In the mid 1980s an inquiry into the development of the public
health function was established in response to two major outbreaks
of communicable disease. The report of the inquiry, chaired
by the then Chief Medical Officer of England, Sir Donald Acheson, recommended,
among other things, that “community medicine” should be renamed
“public health medicine” and that each health authority should
appoint a director of public health, who should produce a report
on the health of the authority’s population each year.1 After
almost 10 years of annual reports from directors of public health
the Institute for Public Policy Research has published a review
of their purpose and form.2
Anne Davies’s review is timely because of the huge amount of
public health activity taking place nationally. Not only has
England its first ever Minister for Public Health, but the current
Chief Medical Officer, Sir Kenneth Calman, is also leading a
project aimed at developing the public health function. Moreover,
Sir Donald Acheson has returned to the fray with additional
work on inequalities in health, and a green paper on the government’s health
strategy Our Healthier Nation is expected shortly.
Davies’s recommendations are certain to create controversy despite
being highly supportive of the concept of reports from directors
of public health. The tradition of local annual reports on the
public health goes back, with some gaps, to the nineteenth century.3
Davies’s recommendation that reports should in future be produced
only every two or even three years will be seen by some directors
as a desirable break from an unwelcome chore. There is, however,
no shortage of important public health issues that need to be
tackled, and annual reports can, and should be, a catalyst to
action. Directors tailor their reports to address various audiences
depending on local health problems, but influencing the results
of the annual planning cycles of both local authorities and
health authorities is an important goal.
Although Davies rightly emphasises the importance of the independent
professional nature of the public health report, the net effect
of several of her recommendations would be to reduce that independence
substantially. In particular, greater government specification
of content and centralisation of funding for reports are potentially
constraining. The independence of the director of public health
needs to be protected, even though some argue that independence
is inversely related to influence. There is little evidence
of the current independence being abused; indeed, if there is
any criticism it is that some directors have not used their
annual reports to speak out on the real determinants of ill
health.
Public health professionals have recently become even more closely
involved with issues in the personal health services, particularly
the operation of the internal market. But circumstances have
never been more favourable for a return to a much wider public
health role. The new and welcome concentration on the social
and economic causes of ill health and on health inequalities
will highlight the importance of public health leadership. We
live increasingly in a world of shared power, where no one organisation
has the legitimacy, power, capability, or intelligence to act
alone on the causes of ill health.4 Directors of public health
are well placed to act as convenors and catalysts for action
in the community, and annual public health reports should be
an important tool. Operating effectively in this way will demand
a substantial change in approach for many directors, who will
also need to avoid the temptation of thinking that the task
is merely to “educate” the public about health. When public
health professionals talk about educating the public they often
mean using more effective means of telling people what, from
a professional point of view, is in their best interests.5 What
we need instead is to develop an approach to leadership which
mobilises others to take part in collective action on public
health issues. The really urgent task is to encourage and empower
directors of public health to grapple with the crucial issues
of poverty, inequalities, poor nutrition, and bad housing.
—By Ann Davies and A Rouse @BMJ 1998 316: 1904
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