Published: 08/01/2004, Volume II4, No. 5886 Page 18 19

Public health in the UK is a picture of largely accidental complexity as power has devolved throughout the UK, but no body or individual is left with responsibility for the massive task of ensuring the population's well-being

In the 19th century the UK was at the forefront of many of the social and scientific developments that have contributed to health improvements throughout the world. The Public Health Act 1848 was a significant landmark.

Yet at the beginning of the 21st century, the UK ranks poorly in many indicators of average population health and inequalities in health. And our institutional arrangements for public health have been neglected to the point where, for example, it is no longer possible to say who (if anyone) is responsible for the control of communicable disease.

Three years ago, the Nuffield Trust convened the high level and multi-sectoral UK Partnership for the Health of the People, which commissioned a research project to inform the required changes. The project concludes that there is a need to modernise the legal framework, coordination and resourcing of the public health function. This could make a significant contribution to assuring health protection, delivering health improvement and thereby, as suggested by the first Wanless report, containing healthcare expenditure in the medium to long term.

Enough is known about what needs to be done to improve the health of the nation. The challenge now is to find ways of ensuring that it gets done.

The project has identified a number of concerns about the current state of the public health function, many of which stem from the fact that throughout decades of change in central and local government and in the health service, little conscious attention has been paid to the role and location of the public health specialty, with the result that there is genuine ambiguity about where leadership and responsibility lie.

The responsibility for local population health was originally firmly lodged with local authorities, but was largely overlooked in successive reorganisations of local and central government and is now dispersed and unclear. It has now almost ceased to be regarded as a subject in its own right even though substantial public health problems remain. At best, the law and institutional provision for the health of the nation can be described as untidy. At worst - for example, in the area of control of communicable disease - it is not at all clear just who is responsible for action.

Public health provisions are not to be found in any one coherent body of law or regulation. No single body or institution has the responsibility to consider the factors that affect the health of the people of the UK or the duty to act upon them. There is no system for gathering the information needed or for putting it in the public domain.

If a public health emergency struck the whole of the UK, no single individual or body could take charge of tackling it. And the currently available legal powers are inadequate for the task. There is no-one that parliament or the public can call to account for preventable shortcomings in the nation's health and well-being which are beyond the individual's power to control.

Among all the interested parties at home country, regional and local level, the minister for public health in England (a post outside the Cabinet) is the only individual whose sole responsibility is to concentrate on delivering improvements in public health.Yet there is no formal framework which links ministers in any executive - or even advisory - way with public health professionals and others working on the ground.

There is no statutory requirement for a chief medical officer to produce a regular report on the state of the health of the people. Similarly, there is currently no duty to act to protect the health of the people. For the purposes of international comparisons this country will continue to be judged at the UKwide level, but below the level of prime minister there is no one body or individual whose responsibility it is to ensure that at that level performance is improved.Neither does the mechanism exist to secure such improvement.

The Scottish Parliament's lawmaking powers include public health and the Welsh Assembly controls the allocation of the health budget for Wales, and with it responsibility for the health of the people in Wales. Like England, the devolved administrations have their own CMOs, but there is a lack of clarity about their role and the extent to which they can act as independent advocates.

Devolution could result in different parts of the country adopting different approaches to tackling common problems; indeed, there are already signs of that happening. CMO for England Professor Sir Liam Donaldson has recently published a strategy for combating infectious diseases which will apply only in England, but infectious diseases will not recognise the boundaries of devolution.

The NHS and local authorities both play important formal roles in public health, yet there is no really effective link between them, and there are few mechanisms for ascertaining the views of the populations they serve. No single person or body has a clear legal duty to control infectious disease. Current legal powers lie with local authorities, but they need decisions by public health physicians who are, in the main, employed by the NHS.

Powers and duties of officers and structures of organisations with explicit public health functions present a picture which is one of largely accidental complexity. Not only do the existing provisions lack coherence, but there are gaps. The project report found that at the national level there is a lack of overall scrutiny of the health impact of government policies and legislation and a lack of coordination in monitoring the health of the population across government. It points out that the problems highlighted by the Phillips report in the wake of the BSE and nvCJD crisis demonstrated a lack of clarity about who is responsible for specific cross-sectoral issues.

The report itself sets out several possible institutional models for taking forward the public health agenda, but that is essentially a matter for politicians to decide.

Some general conclusions can, however, be drawn.

There is a need to strengthen the role in practice of ministers - especially that of the health secretary - in matters for which in theory they have direct responsibility. These include conducting international relations and maintaining a broad health policy overview.

Ministers need to be able to ensure, whether through legislation or otherwise, that the responsibilities of the key players are clearly defined and to satisfy themselves that effective structures are in place for improving the people's health.

The role of the health secretary as the public health minister in the Cabinet needs to be settled in relation to those of the ministers responsible for public health in the nations of the UK.

There is also a need for some framework which will link ministers more directly with public health professionals and others working on the ground. At the same time, ministers may need to be distanced from matters such as the collection and dissemination of information and statistics and matters where local ownership and control are essential for effective local action.

The project marshals strong arguments in favour of establishing a single UK-wide body to provide a point of focus, authority and influence on matters relating to the health of the people throughout the country. It would be a matter for political judgement how that was to be made compatible with the devolution settlements.

Nevertheless, it is evident that practitioners, local authorities, the devolved administrations and ministers themselves would all gain from an orderly allocation of institutional responsibilities, followed in due course by the vesting of clear legal powers and duties at the appropriate levels.

Only then could robust strategies for action be developed and operational plans be put in place to protect and improve the health and well being of the people of the UK.

Steve Monaghan is public health director of Cardiff Health Board and consultant in public health medicine at the National Public Health Service (Wales).He is a keynote speaker at today's conference, 'Health of the People: the highest law?', co-sponsored by the Nuffield Trust, the UK Public Health Association and the Faculty of Public Health.

Nuffield Trust report www. nuffieldtrust. org. uk/policy_themes/index. php? pt=4