Public health is in danger of being sidelined unless special efforts are made to incorporate it into primary care trusts, warn David Hunter and Neil Goodwin

Once again public health faces unprecedented uncertainty at all levels. This comes in the wake of health secretary Alan Milburn's speech setting out the future structure of the NHS at the Modernisation Agency's launch in April.

Paradoxically, the policy climate has never been more favourably disposed towards public health, even if early enthusiasm for a fresh approach appears to have disappeared.

1,2 There is a determination to tackle inequalities and narrow the 'health gap' between social groups.

There is a focus on primary and secondary prevention in the national service frameworks and an emphasis on primary care's importance in improving the health of local populations.

We collected the views of 17 public health directors who met monthly as a development network from November 2000 to June 2001.

Members felt frustrated at being unable to translate policy into practice in a sustained and effective way.

Some of the reasons advanced were systemic, notably the rapid pace of change in as-yet untested organisational forms such as primary care trusts.

But they also felt uneasy at being expected to deliver in new ways for which they felt they had been inadequately trained. The group considered the definition of public health, working with new organisations and skills development.

The public health agenda comprises:

promotion of health, including tackling health inequalities;

quality and clinical standards;

protection of public health and the management of risk.

Each requires partnership working across various professions and agencies. So it may be argued that 'public health' should increasingly be defined as a way of thinking and working for professionals located in many sectors rather than as a wholly separate profession.

Each task will apply to the new strategic health authorities and primary care trusts, although the emphasis within each organisation will vary. SHAs will probably have a greater responsibility for strategy and PCTs will be more responsible for its implementation.However, the political reality is that both organisations will be held to account for the delivery of national objectives.

Public health's contribution is likely to be in the area of clinical strategy and some of the statutory public health responsibilities. The latter might be managed directly, provided on an agency basis, or from another organisation such as a re-engineered Public Health Laboratory Service.

It does not matter which organisations provide these roles. The important thing is to build on the contributions of other professionals involved in local authority strategies and resources, in leisure and housing services, and community nurses and primary care professionals more generally.

It is early days for PCTs to pursue the health improvement agenda. Not unreasonably, PCTs are developing a differential approach to public health support and health improvement alliances. In future, effective partnerships between PCTs and other organisations, particularly local authorities and local strategic partnerships, will become critical.

If PCTs' health improvement function is not to get lost, major cultural change is called for on the part of many GPs who remain wedded to an individualistic problem-solving approach. Investment is needed in public health intervention, implementation and evaluation research to offset the bias towards biomedical research.

The organisational development of PCTs remains patchy. It is taking place against a backdrop of change.

Public health practitioners should set the agenda and determine their needs, supported by directors of public health.

Continuing national pressure to meet health service targets could well result in PCTs pursuing a limited health-improvement agenda, focusing on lifestyle issues such as smoking, teenage pregnancy rates and drug misuse. Such a narrow approach could result in the health inequalities agenda taking second place and drifting into becoming a 'health service inequality' agenda in line with much of the thrust of the NHS plan and national service frameworks.We must continue to focus on improving primary care and other services such as housing, social services and education to restore some balance to the health-improvement agenda.

The SHA public health role is contingent on the overall emphasis and responsibilities of these new organisations. Assuming that the new SHAs have a strong performance management/ development responsibility, then the health inequalities agenda must form part of that process.

Assuming continuation of a director-level public health leader at a local level, the accountability of public health practitioners will require clarification. For example, the respective accountability of HAs and local authorities for health protection will need to be thought through. There is also the need to define the public health practitioner role with regard to the local authority scrutiny committee.

With the likely disappearance of city-based directors of public health, the SHA directors of public health (or health development) may have to relate to several scrutiny committees in conjunction with their PCT public health colleagues.

The changes to NHS regional offices and the Department of Health remain to be clarified. Once known, they will influence local arrangements.

The priority for public health is increasing capacity and personal capability. There are good people in the public health system but not enough.

One solution is to develop the responsibilities of others - the public health profession does not have to lead or implement every initiative personally.

Training programmes for practitioners must change. Emphasis is needed on personal skills development, such as persuasion, and building interpersonal and interorganisational networks, as well as nurturing a 'passion for change'.

A new style of leadership will be required for many managers and professionals for the increasingly complex organisations and systems that will emerge through PCTs and SHAs.

Public health must move away from individualbased leadership to a systems-based, interorganisational or network-based approach.

At both SHA and PCT levels the knowledge base of public health needs developing on how other NHS and non-NHS organisations work from a cultural perspective.Media training and communication skills are crucial for local public health leaders, irrespective of their organisational base.

All this will present challenges to leadership development, particularly when professionals possess little 'positional power' in local NHS organisations.

It does not mean writing more strategies and plans but moving from 'leading and advising' to 'leading, influencing, managing and changing'.

In summary, local public health leaders will have a responsibility to raise the profile of public health, develop effective public relations and ensure that good health is delivered as widely as possible through other organisations and individuals.

Forward march How directors want public health to develop Strong and visible public health leadership must be developed at all levels.

Protection of the public's health should be built around the promotion of quality and clinical standards.

Strategic health authorities and primary care trusts should provide board-level leadership, delivered by professionals who have received appropriate and accredited postgraduate training in public health.

Public health leaders need to find ways to publicise their challenges, objectives and achievements.

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

Neil Goodwin is head of the Public Leadership Centre management consultancy and chief executive of Manchester health authority.

REFERENCES 1House of Commons Health Committee. Second Report: public health.1 (session 2000-01): HC 30-I.

The Stationery Office, 2001.

2 Department of Health. The Report of the CMO's Project to Strengthen the Public Health Function. DoH, 2001.