Published:25/04/2002, Volume II2, No. 5802, Page 16
At times of uncertainty, the world divides into optimists and pessimists, with a few in between. So it is with public health. Some claim to have seen the writing on the wall. Others say the current re-engineering offers the best chance yet to build a strong public health force working at every level, but with local communities in mind.
Some, like me, see elements of both scenarios.
This government is more committed to tough action on tobacco and tackling inequalities than previous ones, but there is little recognition of the investment needed to make an impact at neighbourhood and other levels.While arguments for expansion continue behind closed doors, resources are stretched as far as chewing gum will go across primary care trusts and other organisations.
It is surely a recipe for increased inequalities to let the public health workforce develop only at the patchy pace allowed by the most committed PCTs and local workforce confederations. And tacking national public health workforce planning onto the planning of every other medical speciality seems set to fail. I would be more convinced of the government's intent if resources were put into expanding the struggling cadre of multidisciplinary public health specialists. In the region of 1 per cent of the resources reserved in this year's service and financial framework for consultants in the specialties prioritised in the NHS plan would be a good start.
But money will not provide all the answers. Taking the optimistic view, let us assume the NHS reorganisation allows effective local and regional public health networks to develop, and that the Treasury's comprehensive spending review results in a strong, funded programme to tackle health inequalities.What is missing? First, systems for crossgovernment partnership for health will be vital. Second, only a fraction of total public health potential is ever realised. The number of public health practitioners is potentially vast.
But most do not have public health in their titles, are not trained for modern population practice and many see themselves as serving individuals rather than whole communities.
Third, the divide between too many public health researchers and practitioners dilutes our collective impact. It is evidenced by the tiny resource devoted to good research on intervention, and calls of 'where is the evidence?' when practitioners try to adopt best practice.
Finally, no single body is devoted to ensuring that good research and practice are brought together.Many bodies are responsible for solving parts of the problem. At national level they include the Health Development Agency, the Faculty of Public Health Medicine, the Institution of Environmental Health Officers and other professional associations, the UK Public Health Association and the new national infection control and health protection agency. There are the government, research and development institutions, and single-issue campaigns.
In an age of social policy czars and czarinas, we need a national institute for public health modernisation and a figure to lead it who could integrate public health research and practice. The arguments for professional leadership from the field are as strong for public health as for coronary heart disease, drugs, homelessness and cancers. Such a body should not duplicate what is being done. Its roles would be at four distinct levels. First, across government it would need resources for commissioning case studies of cross-government working for health from abroad.
It could advise on the coordination of public health policy across departments. Its second role would be to promote mechanisms such as public health collaboratives.
Its third task would be to ensure better co-ordination of research across all government departments. Finally, it would need resources to pilot and evaluate and pump-prime new models of practice. For example, can directly observed therapy for TB be delivered more cheaply by a new cadre of trained local, bilingual citizens than by specialist TB nurses who are in short supply? Can non-medical public health specialists lead the strategic health authority public health function as well as medical specialists?
Should an institute be led by the Department of Health, whose focus is still mainly within the NHS, or the Cabinet Office, which might have greater potential to influence other government departments? Either way, a unifying national force - set up by government, but independent from it - would not only convince the pessimists of the renaissance in public health, but bring together researchers and practitioners to catalyse faster results for communities. l