The ever-tightening grip of hospital-acquired infections is leading many experts to call for a public health role within trusts. Ann McGauran reports

The time could be ripe for public health to come out of the cold and assume a far more powerful profile in English acute hospitals, according to leading specialists.

Hospital-acquired infections are costing the NHS£1bn a year, according to a report last year from the National Audit Office.

Antimicrobial resistance, the decontamination of medical instruments, hospital cleanliness and mortuary standards are crying out to be tackled, almost everyone agrees.

All are waiting for shelter under the broadest of public health umbrellas, according to Professor John Ashton, director of public health for North West region.

But he thinks the agenda is even 'bigger and deeper' and has the potential to take in how hospitals treat their employees and relate to their communities - anything from innovative occupational health polices to integrated approaches to transport and green issues generally.

He believes there is a job description to be written for a public health practitioner member of an acute hospital team who wraps up these functions. 'It is become quite a chunky agenda, ' he adds.

His vision is supported by consultant in public health at Nottingham health authority Dr Clive Richards. He proposes a board-level director at acute trusts - backed up by a team where necessary - 'focusing the strategic direction in line with health improvement plans' and in order to concentrate on improving the health of a defined population.

Public health within a trust could mean different things to different people, he concedes. But he lays out four aspects. These are: providing high-quality care when it is needed; making hospitals better and healthier places to be in; contributing to the wider health requirements of patients rather than simply 'treating disease spectacularly'; and working within partnerships such as social services to improve health and meet the needs of the community.

But Dr Richards believes making such a big job work would require NHS managers to have a different concept of why hospitals exist - recognising they have a 'role in improving health rather than improving throughput of patients'.

He identifies the 'most dangerous' thing as 'tokenism'. If the person doing the job did not have the clout that went with the responsibility, 'they would fail, because everyone would pay lip service to it'.

'With the present mindset it would not work at all. But with a different one it could work brilliantly, ' he says.

He does not see the public health specialist as a replacement for the medical director on a board. The medical director role is 'about managing the service' and the other about 'focusing the service'.

John Cooper, chief executive of Hammersmith Hospitals trust in west London, would like both on the board 'if you could afford it'.

He mourns the passing of 'a line of interest' in public health in hospitals that has 'got lost in the last 1015 years'. Before 1990 and the purchaser-provider split, district medical officers were employed by the district health authority, which 'had a great role in manpower and service planning and had overall responsibility for infection control'.

He sees a role for public health doctors in hospitals 'of the type in America', where he says they have a strong background in clinical epidemiology. He has 'always felt there was a wider role' for hospitals in thinking strategically about the needs of their communities.

West Midlands director of public health and policy Professor Rod Griffiths says that in central Birmingham district before the 1990 reforms, each directly managed unit had a public health specialist on the board. In his opinion this had worked well.

But, according to NHS Confederation policy director Nigel Edwards, the 'missing link' is not a dearth of leaders within trusts, but the middle level. 'It strikes me that the problem is not necessarily defective leadership, but is it connected to enough good people to get the delivery done? It is like buying a high-speed train when you still have people on the rails digging with a shovel. '

Whether public health doctors are the right people to take the agenda forward 'is not clear, and from my perspective It is missing the point'.

Susan Macqueen is the past chair of the Infection Control Nurses Association and is a clinical nurse specialist at the Great Ormond Street Hospital for Children. Her personal view is that we would 'just be replacing what we are doing now'.

'There may be weaknesses in infection control teams, but they have to be empowered to do their job. If you have a good infection control team, they should be doing the work, and if the system is right, we should have access to the board. '

The Public Health Laboratory Service has 47 labs in England and Wales based in trusts for diagnostic services, according to its medical director, Professor Brian Duerden.

He says infection control is one of the 'must do's' on which chief executives will be performancemanaged - but that he does not feel it is his position to tell chief executives what to do regarding possible recruitment of public health specialists.

Ian Cumming, chief executive of Morecambe Bay Hospitals trust, says there are 'huge areas' where specialist advice in trusts would be helpful, 'including public health input into clinical governance and around the population benefits of individual treatments'.

In Scotland - at least when it comes to infection control - they are not hanging around.

A fortnight ago the Executive announced that every trust would have to appoint a senior manager to tackle hospital infections. Their role would include decontamination, medical device management and cleaning services.

Simon Williams, assistant director of the Patients Association, believes this shows 'how Scotland is racing ahead and doing things differently' in an imaginative way.

He adds: 'It is OK saying that chief executives have responsibility for clinical governance in this area, but who is doing to do it dayto-day?'

It is all about responsibility and someone taking the issues seriously, he stresses. Appointing someone to cover this sort of agenda at a high level within trusts would allow hospitals to deal not just with-ill health, 'but to promote good health'.

But he suspects that the Department of Health will not rush to provide extra funding.

'Knowing the way things are working these days, it would not surprise me if they said it had to be done within existing resources. '

Chair of the Commons health select committee David Hinchliffe believes boosting the role of public health within trusts is a 'common-sense approach'.

He adds: 'They need to be at board level, but with outside powers. There is an argument for some degree of detachment - but with the power to do more than they can do at the moment. '