The UK government and medical establishment have been warned they will face flak if they do not consult more widely on public health targets, reports Peter Pallot

Public health targets came to Britain seven years ago. One might assume that, as most of the rest of Europe has since also adopted targets, The Health of the Nation got it about right. The evidence from other national systems suggests otherwise.

The World Health Organisation first proposed goals for public health improvement back in 1977.

But while most other countries have devolved target setting to regional or county levels, often with public input, Britain provides the classic example of the head down approach. Targeting is driven straight from the Department of Health, with NHS machinery whipped into compliance.

The contrast was clear at a meeting in Paris of 250 health economists and public health doctors from across Europe. As one delegate put it, The Health of the Nation had all the subtlety and characteristics of a 1960s Kremlin five-year planning directive.

New Labour's successor, Saving Lives, appears not much better, though devolution may smooth the edges. Even so, if people were not consulted British doctors risked being dubbed public health fascists, another speaker warned.

Jean-Pierre Poullier, a WHO adviser, singled out Sweden for its 'enormous and unique' effort to consult the public.

But he admitted that confusion could emerge between need and want in people's minds. 'It is a very difficult exercise to get informed consent to targets.'

Lena Rydin-Hansson, executive director of Linkoping, one of 13 municipalities in Sweden's Ostergotland region, explained how this problem was overcome in launching 26 outcome-related health targets in 1990. All political parties were consulted in picking the targets, which included lifestyle goals and accident prevention. Health experts, lay people and non-governmental organisations were asked to contribute.

Public meetings were staged and the county's 400,000 'silent majority' reached through surveys. People were asked to say what the targets should be and the drive was backed by media campaigns. The upshot was gains in public health and closer co-operation between professional and other groups.

Denmark is striving to improve health after slipping behind its neighbours.

Professor Allan Krasnik, head of the Institute of Public Health at Copenhagen University, said the country was for years widely seen as a model in health terms. Doctors opposed targets, believing money should be spent on sophisticated hospital equipment rather than primary care.

So content were Danes about their health that WHO prevention initiatives were deemed relevant to 'Africans and nurses - certainly not for medical interventions in our part of the world'.

This self-satisfaction, said Professor Krasnik, was punctured in 1993 when the Ministry of Health established that the country had dropped from fifth to 17th place in the international life expectancy league. There were 6,000 excess deaths a year.

If Danes had followed their Norwegian neighbours in data collection and target setting, the country would have been spared the equivalent of four Titanic sinkings a year, he said.

Professor Krasnik said: 'The deaths occurred among the middle-aged, across a spread of diagnostic groups, with no single disease responsible.'

Incidence was worse among women, who had a very high smoking prevalence.

Copenhagen took its own measures.

The city authorities instituted public health initiatives in schools and workplaces. Support services for alcoholics were set up. The plan was based on the WHO European Healthy City Project and was refined to reflect local public opinion as to target choice.

Five-year targets were set in 1994.

Many had been met, said Ib Haurum, deputy director of City of Copenhagen health administration. Health indicators were improving, though the city remains behind others in Europe.

Spain has regionally run health services, required by federal law to have 'integrated' health services and targets.

Some regions have set 100 targets, with an average of 45. Services are organised on the lines of a UK-style internal market. Juan Cabases, professor of economics in Navarra, pointed to the Basque region as one of the most advanced. He said purchasers took account of targets in contract making.

This helped ensure that targets were hit - a model that Britain could perhaps copy.

Among other lessons were that prevention targets should be backed by healthcare targets (such as waiting lists) and progress assessed on quality as well as quantity.

One delegate argued that target -setting on the Spanish model, where money follows the target, is a form of rationing in a cash-limited system. Non-targeted conditions are going to get less.

Euro-experts' opinion is that targets should be long-term and driven by governments, rather than individual ministries - joined-up government. They ask how health service managers can be held accountable for accidents and teenage pregnancies. And accidents largely come under local authorities, making the case for low-tier joined-up government.

But where does the buck stop? Much discussed at the conference - organised by the European Public Health Association, the European Healthcare Management Association and a pharmaceutical company - was how to make targets accountable.

As Dr Anna Ritsatakis, head of WHO European Centre for Health Policy, put it: 'Politicians like to be seen as visionary, but targets are so distant, it is difficult to get them involved.'

Politicians and other decision-makers move on. In the now defunct Health of the Nation, Virginia Bottomley set most of her goals for year 2000. That is only a couple of months away, but three targets in that programme are miles away. And so she.