Published: 10/02/2005, Volume II5, No. 5942 Page 23

David Hunter and Linda Marks on public health and performance management

The real test of the government's commitment to public health will be in implementation. The white paper says so, and the forthcoming delivery plan is expected to elaborate on what must happen to avoid a repeat of the successive failures documented by Derek Wanless.

Effective performance management will be key. Managing for Health: what incentives exist for NHS managers to focus on wider health issues? , our study for the King's Fund, published this month, raises many critical issues which demand careful attention in the design of an appropriate approach.

The temptation will be to move quickly to establish quick wins and introduce a performance management culture into public health that echoes many of the features that have allegedly succeeded in acute healthcare, but which have also been hotly contested.

We believe enforced targets would be a grave error on the part of policymakers. There is much to learn from the perversities and dysfunctional aspects inherent in the performance management of acute care.

Public health is not comparable to acute care. It is more complex, and involves uncertainties around cause and effect, length of time required to produce an impact on health status, and the particular challenge of ensuring that improvements in health are not at the expense of widening inequalities.

It may be that the comprehensive performance assessment methodology adopted in local government could provide the basis of a more appropriate approach for measuring performance in public health.

The weakness of the evidence base, especially in interventions that work, is another problem in the performance management of public health. This is recognised in the white paper and among many interviewed for our study.

But the required investment in closing the gaps will take time to show a return. As a priority, modelling the effects of investment in health would enable the costs and benefits to be identified over time.

Perhaps the biggest threat to effective performance management in public health will be the attitude of trust chief executives. In our study the commitment from chief executives and non-executives was considered crucial for effective performance.

Directors of public health have often struggled to keep it on the agenda in their health communities as the acute sector has absorbed time and energy. If there is to be a rebalancing of the NHS from healthcare to health, with additional resources to match, strategic health authority and primary care trust chief executives must lead on it.

What might a different approach to public health performance management look like? Our study suggests it should be plausible, take account of context, be locally owned and inclusive, be longer-term and balanced across the health system, and be linked to broader strategies. Systems, rather than individual organisations, should be held to account.

But more important than devising the optimal performance management system is developing pro-active public health organisations. These would regard their stewardship function, centred on the protection of the public's health, as uppermost. Without such a cultural shift, public health risks remaining a vulnerable appendage to the NHS.

In a pro-active health system, the NHS would be an important component but not synonymous with it.

David Hunter is professor of health policy and management and Linda Marks is senior research fellow at the Durham University's Wolfson research institute's school of health.

For a copy of their report, visit www. kingsfund. org. uk