Reflections

In this endpiece the author reflects on the book as a whole and on his career in public health over 40 years. He considers the challenges, joys, and frustrations and pays tribute to the giants whose shoulders contemporary practitioners stand on. In taking the long view on how public health has changed during his career, he paints a picture of the route map necessary to make a contribution in the twenty-first century and regrets some of the recent developments in the organizational arrangements in England that have impeded progress. His hope is that this personal account may inspire a new generation of public health workers as they make their way with an ever-evolving agenda.

No health without mental health—mens sana in corpore sano

This chapter approaches the important subject of mental health and wellbeing through the lens of public health. Drawing on his own experience as a physician who specializes in psychiatry before moving into public health the author describes the struggle to move upstream from a sole focus on treating serious mental illness to the recent developments in public mental health and offers a framework for action. This draws on a historical overview of the differing emphases that have played in over the past two hundred years. This framework focuses on public health aspects as well as prevention and mitigation of harm from serious mental illness, and addresses the need for whole population approaches to mental health and mental health promotion. Examples of interventions that draw on public health interventions are given. These include the importance of planned parenthood and sexual health, the appropriate use of psychiatric expertise in support of population and community mental health, the centrality of concepts such as self-esteem, and the necessity to take a public health approach to the new challenge of dementia. Behavioural contagion, the role of the media, and the prevention of suicide are among the topics covered.

Population health care

This chapter addresses the value of health services as a public health measure and makes the case for the use of public health skills in health service planning. The question as to what sort of health services are most appropriate to optimize population health is explored with reference to the development of the World Health Organization Alma Ata Declaration with its emphasis on the eight elements of primary health care. The application of epidemiological thinking in National Health Service frameworks for health care is described. Examples of the use of a public health approach in health care planning include: planned parenthood and family planning services; population-based diabetic retinopathy screening; and whole-system health care transformation in the county of Cumbria. Also covered are the proactive role of the mainstream media in taking the public on a journey of change and the handling of serious clinical service failure in the form of inappropriate organ retention at the Alder Hey Children’s Hospital, breast screening failure in a Cumbrian hospital, and a corporate clinical disaster at the Morecambe Bay University Hospitals.

Roots and foundations

This chapter traces the roots of modern public health to its foundations in the early nineteenth century. By describing the impact of rapid urbanization on the health conditions of the labouring poor, it sets the scene for an account of the work of the early pioneers such as Edwin Chadwick nationally, John Snow in London, and William Henry Duncan in Liverpool. It identifies a series of themes to guide the work of public health practitioners into the twenty-first century. These themes recur throughout the book as public health challenges evolve and mutate, society changes, and science offers greater opportunities for effective intervention.

Healthy cities

In this chapter the origins of the WHO Healthy Cities Project are described, beginning with the project group meeting in Copenhagen. The early days of the project are reported together with an account of how the project developed from small beginnings to become a global movement with political leadership from the city level. The achievements of the project are reported together with issues raised in creating a new dynamic for urban health. The chapter concludes with the latest phase of the project beginning in 2018, which saw Healthy Cities aligned to the pursuit of the 17 United Nations Sustainable Development Goals for 2030.

Protecting health

This chapter explores the concept of health protection, defines its scope, and illustrates how health protection may be needed in relation to a wide range of issues with specific examples that the author has been involved with during his public health career. A framework for health protection which covers both communicable and non-communicable disease threats in both the natural and built environment is proposed. Examples covered include chemical incidents; the emergence of new and novel infectious diseases; the crisis in measles, mumps and rubella vaccination following the publication of a since-discredited scare in the Lancet by former Dr Andrew Wakefield; the Hillsborough football stadium disaster; the humanitarian crisis in North Macedonia during the Kosovo emergency; and a fatal mass shooting in Cumbria. The emergence of the threat of HIV infection to injecting drug users in Liverpool is described together with details of the response which included the first large-scale syringe exchange programme. The importance of preparedness, training, intelligence, and inclusive public communication is stressed as well as the dynamic nature of health protection.

Improving health in Mersey

This chapter sets the scene for the pioneering work in public health carried out in the Liverpool health region from the 1980s onwards. It describes the situation that was left after the tide had gone out on the local authority-based arrangements that had served public health well for almost 150 years and identifies the green shoots of the New Public Health that was about to make its appearance. The key role of visionary and influential leaders who kept the flame alive and handed on the baton to a new generation leading to novel approaches centred on the new notion of health promotion is acknowledged. The importance of developing multidisciplinary and partnership working based on a sound analysis of the challenges to health is stressed. The strategic approach adopted, blending the science and art of public health practise on a foundation of pragmatism and broad-based support is a golden thread.

Culture, arts, and wellbeing

In this chapter the indivisibility of culture and the arts from health and wellbeing is explored through a variety of modalities; the power of the humanities to help us understand and explain the meaning of the challenges that affect us on life’s journey are explained; and the use of public spaces to engage with the public to promote health and wellbeing is described. Examples include: - The extensive use of the total environment of an international garden festival as a ‘health field’ for health promotion; - The value of cultural activity as a means for building peace and trust in the context of the post Northern Ireland Troubles; - An extended partnership and collaboration with the Liverpool artist and poet Adrian Henri, including an extensive programme of events to celebrate 150 years of public health in Liverpool; - The use of culture and the arts to restore public trust after serious clinical service failure; - The role of cultural facilities in providing support for dementia sufferers and their careers; and - The importance of ‘storytelling’ as a tool for public engagement and understanding of health and wellbeing.

Promoting and improving health

This chapter reports on the New Public Health initiatives in the Mersey region, based in Liverpool and traces their antecedents from the post war period. Beginning with the first large-scale lifestyle interventions at the International Garden Festival in 1984, other aspects of the work based on agenda setting, consciousness raising, and developing models of good practice are described. These include exploring the use of public spaces, facilities, and assets to engage with the public and popularize ideas associated with the New Public Health. They also include landmark initiatives in Finland and Sweden to tackle the contemporary challenges of heart disease and teenage pregnancy, deploying methods based on the new thinking. The issue of the ‘Nanny State’ in the context of a libertarian society is confronted together with the role of public agencies as enablers, and asset-based community development is identified as a vital approach. The ways in which this early work paved the way for later developments, including the World Health Organization Healthy Cities project, by building foundations based on extensive personal and organizational partnership working are recorded.

Public health at its peak— the interwar years

This chapter picks up the evolution of public health in the United Kingdom in the period immediately following the First World War. The scene for initial optimism and ambition was set by the goals for reconstruction after the Great War which drove the move for ‘Homes Fit for Heroes’. The demand for resources distracted from the progress that was being made in bringing public health and health care together. Progress was made in organizational development, the appointment of the first Chief Medical Officer in the Department of Health, and the construction of pioneering health centres. The stock market crash and the recession that followed halted progress until the threats of fascism galvanized action in the public sector. The chapter also covers the evolution of public health from the sanitary movement of the 1840s, through the focus on hygiene at the end of the nineteenth century, to the therapeutic era, which began in the 1930s. The origins of the New Public Health, with the central role of the World Health Organization and the convergent thinking from North America and Europe, is described. The tension between hospital-dominated medicine and the preventive orientation of public health is explored. The emergence of a consensus for transformational change to health systems rooted in public health is chronicled. At the heart is a need to reconcile primary care and public health in the face of new challenges. The shift to multidisciplinary working is underlined.