Published: 07/06/2002, Volume II2, No. 5808 Page 20 21

Who needs doctors when nurses can do so many things just as well?

HSJ has noted the controversy surrounding the appointment of non-medical public health directors ('Unknown quantities' 23 May). The same edition also notes that a doctor shortage is putting people with diabetes at risk. It is clear that the public health agenda can be delivered by skilled healthcare graduates who have not been through traditional medical school.

Diabetes can be managed by nurse consultants and dieticians specialising in diabetes and alleviating the doctors' workloads.

In fact, who needs doctors at all? I may be a consultant obstetrician and gynaecologist but I subscribe to the view, secretly shared by many of my colleagues that in 20 years' time we will not have doctors and nurses. There will be healthcare professionals with common core training and education who will work in teams and provide modern NHS care.

I see no reason why a nurse graduate with a higher degree and three years' experience should not become a senior house officer, then embark on the higher specialist registrar training to become the equivalent of a medically qualified consultant. Why stop at nurses? Operating department practitioners with further training in resuscitation would make excellent anaesthetists.

Biological science graduates with higher research degrees could solve the current shortage of consultant pathologists.

I am working on a project to train a nurse consultant gynaecological surgeon and a midwife consultant obstetrician - yes, they will do Caesareans and hysterectomies. Many forward-thinking nurses have expressed an interest in these developments. Such a radical approach would solve the shortage of doctors without the need to steal them from developing countries and will also improve nursing career prospects.

Vincent Argent FRCOG Consultant obstetrician and gynaecologist Eastbourne District General Hospital

It is a little too late for dissent

The Department of Health's Saving Lives: our healthier nation was right to declare in 1999 that public health is a social objective and not just a branch of medicine. It surely follows that cross-sectoral leadership is the primary capacity to deliver population health improvement.

This view is not new. In 1920, US physician CEA Winslow, in his article The untilled fields of public health, famously defined public health as, 'the science and art of preventing disease and prolonging life... promoting physical and mental health and efficiency, through organised community efforts... and the development of the social machinery, which will ensure to every individual in the community a standard of living adequate for the maintenance of health.'

This rather poetically describes the new 'delivery route' for health improvement now defined in England as one of the principal functions of primary care trusts. Community health and preventing inequalities in health are to be secured through health improvement and modernisation programmes, integrated into local community plans managed by a 'joined-up' local strategic partnership - itself involving business, community and local government - the agencies whose actions affect 90 per cent of the determinants of population health.

Opening up public health leadership to competent leaders is surely just a matter of form following function. Anonymous letters by medical dissenters to this particular view have really left it 82 years too late to influence things.

Dominic Harrison Lancaster University

Background is irrelevant as long as you can speak the 'language'

I am a medically qualified public health specialist, with experience as a lecturer in public health, international project management and of working with colleagues with both medical and non-medical public health backgrounds.

Regardless of their original discipline, a public health director's role is to lead, coordinate and manage strategies and interventions and to monitor and improve the health of the population they serve. They need an informed understanding of the health needs of the populations. Inevitably this requires a knowledge of the concepts and the terminology - the 'language' - associated with accurately describing not only health, health status, illness, disease, morbidity, incidence, prevalence etc, but also used to differentiate between ischaemia, lesion or infarction, or between a carcinoma and an adenocarcinoma. Many of these terms are used interchangeably by the less well informed, leading to confusion, misleading comparisons and a mismatch of resources to demand.

As long as leaders and shapers of public health policy share a common understanding of this 'language' and the skills and competencies to effectively deliver real benefits to the population, their background should be irrelevant.

The aims is to seek, attract and value those with the best skills.

We can then deliver any pubic health strategy - and, to borrow a concept from health economists - this is done with minimum effort for maximum health gain for the population we serve.

Andreea Steriu MD Public health specialist PhD student London School of Hygiene and Tropical Medicine

Appointments process was fair

As one of the faculty assessors involved in appointing public health directors, I feel I must write in defence of the process that appears to have come in for criticism in the north of England. I have to say that I have no doubt that the process I was involved with was entirely fair to candidates and employers.

I was involved in two days of interviews in the North West.

We recommended appointment of a high-calibre mix of medical and non-medical public health directors. Some non-medical applicants failed to make the grade, as did a number of medical applicants.

The faculty of public health medicine had two assessors (medical and non-medical) on each interview panel. In all the cases I was involved with we were both in complete agreement about the outcome.

Being a director is not simply an extension of being a consultant, as a number of candidates seemed to assume. It requires additional attributes and skills, not least an understanding of working at board level and corporacy. Some essential skills such as these were not demonstrated in a number of candidates and, as a result, they were not successful.

Dr John Wilkinson Faculty of Public Health adviser (Yorkshire)