Primary care role is crucial in health for all

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WHAT important event with global significance for health happened 30 years ago? In 1977, the then Secretary of State for Health and Social Security, David Ennals, set up the working group on inequalities in health under the chairmanship of Professor Douglas Black, which produced the landmark Black Report, in August 1980. This initiated the movement that has now put the issue of inequalities in health centre stage on the global public health agenda. Other notable events included the publication by the four home health departments of Prevention and Health: Everybody’s Business, a call to take prevention seriously, which remains to be fully heeded 30 years later; the first case of Legionnaires’ disease in this country in Nottingham – a harbinger of outbreaks to come; and the establishment, by Barbara Castle, of the Health Services Board charged with phasing out private practice in the NHS – a radical move which did not survive the change in government in 1979. But the event I want to focus on is the launch of the Health for All 2000 movement by the World Health Organisation (WHO) at its assembly meeting in Alma Ata. It is probably fair to say that the WHO, an arm of the United Nations bureaucracy, is not a body which means much to us in the UK. If the person on the Clapham Omnibus had heard of it at all they would probably associate it with the health problems of the third world, not with what happens in developed countries like ours. In this they would be about right. In 1997, in its Alma Ata declaration, WHO identified reducing inequalities in health in the developing and developed worlds as a key aim, and highlighted the importance for its attainment of two factors – intersectoral collaboration and primary care. Intersectoral collaboration is a bit of a mouthful, which basically means that health is not the sole responsibility of one agency but the joint responsibility of many agencies, which must work together in partnership to make it happen. Today we recognise this as a self-evident truth, but in 1977 this was an important new insight the impact of which it is difficult to overstate. Prior to 1977, collaboration between “health” agencies in the UK was restricted to two areas – social services and education – where it was acknowledged that, for example, the care of the mentally ill and the education of handicapped children required close working between the health service, social services and education departments. A specific mechanism, the Joint Consultative Committee was set up in each locality to promote such collaboration. After 1977, in the wake of the Alma Ata declaration, the ambitious Health for All 2000 movement was launched which quickly manifested itself in a growing number of projects around the world, and in the UK, where local agencies came together to look at how they could improve the health and reduce the health inequalities in their populations. In the course of time, the number of agencies involved grew as evidence accumulated that health was affected by what came to be known as the wider determinants, namely a wide range of social, economic and environmental factors. More recently Wales has institutionalised intersectoral collaboration through its innovative health, social care and wellbeing agenda, which recognises that health and wellbeing is everybody’s business and that all agencies need to work together to deliver it. With our own well developed primary care system this element of the Alma Ata declaration seemed to offer little new, but for many countries this was not the case because the delivery of health care tended to be equated with secondary care that is hospital services. So a message only for the developing world one might think. But this was not in fact the case. For it was implicit in the WHO’s singling out of primary care that this also had a key role to play in preventing ill health as well as in treating it. This message has taken much longer to take root than the intersectoral collaboration one, for only now is the crucial role of GPs and their primary care team colleagues in promoting the health and wellbeing of their registered populations beginning to be recognised.