Public Health - Dr. Selena Gray

Public health has been through a challenging time in the past 12 months. Primary Care Trusts (PCTs) and Strategic Health Authorities came into being just over a year ago, on the 1st April 2002, as Health Authorities and Regional Offices were abolished. Such organisational change at all levels in the system in a relatively short time scale has inevitably caused difficulties as new organisations have had to get up and running from scratch. Although some public health staff were transferred relatively painlessly from the old health authorities, all Director of Public Health posts were advertised nationally, and were opened up to those from any background, not just medicine for the first time. Sadly, some public health staff have opted to move to posts outside public health, and a few have been lost to the service completely. Furthermore, as from April 1st 2003 the Health Protection Agency has come into being, a new national body for England and Wales provided an integrated approach to health protection and reducing the impact of infectious diseases, poisons, chemical, biological and radiation hazards. This will now employ all Consultants in Communicable Disease Control and their control of infection teams, as well as a number of national bodies. The Public Health Group at regional level has moved into the Government Office for the Regions, where they have a new opportunity to engage with, and influence activity around the broader determinants of health such as transport and food. Thus the public health function is now organisationally split between the NHS, the Health Protection Agency and the Department of Health, both centrally and within the Regional Government Offices. As the effects of devolution become clearer however, it is interesting to note that these organisational changes are not mirrored in Scotland, Wales or Northern Ireland. Indeed in Wales, all public health staff have been moved into the National Public Health Public Health Service for Wales, and a single NHS employer will be responsible for employing all staff.

The situation, as always in Avon, is complex. There are now five PCTs - BNSSG as it is referred to in shorthand, including Bath and North East Somerset, North Somerset, Bristol North, Bristol South and West, and South Gloucestershire. Each has a Director of Public health and a small embryonic public health team. Essentially the existing public health and health promotion function of the Avon Health Authority have been divided by five and spread across the new organisations. There is then the Avon Health Protection Unit, a division of the new Health Protection Agency, which covers the geographical area of all the PCTs. Overseeing the performance of both Primary Care and Acute Trusts in this area is the Strategic Health Authority, Avon, Gloucestershire and Wiltshire.

So have the changes been a good thing for public health? At primary care level, there is enormous potential for working with communities, with general practitioners and other primary care staff, and with local authorities, with PCTs generally relating to 100-200,000 population. Most PCTs are co-terminous with local authorities (although this is not the case of course in Bristol where two PCTs cover Bristol City Council), but is true for the other Local Authorities in BNSSG. This offers real opportunities to work properly with local authorities on some of the big issues affecting health such as housing, education, transport and the environment. Health promotion departments have been assimilated into primary care trusts - in some areas they have become quite separate from public health teams. However, there is a real danger that this enormous potential will not be achieved. The cash-starved PCTs are struggling to even establish viable public health departments, whilst dealing with a huge and complex agenda, as well as having to network and meet with colleagues to agree any major decisions around acute services. In clinical governance terms, it must be questionable as to whether a single-handed Director of Public Health and two or three health promotion specialists is an adequate and safe public health function. Ways must be found to support and develop these Primary Care Public Health Teams in order for them to achieve their potential. Individuals must be given the space and time to develop specialist areas of interest that take them outside the PCT, be it in screening, public health information, diabetes or mental health, to support colleagues in more generic managerial roles (including the Director of Public Health). If not, we risk a retrograde development of public health as a speciality. Further challenges remain around co-ordinating the work of the health protection agency with primary care public health teams - the emergence of SARS has graphically demonstrated the serious potential hazards of communicable disease in today's global economy.

Against this background of organisational change there are exciting developments at national level. This year saw the introduction of a ban on tobacco advertising after many, many years of campaigning by public health professionals, an extremely welcome step. Larger warning labels on cigarette packages with the phrase \"Smoking Kills\", vehemently opposed by the tobacco industry, have been introduced. Progress on a ban on smoking in public places is the next logical step, but one that will require sustained campaigning by public health professionals and others. Perhaps it will be helped by dramatic recent findings that a six-month ban on smoking in public places in a Midwestern US town saw rates of heart attack fall by nearly 60%. During the ban, which was eventually suspended after legal action, the number of admissions for heart attack to the local hospital decreased markedly among the citizens of Helena, Montana. Neighbouring towns, outside the smoking ban, saw no reduction in heart attack rates(¹)

¹ BMJ 2003;326:780 News