pct spotlight: In the second of four articles on frontline working in the new primary care trusts, Alison Moore reports on how the shake-up will impact on public health directors

Published: 18/04/2002, Volume II2, No. 5801 Page 16 17

On 2 April, Dr Keith Williams started a new job in a new organisation.He said 'good morning' to the same secretary in the same office, greeted his virtually unchanged team, switched on the same computer - and had his tea in his usual mug. And his secretary says he still doesn't wash it up afterwards.

Dr Williams is one of the few directors of public health for whom the arrival of primary care trusts have not meant enormous upheaval - 'It is been evolution, not revolution' as he puts it.

After more than 11 years as public health director for Coventry health authority, he has made a seamless transition to public health director for Coventry PCT.

But, as he is the first to admit, his case is atypical. The PCT covers the same area as the old HA and is co-terminous with the local authority. With a population of 320,000 and budget of£270m it can fund a substantial public health department.

Many PCTs are setting up public health departments from scratch, struggling to recruit key staff and to get to grips with their new responsibilities, of which public health is only one.

Dr Williams' concerns are more about how he can use the change of structure to refocus thinking about health and healthcare. 'It is important that we are different from HAs and spend more time thinking about the determinants of ill-health, ' he says.

'The challenge for us will be more to have a different emphasis. There would always be the temptation to carry on with more of the same. But we have to make sure we do not spend all of the time on private finance initiatives or waiting lists.'

His role will include reminding the PCT board 'we are not only about having good health services'.

'Probably the thing that has pleased me most in Coventry in the last year is that unemployment has fallen below the West Midlands average.

That has an enormous effect on health.

'I am as interested in the community having decent housing and that sort of issue as I am in having a good hospital.'

He highlights the smokingcessation schemes which the old HA ran as examples of costeffective interventions which saved significant numbers of lives: expect to see more of these sorts of projects in the future.

Good relations and joint working with the local authority are key to tackling some of these broader determinants of health. Dr Williams points out that PCTs which share boundaries with local authorities have a head start.

He also expects the PCT's professional executive committee, with its strong GP and nurse representation, to provide a regular reminder of how much healthcare is provided outside hospitals.

But while public health directors such as Dr Williams have a clear run at improving health, the position is not so rosy in other PCTs. Some regions were still advertising for dozens of public health directors days before the 1 April launch.Only 44 directors out of 302 had been appointed by the end of last week, according to figures collected by the Faculty of Public Health Medicine.

'In some parts of the country it will be May before we know who are the public health directors, ' says Dr Williams. 'And until we have the public health director in post then it is difficult to get the arrangements sorted for the rest of the public health team.'

Inevitably, these PCTs will take some weeks, if not months, before they can even start to tackle the public health agenda.

Dr Williams, who is also registrar of the Faculty of Public Health Medicine, predicts that some posts will be hard to fill, especially in smaller PCTs. A few PCTs have made joint appointments and a number have appointed public health directors who do not have medical qualifications.

One - Rugby - has a job share between a medical director and a non-medical public health specialist.

But on the whole the expansion of public health directors from 100 positions in HAs to more than 300 in PCTs is offering public health consultants a step up the career ladder: one of Dr Williams' consultants has left for a director post in another local PCT, for example.

In the longer-term, nonmedical public health directors may become more common, as more public health specialists complete their training and progress through departments, but this may take anything up to 10 years.

There are likely to be skills shortages in some areas. A recent King's Fund report, Public Health in the Balance, highlighted how health visitor shortages could impact on public health delivery in London.

There is also concern about how specialist public health skills can be maintained in smaller organisations, and how plans to share key skills within public health networks will work out in practice.

It would be easy to be pessimistic, but Dr Williams is upbeat. 'The way I see it is that, in Dad's Army terms, we have to be more like Corporal Jones and say, 'do not panic' rather than, 'We are all doomed'.'

Public Health in the Balance .

www. kingsfund. org. uk/ eKingsfund/html/pr020326b. html