Published: 06/12/2001, Volume III, No. 5784 Page 20
In shifting power to the front line, it is still unclear who will be responsible for annual public health reports - and at what population level.
The 1988 guidance - pre-dating at least two reorganisations - says this is one of the public health director's key responsibilities.
So it might be argued that it should be transferred to the new primary care trust public health directors.
But it is not quite so simple. A modernised public health function means that analytical capacity to report on the population's health will be shared across new public health networks, and specialist areas - such as communicable disease control - may be led by one PCT on behalf of others. Preparing the annual public health report will be a good test of whether cooperation within the networks really can support population health at local strategic partnership level as well as reporting on bigger populations, needed to make sense of progress in implementing the national cancer plan, for example.
Responsibility for reporting on a defined population should not be lost and, logically, this should be the PCT public health directors' responsibility. It will help them in arguing for better health and a better use of resources. If it leads to developing tools to support practice-based and neighbourhood-level analyses, the local focus will have paid off.
The question almost always unsatisfactorily answered in performance management is, 'with whom should we be compared?'Unrealistic comparisons with national averages have often been disincentives for those at the worst end of the 'league'. Equity audits, signalled first in the Acheson report on health inequalities and followed up in the government's recent consultation document, offer a unique opportunity to link target-setting for equity with locally agreed plans. It will be important for strategic health authorities to performancemanage equity audit. This means SHAs will need to provide public health leadership at board level.
While junior health minister Lord Hunt recently made it clear that SHAs would need a senior doctor at board level with strategic and management skills, could they really do their job unless they were a public health physician? SHAs ought to be concerned if anyone other than a trained public health physician was to performance-manage population health.
If this moves us from comparisons with national averages to comparisons with similar local health economies, it will be a step forward. Clusters of local partnerships, which can compare good practice and aspire to it themselves, could provide a learning-oriented approach to equity audit, rather than the familiar carrot and stick models of performance management. This would put public health and equity audit onto the same footing as clinical audit.
Such an approach will be a challenge when public health expertise is spread ever more thinly. It can probably only happen through functional public health networks with groundrules for sharing work and expertise. Public health observatories are already providing region-wide comparisons within which local health economies can fit. Instead of appearing like odd bits of an incomplete puzzle, these ingredients need to be knitted together into a system that works at all levels.
The second vexed question is about the content of annual public health reports, and how prescriptive guidance on it should be. The 1988 guidance is not prescriptive, and the reports have varied from posters and videos to volumes of over 100 pages. Legitimate arguments support each extreme.
In an electronic age, it is extraordinary that past public health reports are not being systematically stored. We risk losing the wisdom and evidence supporting better delivery that public health directors have striven to provide. Each report needs an ISBN number and an exhortation to produce an electronic copy, but also a collective commitment to make it accessible to a wide audience.
This should form part of PCTs' governance process.
Specifying every element of a public health report would prevent locally determined perspectives. But no prescription at all would allow mediocre, uninformative reports to continue.
We need core data to be reported and interpreted regularly, while allowing public health directors to choose key local themes. The same core data does not need to be reported each year.
The annual public health report must retain an ethic of independent reporting on the population's health, while being relevant to local strategic partnerships and others. Some old lessons for the new public health directors are still relevant.
Dr Bobbie Jacobson is director of the London Health Observatory.