Intended for healthcare professionals


Happy 175th birthday to public health

BMJ 2023; 382 doi: (Published 31 August 2023) Cite this as: BMJ 2023;382:p2001
  1. John Middleton, honorary professor
  1. Wolverhampton University

The Public Health Act 1848 was a major landmark in the history of health in England and Wales.1 It is 175 years old on 31 August 2023. Testament to the vision of the act, life expectancy in England and Wales has nearly doubled between 1841 to 2011.2 The largest increases have been through improved drinking water and sanitation, better housing, and better nutrition.3 Life expectancy continued to improve through the first 65 years of the NHS and the welfare state. But austerity policies since 2010 have seen life expectancy stall and inequalities widen. The life expectancy of women in England and Wales has declined since 2010.45 Life expectancy worsened through the covid-19 pandemic, with inequalities in death rates widening, particularly for people from ethnic minorities and for men.6

Five years ago, The BMJ marked public health’s 170th birthday and asked for a big birthday present to go alongside the NHS’s 70th birthday investment.7 Since then we have had the covid-19 pandemic, Brexit, the Russian invasion of Ukraine, and a cost-of-living crisis, layered upon the ever more visible and catastrophic effects of 13 years of austerity policies.

The poor state of the UK’s health before the covid-19 pandemic has contributed to the UK’s high mortality from covid relative to other countries.6 Poverty has accelerated and will rise further with the cost-of-living crisis: 14 million people in the UK are in poverty, four million of them are children.8910 A record three million emergency food parcels were distributed by food banks in 2022-23.11 Destitution resurfaced in austerity Britain and expands shamefully.12 Ill health contributes to our declining economy; over two million people are unable to work due to sickness.13

At a time of increased health and healthcare need, we have seen the erosion of public health funding and the undermining of the public health system.14 Excess mortality in the UK remained high through 2022, when other comparable countries experienced a return to pre-covid mortality levels. This was plausibly related to extended waiting times in emergency departments and whole system back logs in the NHS brought about by gaps in social care, which is underfunded and has been drained by the pandemic.1516 Waiting lists for hospital procedures have reached over seven million.17. Years of underfunding and neglect have weakened the NHS.17

Brexit has been a major factor in undermining the culture and science in the UK. The health community is impacted directly by the isolation and exclusion of our researchers from the Horizon programme.18 Brexit is a major cause of the UK’s worsening economic and trading position19, and a major contributor to our inability to sustain the workforce in health and social care, agriculture, hospitality, and the logistics sectors. Brexit is forcing up wages in the private sector, compared to the public sector and one of the reasons UK inflation is higher than western European country comparators. It also makes the cost-of-living crisis worse for those on lower wages.20

The Russian invasion of Ukraine and recovery from the covid-19 pandemic have distracted from the impacts of the cost-of-living crisis. However, corporate profit is the driver for high inflation.21 Current policies on interest rates do nothing to address the problem, but lead to further impoverishment of everyone, except the top 5%.9 There has been excessive profiteering by oil and gas companies, while the population have struggled with the cost of fuel for heating and cooking.22 Bank of England interest rate rises bring windfall profits to banks.23

In 2007, readers of The BMJ voted sanitation and clean water as the biggest medical advance since 1840.24 Incredibly, we are now confronted with the return of Victorian sanitary ill health. Our rivers and seas are being poisoned with raw sewage.25 We are witnessing the squandering of water—our most precious health asset—sacrificed on the altar of corporate greed. There has been inadequate action from water companies, the regulator, and the government.

In 1842, the Poor Law commissioners saw a society drowning in excrement, choking from air pollution, with widespread destitution, poor housing and homelessness, poor nutrition and hunger, poor education, and childcare. We cannot take for granted the improvements that arose from the policies they proposed. Those gains are being frittered away by a combination of neoliberal policies, vested and destructive commercial interests, a populist culture war, and industrial-scale disinformation. We are operating in this cultural and political environment and confronted by existential threats such as global climate breakdown, widening conflict and mass migration, and the threat of nuclear war.26

So, a big birthday present is needed for the public’s health more than ever. Most recently, the welcome “Covenant for Health” sets out a ten year programme for greatly expanded investment in preventive services and policies.27 A Royal Commission for health, and for the NHS, has been called for, from widely different perspectives.1528 It would certainly raise the level of public discussion, but to get to that would require a government which pays more than lip service to the importance of health. We are at a point in the electoral calendar where a Royal Commission is unlikely. We need a new, and major Public Health Act that shows how our society will address the unacceptable causes of inequality in health, which are caused by economic, environmental, and educational inequality. At the very least, we need to see health at the centre of all policy making.29 We need leadership for health and a vision that sees health as the highest law, and the highest policy objective. After the pain of the covid-19 pandemic, and with the threat of climate catastrophe, we need to plan for an outbreak of health.

Competing interests: JM is Honorary Professor of Public Health, University of Wolverhampton; Visiting Professor of Public Health, Chester University; Past President, United Kingdom Faculty of Public Health (UKFPH); Immediate President, Association of Schools of Public Health in the European Region (ASPHER); and Vice President, Global Network for Academic Public Health (GNAPH). He is an elected, unpaid official of GNAPH, and formerly an elected, unpaid official of the UK Faculty of Public Health and the Association of Schools of public Health in the European Region.


  • Acknowledgments: Thank you to Jennifer and Medea Middleton for helpful comments shaping the final paper.

  • Provenance and peer review: not commissioned, not peer reviewed.