Public health and mental health
We have a good - proud and strong - example of this move in the UK. One key medical profession - public health - has recently transferred from health service management (back) into local authority control. I'm referring to public health working at the level of population and planning, rather than at the level of the individuals, to help a city or a community stay healthy, and to protect them from threats to their health. Public health professionals aim to improve health and quality of life through improving the way that we prevent and treat diseases. They aspire to the World Health Organization's aim: health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. Public health, like mental health, is a team effort, with input from physicians, epidemiologists, statisticians, nurses, microbiologists, environmental health officers . .. even lawyers. Typical policies address things like reducing smoking and helping people to quit, reducing drugs misuse and dependence, giving all children a healthy start in life, reducing harmful drinking, planning for health emergencies such as epidemics and pandemics, screening for cancer, reducing obesity and improving diet, and promoting breastfeeding. Public health services, of course, also address mental health.
Until 2013, local public health services were organised from within the NHS - by Primary Care Trusts (PCTs). In a rather controversial move, the same legislation that introduced Health and Wellbeing Boards also transferred responsibility for public health services from the NHS (in this case PCTs) to local authority control. Although (at least in principle) the amount of taxpayers' funding available to public health was protected, and although the responsibilities for the public health service remain unchanged, public health services are now part of the infrastructure of local authorities.
This has, of course, been a challenging period for many of my colleagues in public health. In my view, however, local authority management is the right place for public health. Maybe an example will help explain why. Again it's from the city where I work, Liverpool. Part of Liverpool's civic pride includes the legacy of Dr William Duncan. Like most doctors in Victorian Britain, Duncan came from a privileged background. But, after qualifying as a doctor in 1829 and working as a GP or family doctor in a working class area of Liverpool, he became interested in the health of the poor and started researching the living conditions of his patients. He was shocked by the poverty he found, and in his observations of the clear link between housing conditions and the outbreak of diseases such as cholera, smallpox and typhus. Dr Duncan started a lifelong campaign for improved living conditions and, together with Liverpool's Borough Engineer, James Newlands, started to tackle the problems he saw. This led to his appointment as Liverpool's first Medical Officer of Health, and in the passing of Liverpool's Sanitary Act in 1846. Dr Duncan undertook all of this rather splendid activity without compromising his role as a doctor and this was an excellent use of his medical training, but it was all enacted through and with local civic authorities. So the recent move of public health services to local authority management is in keeping with the best traditions of the profession.
Public health professionals themselves stress the extent to which our health is socially determined. Many argue that by far the most effective policies are those enacted at the population level. Researchers point to the extent to which our health is a product of social factors, and particularly how social inequalities lead to inequalities in health outcomes. More importantly, perhaps, the most effective interventions are social interventions - health education and promotion campaigns to reduce smoking, alcohol use; improve unhealthy diets; improve take-up of immunisation; improve breast-feeding rates and condom use; reduce UV sunbed use to prevent melanoma; prohibit advertising of cigarettes and sales of alcoholic drinks aimed at young drinkers; promote campaigns on licensing laws, housing policies ... some of the most important public health activities are central to local authority responsibilities. More importantly, interventions aimed at individuals are less effective, in many cases, than genuinely public health interventions. Three straightforward examples involve food, cigarettes and alcohol. It seems abundantly clear that nearly everyone in industrialised democracies understands the health risks associated with obesity, smoking and excessive drinking. But we all find it difficult to change our individual behaviour, and it is often difficult for health professionals to help us. Probably because most of us already understand the negative health consequences of our behaviour, it isn't very effective for health professionals merely to encourage us to eat less, to take more exercise or to stop smoking or drinking. We know that. The point is, however, that despite knowing it, we don't do it. Public health professionals believe that what is needed is more activity at the level of public bodies. We need to examine the way in which cities are constructed - encouraging public transport, cycling and walking. We need to look to taxation systems - to reward healthy eating and drinking and to put economic pressures on unhealthy choices. We need to look to regulation and licensing - addressing the advertising industries (especially where they target groups such as children) and food labelling (identifying hidden fats, salts and sugars in processed foods). And we need to look at local authority planning regulations and make choices about what and how we build, at least partly, on the basis of health considerations. The action of individuals is, of course, crucial. We all need to attend to our own health and the choices we can make as individuals. But the role of local authorities in public health is crucial.
The principal drivers for the changes in how UK public health services are organised and delivered, including the key move of public health from NHS to local authority management, are related to physical health. But the arguments for these changes are even more powerful in mental health. Even more than with physical health, there are strong social determinants of psychological well-being. Social, and particularly economic, inequalities are significant predictors of a wide range of problems. And the social and psychological mediators - including, but not limited to lifestyle factors - that accompany these social and economic inequalities are strong predictors of our psychological as much as our physical health. Many psychologists, psychiatrists and sociologists have pointed out how much of our mental health is dependent on the same social and economic pressures (and especially inequalities) as those which lead to problems with physical health. Perhaps more importantly, we know that crises such as divorce, marital difficulties, unemployment, stresses at work, financial difficulties, illnesses in family members, crime (both as a victim and as a perpetrator, when caught up in the criminal justice system), assaults, bullying and childhood abuse are all powerful direct causes of mental health problems. Street or recreational drug use is also often implicated, and it is abundantly clear that the abuse of street drugs is a quintessentially social problem. It is these factors, of course, that impel psychiatrists such as Pat Bracken and Phil Thomas to be such powerful advocates for 'social psychiatry'.
The same arguments apply to interventions. Nobody would deny the benefits of direct medical care. But progress in improving the health and well-being of citizens also requires intervention at the population level. In the case of physical health care, many of the most deadly killers - heart disease, diabetes, stroke, cancer, and sexually-acquired infections - need to be addressed through public health measures for maximum benefit. This is also true for mental health.
Therapy, even medication, may be helpful for some, but real improvements in the overall psychological health of the population require action at a societal level. We need to address the causes listed earlier. Because marital separation is a major source of emotional stress, we should be ensuring that there is sufficient support for people going through separation or marital difficulties: mediation services, support for single parents, and equitable laws concerning divorce proceedings and child custody. Because unemployment is a major source of distress, we should aim for full employment, and certainly do what we can to protect people from the emotional and economic impact of unemployment. Conversely, work-related stress is also a big issue for many people. We need to ensure equitable and supportive employment practices, including employee relations, a living wage, decent terms and conditions and appropriate employee representation. Services such as Citizens Advice (a Government-funded, but independent, network of advice agencies with offices in most towns across the UK), debt counselling agencies and Victim Support are vital to help people in financial difficulties, victims of crime and people dealing with a range of other traumatic life events. Similarly, drugs advice and drugs counselling services play vital roles in maintaining the well-being of citizens. Psychologists and psychiatrists throughout history have realised that our experiences in childhood are fundamentally important in determining future mental health problems, and that emotional neglect, bullying, and childhood emotional, physical and sexual abuse are all powerful direct causes of mental health problems. It is therefore vital that we, as a society, act to protect children - not merely mop up the emotional consequences later in life. This means developing coordinated services to support families and parents in difficulty. It means supporting teachers and educational psychologists in schools, and it means supporting a network of children's services. And, no matter how politically controversial it might be, we should press for social justice and in particular for a more equal society.
For all these reasons, I see local authorities as the right place for the management of psychological health care. I believe that mental health care will remain inappropriately dependent on a medical, disease-based, ethos so long as it is seen as another branch of medicine. I see the journey of public health from PCT management to local authority management as offering a pioneering route for the transfer of mental health care from hospital-based services to local authority control. This vision would see opportunities for GPs, properly trained in mental health care, to help support the well-being of their clients. It would obviously see many more clinical psychologists ... . But, as with our medical colleagues, they would be working in the community, not in hospitals or 'clinics'. As mentioned earlier, medical psychiatrists would be consultants to, not in charge of those teams. I envisage psychology-led teams (with an appropriate mix of staff) delivering psychosocial services in the community, not psychiatrist-led teams with medical and nursing colleagues delivering medical services to the community.
Pregnancy is a suitable analogy here. Pregnant women (and their babies) often benefit from high-quality medical care, and both doctors (of various kinds) and midwives have vital roles to play. But pregnant women are not 'ill' by virtue of their pregnant status. Pregnancy is not an illness that should be diagnosed and treated. Pregnant women need the support and intervention of medical colleagues. Some more than others. When there are problems in pregnancy, the role of medical colleagues becomes greater. When pregnancies are unplanned and threaten a woman's well-being, again, the advice and assistance of medical colleagues is often vital. But we still do not regard a pregnant woman as 'ill' and we don't regard pregnancy as an 'illness'. Similar analogies can be made across the work of GPs as they deliver medical help to people in many facets of their lives. Similar analogies could be made with the work of medical colleagues as advisors to athletes. Medical science is invaluable as people fulfil their potential in all aspects of life. But an athlete does not have to be 'ill' to benefit from the advice of a team doctor.