Public Health (1991), 105, 35 38
© The Society of Public Health, 1991
T h e A r t o f Public H e a l t h M e d i c i n e Frada Eskin Consultant in Public Health Medicine, Yorkshire Health, Park Parade, Harrogate HG1 5AU. North Yorkshire
This paper discusses the two dimensions of public health medicine competence - science and art and explores the reasons for the importance of public health medicine artistry within an organisational context. The skills of artistry are identified as political and people management and it is noted that although the science dimension is vital, without the skills that comprise artistry, public health physicians are inadequately prepared to tackle the work of improving the health of the population. It is recommended that these skills should become an integral component of public health medicine training.
Introduction Public health medicine has been defined as 'the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society'. ~ It differs from clinical medicine in one vital respect. All doctors are concerned with disease prevention, prolonging life and promoting health but it is the public health doctors' unique responsibility to do this 'through the organised efforts of society'. There is no other effective way in which health o f a population can be positively influenced. The extent of ill health and disease in a population represents the end result of all the interactions of its individuals with the totality of their environment. 2 Genetic constitution combined with the behaviour and life-styles adopted will protect or enhance individual vulnerability to the physical, socio-economic and cultural components o f the environment in which they live and work and it has been well-established 3,4 that behavioural and environmental change has more influence on health than the provision of medical care, however excellent this may be. G o o d housing, effective sanitation, an income above the poverty level, safe working conditions, psychological security, better nutrition, moderate alcohol intake and the avoidance o f drug usage and smoking all make a major contribution to health improvement. In addition, the type and quantity of health care services required reflects the way in which society understands and manages its total environment. Effecting behavioural and environmental change and providing services to meet existing and future need can only be achieved through the development of an appropriate organisational framework, i.e. 'the organised efforts of society'. Health is a political issue and the nature, goals and objectives of health m a n a g e m e n t organisations are determined nationally, reflecting the prevailing values of the government of the day. Sometimes these values make it difficult for public health medicine to achieve the necessary changes. But however hard the struggle, public health physicians can only make a difference if they are an integral part of a society's health m a n a g e m e n t organisations. To this end, public health physicians must firmly establish themselves and their role within the National Health Service if they want to improve the population's health. This is not, as some see it, 'selling out' but 'buEing in'!
36
Frada Eskin
Since the appointment of Dr Duncan in Liverpool in 1847 as the first official UK medical officer of health, public health medicine has been rebadged on several occasions and has had to operate at different hierachical levels in many organisational and political settings. Within such a dynamic framework, epidemiology, statistics, management science, environmental science, political theory, sociology and psychology, however necessary to the effective study o f health and disease in populations, are insufficient tools to equip public health doctors for their complex and difficult role. They also need their art, and public health medicine artistry requires an additional and quite different combination of skills and abilities. The need for this dimension of practice has, to date, remained scarcely recognised in any training curriculum but without it the public health physician will be ill-fitted for the tasks ahead. The purpose of this paper is to explore the artistic dimension of public health medicine, its relevance to organisational life and the skills required. What is the Art of Public Health Medicine?
Although the pattern of health problems confronting western society in the late twentieth century is markedly different from that of the mid-nineteenth century, with coronary heart disease, cancers and accidents replacing infectious diseases as the major causes of premature mortality, the rote of public health medicine improving the health of the population remains exactly the same. Dealing with changing health problems are a fact of life for public health physicians and this would not be a major issue if the organisational context of practice remained stable. But because of the intensely political nature of health and health care, public health physicians have been and continue to be required to fulfil their role and functions within a constantly changing organisational framework. Historically, they have variously operated in Local Authorities, in Regional Hospital Boards and, since 1948, in the National Health Service. The 1974 N H S reorganisation, which integrated local authority preventive health and hospital services, presented an enormous challenge to public health doctors, who had previously worked in one or other service and there was hardly time to come to terms with this before three further reorganisations occurred in 1982, 1985 and 1989. This rapid rate of change has created a great deal of uncertainty and confusion for health personnel generally and for public health physicians in particular. Because of this, survival tactics have often taken precedence over improving the population's health and well being. Within such a climate, the only effective way to achieve public health goals is to do so through the application of two key skills political and people management. By combining the ability to work with the relevant people whatever the context of practice together with a clear understanding of the nature, goals and objectives of the organisation it becomes possible to achieve an acceptable, though delicate, balance between professional goals and those of the organisation. The latest changes occasioned by the White Paper Working for Patients 5are probably the most fundamental and in many ways offer public health physicians the best opportunity ever presented to them to impact on the population's health and health care. General managers are looking to public health physicians to provide them with the information and priority setting that [hey need, through the process of health care needs assessment, to inform the new contracting process for service provision. The goals of general managers and public health physicians are entirely congruent in this respect although, as has already been noted, improving the health of the population extends far beyond service provision. In order to pursue the wider goal, public health physicians must establish their organisational credibility through meeting the needs of their authorities and general managers. The level of ability to do this and to retain professional integrity is a measure of artistic competence.
The Art of Public Health Medicine
37
The Skills Required Public health physicians are organisationally based and must therefore have the skills to understand the organisadon's goals and objectives and how the system works if they are to utilise its full potential. They must be clear about where the power lies and who has the power to effect change. They must also understand about hidden agendas, vested interests and the importance o f choosing the right time to propose and to implement change. It is no use trying to implement action if the action does not concur with the prevailing views of those who have more power, even if, in public health medicine terms, it seems entirely appropriate to take such action. The end result o f sailing against the wind will be frustration and unproductive conflict. The ground for change must be well prepared, the alliances made and attitudes changed. All this takes time and public health physicians must be prepared to bide their time patiently. As noted above, health management is a political issue and sometimes there will be changes which do not accord with the values o f public health medicine. The skill is to manage the situation and to look for commonalities rather than to accentuate differences. People management is the second component of public health artistry. Unless public health physicians have the ability to understand and to work with a wide variety of individuals from different disciplines and professions they will have no chance of fulfilling their role. They must learn to read people in terms o f understanding how they operate and what they need to work effectively, to value their skills and efforts, to motivate them to give of their best, to provide leadership, to work well in teams and groups and to manage conflict through valuing differences of views and through understanding that these can lead to positive rather than negative outcomes. Personal development is an extremely important dimension of managing others. Understanding and working well with other people demands a high degree of self-knowledge and the willingness to change oneself. In Conclusion People management and political skills have never been fully integrated into the public health medicine training programme although at senior registrar level, experience is generally provided which incorporates the opportunity to practise applying both sets of skills. However, unless this experience is skilfully guided it is unlikely that the appropriate learning will be accomplished. Public health medicine trainers must learn how to impart political and people management skills to their trainees and should not be allowed to act as trainers unless they can demonstrate proficiency in public health artistry. The effective practice of public health medicine reql~ires the integration of art and science. In the past, insufficient attention has been paid to the importance of the artistic component in either training and practice. The recent organisational changes have reinforced the need for public health medicine to pay attention to their art. The great teachers of public health medicine have attempted to point this out to us since the time of Hippocrates 6 without too much success. As Professor Alwyn Smith, past president o f the Faculty of Public Health Medicine, was once heard to say (Smith, A. E. (1978) Personal Communication) 'That epidemiology is the basic science of public health medicine there is no doubt, but without organisational sense, sensitivity to people and a vision of the future, the application of epidemiology to the service of the population will remain an unrealised h o p e ' ] Perhaps this time we will take a lesson from history and make the necessary leap forward so that the upheavals consequent upon any future re-organisation will be taken in our stride and will not deflect our energies from our main task - to improve the population's health.
38
Frada Eskin
References 1. Department of Health (1988). The Acheson Inquiry: Public Health in England, London: HMSO. 2. Sepulveda, C. R. (1979). Systemic health planning. Long Range Planning, Vol. 12: 62-72. 3. Marmot, M..G. & Morris, J.N. (1984). The social environment, Chapt. 7 In: Holland, W.W., Detels, R. & Knox, G. (eds). The Oxford Textbook o f Public Health, Vol. l, Oxford: Oxford University Press. 4. McKeown, T. (1977). The Role o f Medicine Dream, Mirage or Nemesis? Oxford: Basil Blackwell. 5. Department of Health (1989). Working for Patients: The Health Service - Caring for the 1990s. London: HMSO. 6. Hippocrates, "Airs, Waters and Situations." Upon Epidemical Diseases: Upon Prognosticks, in acute cases especially. (Watts, J. (1734)).
© The Society of Public Health, 1991
T h e A r t o f Public H e a l t h M e d i c i n e Frada Eskin Consultant in Public Health Medicine, Yorkshire Health, Park Parade, Harrogate HG1 5AU. North Yorkshire
This paper discusses the two dimensions of public health medicine competence - science and art and explores the reasons for the importance of public health medicine artistry within an organisational context. The skills of artistry are identified as political and people management and it is noted that although the science dimension is vital, without the skills that comprise artistry, public health physicians are inadequately prepared to tackle the work of improving the health of the population. It is recommended that these skills should become an integral component of public health medicine training.
Introduction Public health medicine has been defined as 'the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society'. ~ It differs from clinical medicine in one vital respect. All doctors are concerned with disease prevention, prolonging life and promoting health but it is the public health doctors' unique responsibility to do this 'through the organised efforts of society'. There is no other effective way in which health o f a population can be positively influenced. The extent of ill health and disease in a population represents the end result of all the interactions of its individuals with the totality of their environment. 2 Genetic constitution combined with the behaviour and life-styles adopted will protect or enhance individual vulnerability to the physical, socio-economic and cultural components o f the environment in which they live and work and it has been well-established 3,4 that behavioural and environmental change has more influence on health than the provision of medical care, however excellent this may be. G o o d housing, effective sanitation, an income above the poverty level, safe working conditions, psychological security, better nutrition, moderate alcohol intake and the avoidance o f drug usage and smoking all make a major contribution to health improvement. In addition, the type and quantity of health care services required reflects the way in which society understands and manages its total environment. Effecting behavioural and environmental change and providing services to meet existing and future need can only be achieved through the development of an appropriate organisational framework, i.e. 'the organised efforts of society'. Health is a political issue and the nature, goals and objectives of health m a n a g e m e n t organisations are determined nationally, reflecting the prevailing values of the government of the day. Sometimes these values make it difficult for public health medicine to achieve the necessary changes. But however hard the struggle, public health physicians can only make a difference if they are an integral part of a society's health m a n a g e m e n t organisations. To this end, public health physicians must firmly establish themselves and their role within the National Health Service if they want to improve the population's health. This is not, as some see it, 'selling out' but 'buEing in'!
36
Frada Eskin
Since the appointment of Dr Duncan in Liverpool in 1847 as the first official UK medical officer of health, public health medicine has been rebadged on several occasions and has had to operate at different hierachical levels in many organisational and political settings. Within such a dynamic framework, epidemiology, statistics, management science, environmental science, political theory, sociology and psychology, however necessary to the effective study o f health and disease in populations, are insufficient tools to equip public health doctors for their complex and difficult role. They also need their art, and public health medicine artistry requires an additional and quite different combination of skills and abilities. The need for this dimension of practice has, to date, remained scarcely recognised in any training curriculum but without it the public health physician will be ill-fitted for the tasks ahead. The purpose of this paper is to explore the artistic dimension of public health medicine, its relevance to organisational life and the skills required. What is the Art of Public Health Medicine?
Although the pattern of health problems confronting western society in the late twentieth century is markedly different from that of the mid-nineteenth century, with coronary heart disease, cancers and accidents replacing infectious diseases as the major causes of premature mortality, the rote of public health medicine improving the health of the population remains exactly the same. Dealing with changing health problems are a fact of life for public health physicians and this would not be a major issue if the organisational context of practice remained stable. But because of the intensely political nature of health and health care, public health physicians have been and continue to be required to fulfil their role and functions within a constantly changing organisational framework. Historically, they have variously operated in Local Authorities, in Regional Hospital Boards and, since 1948, in the National Health Service. The 1974 N H S reorganisation, which integrated local authority preventive health and hospital services, presented an enormous challenge to public health doctors, who had previously worked in one or other service and there was hardly time to come to terms with this before three further reorganisations occurred in 1982, 1985 and 1989. This rapid rate of change has created a great deal of uncertainty and confusion for health personnel generally and for public health physicians in particular. Because of this, survival tactics have often taken precedence over improving the population's health and well being. Within such a climate, the only effective way to achieve public health goals is to do so through the application of two key skills political and people management. By combining the ability to work with the relevant people whatever the context of practice together with a clear understanding of the nature, goals and objectives of the organisation it becomes possible to achieve an acceptable, though delicate, balance between professional goals and those of the organisation. The latest changes occasioned by the White Paper Working for Patients 5are probably the most fundamental and in many ways offer public health physicians the best opportunity ever presented to them to impact on the population's health and health care. General managers are looking to public health physicians to provide them with the information and priority setting that [hey need, through the process of health care needs assessment, to inform the new contracting process for service provision. The goals of general managers and public health physicians are entirely congruent in this respect although, as has already been noted, improving the health of the population extends far beyond service provision. In order to pursue the wider goal, public health physicians must establish their organisational credibility through meeting the needs of their authorities and general managers. The level of ability to do this and to retain professional integrity is a measure of artistic competence.
The Art of Public Health Medicine
37
The Skills Required Public health physicians are organisationally based and must therefore have the skills to understand the organisadon's goals and objectives and how the system works if they are to utilise its full potential. They must be clear about where the power lies and who has the power to effect change. They must also understand about hidden agendas, vested interests and the importance o f choosing the right time to propose and to implement change. It is no use trying to implement action if the action does not concur with the prevailing views of those who have more power, even if, in public health medicine terms, it seems entirely appropriate to take such action. The end result o f sailing against the wind will be frustration and unproductive conflict. The ground for change must be well prepared, the alliances made and attitudes changed. All this takes time and public health physicians must be prepared to bide their time patiently. As noted above, health management is a political issue and sometimes there will be changes which do not accord with the values o f public health medicine. The skill is to manage the situation and to look for commonalities rather than to accentuate differences. People management is the second component of public health artistry. Unless public health physicians have the ability to understand and to work with a wide variety of individuals from different disciplines and professions they will have no chance of fulfilling their role. They must learn to read people in terms o f understanding how they operate and what they need to work effectively, to value their skills and efforts, to motivate them to give of their best, to provide leadership, to work well in teams and groups and to manage conflict through valuing differences of views and through understanding that these can lead to positive rather than negative outcomes. Personal development is an extremely important dimension of managing others. Understanding and working well with other people demands a high degree of self-knowledge and the willingness to change oneself. In Conclusion People management and political skills have never been fully integrated into the public health medicine training programme although at senior registrar level, experience is generally provided which incorporates the opportunity to practise applying both sets of skills. However, unless this experience is skilfully guided it is unlikely that the appropriate learning will be accomplished. Public health medicine trainers must learn how to impart political and people management skills to their trainees and should not be allowed to act as trainers unless they can demonstrate proficiency in public health artistry. The effective practice of public health medicine reql~ires the integration of art and science. In the past, insufficient attention has been paid to the importance of the artistic component in either training and practice. The recent organisational changes have reinforced the need for public health medicine to pay attention to their art. The great teachers of public health medicine have attempted to point this out to us since the time of Hippocrates 6 without too much success. As Professor Alwyn Smith, past president o f the Faculty of Public Health Medicine, was once heard to say (Smith, A. E. (1978) Personal Communication) 'That epidemiology is the basic science of public health medicine there is no doubt, but without organisational sense, sensitivity to people and a vision of the future, the application of epidemiology to the service of the population will remain an unrealised h o p e ' ] Perhaps this time we will take a lesson from history and make the necessary leap forward so that the upheavals consequent upon any future re-organisation will be taken in our stride and will not deflect our energies from our main task - to improve the population's health.
38
Frada Eskin
References 1. Department of Health (1988). The Acheson Inquiry: Public Health in England, London: HMSO. 2. Sepulveda, C. R. (1979). Systemic health planning. Long Range Planning, Vol. 12: 62-72. 3. Marmot, M..G. & Morris, J.N. (1984). The social environment, Chapt. 7 In: Holland, W.W., Detels, R. & Knox, G. (eds). The Oxford Textbook o f Public Health, Vol. l, Oxford: Oxford University Press. 4. McKeown, T. (1977). The Role o f Medicine Dream, Mirage or Nemesis? Oxford: Basil Blackwell. 5. Department of Health (1989). Working for Patients: The Health Service - Caring for the 1990s. London: HMSO. 6. Hippocrates, "Airs, Waters and Situations." Upon Epidemical Diseases: Upon Prognosticks, in acute cases especially. (Watts, J. (1734)).
