Public Health (2002) 116, 102–105

ß R.I.P.H. 2002
www.nature.com/ph

Caring for the health of the public: cross sectional study of the activities of
UK public health departments
DA Lawlor1*, K Morgan2 and S Frankel1
1
Department of Social Medicine, University of Bristol, Bristol, UK; and 2Avon Health Authority, Bristol, UK

The relative time spent in different areas of work in public health departments in the UK was assessed by means of a
postal questionnaire. Departments spend one third of their time on population health work, this being similar to the
amount of time spent on planning health services. Having a planning department in the health authority did not affect the
amount of time spent in any area of work. Having a greater number of consultants in the department was associated with a
tendency to spend more time on population health and being involved in training was associated with spending less time
on planning. Public health departments in the UK are the only part of the health service with responsibility for the broader
aspects of public health. Whilst the tensions between medical care and the wider influences upon population health may
represent a false dichotomy, public health professionals must maintain a central focus of their work on the wider
influences upon population health if balance is to be maintained within the National Health Service.
Public Health (2002) 116, 102–105. DOI: 10.1038=sj=ph=1900820

Keywords: population health; planning; health services

Introduction working patterns in UK health authority departments of

Health improvements in the developed world over the last
two centuries have been largely the result of improved
social and environmental conditions.1,2 However, earlier
assertions that medical services have little impact upon
mortality1 are no longer relevant now that more effective
treatments for commonly fatal conditions have emerged.
Health services may account for some 5 of the 30 years’
increased life expectancy seen this century.3 Despite these
advances social and environmental factors remain the most
important threats to health in both developed and develop-
ing countries.2,4 Public health practice has a clear role both
in determining the mechanisms by which factors such as
income inequalities and environmental damage affect
health, and in preventing and controlling their detrimental
effects.5 Over the last three years political attention in the
UK has rightly reverted back to issues of direct relevance to
public health.6,7 Public health practice is changing in
response to these initiatives and the chief medical officer’s
report on the public health function emphasised the impor-
tance of tackling the ‘social, economic and environmental
factors which lead to poor health’. How these changes are
reflected in the working patterns of public health profes-
sionals is unknown. In this study we describe the current
public health.
Methods
A questionnaire was developed and piloted among con-
sultants and Directors of Public Health (DPH) in the South
West region (see appendix for copy of questionnaire). This
was then mailed (in April 2000) to all DPH in England,
Scotland and Wales. The questionnaire asked for the
percentage of time, spent by the whole department, in
five areas of work. The areas of work had been determined
through discussions with consultants in public health med-
icine in the South West region and through piloting of the
questionnaire. The aim was to cover broad areas of work
using terms that would be understandable to DPH and that
could be included in a brief questionnaire. Details of staff
numbers and a list of all of the departments within the
health authority were also requested. Respondents were
asked to indicate on a five point scale how accurately they
felt the questionnaire enabled them to describe the working
patterns within their department. A second postal reminder
was sent to all non-respondents, followed by a telephone
reminder.

*Correspondence: DA Lawlor, Department of Social Medicine,

University of Bristol, Canynge Hall, Whiteladies Road, Bristol,
Results
BS8 2PR, UK.
E-mail: d.a.lawlor@bristol.ac.uk We received 101 (84%) out of 120 responses. Similar
Accepted 29 November 2001 proportions of time (30%) were spent on planning health
 Caring for the health of the public
DA Lawlor et al
103

Figure 1 Mean proportion (%) of time spent in each area of work, UK Public Health Departments.

Table 1 Mean percentage (95% confidence interval) of time spent in each working area for departments of public health categorised by
size, training status and whether the authority contained a planning department
Departmental size

Small n ¼ 23 Intermediate n ¼ 40 Large n ¼ 38

(Less than 4 whole time (4 or 5 whole time (more than 5 whole time
equivalent consultants) equivalent consultants) equivalent consultants) P-value
Population health 29.0 (22.0 – 36.0) 26.7 (22.7 – 30.7) 33.0 (28.3 – 37.7) 0.06
Planninga 29.0 (22.9 – 35.0) 35.0 (30.3 – 39.7) 29.8 (25.6 – 34.0) 0.9
CDCb 18.9 (15.4 – 22.4) 18.2 (15.7 – 20.7) 17.2 (14.9 – 19.5) 0.7
Medical advice 9.0 (6.7 – 12.2) 7.3 (5.5 – 10.0) 6.7 (5.0 – 9.0) 0.4
Other 16.4 (12.2 – 24.5) 14.9 (11.0 – 20.1) 13.5 (10.0 – 18.2) 0.4
Involved in training
Yes n ¼ 92 No n ¼ 9
Population health 30.3 (27.3 – 33.3) 22.2 (15.8 – 28.6) 0.1
Planninga 30.4 (27.5 – 33.2) 44.8 (37.4 – 52.1) 0.00
CDCb 18.1 (16.5 – 19.7) 16.9 (11.3 – 22.5) 0.6
Medical advice 7.4 (6.2 – 8.7) 7.1 (4.2 – 21.6) 0.9
Other 14.9 (12.6 – 17.5) 12.6 (6.3 – 18.2) 0.7
Planning department within authority
Yes n ¼ 42 No n ¼ 58
Population health 27.7 (24.2 – 31.2) 31.2 (27.0 – 35.4) 0.2
Planninga 31.8 (27.5 – 36.1) 31.2 (27.5 – 34.9) 0.8
CDCb 18.1 (16.3 – 20.1) 18.2 (16.3 – 20.1) 0.9
Medical advice 6.7 (5.5 – 8.2) 8.2 (6.7 – 10.0) 0.3
Other 16.4 (13.5 – 22.2) 12.2 (10.0 – 14.9) 0.06
a
planning, contracting or commissioning activities.
b
Communicable Disease Control.
6 respondents could not name departments in their authority because of ongoing change.

Public Health
 Caring for the health of the public
DA Lawlor et al
104
services and population health (Figure 1). The most com-
monly mentioned ‘other’ areas of work were partnership
work (n ¼ 19), clinical governance (n ¼ 18) and teaching
and training (n ¼ 12). Having a planning department in the
health authority did not affect the amount of time spent in
any area of work. Having a greater number of consultants
in the department was associated with a tendency to spend
more time on population health and being involved in
training was associated with spending less time on planning
health services (Table 1). Sixty respondents (59.5%) indi-
cated that the questionnaire enabled them to describe the
working patterns of their department accurately or very
accurately. The number of departments in each health
authority ranged across the country from 1 to 9 with a
mean of 4.5 (s.d. 1.1). There appeared to be a substantial
variation in the structures of health authorities with a total
of 46 different departmental titles.
Discussion
This study presents the current working patterns of depart-
ments of public health in the UK. Public health departments
across the country spend a mean of one third of their time
on planning health services, and only a similar amount of
time on population health. This may reflect the current
political agenda, the priorities of the NHS and=or the
preferred areas of work of contemporary public health
practitioners. However, the equal emphasis placed upon
planning health services and upon the wider determinants
of population health is a concern.
The large number of different titles for health authority
departments is confusing. This may reflect different names
for the same functions or differing emphasis on what
authorities across the UK actually do. Departmental respon-
sibilities may not be obvious from these titles and this
multiplicity of local arrangements hinders comparison
between health authorities and may hamper multi-agency
working and good communication with the public.
Study limitations
Questionnaire responses may not accurately reflect time spent
in each activity, particularly since the departmental head was
responding forthe whole department. Ourpilot study indicated
that DPH were confident about describing working patterns for
the whole department and sixty percent of respondents indi-
cated they were able to do so accurately. We believe that this
study provides a useful snapshot of current working patterns
and could be repeated to monitor changes.
In the UK, as in many countries, there is a tension
between the provision of medical care and the need to
manage the wider influences upon population health.
Mckeown in the 1970s suggested that improvements in
living conditions — better sanitation, drinking water, nutri-
tion and housing — were the most important determinants
Public Health
of health and argued that medical interventions were
largely irrelevant.1 By contrast Bunker has provided evi-
dence to suggest that medical care has contributed impor-
tantly to the increase in life expectancy over the last
century, and asserts that improvements in public health
are essentially complete in the developed world.3,8
Clearly ensuring effective and efficient delivery of
medical services is an essential objective of the National
Health Service and makes an important contribution to
health outcomes. But Bunker is wrong to assert that the
wider influences upon population health have been dealt
with in the developed world. Deprivation and societal
inequalities remain important determinants of health,2,4 – 6
global warming is set to become a major determinant of
health over the next century9 and without environmental
changes some medical interventions may have no chance of
success. Over the last fifty years industrialised populations
have become less active and more obese but even the most
intense medical interventions to increase levels of physical
activity (including motivational interviews, free exercise
classes and detailed information on individual health needs)
fail to have an impact.10,11 These findings are perhaps not
surprising when one considers how hostile most western
environments are to being physically active.12
We would argue that the tension between medical care
and the wider influences upon population health is a false
dichotomy; both are clearly required in a modern health
service.13 However, whilst ensuring effective and efficient
delivery of medical care can be, and is done by profes-
sionals working throughout the NHS — for example
through the work of the National Institute for Clinical
Excellence, the Cochrane Collaboration, primary health
care groups and trusts, and the requirement for doctors
qualifying in all clinical specialities to demonstrate critical
appraisal skills — departments of public health are the only
part of the NHS with responsibility for the wider aspects of
public health. If departments of public health do not make
dealing with the main social and environmental determi-
nants of ill health their priority it will be easy for this to be
removed from the political agenda and aims of the health
service. As local health authorities merge and the future of
public health in the UK is uncertain it is more important
than ever for public health professionals working within the
NHS to recognise the importance of their role in determin-
ing and managing the wider determinants of population
health. Planning health services is important, but this does
not require the unique skills and competences of public
health professionals.
References
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2 McMichael A, Beaglehole R. The changing global context of
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3 Bunker JP. Medicine matters after all. JRCP 1995; 29: 105 –
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4 Lynch JW, Smith GD, Kaplan GA, House JS. Income inequal-
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5 Beaglehole R, Bonita R. Reinvigorating public health. Lancet
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6 Department of Health. Saving lives: our healthier nation.
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9 McMicheal AJ, Haines A. Global climate change: the potential
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Appendix
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DA Lawlor et al
105
10 Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D.
The Newcastle exercise project: a randomised controlled trial
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Public Health