Understanding the Theory and Process of Strategy Development: Historical
development of personal health services and of public health.
Overall, personal health is achieved through a combination of physical,
mental, emotional, and social well-being.
Physical fitness: refers to good body health, and is the result of
regular exercise, proper diet and nutrition, and proper rest for physical
recovery. Hygiene is the practice of keeping the body clean to prevent infection
and illness, and the avoidance of contact with infectious agents.
Mental health: refers to an individual's emotional and psychological
well-being. Prolonged psychological stress may negatively impact health, e.g. by
weakening the immune system and mind.
Emotional, and social well-being: personal health depends partially on
the social structure of one's life. The maintenance of strong social
relationships is linked to good health conditions, longevity, productivity, and
a positive attitude.
Personal Health Services:
Personal Health Services incorporates the prevention, treatment, and
management of illness and the preservation of mental and physical well being
through the services offered by the medical, nursing, and allied health
The NHS provides the majority of healthcare in England, including primary
care, in-patient care, long-term healthcare, ophthalmology and dentistry.
Primary care providers act as a first point of consultation for all
patients. Continuity of care is also a key characteristic of primary care.
Primary care includes all ages of patients, patients of all socioeconomic and
geographic origins, patients seeking to maintain optimal health, and patients
with multiple chronic diseases.
Long-term care (LTC) is a variety of services which help meet both the
medical and non-medical need of people with a chronic illness or disability who
cannot care for themselves for long periods of time. Long-term care can be
provided at home, in the community, in assisted living or in nursing homes.
Long-term care may be needed by people of any age, even though it is a common
need for senior citizens.
Ophthalmology is the branch of medicine which deals with the diseases
and surgery of the visual pathways, including the eye, brain, and areas
surrounding the eye, such as the lacrimal system and eyelids.
Dentistry is the known evaluation, diagnosis, prevention, and
treatment of diseases, disorders and conditions of the oral
cavity, maxillofacial area and the adjacent and associated structures and
their impact on the human body. Dentistry is widely considered necessary for
complete oral health.
The NHS is committed to providing quality care that meets the needs of
everyone, is free at the point of need, and is based on a patient's clinical
need, not their ability to pay.
Department of Health:
The Department itself does not directly deliver healthcare and social
services to the public. Instead, the Department works, at both a national and a
regional level, with many different external partners: other government
departments, the NHS, local authorities, arms length bodies and other public
and private sector organisations.
The Department is responsible for the stewardship of over £100 billion of
public funds and advises ministers on how best to use this funding. The services
are delivered locally by 1.3 million staff in more than 300 organisations and
through approximately 5,200 GP practice premises, as well as other primary care
services. These services are in contact everyday with over 1.5 million patients
and their families. Its staff are responsible for leading and driving forward
change in the NHS and social care, as well as improving standards in public
The Department also sets the strategic framework for adult social care and
gives advice and guidance to local authorities. Almost 1 million staff work in
the social care sector providing services to 1.7 million users most of whom are
The Department holds the lead role across government for the improvement and
protection of the publics health and the reduction of health inequalities. It
runs health protection programmes covering such matters as immunisation or
infectious disease surveillance, and health improvement programmes such as
tobacco reduction. These services are delivered through key partners such as the
NHS, local authorities and the Health Protection Agency. At a broader level the
Department works with other government departments and also with local
government offices in delivering these aims due to the significant impact of
issues such as education, employment, economic well-being, transport,
environmental health and housing on peoples health.
- the science and art of preventing disease, prolonging life, and promoting
health through the organised efforts of society (Acheson Report 1998)
- health care is vital to us some of the time, but public health is vital
to all of us all of the time (C.Everett Koop, former
Public Health Services:
The origins of the domains of public health lie in the historic importance of
the control of communicable disease, health education and the role of hospital
and community services over the last 150years. Three domains of public health
have been recognized (Hunter 2007):
- Health protection: embraces the prevention and control of
infectious diseases; response to emergencies from chemical poisons,
radiation, bioterrorism and environmental hazards (see HK2: Disease
Causation & Prevention g) Communicable Disease Control)
- Health improvement: embraces tackling inequalities; working with
partners in the NHS and other sectors in education, housing, and workplaces;
engaging with structural determinants as well as working with individuals
and their communities to improve health and prevent disease through adopting
healthier lifestyles (see HK2: Disease Prevention i) Principles and
Practice of Health Promotion)
- Health service quality improvement: embraces promoting clinical
effectiveness through evidence based practice, service planning and priority
setting, audit and evaluation; supporting clinical governance (see HK
5: Organization & Management of Care Understanding Individuals,
teams and their Development)
Although an alternative typology (Holman 1992) describes a broader function
- Health protection
- Preventive medicine
- Health education
- Healthy public policy
- Community empowerment.
Over the past two centuries the relationship between personal health
services, public health, and social and scientific change, has evolved in
complexity. The PDF table
(available here) demonstrates the range of social and
scientific changes in events, legislation and documentation affecting personal
and public health services between the 18th and 21st
Personal Health Services
Key Areas to note:
- There has been some form of state-funded provision of health and social
for 400 years.
- Historically, care for the poor, infirm and elderly was provided through
religious orders and monasteries, although following the dissolution under
King Henry VIII, much of this care was removed.
- Almshouses established under Queen Elisabeth I, and brought together under
the first Poor Law, provided some support for the most needy.
- 18th century Acts, such as, the Workhouse Test Act in
1723, gave legislative authority for the establishment of parochial
workhouses, and gave parishes the option of providing grants of money,
clothing, food, or fuel, to the parish poor.
- By the 19th Century the benevolent attitudes had changed and
outdoor relief was abolished with the establishment of austere workhouses,
providing accommodation for the poor, orphans and the elderly. Towards the
end of the century annexes were added to house the sick cared for by
untrained volunteers and voluntary hospitals for infectious diseases and
others for people with mental illnesses and handicap.
- Primary and community care evolved separately from hospitals with
community care, domiciliary services, plus environmental and public health
services the responsibilities of local authorities. At the start of the 20th
Century however, the developing family doctor service was funded though
- The imminent war (WW2), obliged the government to establish an Emergency
Medical Service in 1938, leading to an integrated, state-funded hospital
service established by 1948, and the National Health Service was created.
- During the 20th century, advances in medicine provided unprecedented
opportunities to improve both the detection and prevention of disease, and
it was the National Health Service which made these advances available to
everyone, regardless of their ability to pay.
- The three main strands of the NHS persisted for many years through state
owned (nationalized) hospitals, a national network of general practitioners
and community and domiciliary health services. These strands were financed
centrally but managed separately.
- The internal market reforms of the 1990s aimed to produce a more
responsive and efficient service where the provision of care matched
available resources by devolving budgets to NHS Trusts, individual
directorates within them and to GP Fundholders.
- Since 1997, the priorities of the NHS have been to improve preventative
care and address the wider social determinants of poor health (see Table
- By the 21st century, the central aims of the NHS were concerned
with the transformation of conventional health-care delivery by, putting
people at the centre of health care, harmonizing mind and body, people and
There is a growing realization (WHO 2008) that conventional health care
delivery, through different mechanisms and for different reasons, is not only
less effective than it could be, but suffers from a set of ubiquitous
shortcomings and contradictions summarized below.
Inverse Care: people with the most means whose needs for care are
often less consume the most care, whereas those with the least means and
greatest health problems consume the least. Public spending on health services
most often benefits the rich more than the poor.
Impoverishing Care: Wherever people lack social protection and
payment for care is largely out-of-pocket at the point of service, they can be
confronted with catastrophic expenses. Over 100 million people annually fall
into poverty because they have to pay for health care.
Fragmented and fragmenting care: The excessive specialization of
health-care providers and the narrow focus of many disease control programmes
discourage a holistic approach to the individuals and the families they deal
with and do not appreciate the need for continuity in care.
Unsafe care: Poor systems design that is unable to ensure safety and
hygiene standards leads to high rates of hospital-acquired infections, along
with medication errors and other avoidable adverse effects that are an
underestimated cause of death and ill-health.
Misdirected care: Resource allocation clusters around curative
services at great cost, neglecting the potential of primary prevention and
health promotion to prevent up to 70% of the disease burden. At the same time,
the health sector lacks the expertise to mitigate the adverse effects on health
from other sectors and make the most of what these other sectors can contribute
Table 1: Highlights from The 1997 reforms: the new NHS, Modern, Dependable
(Greengross et al 1999) and subsequent changes
|Proposal||Objective||Supporting legislation and changes|
|The abolition of the internal market||Reduced transaction costs, more co-operation between
Trusts, Primary Care, Health Authorities and Social Services
|Care Trusts 2002|
|The introduction of Primary Care Groups (PCGs), each
responsible for commissioning health care for populations of about
1000,000 people, and the abolition of fundholding
|Abolish inequity between patients registered with
fundholding and non-fundholding practices. Reduce commissioning costs.
Single budget for primary care including prescribing
the balance of power: Primary Care Trusts - Governance arrangements,
remuneration and allowances 2002
|Health Authorities to assume a strategic role by
developing three-yearly Health Improvement Programmes (HimPs) in
conjunction with the local NHS, PCGs and Local Authorities
|Co-operative, longer-term approach to planning services.
Delivery of health (and social) care embedded within a broader strategy
|The NHS improvement plan : putting people at the heart
of public services 2004
The Local Government and Public Involvement in Health Act 2007
|The introduction of Clinical Governance, imposing a
statutory upon Trust Chief Executives for the quality of care delivered
|Placing quality at the heart of NHS activity and closer
monitoring of clinical practice
|Essence of Care: Patient-focused benchmarks for
clinical governance 2001
|A new performance management Framework||Broader performance indicators to reduce perverse
|NHS Performance Framework Implementation Guidance 2009|
|The establishment of two new bodies. A National Institute
for Clinical Excellence (NICE) to develop National Service Frameworks
for care delivery
|Improve and monitor quality and effectiveness of care
using national standards
|National Service Frameworks: a practical aid to
implementation in primary care 2002
|A Commission for Health Improvement (CHImp) to evaluate
clinical care against these and other standards
|More appropriate care delivery, better inter-sectoral
|Commission for Health Improvement ceased operating
2004. Functions taken over by the Healthcare
The Healthcare Commission, ceased to exist on
The Care Quality Commission is the health and social care
Public Health Services
Key Areas to note:
- In the 19th century, public health issues tented to be ignored with many
politicians opposing the great public health reforms designed to improve
living conditions in the
slums until the stench from
hung over the House of Commons terrace, and the death toll from cholera ran
to tens of thousands.
- People at the time thought that diseases like cholera were spread through
the air, or miasma as it was called then. It was a cluster of cholera
in 1854, now
, that led John Snow to discover that cholera was in fact spread through the
water supply. Having made this link, he took the simple action of
removing the handle of the water pump and thus prevented further spread of
as elsewhere, the crucial decisions that sanction and fund the public health
effort always come, ultimately, from the political realm. The solutions to
the range of health challenges faced by the Victorians, purifying water,
constructing sewage systems or slum clearance, appeared easy to identify
once the political will had been secured (Hunter 2007).
- During the 20th Century there were major improvements in the control of
infections, safety from radiation sources and reduced pollution with
advances in medicine providing unprecedented opportunities to improve both
the detection and prevention of disease.
- The 21st Century has seen an emergence of new problems, including
environmental hazards such as pollution from transport, an increased number
of chemicals in everyday use, global warming, disposal of waste at landfill
sites and building on contaminated land, together with the emergence of new
infections such as SARS and avian and swine flu.
Progress in health has been deeply and unacceptably unequal, with many
disadvantaged populations increasingly lagging behind or even losing ground. The
nature of health problems is also changing dramatically. Urbanization,
globalization and other factors speed the worldwide transmission of communicable
diseases, and increase the burden of chronic disorders. Climate change and food
insecurity will have major implications for health in the years ahead thereby
creating enormous challenges for an effective and equitable response.
However, total health expenditure on prevention and public health has doubled
over the last 10 years. Tackling health inequalities is now a top priority for
this Government, and it is focused on narrowing the health gap between
disadvantaged groups, communities and the rest of the country, and on improving
- Department of Health (2000) The NHS Plan: A Plan for investment A plan
- Department of Health (2007) Our NHS our future: NHS next stage review -
interim report summary
- Gorsky, M. (2008) The British National Health Service 19482008: A
Review of the Historiography Social History of Medicine 21(3):437-460
- Greengross, P, Grant, K, and Collini, E. (1999) The History and
Development of the
National Health Service
- Health Protection Agency (2005) Health
Protection in the 21st Century - Understanding the Burden of Disease London:
- Hunter, D. (2007) Managing for Health
- WHO (2008) Closing the gap in a generation Final Report of the
Commission on Social Determinants of Health
- World Health Organization (2008) World Health Report 2008: Primary
Health Care now more than ever
© Sally Markwell 2009