Health promotion in local government: a British experience.

Historically, the development of health promotion work in Britain centred largely upon the activities of elected local authorities. From the mid-nineteenth century onwards, these authorities were primarily responsible both for major interventions in the physical environment, such as improved housing and sanitation, and for the development of community-based preventive and primary care services, such as ante-natal care, health-visiting and district nursing. The importance attached to such work was underlined by the statutory requirement that local authorities should appoint a Medical Officer of Health who could not be dismissed without specific Ministerial approval. Yet in recent decades, this long-standing tradition has been undermined, with both public health doctors and the community health services being displaced from their historical local authority base and placed instead within the the National Health Service, where they are substantially outnumbered by their hospital-based colleagues. As a result, a major political and administrative focus for developing public health approaches has largely disappeared. This loss of a health focus has become a matter of concern to a growing number of local authorities in Britain; a concern which reflects their public health tradition and newer policy issues and approaches which began to affect British local authorities from the late 1970s onwards. This paper considers the example of one such authority, the London Borough of Greenwich, where the author was employed during the early 1980s. In particular, it examines the political and practical problems faced when attempting a systematic review of the authority's role and potential for promoting health through its policies on housing. In the light of this experience, some tentative suggestions are made about the kinds of structures which will be needed if local authorities are to revitalise their public health tradition in a political and economic climate hostile even to existing levels of State intervention.