Intended for healthcare professionals

Rapid response to:


Public health at 170

BMJ 2018; 362 doi: (Published 30 August 2018) Cite this as: BMJ 2018;362:k3653

Rapid Response:

Lessons from history – public health successes.

Professor Middleton’s editorial reminds us of the significant health gains that were achieved when investments were made in public health.(1) Actions in areas as diverse as child safety and sexual health have had a tremendous impact on health and life expectancy.(2-6) However, for too long many of the improvements have been taken for granted particularly in high income countries. We think it is important to note that lessons from history not only act as reminders about what it was like in the past, but also help inform us about potential future gains.

We are pleased that the government has asked the NHS to develop a new 10-year plan before the end of this year and firmly believe that the foundation of the plan should be a commitment to bring about improvements in population health and to tackle the ubiquitous problem of inequalities.

In the recent past there has been a tendency to adopt the “silver bullet” approach to public health where simplistic interventions have been developed to bring about behaviour change without a strategic focus on health. If the goal is purely behaviour change then some individuals may just swap one unhealthy habit for another. A holistic approach is needed.

We strongly believe that a long-term comprehensive and robust health strategy is needed. It should be based on a seminal public health document – the Ottawa Charter.(7,8) The Charter proposed a positive empowering view of health and recommended creating supportive environments in different settings including schools, hospitals and workplaces. In order for the settings approach to fulfil its promise coordination is needed – a key role for public health staff.(9)

Another lesson from public health history is to do with the thorny issue of funding. Many glossy public health strategies and plans have been produced with no mention of funding: there has always been far more rhetoric than resources. Although effective public health is likely to save some funds for our beleaguered NHS in the long term, in the short-term interventions will need to be financed if they are to have a real impact on population health.

Expenditure on health improvement is failing to keep up with the major public health challenges this country is facing including: accident prevention, diabetes, mental health, smoking, food poverty and obesity. Although health is improving for some, inequalities are widening. However, it need not be like this. There are effective interventions that can be implemented but it will need firm political commitment at a national level.

The case for greater funding for public health is being made by a growing body of eminent individuals and organisations. (10-17) The Institute of Health Promotion and Education has campaigned on this issue for a number of years.(9, 18-24) We strongly believe that Directors of Public Health with adequately resourced multidisciplinary teams have pivotal roles to play in championing public health action and influencing the agendas of key people in different settings. With sufficient resources public health teams could have a significant impact on life expectancy, healthy years of life and demand for NHS services.

1) Middleton J. Public health at 170. What’s needed now is a big birthday present. BMJ 2018;362:k3653.

2) CDC. Ten Public Health Achievements of the Twentieth Century - United States, 1900-1999. MMWR Weekly 1999;48(12):241–3

3) Tones K, Tilford S. Health promotion: effectiveness, efficiency and equity. Nelson Thornes, 2001.

4) Gray S, Pilkington P, Pencheon D, Jewell T. Public health in the UK: success or failure? J R Soc Med 2006;99: 107-11.

5) Hemenway D. While We Were Sleeping. Success Stories in Injury and Violence, Berkeley: University of California Press, 2009.

6) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health. 2016; 26(5), 194-199

7) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.

8) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018,56(2), 73-84.

9) Watson MC and Lloyd J. Re: BMJ briefing: meet the new masters of public health. British Medical Journal Rapid Response 8th July 2013

10) Department of Health. The Report of the Chief Medical Officer’s Project to Strengthen the Public Health Function. London: Department of Health, 2001.

11) Wanless D. Securing our future health: taking a long-term view. Final report. London: HM Treasury, 2002.

12) Department of Health. On the state of the public health: Annual report of the Chief Medical Officer 2005 London, Department of Health, 2006.

13) Marmot M, chair. Fair society, healthy lives (the Marmot review). UCL Institute of Equity, 2010.

14) Richmond Group of Charities. What is preventing progress? Time to move from talk to action on reducing preventable illness. 6 Nov 2014.

15) BMA. Funding for ill-health prevention and public health in the UK. May 2017.

16) Royal College of Paediatrics and Child Health. State of child health. 2017.

17) Ham C, Murray R. The NHS 10-year plan: how should the extra funding be spent? London: King’s Fund, 2018.

18) Watson M C and Lloyd J. Raiding the public health budget. Action is needed to tackle current public health threats BMJ 2014;348:g2721

19) Watson M C and Lloyd J, 2016. Need for increased investment in public health BMJ 2016;352:i761.

20) Watson M C and Thompson S. Re: Government must not shy away from bold action on public health, says MP. British Medical Journal Rapid Response, 25th November 2016.

21) Watson M and Tilford S. Re: Government’s response to inquiry on public health raises fears of more cuts. There should be investment – not cuts. British Medical Journal Rapid Response 10th January 2017.

22) Watson M and Tilford S. RE: Next government must tackle public health “ticking time bomb,” says BMA. 15 May 2017

23) Watson M C and Lloyd J. RE: Spending on public health cut as councils look to save money. British Medical Journal Rapid Response, 14 July 2017.

24) Watson M C and Thompson S, 2018. Government must get serious about prevention. BMJ 2018;360:k1279.

Competing interests: No competing interests

09 September 2018
Michael Craig Watson
Associate Professor in Public Health.
Sylvia Cheater, MBE (President, Institute of Health Promotion and Education,
University of Nottingham, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham. NG7 2HA.