Human Rights Bill.

(ii)   Where do we want to go?

  In terms of a legal response to this question, the main concerns from the background papers could be summaried as:

    —  the use of broad principles, such as the precautionary principle, to guide action and their treatment by the courts, and other reliance on the common law;

    —  rights of participation and how these are treated by the courts;

    —  the limits of duties and discretions, rights and duties, using the example of resources;

    —  the forms in which new powers are granted, and the issue of accountability;

    —  an institutional approach.

(iii)   The use of broad principles and other reliance on the common law

  The language of broad principles can be used in statutes, but in practice the courts have not been happy with broad concepts and have regarded their interpretation not as justiciable, but as a policy matter. Interpretation of broad principles therefore needs to be incorporated in guidance: Acts of Parliament alone are not enough.

(iv)   Rights of Participation

  Rights of participation are not in themselves a problem: judges are happy to uphold them if a question of how to go about things is involved. But the question should be considered: is participation necessarily always desirable? An alternative view would be that such rights should be targeted carefully, and used judiciously, or concern with the democratic deficit may come to be considered more important than effective decisions.

(v)   Rights and duties and the use of discretions

  Recent cases show that there can be a wide range of types of duties, from the general or target duty to the very specific; and this can place judges in a difficult position in determining the precise nature and extent of the duty in question. In imposing a new duty, therefore, it is important to be clear whether it is a duty to think about, to consider, or to do, as this will have important implications for drafting.

(vi)   powers for public bodies—a new framework?

  The questions of the need for new powers, clarification of existing ones and removal of possible barriers to effective action, which are central to consideration of the future of public health, are currently being addressed in the context of local government, following the publication in February 1998 of the government consultation paper Modernising local government: Local democracy and community leadership. Here, as in public health, the issue is, how new powers should be formulated. The inhibiting effect of the ultra vires doctrine has been criticised:

    —  it results in legal uncertainty;

    —  most statutes are not drafted with its restrictive formulation in mind, so that purpose or "function" is not always defined sufficiently clearly or widely;

    —  this results in increased emphasis on judicial interpretation;

    —  there can be a lack of understanding on the part of the judiciary of practical and political realities;

    —  time and resources are wasted;

    —  further legislation may be needed to reverse impractical decisions;

    —  innovation is inhibited; and

    —  in the absence of a positive constitutional statement, the status of local government appears in an essentially negative light.

  There are a variety of ways by which the inhibiting effects of the ultra vires doctrine could be addressed:

    —  "sticking plaster" legislation, designed to remedy specific problems, but without necessarily resolving the underlying issue;

    —  sanction schemes, which allow the Secretary of State to grant a sanction to an item of account that is contrary to law;

    —  a combination of "sticking plaster" legislation and sanctions, as seen in the recent Hunt Bill;

    —  private Acts and bye-laws: less relevant to public health than to local government;

    —  reform of section 137, in connection with:

    —  the new economic, social and environmental power proposed for local government;

    —  reform of the ultra vires doctrine itself;

    —  the "new framework": a wider version of the combined "sticking plaster" and sanctions approach, this would provide extremely wide enabling powers, under which local authorities could bring schemes to the Minister, supported by schedules of necessary legislative amendments and statements of the effect these would have; this approach has the potential for great creativity, through the question of accountability needs to be addressed; and it could be applicable in the field of public health;

    —  creation of a power of general competence: a solution not apparently favoured by the government currently, but which would make for easier operation within the authority, without displacing, judicial control;

(vii)   An institutional approach

  Either a new institution can be created, with new powers and/or existing powers taken from other institutions; or existing institution(s) can be redefined. The former is likely to be time consuming and require substantial legislation, but creates the opportunity to rework existing law and rethink strategy. Co-ordination of existing institutions may be initially more attractive (and will in any case be necessary to some degree if a new institution is created) but to be effective may itself require legislation.

  Overall, it may be suggested that if only relatively minor change to powers is necessary, then the existing legal framework supplemented by administrative guidance is likely to be the simplest and most effective way of proceeding. If more major change is envisaged, it is likely that new powers will be needed, to be vested in either existing or new institutions. The creation of a new executive body for all public health functions could be unwieldy, time consuming and divisive, but with appropriate enabling legislation a new body could be effective in harnessing relevant expertise, devising procedures for co-ordination, issuing guidance and, on the model of the Audit Commission, providing accountability. This could be a way of achieving a balance between diversity and flexibility on the one hand and effectiveness and control on the other.


  The legal basis of current public health initiatives at the level of the European Union is found in Articles 3(o) and 129 of the EC Treaty as amended by the Treaty of Maastricht of 1992. These will become Articles 3(p) and 152 of the EC Treaty as amended by the Treaty of Amsterdam. Not until this treaty was the general public health function brought into European law. There are, however, a number of other areas of European law, for example those concerned with the environment and water quality, which clearly have public health implications. But in terms of implementation, the nub of the problem is the relationship between public health law and policy and other areas of EU law and policy.

  Article 3(o) addresses the need for a high level of health protection in the activities of the Community as set out in Article 2. The question is, however, whether Article 3(o) addresses the need for a high level of health protection in the context of the overall goals of the EU. What is not at all clear is whether the provisions of the Article 3(o) take priority over the overall economic, social and political objectives of the EU as set out in the various treaties. As a corollary, the question of whether Article 3(o) is justiciable—ie of whether the Article can be examined by the courts—also arises. Article 129 sets out duties governing public health policy, requiring the Community to contribute towards ensuring a high level of human health by encouraging co-operation between Member states, and if necessary supporting action "directed towards the prevention of diseases, in particular the major health scourges, including drug dependence, by promoting research into their causes and their transmission, as well as health information and education." It also states that "Health promotion requirements shall form a constituent part of the Community's other policies".

  In practice, Article 129 has proved problematic; it was a compromise, and it soon became clear that there was no consensus about its meaning, with some Member States seeing it as setting limits to any expansion of European Union public health activities. A Resolution of the Council and the Ministers for Health in 1993 accepted the need for collaboration, but left responsibility for public health policy, "except where the Treaty provides otherwise", with Member States. The Resolution was very much disease-based; it set out broad criteria for activity in pursuit of public health in guidelines annexed to the main text. These set out as objectives, "adding years to life" and "adding life to years", and provided broad criteria for the selection of areas of activity.

  In response to the Resolution, the Commission in 1993 put forward proposals for a Framework of Action, which contained a number of different and potentially conflicting analyses of public health: as promoting economic improvement; and as a good in itself and an ethical and legal obligation on Member States. The framework for action led to the selection of areas arising under Article 129 designated for programmes of work, including: health promotion; cancer; AIDS and other communicable diseases; drug dependence; and health monitoring. Other initiatives moving towards finalisation include: injury prevention; pollution-related diseases; and rare diseases.

  Overall, there is a lack of coherence in these activities and no clear agreement on where public health policy should be going. This became especially clear with the BSE crisis, which was the catalyst for recognition in the EC that public health had not been adequately sorted out. There was, however, no evidence of awareness of what should be done, and although the crisis ensured that public health was on the agenda at Amsterdam, European monetary union was the main preoccupation there. Article 152 was a late addition, tabled by the Dutch government and adopted without prior discussion. It has been argued that the adoption of Article 152 represented a missed opportunity; the Dutch concern was specifically to provide for individual Member States to be able to control standards for blood supplies, transplantation and blood safety [section 4(a)]. The problem of co-ordination on public health across different areas was not addressed, and harmonisation of the laws and regulations of Member States was specifically excluded, without any discussion of whether this was appropriate. The question of methods for assessing the impact of policies on public health was omitted from consideration, partly because of the difficulty of securing agreement on interpretation.

  The general conclusion from this review is that European public health policy is in a state of flux; the need for a more integrated approach has been recognised by the Commission, which has suggested a future policy based on three "strands of action":

    —  improving information for the development of public health;

    —  reacting rapidly to threats to health; and

    —  tackling determinants of health through health promotion and disease prevention;

but the administrative problems have not been addressed, and there is as yet no framework for dealing with possible detrimental effects on health resulting from policy development in other areas. Action under Article 152 cannot take place until the Treaty of Amsterdam has been ratified by all member states.


  There are, it was thought, recognisable similarities between the situation faced by Chadwick in the period leading to the 1848 Act and the present: now, as then, the art of the possible should be recognised, with the added problem that making progress is much more complicated at the multi-country level. Ensuring the public health dimension is taken into account could also be complicated even at the local regional level, as shown by the recent experience of the Council of the North East in seeking to link public health in with economic regeneration.

  From a historical perspective it was interesting to see where the different frameworks started, as a way of understanding how the law looks the way it does. In the UK, in 1848 there was no national social policy—all social policy was local, by contrast with the late 20th century and in the mid-19th century social, housing and other related concerns all came under public health; 20th century specialisation could therefore be seen as part of the process of losing coherence about what public health is. It is also worth noting that the mid-19th century approach was discretionary.

  Europe has now abandoned harmonisation in favour of subsidiarity. Health protection is a broad notion, but attention at the European level focuses primarily on a narrow range of specifics, which might appear something of a contradiction. The origins of the European approach lay in the original pre-EEC institution, the Iron and Steel Community; reflecting this, the original European legislation was concerned with the protection of workers in these industries, and this led to the emphasis on productive work and on health protection, with a levy to fund research into the latter.

  There were divergent views about the usefulness of health impact assessment: from one point of view, experience with the ineffectiveness of family impact policy statements led to scepticism about the likely impact of health impact assessment on policy; on the other hand, there was greater confidence in the potential of the approach, for example in the field of transport policy.

  The difficulties in the EC of achieving co-ordination across the 25 Directorates General of the EC were recognised as perhaps a more serious problem than the broad generalities of Article 152. However, section 1 of Article 152 is a very high flown statement of intent, and the Article raises but does not resolve two main issues: how to get co-ordination assured, or even started, around public health across all the Directorates; and how to ensure the health dimension was recognised in decision-making in all areas; health impact statements would be a way of achieving this, though the approach would have significant implications: for example, in the area of tobacco subsidy, a health impact statement would make current policy unsustainable.

  The influence of underlying constitutional systems was recognised: unlike the UK, which has no written constitution, European institutions were created, of necessity, with formally documented objects: the preamble to the European treaties made explicit and central to the institutions of the EC the achievement of economic and social progress through the creation of a free internal market. This economistic approach created an underlying problem in developing an approach to public health at the European level. But the Community is nonetheless committed to a high level of health protection, which makes it necessary to devise a method of assessing health impact. Two approaches are possible here: to adopt broad statements of intent without specific meanings, which would be added later; or to make specific and rigid rules. These also could be seen as the enabling versus the statutory approach.

  In this context it was suggested that it could be helpful to revisit the role of the UK Medical Officer of Health, whose work was based on a system of notification, registration and advice; as a starting point it would be helpful to establish uniform notification and registration practice across Europe. A reliable intelligence base is needed to inform policy, which would vary locally, unless common action has to be mobilised to respond to a crisis, for example BSE—and there is a remarkable lack of mechanisms to achieve such mobilisation.

  It is also important to remember that public health is a local government as well as a health concern and that this in turn means partnerships and joint planning mechanisms are necessary. In the UK, local authorities are now required to produce community plans, and this provides an opportunity to draw strands together, while addressing the democratic deficit and modernising the agenda.



  The starting point of the workshop, the 1848 Public Health Act, represented a remarkable overview, and although there are some contemporary concerns, for example waste disposal and planning procedures, that it did not cover, in general its provisions still hold good at the end of the twentieth century. However, there will be in the coming months a number of opportunities to present the outcome of a review of public health so as to influence its future development:

    —  the Chief Medical Officer's project to strengthen the public health in England, meeting on 30-31 July 1998, could take into account the conclusions of the workshop;

    —  the Chief Medical Officer's annual report meeting on 18 September 1998;

    —  the follow up to the Our Healthier Nation green paper: this could be influenced if Ministers were persuaded that there were clear and practical measures that they could support;

    —  so far Parliamentary time for a new Public Health Act has not been possible and the pressure of other new legislation in the manifesto makes obtaining time in the near future unlikely. However, opportunities of using other legislation to further the public health agenda, and in particular control of communicable diseases, may arise and need to be fully exploited.

  Given these opportunities, the question is what provisions, if any, should be proposed. There is a great potential for health, the term "potential" combining the idea of real power, the idea of a gap between the actual and the possible, and the notion that something could be done. It was argued that current knowledge is sufficient; it would be perfectly possible from what is already known to draw up a list of the 10 key questions that should be dealt with to improve the health of the people, without waiting for the result of further research. There are however a number of factors that should be born in mind in formulating recommendations.

    —  Firstly, the term "public health" itself is very restrictive; by being linked to a specific group of people it inhibits consideration of the broader agenda of "the health of the public", which is concerned more with quality of life than with living longer: the health of the public should be linked with the idea of happiness as well as that of the absence of ill health. Thus a change in culture is needed, from "public health" to "the health of the people".

    —  The 1848 Act created a Board of Health, now lost. It would be worth considering whether there is a need for some sort of national institution, chaired by the Minister, with a subordinate network of regional bodies, and at "district" level a local authority—health authority link. At present there is no organisation with specific responsibility for supporting the public health, and the system lacks the capacity to deliver what Ministers want.

    —  Change almost always takes place in response to crisis.

    —  Improving health involves not just the NHS, but also employment, housing, education and a whole range of other influences.

    —  Health is a political issue; if politicians are not in favour of change, it won't happen.

    —  The role of women in health is crucial.

    —  Research is important in increasing the knowledge base.

    —  The influence of values should be recognised as the basis of much political decision-making.

    —  A means of addressing bioethics questions at a national level is needed; a National Bioethics Committee might be the way to achieve this; a number of time-limited or permanent committees look at specific bioethics issues; the advantages and disadvantages of replacing the present arrangements should be considered.

    —  Public participation must be an integral part of the process.

  Specifics which would have a major impact on public health include legislation on, for example, housing , Transport, tobacco and alcohol. And violence is a major problem in contemporary society, with a particular significance in health terms.


  There was some concern at the UK tendency to try to deal with problems by creating new institutions. In the public health context, however, though the health authority offers potential, there is no formal link between it and the local authority—and past experience of attempts at joint working is not encouraging, although the new government is committed to achieving improvements here. At regional level, there are NHS Executive Regional Offices, but they are generally not connected with Regional Government offices, so something is needed to achieve co-ordination. And at national level, though there used to be a Committee for the Health of the Nation, there is nothing. In consequence, although there are mechanisms such as the Public Health Group in the Department through which public health concerns can be considered before they reach the Minister, the most obvious means of access to the Minister is by writing direct. Although we know a lot about how to improve health—and healthcare—for example, on tobacco, the problem remains that nothing much is being done.

  The question of how the workshop could best contribute to the debate was considered. For example, there is good evidence that income differentials have an important influence on public health; under the previous government this was largely disregarded, but it is not clear whether the present government would be more sympathetic to addressing the issues involved. There are other areas, too—fluoridation for example—which are recognised to be political, and which, if Ministers decide to do something, will become politically contentious. But nonetheless there is a need for action in support of pronouncements.

  At the local level, it was argued, the problem centres on giving hope to the community, and in particular to young people—and there has been very little about children in any of the recent publications. However, there is a political will to do something different, and locally to challenge existing activities and programmes, to look at what is being done, for whom and why: there is an emerging culture of change, which starts with making a connection between what's being done locally and the health of the public. In this context, the links between local government and Primary Care Groups will be critical, though it is by no means clear these have been thought through. But there is an opportunity now to refocus links.

  The significance of globalisation—which was not an issue in 1848—should be taken into account. There is an increasing willingness to address concerns that can be broadly categorised as "environmental" at international level, while more "communitarian" issues are being dealt with at local level. The difficulty here is that the quality of local activity is very variable; this raises the issue of what kind of legislative framework would be fit for purpose for public health. Accepting that structure should follow function, the sheer complexity of the issues to be addressed could be seen as the major difficulty. If it is accepted that there is wide agreement on what needs to be done—and the NHS R and D programme has been focused on this—the question becomes, how do we do it. In public health, research is needed into how to implement change, where our understanding is still at a very primitive level, and we need to develop methods to research the effectiveness of interventions.

  The need to involve the public, the extent to which the public could influence public health directly, and the relationship between individual rights and social factors was considered. The 1848 Act, it was pointed out, put the rights of society above those of the individual. In contemporary society, many of the changes needed for the improvements in the health of the public are negative: stop smoking, stop speeding; it was doubted whether legislation could achieve outcomes of this kind.

  In considering the rights of society, it was suggested, it would not be possible to turn back the tide of individualism; but the concept of social capital could be valuable in changing the approach to thinking about risk: there is some sort of a shift in culture going on at the moment, and this should be recognised as part of the context of discussions about public health.

  The importance of public health surveillance was stressed: continuing reports, year on year, covering for example road safety, can achieve results, and getting information into the public domain is important. An independent organisation that could achieve this would be valuable: surveillance of health systems with a duty to report on health inequalities would be of major importance. For example, there are wide variations in hospitalisation rates across the country: is this the result of better health in some areas, or worse access to care? The public are going to demand explanations for the differences they learn about, especially in the information age, and a national level institution would be able to respond to this. Moreover, in the new millennium any debate will be in the context of a Freedom of Information Act: which may be expected to usher in an era of openness and opportunities for constructive, creative intelligent "trouble making".

  If a new institution—a Commission for example—is to be recommended, the work of existing agencies will need to be reviewed. One area in which a new institution could be of great value would be disseminating examples of good practice. There are, for example, good local examples of projects, involving the public and with much to offer; indeed, engaging people has to be done at local level: examples include smear testing projects, healthy heart programmes, working with children to combat crime; health living centres and Health Action Zones offer examples of worthwhile and effective initiatives. What is needed is a structure that ensures that this local learning and these local successes are disseminated nationally.

  This raised the question: could a legislative underpinning be envisaged that would bring together all these concerns: the notification/registration/advice theme, the surveillance requirement, information and explanation, dissemination of good practice, and the other public health concerns identified in the discussion. It was pointed out that this range of concerns would require the broad framework approach in any legislation with the trade-offs this would involve. But if it was accepted that something was needed, then a condition of success would be to convince people of the need for action.


  Starting with the legal overview, it is noticeable from the lists of statutes presented in Halsbury that 1959 was a watershed in British politics, when the rush to legislate began: three quarters of the legislation listed in Halsbury dates from after 1959—although earlier legislation tends to be consolidated in subsequent statutes, in public health as in other fields. The consequence is that the citizen is entirely bewildered by all this, except at the local level: we're not short of legislation, we're overwhelmed by it. But if we turn to Europe, we find it lacks a satisfactory political and legal structure, and isn't capable of dealing with public health issues.

  In addition to this, it has to be recognised that globalisation is now a public health issue. And when we come to consider inequalities, it is important not to forget the law of unintended consequences: for example, the effect of the Lottery on the incomes of the poor. The law has been presented in all its majesty, but the problems of public health resemble an impenetrable octopus.

  In modern politics, the first essential is a point of authority, focus, influence, so any programme must start by achieving this. The task for the workshop might therefore be, first, to be clear about the ten things that could be done quickly; the principle of ubiquity should be kept in mind; and anything proposed must provide a point of focus, at the centre of power and able to undertake research, investigations, and—essential in today's world—engage in propaganda. Without this, it will be impossible for the individual to get a notion of what's happening; and it should happen at the centre, to provide the basis for local engagement.

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