Talking about 'public health' : an exploration of the public health roles of primary care practitioners in England
The British Government, since 1997, have placed a strong emphasis on public
health and the reduction of health inequalities. Alongside this, they have
progressed a major reform of the NHS which aims to 'shift the balance of
power' to the frontline. Primary care is an increasingly important aspect of the
Government's new agenda, which aims to improve health for everyone, and for
the worst off in particular.
This thesis identifies general practice, and the core practitioners that work
within it, as key potential contributors to a public health agenda. But 'public
health' is a conceptually contested terrain, and as a concept, can be
understood and interpreted in a myriad of ways. The impact of this lack of
shared understanding is explored both for policy making and implementation,
and for the development of public health practice in primary care.
This research brings together public health and primary care literatures in
order to illuminate the historical and organisational contexts within which
current developments are taking place. It critically analyses the public health
discourse of New Labour policy documents in order to explore the ways in
which 'public health' is understood and talked about within recent government
policy, and the government's expectations of primary care practitioners, in
terms of their public health roles. Finally, the research draws on case study
material from one (pre-2002) health authority area in England to examine
practitioners' understandings of public health, and their perceptions of their
public health roles. Using Wenger's (1998a) social theory of learning as a
framework, it looks at the organisational and wider contexts in which
practitioners work, and explores how varied and unclear understandings of
public health, both in policy and practice, might be affecting practitioners'
engagement with public health.
The study highlights the dangers of vagueness surrounding the term public
health, and finds a tendency both in policy and practice to regard it as a set of
activities, rather than as an approach to work. Its malleability means that it can
be interpreted both in a politically acceptable way, and in a way that fits within
existing practice. Thus, as a concept, it loses its radical edge and is no longer
something that challenges or guides policy and practice. The research finds
that the ways in which practitioners interpret public health can contribute to
their non-engagement in the public health agenda. This is not helped by
conflicts within policy which threaten the development of stronger public health
roles within general practices. The thesis concludes by recommending the
development of shared understandings of public health, particularly as a valuedriven
approach to work, rather than as a set of activities.