Professor Liam Donaldson, Chief Medical Officer, Department of Health, Rm 111 Richmond House, 79 Whitehall, London SW1A 2NS, UK.
Abstract
This lecture focuses on a paper that Jerry Morris published in the Lancet of Saturday 18 October 1969 entitled Tomorrow's Community Physician.1 It was a seminal paper in which a vision of the role and potential of a new breed of public health practitioner was set out. The themes raised in the original paper which examined population health and health service issues, are revisited, by assessing how things have changed, and in particular examining the extent to which the vision set out in the paper has become reality over the last 30 years.
Accepted 21 March 2001
Many of Morris's papers were seminal to epidemiological method or policy on disease prevention but one had a major influence on the development of public health practice. It was published in the Lancet of Saturday 18 October 1969, entitled Tomorrow's Community Physician1 and set out a vision of the role and potential of a new breed of public health practitioner: the tasks of the community physician as an administrator of local services, epidemiologist and counsellor are considered in relation to changes in medical needs, in clinical practice and in prevention.
I will take the story on 30 years and assess how much of Morris's vision has been realized and how much of it is still relevant today.
Condition of the people
Morris began by looking at the condition of the people.
First let me take some readings of the people's health.1
Population
In examining trends in mortality between the beginning and middle of the 20th century (Table 1), he observed that:
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This section of the paper was pessimistic and spoke of gains being absorbed, a chapter of improvement closing and a rougher road ahead. However, the trend did not remain stuck and mortality fell again during the period from the 1970s through to the late 1990s (Table 2) but in some other respects, Morris's pessimism of 1969 has been borne out.
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Burden of disease
The section of Tomorrow's Community Physician on the condition of the people also dealt with the burden of disease and drew attention to the growth in hospital admissions arising from:
Since then, there has been a huge rise in the intensive use of hospitals (Table 3). Even in the last decade the major implications of the ageing population on acute hospital admission rates have been very apparent.
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Chronic sickness
Morris then turned to the burden of chronic diseases. Where Tomorrow's Community Physician used absence from work data as a proxy for chronic disease prevalence as well as sedative prescriptions in general practice, there are now better data on chronic disease through the excellent morbidity statistics collected in general practice. This shows the important chronic conditions that take up the time of primary care services (Figure 1). It is perhaps interesting to see that, despite the hierarchy of prevalence, only 419 members of the Royal College of General Practitioners specialize in cancer compared with 1253 who specialize in diabetes (from a total membership of 18 624).3
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Hospitals are changing. The acute element is more intensive and critical and extended to the very old and the very young. Sophisticated personnel and hardware have to be available around the clock.1
The second theme of Tomorrow's Community Physician dealt with the organization of clinical services. Since then, there have been large reductions in acute and elderly beds (Table 5). For example:
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Whilst admissions have continued to rise bed numbers have fallen due to shorter length of stay and increased numbers of day cases. For example, over the last 10 years alone:
The increase in day case admissions has been accompanied by an increase in beds for day use only. From 0 in 1969 to 8000 in 1999. Recently in the acute sector, bed reductions have slowed. There has been a steady decline in the number of mental health inpatient beds. Table 5 shows that over the last 30 years:
Reductions in mental health beds are a result of the long-term policy of moving patients out of hospitals and other NHS institutions into community settings. For adults, the large fall in NHS provision has been almost entirely in long stay facilities and has been matched by an increase in the available places in private nursing homes and private, voluntary and Local Authority residential care homes. This change was driven by the increasing availability of medication to control symptoms and the recognition that institutional living harmed the quality of life and ability to function in society.
Enduring verities
Much of the vision in Tomorrow's Community Physician was captured in reflective observations which ran alongside the main themes.
If only the trouble is taken to look, nagging disparities are repeatedly found.1
These nagging disparities are indeed still found, for example amongst care of diabetics and access to coronary artery bypass graft operations.4
Fair shares is at the heart of any morality of medical care.1
In an ageing population, burdened with chronic diseases that cannot be cured and are not avoided, the quality of care is a major element in preventive medicine.1
Quality of care has been a relatively recent focus of NHS attention. At its outset, the NHS set no specific agenda for quality improvement aside from developing the infrastructure of care and embracing clinical advances and new technologies as they arose. In the early days, quality assurance was implicit and based on an assumption that highly educated, well-trained staff would service the needs of patients to a high standard.
That was still the case in 1969 when Tomorrow's Community Physician was published. In the late 1960s and early 1970s, there was little flow through of new quality concepts into practice or health system design. However, throughout the history of the NHS, professional-led quality initiatives particularly clinical audit have been carried out in many centres. One way or another quality strategies in the NHS have fallen into one of these categories:
Our response today has been to put in place a comprehensive system of quality improvement. As part of its new policies for the NHS in the late 1990s, the new Government placed a duty of quality on every health organization within the NHS. At local level this is translated into clinical governance defined as:
A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.5
Clinical governance is essentially an organizational concept aimed at ensuring that every health organization creates the culture, the systems and the support mechanisms so that good clinical performance will be the norm and so that quality improvement will be part and parcel of routine clinical practice. Clinical governance will mean, for example, health organizations:
Placing a duty of quality on the NHSa duty not just to assure high standards but to improve year on yearis a bold and imaginative challenge and an approach which attempts to reset the balance in which financial and workload targets have dominated management thinking in the NHS.
The local duty of quality is reinforced by the creation of two new national bodiesthe National Institute for Clinical Excellence (NICE) which will set standards and the Commission for Health Improvement which will inspect local clinical governance arrangements and investigate where services appear to be failing.
Prevention
In his seminal text Uses of Epidemiology6 Morris called for four cheers for prevention and it was also an important theme of Tomorrow's Community Physician. In assessing our progress in prevention we must look critically at the public health delivery system. How effective has it been in improving local population health and reducing inequalities?
As a first step, strong public health delivery needs strong Government. A Government which sees health as both a priority and as a responsibility for all Government Departments not just the Department of Health. Essentially this was one of the core messages in the Black Report7 of which Morris was a co-author.
In the late 1990s, action has been informed by the work of Donald Acheson's Inquiry into Inequalities in Health8 which played an important part in guiding the production of the White Paper, Saving Lives: Our Healthier Nation.9 An impressive range of cross government action is already in place, for example: tackling social exclusion through a Social Exclusion Unit accountable to the Prime Minister, the Sure Start programme to give children in disadvantaged communities a better start in life10 and a sustainable development strategy for the environment.11 Government can improve the public health by:
At a more local level public health in the recent past has lacked a clear delivery system where there is clarity of accountability for achieving results. The strengths of our system have been:
The weaknesses have been:
The aim for the new century is to create a cohesive delivery system by action from Government, through local partnerships and helping and supporting the individual.9
Community diagnosis
Another major theme of Tomorrow's Community Physician was the importance of information and knowledge to effective public health practice.
Tomorrow's community physician will administer local medical services but can succeed only by building an effective intelligence system.1
Without knowledge, there can be no planning to realise an image of the future.1
Since 1969 we have seen a growth in information technology which many would argue has not been matched with realizing its potential to deliver good information to the fingertips. On the public health information front there have been some notable gains with the creation of invaluable data sources (Box 1).
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The major evaluative development of the 1990s has been the rapid inculcation of a philosophy of evidence-based practice, initially into clinical medicine,12 but gradually extending to public health interventions and evidence-based decision-making in health care more generally. This was inspired by the work of the first President of the Faculty of Public Health Medicine, Archie Cochrane.13 A shift from greater scientific understanding into public health practice has been slow but a research and development strategy backed up with more effective learning from and use of evidence is now national policy.9
Participation
Tomorrow's Community Physician also made this visionary statement.
The object of participation is to assure that services are run for people.1
Progress can be accounted for in four areas:
Firstly, it has been uncommon to ask communities for their view on their own health problems but when it is done there are some interesting results (Box 2)
Box 2 What people in disadvantaged communities said about health When you don't have much money, you buy things like chips ... they're cheap and fill you up ... pre-packed salads, they're so expensive ... and special offers are always on cakes and biscuits, not the healthy stuff. Female, 2029, Wolverhampton I smoke to have a break from the kids, to relax. It's one of life's pleasures. Female, 2029, Wolverhampton When I close the curtains at night, it's the most horrible feeling in the world, you can't go out and you know it's just you on your own. Male, 65+, Wolverhampton More council leisure centres, there's only posh ones near us ... it should be free for low income families too. Male, 2534, Doncaster We went to the country for the weekend and the kids played outside all day, running around ... they'd never be fat if we lived there. Female, 2534, Oldham When you don't work you just sit around and get boredsometimes you just eat because there is nothing else to do. Male, 2025, Glossop Source: MORI
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Thirdly, patient participation is a key element of health care and this has been a focus of recent quality strategies.15
Fourthly, we are in a society where risks to health are a daily part of the public debate: genetically modified food, mobile telephones, pesticides in fruit and vegetables, variant Creutzfeldt-Jakob disease (vCJD) are only some of the issues which have achieved prominence since Tomorrow's Community Physician was published. This is a new dimension to public health practice. It is a major challenge. Strong public health must mean that it is credible and trustworthy in the eyes of the public and there have been serious problems in this area in the last 5 years.
Community physician
Finally, what of the community physician or public health practitioner as we might refer to her or him today.
I have been considering the evolution of the community physician as epidemiologist, administrator of local medical services, community counsellor, professional and public servant: their advent is in itself I believe a priority.1
What has been their fate over the last 30 years? What about the practice of public health itselfhow far has the vision of Tomorrow's Community Physician been realized?
Perhaps the difficulties ahead for the new discipline of medical practice, community medicine (as it was then), could not have been foreseen in 1969yet there has undoubtedly been turbulence. In part this turbulence has reflected the extent to which the specialty became caught up in the various reorganizations of the health service. Community medicine came into being with the 1974 reorganization of the health system which ended the old tripartite structure: local authority public health and community services, executive councils and hospital boards (regional and local). The resulting unified health service marked, inter alia, the passing of the Medical Officer of Health and created a clear role for community medicine but one that did not immediately become clear to those doing the job, their clinical colleagues or the other members of the management teams of the bodies in which they worked. As a result, there was too great a period of soul searching as the new specialty tried to find itself and address the conceptually difficult task of identifying ways to improve the health of local populations. The advent of general management in the NHS of the late 1980s saw the end of consensus management and the introduction of executive posts. The community physician had a management accountability, a corporate accountability and a professional accountability. There was palpable tension between the professional and the executive role with many people falling into one of two camps: those that embraced the notion of corporateness and those that saw themselves as advisers.
Although public health staff who are medically qualified have played a vital role in the development of the public health movement, the people who should make up the modern public health workforce will come from a wide range of professional backgrounds. Indeed, the range of professional staff who have or could have a public health role as a component of their jobs is very broad. There are five main groups: the public health specialistindividuals from any background who have moved from their initial degree or professional qualification to undertake an accredited training programme in public health; the health professional or practitionerincreasingly all health professionals (e.g. health visitor, district nurse, general practitioner, hospital doctor) will be expected to play their part in improving the health of the population; the public health expert or scientistthe task of improving the health of the population and protecting the public health needs expert and scientific help to underpin it. Expertise which can help to enhance the effectiveness of health programmes covers, for example, environmental science, toxicology, nutritional science, communicable disease control, epidemiology, health services evaluation, health economics, applied psychology. In some cases, the availability of such expertise is vital in urgent interventions to protect the public health; non-health sector professional staffmany staff with professional qualifications outside the health or health care sector can have an important role in improving public health; managers of health and other public sector organizationsmost health organizations and many others in the public sector now have a clear management structure with executive and non-executive functions. The chief executive (or equivalent) and other senior managers are people responsible for driving forward strategy. Their knowledge, attitudes, skills, and experience of public health are vital determinants of ensuring that all such organizations have a clear orientation towards health.
So, Tomorrow's Community Physician has become today's public health practitioner, only some of whom are medically qualified. The potential benefit of ensuring that a diverse grouping of individual professionals becomes a true public health workforce is huge and is a major challenge 30 years on from 1969.
Conclusions: how many cheers?
An appropriate index in a score card of the progress made since 1969 might be the Morris cheer (Table 6). The cheer was one of four applied to prevention in his Uses of Epidemiology.6 I regret that I cannot give four cheers to prevention although I would still give four cheers for prevention as Morris did. My rating of progress in 30 years against the themes in Tomorrow's Community Physician is as follows:
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Organization of clinical services
I have given three cheers for the endurance of the NHS, for the undoubted growth in medical innovation which has been so beneficial, and for the recent emphasis and coherent programme on quality. I have given no fourth cheer because of inequity in access, variation in process and outcome, and poor responsiveness which still persist in too many areas of service and in too many parts of the country.
Prevention
Prevention gets two cheers because the focus is now on the root causes and determinants of poor health, because cross government action to address them is now strong, and because we do have a broad-based public health service in Britain. All this is good but to earn the other two cheers we must start to see public health programmes have a major impact in the most disadvantaged parts of the country and start to narrow the health gap.
Community diagnosis
Only one cheer here. Whilst there are stronger public health information systems than existed in 1969, not enough has been done to use them, e.g. needs assessment is not in the mainstream, nor is high quality information used day-to-day in taking public health policy decisions or in making interventions to protect the public health.
Fair shares
One cheer here speaks for itselfequity is still one of the greatest challenges which is not being met.
Participation
One cheer because public participation is a relatively recent phenomenon. There are islands of excellence and the outlook is promising but there is still much to do to raise the other three cheers.
Knowledge
I have given four cheers here, not for perfection but for commitment. We must recognize that the evidence base in public health is not as large as it should be. However, the drive to sustain research and generate new knowledge has been strong. For example, most permanent staff in academic departments of public health have been almost entirely supported through NHS, not university, funding. This has kept research and the quality of teaching alive these last 30 years. British epidemiologists still rank highly internationally; the work of a British public health doctor (Cochrane) inspired the whole evidence-based practice movement which was one of the most important developments in health care during the last century and another helped to implement it (Chalmers).
Community physician
The survival of the community physician/public health practitioner is in itself a reason for two cheers and understandable in view of all the reorganizations of the NHShalf a dozen since 1969. The remaining two cheers must be earned by the melding of a disparate workforce into an effective multidisciplinary system of practice which leads and inspires public health at local, regional and national level.
Conclusion
Jerry Morris has been an inspiration over his long career. Revisiting the vision in Tomorrow's Community Physician shows that the model of public health he set out in 1969 is as powerful, relevant and far-sighted today as it was then. Over these 30 years, we have struggled to live up to it but it must remain a driving force for change.
Notes
Based on a speech given at the 90th birthday conference to celebrate Professor Jerry Morris. Friday 21 July 2000, 2.002.30 p.m. Manson Lecture Theatre, London School of Hygiene and Tropical Medicine.
References
1 Morris JN. Tomorrow's Community Physician. Lancet;18 October 1969:81116.
2 Drever F, Whitehead M (eds). Health Inequalities: Decennial Supplement: DS Series No. 15. London: The Stationery Office, 1998.
3 Personal communication, Royal College of General Practitioners.
4 Donaldson LJ. Health services and the public health. J Epidemiol Community Health 2001, In Press.
5 Department of Health. A First Class Service: Quality in the New NHS. London: Department of Health, 1998 (Health Service Circular: HSC(98)113).
6 Morris JN. Uses of Epidemiology. London: Churchill Livingstone, 1975.
7 Department of Health and Social Security. Inequalities in Health: Report of a Research Working Group (The Black Report). London: HMSO, 1980.
8 Acheson D. Report of the Independent Inquiry into Inequalities in Health. London: The Stationery Office, 1998. Chairman: Sir D Acheson.
9 Department of Health. Saving Lives: Our Healthier Nation. London: The Stationery Office, 1999 (Cm 4386).
10 Department of Health. Sure Start. London: Department of Health, 1999 (Health Service Circular 1999/002).
11 Department of the Environment, Transport and the Regions. A Better Quality of Life: A Strategy for Sustainable Development for the United Kingdom. London: The Stationery Office, 1999 (Cm 4345).
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Evidence-based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268:242025.
13 Cochrane AL. Effectiveness and Efficiency. Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972.
14 Nye Bevan Awards Go to NHS Trailblazers on NHS 51st Birthday. Department of Health Press Release 1999/0406, 5 July 2000.
15 Secretary of State for Health. The NHS Plan: A Plan for Investment, A Plan for Reform. London: The Stationery Office, 2000 (Cm 4818-I).