Partnerships for Public Health and Well-being

Policy and Practice

Rob Baggott

• Publisher: Bloomsbury Academic
• Year: 2013
• ISBN:
  9781350313446
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Written by a leading author, this text provides a much needed account of UK public health and well-being policies and considers their influence on practice.With an emphasis on the importance of inter-agency and inter-professional approaches, this text is vital reading for all students and practitioners of public health and well-being.

1	Partnerships for public health and well-being

Introduction

The purpose of this book is to explore partnerships in the field of public health and well-being. Its central focus is upon the establishment of partnerships, their rationale, practices, relationships, the problems they face, and how these can be understood and addressed. This chapter is in three parts. First, there is an examination of the rationale for partnerships in the context of public health and well-being. Second, an analysis of the historical context of partnership in this field is undertaken, which identifies key themes to be explored in later chapters. Third, key concepts and frameworks relating to the analysis of partnership and collaborative working are explored.

Public health and well-being

Although there is disagreement about the precise meaning of public health, there is consensus that at its heart lies a collective and collaborative enterprise. Rosen (1993, p. 1) observed that ‘throughout human history, the major problems of health that men have faced have been concerned with community life’. Even in modern times, when individualism and consumerism have exerted a powerful influence over how we conceptualize and respond to social problems, public health is an area where collective action is still acknowledged as being extremely important (Cm 289, 1988; Wanless, 2004; Nuffield Council on Bioethics, 2007). In this context, collective action is much broader than the state acting on behalf of the community. Although state institutions do have an important role to play in public health, so do others, such as the voluntary sector and commercial organizations. Furthermore, individual citizens and communities have a key part to play in health improvement and protection.

The case for a broad, inclusive, collective approach to public health was rooted in the World Health Organization’s (WHO) definition of health as a ‘state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (WHO, 1946, p. 100). The emergence of a salutogenic paradigm (Antonovsky, 1979, 1996) further highlighted the importance of wellbeing (Felce and Perry, 1995; Kahneman et al., 2003; Huppert et al., 2005) and potentially widened public health to include more areas of individual and public welfare. This served to expand the scope for collective and collaborative action, bolstered by the emphasis placed by the WHO and others on ‘healthy public policy’, gearing public policies across different sectors to public health objectives (Milio, 1986). Healthy public policy (and the ‘health in all policies’ approach discussed further below) highlighted the importance of intersectoral working, bringing in actors across a wide range of policy areas (agriculture, trade, education and the environment, for example) to address health issues. It also provided a rationale for working with non-government sectors such as commerce, the voluntary sector and civil society.

A further impetus for collaborative action came from the growing interest in health inequalities and in ‘social determinants’ of health (WHO Commission on Social Determinants of Health, 2008; Strategic Review of Health Inequalities in England, 2010). There is much concern over the impact of social structures and material conditions on health and well-being. It is increasingly acknowledged that collaborative and intersectoral action in these policy areas, engaging with actors such as central government agencies, local government, business and voluntary and community organizations, could help to address the root causes of health inequalities and disadvantage. Furthermore, the challenge of climate change and the imperative to promote sustainable development has further highlighted the need for collaboration in public health. Modern ecological models of health place emphasis upon complex interactions that affect public health and seek to address problems and risks in an integrated way (Lang and Rayner, 2012). Collaboration is central to such action, and this is reflected in the importance given to, for example, partnership working in the field of environmental health and climate change (see, for example, UN, 1993, 2012a; WHO Regional Office for Europe, 2010).

Although collaboration is an essential ingredient of collective action in public health and well-being, it does not occur purely by chance. It is widely recognized that a proactive approach is essential, including the formation of partnerships to provide a foundation for cooperation and collaboration. Yet despite lip service being paid to its importance, effective partnership working is often very difficult to achieve in practice.

Partnerships in historical context

Problems of partnership working in public health are long-standing, and a brief historical review is worthwhile. The efforts of ancient civilizations in preventing illness are well known (Rosen, 1993). These included urban planning, sanitation and rules on hygiene. As these functions developed, political and logistical problems familiar to modern societies emerged, including the need for different authorities and sections of society to work together. For example, in Ancient Rome, specific public health functions included the supervision of public baths, the provision of water supplies, sanitation, street cleaning and food regulation, and efforts were made to integrate these functions within a coherent system of public health administration (Rosen, 1993; Robinson, 1994; Porter, 1999).

Closer to modern times, the Victorians expanded state activities in public health, but this occurred in a rather haphazard way (Hodgkinson, 1967; Wohl, 1984). Within central government, responsibilities for public health were allocated among different agencies, boards, departments and inspectorates, but there was no effective coordination of their activities (Sheard and Donaldson, 2006). There were calls for rationalization, including from the Royal Sanitary Commission in 1871. However, it was not until the creation the Ministry of Health in 1919 that comprehensive national responsibilities for public health were set out. Poor coordination and fragmentation were also found at local level. An array of different boards and committees dealt with the same underlying problems (Hodgkinson, 1967; MacDonagh, 1977). Crucially, public health administration was strongly influenced by the system of relief for the destitute, known as the Poor Law (Wohl, 1984). There was often poor liaison between Poor Law boards and other local bodies, to the detriment of public health. This was exacerbated by conflicts between professionals employed by different agencies (Hodgkinson, 1967).

During the first half of the twentieth century, state intervention in social welfare and public health increased without a corresponding improvement in collaborative governance. Both Poor Law boards and local authorities undertook disease prevention. Calls to integrate these services were ignored. For example, the Minority Report of the Royal Commission on the Poor Laws recommended the establishment of health committees at local level combining relief for the poor and sanitary functions with wide responsibilities for illness prevention and health service provision (Cd 4499, 1909). Yet it was not until 1929 that the Poor Law boards were abolished and their public health functions transferred to local authority health committees.

As local authorities became more active in public health from the late Victorian period onwards and into the early twentieth century, there was an increase in professional tensions between GPs, concerned about the encroachment of free or subsidized local services on their paid work, and the Medical Officers of Health who led local public health departments (Lewis, 1986). As a consequence, there was a poor coordination of public health services. In the interwar period, it was increasingly acknowledged that health services must be organized on a more rational basis, especially with regard to the integration of prevention and treatment (see the Dawson Report, Cmd 693, 1920), but this was not addressed.

The NHS

The creation of the NHS was in many respects a major public health achievement, extending access to comprehensive health services to the whole population, irrespective of ability to pay. It was also believed that a single national service would give greater scope for preventing illness and for integrating different services to meet health needs. However, the principal focus of the NHS was on diagnosis and treatment, leading to criticism that ‘the NHS was in reality a sickness service rather than a genuine service for health’ (Webster, 1996, p. 769). Consequently, there was a lack of leadership and coordination of public health at a national level, especially after 1951 when the Ministry of Health’s responsibilities for environmental health, housing, water and other public health-related services were transferred to other departments.

To make matters worse, divisions between different parts of the health service were institutionalized. The three main parts of the NHS – hospital services, family practitioners (GPs, dentists, pharmacists and opticians), and community and public health services – had separate administrative structures, and collaboration between them was poor. At this time, local authorities were responsible for managing community services, including district nursing, health visiting, ambulance services, maternity and child welfare clinics, the school health service and health education. During the 1960s, attempts were made to bring local authority community health professionals into closer contact with GPs. However, collaboration remained problematic, and for the most part hospitals, primary care and community/public health occupied different worlds.

In 1956, the Guillebaud Committee rejected incorporating local authority health services into the mainstream (Cmd 9663, 1956), although one of its members, Sir John Maude, argued that primary healthcare services should be unified under local government. In the late 1960s, the possibility of bringing the NHS under a reformed system of local government was raised by the Royal Commission on Local Government (Cmnd 4040, 1969a). In a minority report, one of the Commission’s members went further, recommending the transfer of all health services to local authorities (Cm 4040, 1969b).

However, calls to integrate NHS services under local government were rejected. Instead, community health and public health services were transferred from local government to new health authorities in the NHS reorganization of 1974. Local government remained responsible for environmental health and social services. Local authorities were represented on the new area health authorities (whose boundaries were largely co-terminous with those of the shire county and metropolitan district local authorities that provided social services). A working party explored further key issues of collaboration between local government and the NHS. It recommended that duties to work together be imposed on both, and that joint committees be established to manage their interface. A statutory duty of cooperation was subsequently placed on health authorities and local councils.

Joint consultative committees were established with members drawn from health authorities and local authorities (and later, voluntary organizations). These primarily addressed, at the health–social care service interface in particular, services for people with mental illness, learning disabilities and physical disabilities, elderly people and children (Snape, 2004). Health promotion and public health issues were a legitimate topic for joint discussion (see Cmnd 7047, 1977, p. 73) but not a primary concern. The impact of the Joint Consultative Committees was marginal and variable across the country (DHSS, 1985), and they were mainly regarded as talking shops.

Attempts were made to strengthen collaboration in the late 1970s, with the creation of joint care planning teams, consisting of officers from health and local authorities. A joint finance scheme was also established to develop services, particularly in relation to health and social care. Nonetheless, the problems of fragmentation remained and may have even become more entrenched (Wistow, 2012). As a result, ‘cooperation remained an elusive objective, belonging to the realm of pious exhortation and utopian prospectuses’ (Webster, 1996, p. 495). The situation specifically with regard to public health was arguably even worse, given its low profile in these arrangements.

The Thatcher and Major governments

Although the organization of public health before 1974 was imperfect, with poor collaboration and insufficient attention to prevention and population health, it is acknowledged that there had been a further deterioration by the mid-1980s (Lewis, 1986; Webster, 1996; Hunter et al., 2010). Another NHS reorganization in 1982, undertaken by the Thatcher government, was criticized for undermining collaboration by abolishing area health authorities (most of which, as noted, had common boundaries with shire county and metropolitan district councils). As with all reorganizations, there was also a potential disruptive effect on partnerships as personnel and organizations changed, although this seems to have been short term (DHSS, 1985). In addition, the Thatcher government was reluctant to acknowledge public health issues that might otherwise have stimulated efforts to promote collaboration. It chose to ignore the role of socioeconomic factors in health and illness and refused to commit to a comprehensive public health strategy. This stance effectively discouraged collaborative working in areas such as health inequalities, as well as on lifestyle issues such as smoking, alcohol and diet.

Even so, health authorities were exhorted to produce health promotion and prevention strategies and to work with local authorities and others on these issues (DHSS, 1981). Policy documents on primary care emphasized the importance of prevention and the need for all parts of the health service to work together to improve health (Cm 249, 1987). Furthermore, following two major communicable disease outbreaks in the mid-1980s (Cmnd 9716, 1986; Cmnd 9772, 1986), which reve...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of boxes and figures
• Acknowledgements
• List of abbreviations
• 1. Partnerships for public health and well-being
• 2. Partnerships at the global and international level
• 3. Partnerships under New Labour
• 4. Partnerships and the Coalition government
• 5. Partnerships with the community and citizens
• 6. Partnerships with the voluntary sector
• 7. Partnerships with the private sector
• 8. Conclusion
• Bibliography
• Index