opinion UNIVERSITY CHALLENGE DAVID HUNTER

Published: 19/09/2002, Volume II2, No. 5823 Page 18

The promotion of Hazel Blears to public health minister at the start of the summer passed with little comment.Yet it could herald a new dawn.

Excluded from the attention lavished on the NHS modernisation project, public health has slipped from view.

1Ms Blears' arrival coincided with the impact of the Wanless review on health policy - not so much in the Department of Health, but certainly in the Treasury.

The review criticised the imbalance in health policy, with attention too focused on the acute hospital setting. If pressures on the NHS were to be eased over the next 20 years or so, more success in public health was needed.

Of the three scenarios offered by Wanless, the Treasury has accepted the most optimistic and challenging - the 'fully-engaged scenario'. It contains implications for public health since it assumes it will improve 'dramatically with a sharp decline in key risk factors such as smoking and obesity, as people actively take ownership of their own health'.

The aim is to see the largest reductions in risk factors where they are highest, in the most deprived areas.

To realise this, strong political leadership is vital. Unusually for a minister, Ms Blears comes with the right credentials, including experience on the ground. She knows from her local government career how interconnected, messy and complex the issues are.

Moreover, she is passionate about public health. If public health has lacked anything over the past 30 years, since its fortunes became tied to the acute healthcare agenda, it is passion.

But the minister will need more than passion. She will need to be tough, smart and willing to take on the powerful vested interests, including many of her own colleagues, that inhabit healthcare but not - the distinction is crucial - health policy.

Ms Blears is aware of the sceptics who believe efforts to promote the public's health do not make any difference.Unfortunately, from her speech to the Faculty of Public Health Medicine last June, Ms Blears subscribes to a rather na´ve rational view that if only the evidence existed, it would see off the sceptics.

It wouldn't, just as it hasn't in medicine. Evidence will always be imperfect and incomplete, especially in public health.

We should admit the issues are primarily ones of politics and power. After all, the evidence on the benefits of a tobacco advertising ban is overwhelming.

Yet it has not led to the ban promised when Labour took office in 1997.Action may soon occur, but only thanks to a private member's bill the government has had little alternative but to support.

Hiding behind the evidence, or lack of it, is to use evidence as a smokescreen.

Ms Blears will also have to show greater independence from the DoH line on engaging local (and in time regional) government with the public health agenda.

The new regional role in public health is welcome, but it is still too cluttered with NHS business of a clinical nature. The commons health select committee inquiry into public health (published in March 2001), received a mass of evidence testifying to the dysfunctional dominance of public health by the NHS and by a disease model of health.

Other agencies had difficulty engaging with such a narrow approach. As one written submission put it: 'It is irrational that most of the interest, skills and resources to improve public health are outside the NHS, while the director of public health is locked into it.'

Public health must be eased out of the NHS box.

Primary care also requires urgent attention to ensure public health is not eclipsed. Pressures mean primary care trusts must focus on the 'must dos' in the NHS at the expense of attending to wider health needs of their communities.Yet, all the early promises centred on PCTs' contribution to improving health. There is little mention of that these days.

Much government policy plays directly to a strong public health function. But powerful pressures are also working in the opposite direction. The public health minister is located at the apex of these conflicting forces.

For the sake of the public's health, the hope must be that she can find a way through them.

REFERENCE

1Calman K, Hunter DJ, May A. Make or Break Time? A commentary on Labour's health policy two years into the NHS plan. Durham University, 2002.

David Hunter is professor of health policy and management at Durham University.