PUBLIC DOMAIN BOBBIE JACOBSON

The Commons health select committee has just completed taking written evidence for its latest inquiry - into public health. You could argue it is a good thing someone cares, as national health policy seems to have ditched wider public health issues. But is that really why the committee chose this topic?

Cynics might see a review of all the health action zones, health improvement programmes, public health directors and role of the public health minister to boot as an opportunity to signal dissatisfaction with the lot of us.

Its inquiry will include inter-agency working, the Health Development Agency, primary care groups and trusts, as well as what sounds like an afterthought: the extent to which public health policy is reducing health inequalities. Any serious scrutiny of that would require the biggest cross government impact assessment ever conceived.

Taking the committee's terms of reference in turn, how are the dizzying numbers of HAZs shaping up? Slowly. The national research commissioned at great expense to judge their effectiveness is only just underway. Public health programmes to tackle long-standing inequalities take time. The government acknowledged this was at least a 10year agenda in its - mostly forgotten - white paper, Our Healthier Nation, and at least a seven-year programme for HAZs. But do the cuts in the forecast HAZ budget this year suggest ministerial fuses on the public health agenda are getting shorter?

As for as the effectiveness of interagency co-operation, this is also the subject of formal evaluation within HAZs. Three obvious changes need to be made. First, we should await the evaluation findings before judging.

Second, the wisdom of supporting multiple health authority, local borough HAZs needs revisiting. It seems self-evident that those HAZs such as Sandwell and Brent - each coterminous with one borough - that have the luxury of focused crossfertilisation with relatively few organisations, are likely to progress most. If the different government departments stopped to gather all their 'zoning power' together to make the most of all the initiatives, not only would it help mainstream the best innovations, it would stop the pointless fragmentation of these potentially important programmes into ineffectual silos. The model of a Social Exclusion Unit approach bringing these initiatives together across government would go a long way to demonstrating cross-agency commitment to tackling inequalities in health.

HImPs are an essential, but missing element of most community plans.

The community plan provides an umbrella for influencing the determinants of health, and most HImPs articulate the health outcomes and inequalities to be tackled. If we were required by a joint duty of partnership to integrate and agree these plans, not only would we save paper, we might be closer to focusing on budgets such as leisure, housing and education - vital elements of the real health budget. The duty to take into account the findings of annual public health reports could be added.

The HDA's work is under scrutiny too, though it has only just begun .

Most of us never heard anything from its predecessor, the Health Education Authority, so there is only one direction to go.

Little attention has been paid to PCGs' and PCTs' health improvement role yet. First and foremost, PCTs need a well resourced drive to support the development of public health capacity. While public health departments and PCGs debate the finer points of the odd 0.2 whole-time equivalent of a public health consultant that they would like, who is planning how to develop public health skills among all primary care practitioners? As a GP told me: we need every GP to become the public health director for their practice population.

To embed this in PCT development, the select committee should recommend three things:

development money to normalise and embed training in practical public health skills through education consortia; joint formal recognition of public health training in general practice and community nursing disciplines; and proper implementation of the public health white paper's recommendation to expand multidisciplinary public health.

Possibly the most fundamental ingredient to enable PCTs to tackle health inequalities is that the local authority is the appropriate boundary for a PCT. This would resolve many cross-agency nightmares that some PCTs will otherwise face, and increase the chances of proper partnerships with local authorities, whose actions have more influence on health than the NHS. Non-coterminous PCTs should not be supported. This guidance applied to drug action teams; it should do so for PCTs.

The public health minister's role is easy to define: focus on the wider causes of ill-health and leave healthcare to the minister for the NHS. Achieving this means making sure the health secretary is just that, with NHS ministerial portfolios below, or moving the public health portfolio to Downing Street.

As for public health directors, we should all be jointly appointed to health and local authorities. We should have statutory backing - emphasised by the duty of partnership - for this independent advisory role. To do this effectively we would need to be supported by properly trained public health practitioners working at all levels to support health improvement. Every health and local authority should have its named public health director.

There is no reason why we cannot be drawn from a multidisciplinary group of qualified practitioners, as in academe. If we don't bite the bullet now, the whole public health function could disappear in a puff of further organisational change.

Dr Bobbie Jacobson is public health director, East London and the City health authority.