Andrew Furber: What is the role of public health in a modern democracy?

andrew_furberAccording to Winston Churchill, “Democracy is the worst form of government, except for all the others.” For good or ill we elect our representatives, they have the democratic mandate to make decisions, and if we don’t like them we vote for someone else next time.

Part of good public health is informing and influencing the decisions that our elected representatives make. Recent articles in The BMJ have suggested that this ability has been lost in England. [1,2] But is this true?

A historical view of public health would suggest that the speciality began to lose its influence with the creation of the welfare state in the post war period. Powers to run hospitals moved to the NHS. Social care moved to directors of adult social services. Environmental health officers took on roles previously under the medical officer of health (MoH). In an attempt to salvage the public health function, MoH posts were abolished and the specialty was transferred to the NHS in 1974. [3]

While there were many significant public health achievements during its 39 year sojourn in the English NHS, there is little doubt that it remained the poor relation of clinical services. Stories of preventative services being cut to bail out hospital overspends are legion. Directors of public health held relatively little of the budget, opportunities to tackle the real determinants of health were limited, and inequalities widened.

Only time will tell whether the return of public health to local government in England in 2013 represents the beginning of a golden age or continued decline. There is no doubt that austerity has had a negative effect, but any notion that public health budgets would have been protected in the NHS would seem to neglect recent history. Within local government there has been a steady rise in the number of directors of public health (DPH) with wider portfolios including adult social care, leisure services, and housing. Even where this is not the case it is usual that the DPH will have influence across a wide range of council services. If this is not so then the local authority has not fulfilled its statutory duty in appointing a DPH who is “the person who elected members and senior officers look to for leadership, expertise, and advice on a range of issues, from outbreaks of disease and emergency preparedness through to improving local people’s health and concerns around access to health services.” [4] Elected councillors will take the final decision, but it should never be without the advice of the DPH.

Which brings me onto the tragedy of Grenfell Tower that happened earlier this summer. We should all feel angry that so many lives were lost in a building which should have been safe. The enquiry will uncover the causes and hopefully the causes of the causes. But there is no doubt that this country’s poor housing stock remains a significant cause of health inequalities. Directors of public health have been vocal about this, for example in responding to the government’s housing white paper. [5] In the response we make it clear that “the current housing system is failing the most vulnerable people in our population.” At a local level too we have been taking action. In my own case I’ve helped my council quantify the impact of poor housing on health and to take steps to reduce the negative effects. My team have also helped in the redesign of our vulnerable adults service to ensure issues like homelessness are dealt with better. There will be councils where the DPH has done much more.

We need public health specialists around the table with politicians. We need to respect their democratic mandate and earn their trust. We need to ensure we are listened to. Others will be in positions where they can wave placards—either literally or metaphorically. A mature public health system uses all these opportunities to best effect. Publicly criticising one another does none of us any favours.

For all its frustrations, we are immensely privileged in the UK to live in a modern democracy. Directors of public health continue to make sure that our democracy has health and wellbeing at its heart.

Andrew Furber is the President of the Association of Directors of Public Health UK but has written this blog in a personal capacity. The views expressed are personal and not necessarily the view of his employer or ADPH.

Competing interests: None declared. 


[i] Ashton, J. Public Health must constantly be challenging

[ii] McKee, M. Grenfell Tower fire: why we cannot ignore the political determinants of health. BMJ 2017;357:j2966

[iii] Gorsky, M; Lock, K; Hogarth, S; (2014) Public health and English local government: historical perspectives on the impact of ‘returning home’. Journal of public health (Oxford, England). ISSN 1741-3842 DOI: 10.1093/pubmed/fdt131

[iv] Directors of Public Health in Local Government: Roles, responsibilities and context Department of Health, London, 2012.

[v] Response to the Government’s Housing White Paper Association of Directors of Public Health, London, 2017.