Personal views: End of term report for Alan Milburn
Authors: Michael Clarke
Journal: BMJ (2001)

(following his government's response to the House of Commons Select Committee on Health's second report on public health; see p 249)

Dear parent/guardian,


I have become rather worried about Alan's performance in the last few months. In particular much of his written work has left a great deal to be desired. I am also sorry to say that Alan and some of the bigger boys have been picking on the public health team, who, as you know, are a small group and not as tough as many of the other children. 


Did foot and mouth disease leave Alan confused, so all he could think about was culling?



Most disappointing of all was his recent essay on improving the public health, for which he was given a borderline fail grade. Although he had a brave attempt at addressing the problem, his ideas were poorly developed and he showed little evidence of reading around the subject.

Firstly, he implied in the essay that public health improvements were all to do with transport, education, housing, and so on. While these factors have a major part to play, to have not seen a role for the NHS in improving the health of the public was a serious oversight. He should take a look at a book written by one of our old boys, Donaldson (whom I thought Alan had met), who clearly spells out the contribution the NHS can make in primary, secondary, and tertiary prevention. I never much liked this taxonomy but what it says in simple terms is as follows:



Primary prevention seeks to prevent the onset of a disease. The goal is to alter some factor in the environment, to bring about a change in the status of the host, or to change behaviour so that disease is prevented from developing.


Secondary prevention aims to halt the progression of a disease once it is established. This is achieved by early detection or early diagnosis followed by prompt, effective treatment. An example of secondary prevention is screening.


Tertiary prevention is concerned with rehabilitation of people with an established disease to minimise residual disabilities and complications.




Clearly much of this preventive activity takes place within the health service. Indeed, these programmes are patient centred, and use age, sex, and other registers that are held in the NHS.

Secondly, some years ago the public health teams at the health regions all became civil servants. Alan took this curious idea further by suggesting that the way to improve the public health was to reduce the size and numbers of health authorities and call them “strategic”—a dramatic reduction from 90 to 30 strategic health authorities. He didn't seem to realise that the public health team would be reduced to a peacekeeping force whose main task would be to monitor the performance of the service as a kind of “governance police” responsible for detecting deviant death rates. No time to be strategic, and no time or other resources to develop and run health promotion programmes.

Thirdly, Alan should have thought more clearly about the public health function at the primary care trust level. Although staff from health authorities will transfer to primary care trusts, many health authorities have modest public health and epidemiology skills and these will be divided between six to eight primary care trusts—barely one public health doctor for each primary care trust. He was correct to say the public health team is more than just medical input, but few health authorities have reached the staffing level recommended by Acheson in 1988, of 15 for every million people. At a time when, throughout medicine, clinical teams need to become larger and more specialised, no such proposal is made for public health—instead the opposite is proposed.

Fourthly, perhaps the most disappointing part of Alan's essay was the lack of vision for the future. I wondered whether foot and mouth disease had rather left Alan in a state of confusion, so all he could think about was culling. Where was the vision for the future? Public health departments could become centres for health promotion and disease prevention. Why shouldn't we see a future of public-private partnerships where supermarket nutritionists work with NHS dietitians and patients to help improve eating habits and culinary skills? Why can we not envisage a future where health clubs work in partnership with colleagues in physiotherapy and sports medicine to offer pleasant, effective exercise programmes for all the population, not just superannuated professionals who are already fit? In a recent essay reviewing progress on prevention, McPherson, an able boy, said much still needed to be done on the prevention front (Lancet 2001;357:1790).

Alan should remember what Nick Day, the master in charge of cancer studies, said: “For every five pounds we spend, three should be on prevention, one on screening and one on treatment.” Busy hospital trusts and primary care trusts can do a lot, but they cannot do everything.

Do encourage Alan to try harder, because if he does, I am sure he could have a rewarding life in public health.

All the best,

Michael Clarke

(Deputy Head in Optimistic Studies)