In his London School of Economics health lecture, delivered in March, health secretary Alan Milburn made some important remarks about public health and its place within the NHS.

He said it was time 'to take public health out of the ghetto' and confront its marginalisation from the NHS and other health partners. He went on: '. . . rather than define the NHS as healthcare delivery, and then assert that the NHS has very little to do with health improvement, the time has come to reframe what we mean by the NHS and how it acts.'

For Mr Milburn, tackling health inequality, better prevention and faster intervention are all part of public health. It is evidence that the health secretary subscribes to a 'whole-systems' perspective. This is a welcome and significant rebalancing of the health policy agenda that for too long has been narrowly focused on downstream treatment issues to the exclusion of everything else.

But the dilemma remains: how to convince managers, many sceptical of their political masters' true intentions, that the health secretary's notion of public health has major implications for them. In particular, the way in which they are performance managed must surely reflect the notion that the NHS is about health improvement in the round, combining upstream preventive strategies with downstream curative ones.

But how realistic is it to expect the NHS to operate in this way and to be judged accordingly? After all, hasn't the tension between the NHS as a health service on the one hand and a sickness service on the other existed for as long as the NHS? And hasn't it always been resolved in favour of the immediate, short-term pressures arising from the NHS as a provider of healthcare? What hope, then, of shifting the focus?

The national service frameworks are held out as the answer. Maybe, but it is surely expecting too much from these when the root cause of the problem is the culture within the NHS, together with public expectations of its role.

Perhaps in time the NHS can be reconfigured in the way proposed by Mr Milburn. But the NHS is at present too preoccupied with its own survival to spearhead this shift, even one that is fundamental to its survival. For a time at least, it may be that taking public health out of the ghetto can only be achieved by taking it out of the NHS and giving the lead to somebody else. But who? Local government? The Local Government Association would welcome such a move, but support for it is not strong elsewhere.

1Another possibility starting to surface involves the regional level of governance. Health may not yet be central to the work of the regional government offices, regional development agencies or assemblies. But it could quickly become so, especially in the aftermath of Mr Milburn's lecture, in which a powerful case was made for seeing a healthy economy and a healthy society as inseparable.

Support for a strong regional presence comes from an unexpected quarter - the Cabinet Office. In a significant analysis of the government's programme for improving local services in areas such as education and health, the performance and innovation unit believes that the government's impatience with current under performing public services may be part of the problem. The result is '. . . too many government initiatives, causing confusion; not enough co-ordination; and too much time spent on negotiating the system, rather than delivering'.

2Amore coherent presence at regional level is proposed as a way of overcoming the confusion. The report suggests that government offices are best placed to be the starting point for a better coordinated approach.

Even supposing better coordination can be achieved at regional level, there remains the problem of leadership for health. And that's where the rest of Mr Milburn's lecture comes in. His references to health as a key part of wealth creation plays directly into the regeneration and sustainable development agenda. The regional government level is key to this.

It would be a bold move and a victory for joined-up policy if this level were to be given the lead role for public health. Local areas would have more discretion on how to achieve results, although this might cause the government some discomfort given its desire to remove variations.

Of course, the interface with the NHS would need to be managed in order to achieve integrated care, but at least health might not remain marginalised and could be given a new lease of life as part of an endeavour that was aimed at improving the health of local populations and not merely the healthcare of individuals.

Changes at local level will not be sufficient if separate silos remain at the centre. Another bold move would be to place the responsibility for health with the Department of the Environment, Transport and the Regions. If responsibility for health were to be removed from the Department of Health, it would create the basis for a new constituency for health. At a stroke, it would remove public health from its ghetto in public health medicine and the NHS.

Even if removed from the NHS, there would remain a need for primary care organisations, health authorities and trusts to take public health seriously.

This is the essence of the policy conundrum. The ideal may be for public health to be fully integrated with the NHS. Indeed, this was the vision of the architects of the 1974 NHS reforms. But over a quarter of a century later the problem remains - how best to pursue a public health agenda that is forever being marginalised?

REFERENCES

1 Joint response to the public health white paper, Saving Lives: our healthier nation. Local Government Association and UKPHA, 2000.

2 Reaching out: the role of central government at regional and local level. A performance and innovation unit report. Cabinet Office, 2000.