1948 did not only usher in free universal access to primary health care; it also brought with it an idea radical for its time – that the NHS should “encourage a new attitude to health…the promotion of good health rather than only the treatment of bad.”*
Public health of course existed long before the NHS was established, but provision in the early 19thcentury was administered by charities and often patchy. Maternal mortality rates were high; disease was rampant. If you were a working-class man, you wouldn’t expect to live much longer than 30.
Major advances in the years running up to the birth of the NHS revolutionised public health but it was the founding of a comprehensive health service, free at the point of use that truly enabled public health to blossom.
Now, public health includes a wide range of services – from health visiting and school nursing, to outbreak prevention, to environmental health, sexual health, alcohol and drug misuse recovery, weight management, immunisations and much more.
But since 2013, when provision for many of these services was transferred from the NHS to local authorities – whose budgets have been systematically slashed under austerity – public health is now under serious threat.
“People forget that even though public health under the NHS was first being carried out by local authorities until 1975, public health was from the beginning considered part and parcel of the NHS,” explains Doctors in Unite (DiU) vice president Steve Watkins.
“It wasn’t until the 2012 reforms that public health was totally separated from the NHS.”
And this separation, Watkins tells UniteWorks, is what has enabled swingeing cuts to public health in the first place – now that public health isn’t considered part of health spending, its funding is easy pickings in an era of austerity.
Since public health essentially deals in long-term outcomes it can sometimes be difficult to understand its urgent importance. But GPs and other health staff on the frontline know the crucial role it plays.
“We’re now in the midst of a childhood obesity epidemic,” explains DiU deputy chair and GP Dr Jackie Applebee. She points to the wrongheadedness of cuts to school nurses, who can play a vital role in tackling youth obesity.
“We know that a young person who is obese is much more likely to be an obese adult – which in turn can lead to serious, chronic conditions such as diabetes and heart disease that end up costing the NHS much more in the long-run.”
Applebee highlighted that cuts to sexual health services, particularly clinic closures, have had an immediate impact on already pressured GPs, who simply don’t have the resources to take on the work of specialised clinics.
“Having fewer sexual health outlets leaves patients with fewer choices – often patients want to go to a clinic because it gives them that anonymity. Without that, they may avoid getting tested or seeking advice treatment altogether.”
The impact of deep cuts to sexual health has already surfaced – in June, new figures showed syphilis diagnoses last year have shot up to levels not seen since 1949.
Sometimes the effects of public health services, or the lack of them, don’t materialise until decades later.
Untreated post-natal depression, for example, can disrupt the critical bonding period between a child and parent, which can have lifelong consequences for generations – research has shown that 80 per cent of long-term prisoners have attachment problems developed in babyhood, and children who don’t form proper attachments with their parents often go on to raise children themselves who aren’t securely attached.
“We know post-natal depression is best treated if it’s caught very, very early on,” explained Unite lead professional officer for health visitors Obi Amadi. “Health visitors who are properly resourced and trained are often the only people who can spot the signs early.”
But health visiting is also under the chopping the block after several years of advances. In the last two years alone, health visitor numbers have fallen by 2,000, Obi explained. Much of their work is being delegated to other roles such as nursing associates who have less of the sort of specialist training that can help struggling new mothers before they do slip into depression.
Watkins believes that the very future of an affordable health and social care system rests on properly resourced provision for healthy aging.
“It’s easy to cut public health because we don’t feel the effects right away,” he said. “But what we’re doing now is stripping the lead off the roof to make buckets to catch the rain water with.”
For DiU public health specialists committee chair Ruth du Plessis, the importance of public health is a matter of social justice.
“Public health is about looking after people who need it most,” she said. “It’s about fairness and tackling the inequalities that lie at the heart of so much ill-health in this country.”
Indeed, stubborn health inequalities in the UK now aren’t, in their own way, very much different from the 19th century – a baby boy born today in Blackpool can expect to live to only 74 years, nearly a decade less than a baby boy born in Chelsea.
For homeless people, whose numbers have proliferated under austerity, the picture is even direr – their life expectancy won’t exceed 50.
It is these burning inequalities that father of the NHS Aneurin Bevan hoped to address when he laid out the nascent health service’s core principles 70 years ago – among them that that no matter who you are, or how much you earn, you deserve to be healthy.
And even though today’s government may have torn the NHS and public health apart, it is this primary value – that everyone counts – that will always bind the two together.
*NHS white paper, 1944
This feature first appeared in Unite Works, Summer 2018