Intended for healthcare professionals

Opinion

A Spartacus moment for public health physicians?

BMJ 2023; 382 doi: https://doi.org/10.1136/bmj.p2233 (Published 29 September 2023) Cite this as: BMJ 2023;382:p2233
  1. Carol Brayne, professor of Public Health Medicine1,
  2. Martin McKee, professor of European Public Health2
  1. 1University of Cambridge, Cambridge, UK
  2. 2London School of Hygiene & Tropical Medicine, London, UK

The General Medical Council’s (GMC) Good Medical Practice sets out the standards required of doctors registered with it. Its latest version will come into force on 30 January 2024.1 Among the changes from previous versions is an addition to the section “Responding to safety risks” that says, “If you have a formal leadership or management role, you must take active steps to create an environment in which people can talk about errors and concerns safely,” with an earlier part of the same section specifying that risks can arise from “policies and systems.” We contend that this may pose problems for many of our public health medicine colleagues.

Most public health doctors do not see individual patients. Rather, they work to safeguard and improve the health of entire populations. Thus, the definitive book on the history of chief medical officers in the UK, which is also co-authored by a former holder of that post in England is entitled “The Nation’s Doctor.2 Current guidance on the role of directors of public health in England says that they should “be an independent advocate for the health of the population and provide leadership for its improvement and protection.”3 The corresponding legislation requires them to “take steps to improve the health of the people in [the local authority’s] area.” Thus, we argue that, for these doctors, their “patients” are the populations for which they are responsible. Yet, every day, public health doctors are working to counter the effects of “policies and systems” that place those for whom they are responsible at risk.

The evidence of the harm that is being done by current policies and systems is overwhelming. While one can quibble about the precise numbers, there is now no doubt that by choosing to impose and maintain a policy of austerity since 2010, successive governments have created the conditions that led to tens of thousands of premature deaths, with life expectancy in the UK falling further behind that in many comparable countries.45 Austerity also seems likely, contrary to the arguments of its proponents, to have left the UK more vulnerable to the effects of the covid-19 pandemic,6 while systemic failures in the machinery of a government distracted by the chaos of planning for Brexit left the country far less prepared than it should have been.78 The list of specific policy and system failures leading to illness and premature death is long. Windrush,9 Grenfell Tower,10 and the impact of the Post Office computer scandal11 and benefits sanctions12 are some of the better known, but there are many others.

Some may argue that this argument takes the GMC’s standards beyond what they are intended for as, in their view, a doctor is only responsible for those individual patients whom they diagnose or treat. Yet Good Medical Practice makes explicit reference to the responsibility to our “wider responsibilities to patients and the wider population” [emphasis added] in decisions on the use of resources and it expects us to consider sustainability and the environmental impact of healthcare. It now contains specific guidance on the use of social media that, by definition, involves interaction with the general population.

Public health has always involved politics. We are obliged to seek the “causes of the causes” of disease,13 a search that often brings us to its political and commercial determinants.14 Many of our most effective tools involve legislation and regulation. This can bring us into conflict with powerful vested interests, which often act through influential so-called “think tanks” that have been very successful in capturing the narrative.15 Thus, public discourse about the recent extension of the Ultra Low Emission Zone in London, a measure with a clear public health rationale, to reduce the high burden of illnesses due to pollution from motor vehicles, has been dominated by questions of individual liberty. If we are serious about promoting the health of the populations for which we are responsible, we must challenge the “policies and systems” that allow them to exert so much influence.

Yet we can see a risk that some public health doctors in leadership and management roles, whether in local authorities or central government, including the Office of Health Improvement and Disparities and the UK Health and Security Agency, may struggle with this duty. This is especially so where the politicians whom they advise are ideologically opposed to those measures most effective in promoting health or who have financial or other ties those with vested interests in products that harm health.16

David Oliver sees the GMC’s new guidance as a major opportunity for frontline clinicians to speak out against the policy failures that have done so much damage to the NHS, now suffering from over a decade of sustained underinvestment.17 He invokes the saying “I am Spartacus” to argue that, if we all speak out, we will be impossible to ignore. We hope that he will be listened to. However, we also believe that public health doctors must speak out too. The Royal College of Emergency Medicine has offered us an example,18 highlighting the large number of avoidable deaths each week that can be attributed to delays affecting the departments in which its members work.19 Public health doctors, individually and collectively and whatever their employment conditions, must accept that they too have a duty to those they serve and our leaders must embrace the challenge of creating the environments in which their concerns can be aired openly and safely.

Footnotes

  • Competing interest: MM was President of the BMA in 2022-23

References