Reviews of public health in two counties showed divergent views - and proved there is a long way to go before primary care is ready to assume a major role. Sian Griffiths and colleagues report

As more primary care groups in England move towards trust status, public health departments in health authorities will have to extend their roles to work with them. Where primary care trusts and the local authority are coterminous, the upheaval may not be a major structural issue. But the structural issues are greater for shire counties facing the emergence of multiple PCTs that are not always coterminous with their constituent district councils.

The focus on public health in primary care requires new ways of working and using specialist public health skills. It means developing public health capacity and capability within HAs and primary care to ensure efficient use of resources and avoid duplication. Berkshire and Oxfordshire have carried out reviews to address these issues.

If all goes according to plan, both HAs will be significantly reconfigured from April 2001.

Oxfordshire public health directorate will support five PCTs, formed out of six PCGs, and none of them coterminous with the five district councils.

In Berkshire, the public health directorate will be supporting four PCTs formed from five PCGs and two PCGs within a context of six unitary local authorities. Both counties asked the public health resource unit in Oxford's Institute of Health Sciences to assist with public health reviews last year.

In Oxfordshire a multi-agency review of the public health function was agreed via the health improvement programme board and involved all relevant partners, including local government. In Berkshire, the review concentrated on public health support to PCGs moving to PCT status, and on mapping public health skills of the PCG staff.

Both reviews used the definition of key activities of specialist public health practice drawn up by the Faculty of Public Health Medicine and the Tripartite Project.

1The table opposite describes the aims and methods.

Both reviews showed a wide spectrum of views on what public health was and how different organisations could contribute. Local government, community health councils and primary and community services felt the public health role lay in tackling the broader determinants of health. HAs and trusts considered the public health role fell within the remit of the healthcare system. So a reconciliation of these two perspectives is needed, along with greater clarity of what can be expected from the specialist public health resource.

A common understanding All organisations were enthusiastic about working together. But it was seen as requiring commitment at senior level from each organisation to develop a common agenda. There was support for the HImP as a vehicle to take this forward. Concern was raised that it could lose credibility if it did not produce effective local action.

A common understanding is needed between PCG/Ts, the HA and local authorities on how their activities impact on local health status and the expected role of the public health team in delivering this.

Certain statutory public health functions need to remain at HA level, such as communicable disease and producing the annual public health report.

Functions such as support to specialist commissioning need to be provided not only at supra-PCT level but at supra-district level.

The role of the public health specialist on the PCT executive will be crucial in linking public health expertise at a supra-PCT level with more generalist support from primary and community care practitioners. HA public health staff may continue to offer expertise in specific clinical, care group or skill areas to all local PCG/Ts and trusts as well as parttime generalist support to one or more PCG/Ts.

HA public health staff are feeling the pressure of balancing central and local work and unrealistic expectations. Nevertheless, they must lead and encourage the development of PCG/T public health capacity and capability.

PCG/Ts need to become more aware of their public health role. This applies to all levels of staff but is a particular priority for board members.

Many primary care professionals have relevant public health skills and huge enthusiasm for taking forward the public health agenda at a PCG/T or primary healthcare team level - community nurses, health visitors and school nurses.

More effort is needed to harness their skills and give staff confidence and time to undertake this work. Existing skills included understanding factors influencing the health of the population, accessing and interpreting evidence on clinical effectiveness and planning services based on needs assessment. Skills needed include interpretation of information and policy, implementing change and evaluating services.

A common agenda with local government Local government members and officers need to be signed up to shared locally based and longer-term health targets and strategies. PCG/Ts present a real opportunity to develop common local agendas.

Mutual secondment of staff and shared training opportunities would be welcomed, as would shared training opportunities for local authority members and PCT non-executives.

Lack of coterminosity presents a real barrier and adds to the complexity of local joint working.

The reviews found support for agreements to clarify mutual commitment. The major gaps identified were the need to:

develop a greater awareness of public health practice and approaches with all relevant organisations;

survey current available skills, development and governance needs of the workforce in all sectors of the health economy and local authority;

develop a cohesive network among public health professionals in the county.

Both counties are now working on developing managed public health networks - a concept that emerged from discussions between several public health directors and was commended by the Faculty of Public Health Medicine.

2These networks will set up local public health teams to harness the available expertise in a range of organisations and provide a framework for public health work during considerable organisational change. Local team members will include HA employees such as public health consultants/ specialists, senior registrars in public health, health promotion specialists and information specialists.

Health visitors, school nurses and other locally based NHS staff may participate, as may local authority staff such as environmental health officers.

In Oxfordshire and Berkshire, the directors of public health and health policy will co-ordinate and oversee the creation of the networks across the counties. They will be accountable to the HImP board in Oxfordshire and to a strategic chief executives partnerships group, the executive control team, in Berkshire.

Each public health team within each PCG/T will be co-ordinated through the public health specialist sitting on the PCT executive teams. In the first instance, senior specialists will be seconded for a proportion of their time to provide this specialist support. In the longer term this approach will require management time and resources if the workforce is to be appropriately trained and supported.

The creation of local public health teams and the managed public health network will incorporate the public health skills of staff within PCTs and local authorities and establish the public health directorate as a strategic resource at the HA, giving greater responsibility to primary care-based staff.

But it will require significant investment in line with the principles of workforce planning, development and leadership described within the NHS plan. The emergence of PCTs and their role of improving health of their populations provides opportunities for public health. We intend to make the most of them.


1 Standards for Specialist Public Health Practice. Standards Committee, Faculty of Public Health Medicine and the Tripartite Project, 2001.

2 Faculty of Public Health Medicine. Developing Public Health in Primary Care Trusts: a framework for discussion. 2000.