Changing titlesBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7537.370-a (Published 09 February 2006) Cite this as: BMJ 2006;332:370
All rapid responses
Dr. Ramaiah's article makes for sober reading especially for public
health specialists and public health trainees who are not spared the
negative effects of a continuously disrupted learning base.
His suggestion of a national public health service (call them Public
Health Trusts) akin to the type operating in Wales is worthy of note. The
Welsh Public Health Service is a single organisation responsible for
managing public health resources and providing locally delivered guidance
and advise to Local Health Boards. The service has inputs from academic
public health departments and has a critical mass of public health
professionals like community pharmacists, health visitors etc. This model
of public health functioning appears to ensure stability in the
occupational circumstances of practitioners and accords a good profile to
the speciality, something which would easily be lost if Public Health
specialists were to privately contract themselves to offer services to GPs
under the new Practice Based Commisssioning, as suggested by Ashworth
(See 'Protecting the Public Health Protectors').
While the article acknowledges the role of the Faculty of Public
Health in ensuring training standards as well as its limited influence on
reorganisation, one wonders if it would be beneficial for Public Health
professionals to engage more extensively in the debate on whether there
might be yet unexplored opportunities to expand the remit, diversity and
relevance of public health.
Additionally, we would suggest that the reason General Practitioners
have been apparently sheltered from the chaos of reorganisation is not
solely because of private contractorship but also the relevance of what
they have to offer as well as the protection offered by prevailing
government health policy. If there were not such a policy making GPs the
primary gateway to secondary care, we argue that private contractorship
alone would not have accorded it much stability in the face of
Therefore, the challenge is that of public health professionals to
engage health policy makers in such a way as not only to advocate and
promote population health, but also to protect the futures of those who
speak up for the health of their communities.
Competing interests: No competing interests
The debate to be generated by Dr Ramaiah’s initial concern regarding
NHS re-organisation and the future of public health physicians should be
an interesting one. He points out a number of important dimensions and
issues surrounding the range and size of the public health workforce and
infrastructural arrangements for delivering public health. Dr Ashworth’s
response focuses on the useful dimension of where to locate public health
expertise within the NHS and ensuing benefits to the public health
Public health practitioners and champions must not be passive
observers of the inevitable change process. I suggest that further
elucidation of the aforementioned dimensions in order to generate a wider
debate, engender clearer answers and durable solutions to questions and
problems posed, is a good starting point.
Fine-tuning the questions to be answered should help focus the
attention of the various actors who will drive or deliver the changes to
come. My departure point will be that although we need to pose specific
questions, a comprehensive view of the issues should also be maintained. I
highlight here three major questions and some options around them viz.:
1. Who constitutes the public health workforce and how are they
affected by proposed changes?
The current public health workforce includes more than doctors or
public health physicians, this is an important point because although
doctors may have or perceive peculiar professional issues, we must not
tolerate half-baked measures that do not address concerns of the global
public health workforce.
Other Public Health Practitioners including Environmental Health
Officers and Health Promotion Officers are scattered across NHS
organisations and partner local authorities. These practitioners are also
anxious about ongoing changes including Agenda for Change and the
ubiquitous public service re-organisation.
It may be that the current dilemma presents an opportunity to
properly enumerate the public health workforce, bolster its identity,
widen its base and place such a workforce in the type of national agency
proposed by Dr Ramaiah.
Such system-wide thinking and re-organisation, daunting as it seems,
might actually be less destabilising, and more effective compared to the
frequent, incremental tinkering which is the status quo. After all, public
health practitioners are supposed to have similar professional goals.
2. What is the optimal public health infrastructure to ensure and/or
sustain population health?
This is a fundamental question with no easy answers. Nonetheless, I
think it precedes any questions of whether a change to the system is
currently required or which professional interests will benefit or lose
due to any proposed changes.
It remains unclear and the evidence should be sought to determine
whether centralised agencies, localised “deconcentrated” departments of
such central agencies or devolved/decentralised local directorates (be
they PCGs, Health Authorities or PCTs) with increased ability to determine
and decide on budgets and policies is the better option?
It could easily be that a mixed-model will be always be required as
some public health functions are best delivered centrally whilst some can
only be effectively arranged and delivered locally.
So, what are we worried about when a change seems to propose further
local devolution and a mixed-model NHS health economy?
The problem, apart from those already mentioned by the other
contributors is that despite all our emphasis on evidence-based health
interventions, we seem to be quick to change and re-organise the base from
where these interventions should be planned and deployed with little
regard or consensus on the evidential need for change.
3. Where at the local level is public health expertise best placed?
Dr Ashworth raises a very interesting point about the location of
public health expertise. I generally favour decentralised local
directorates for delivering public health services and intereventions
where an appropriately sized and suitable catchment population has been
enumerated. I am also eager to see local GPs and public health
practitioners working together seamlessly.
However, I will hesitate to campaign for public health physicians to
be contracted by GP (Practice-Based) Commissioners as I think that there
is a slight risk of “over-medicalisation” of public health where other
public health practitioners, the wider workforce, partner organisations,
and the community then begin to see public health solely through the prism
of the local GP practice (although I recognise and hope that GP practices
should and will not merely be clinics once Practice-Based Commissioning is
in full swing).
If public health is contracted by GP commissioners, who will advocate
for the community when there are tensions between local commissioners’
views and that of the communities' regarding level and types of services?
Who will be the independent advisor looking at the range and
magnitude of preventive and protective health services commissioned
How would the current public health structure geared itself towards
an increasingly service-delivery function in such an arrangement and
I am also uncertain about how stable Practice-Based Commissioning
arrangements will become as there are not yet very clear indications of
the level of participation by GPs in many areas. However, without
discounting the important roles that the local public health workforce
will play in practice-based commissioning, I am generally inclined to
suggest that local public health function/expertise/workforce should be
placed at the local authority level.
There is already an emerging pattern of large Care Trusts, joint
appointment of social service and public health directors, and a plethora
of partnership initiatives including Local Area Agreements between PCTs
and local authorities. I consider it natural that any organisational
change(s) to the current public health structure follow this direction.
There is wide recognition of the need for a broad statutory,
political, financial, and local base from which to launch public health
Local authorities may offer such a base and irrespective of ongoing
reforms they remain a more permanent fixture of the local Health and Socio
-Political Economy. I’m afraid it’s “back to the future” on this one and
that’s my suggested change of title.
Competing interests: No competing interests
Dr Ramiah describes “another season of reorganisation” but then
frames his further argument for the future of his speciality within the
constraint of simple reorganisation (new agencies, employment contracts).
Another view is that there is (and probably always has been) confusion in
the mind of Government between “Public Health Medicine” and “Public Health
Policy”. In an ideal world, the former would advise the latter but
centrist governments seek a reversed relationship and market driven
governments don’t see the point of the policy in the first place.
GPs probably peddle preventative medicine to many more individuals than
Public Health Physicians because we are at the delivery end of Public
Health Policy: our position has been maintained robustly since 1948. I
argue that this is the result of our status as independent contractors,
others feel that direct accountability to a local registered population is
If Public Health Medicine is so vulnerable, perhaps it needs to meet the
imposition of reorganisation with self imposed reform: Public Health
Physicians could contract with, say, commissioning GPs to guide
preventative practice and with other authorities (or even their insurers)
to advise on the avoidance of catastrophes. Such a move would probably
benefit the Public Health but the question Dr Ramiah must answer to
convince his colleagues is “Would it benefit Public Health Physicians?”
The move to independent contractor status would be bold but it could
provide the stable environment (as it has for GPs) to permit development
of an effective force to improve the Public Health.
Competing interests: No competing interests