More changed against than changing? Public health in the new NHS
Authors: R E Stanwell-Smith
Journal: Journal of the Royal Society of Medicine (2002)

According to the philosopher Hegel, people and governments never learn from history—a depressing thought for reformers. One of the worries about the current restructuring of the NHS1,2 is that reformers are failing to learn from previous mistakes and that the public health function will emerge seriously damaged. In the April JRSM Professor Walter Holland3 called for much deeper scrutiny of the latest proposals, in the light of past experience and future needs. Similar anxieties have been expressed elsewhere4,5. On 26 February the RSM's Section of Epidemiology and Public Health debated the motion, The current government reorganization of the structure of the NHS will damage the public health function. Participants were asked to put aside concerns6 about yet another round of reorganization, restructuring and reapplication for posts and to focus on whether this further tidal wave of change could be justified in terms of outcome.

One theme was people's attitudes—whether, before the changes come in, the glass is perceived to be half full or half empty—or, as a member of the audience quipped, three-quarters full. Proposers of the motion argued against yet another change before systems have been allowed to settle, or to be properly evaluated, from previous reorganizations. Opposers claimed this was a pessimistic reactionary view, unfitted to the change-agent role claimed by public health specialists. But, ran the counter-argument, agents of change exist to achieve reforms rather than become victims as in a cruelly reversing and distorting mirror; the turmoil of successive changes has left little time or energy to make the required impacts on surveillance, disease prevention and healthcare planning. Yet, argued the opposers, it is precisely because of the perceived poor impact on population health that more change is necessary: the current government focus acknowledges the worsening of many health inequalities over the past three decades; one aim of the reform, and one of the three aims of the primary care trusts (PCTs) that will have responsibility for the public health function, is to base public health activities more directly at the primary care level and so make them more effective, with new opportunities for influencing decisions and networking across community and agency boundaries. Critics reject this argument, declaring that dispersal into small units will cause the public health function to become marginalized.

So, a shift of balance to improve the service, or a shift of blame to another part of the health system? Another theme was the chaos caused by reorganization and the tendency of change to destabilize. Here the metaphor shifted from the half-full/half-empty glass to whether we should be looking for green shoots rather than dying roots. Restructuring is painful but potentially fruitful, claimed the supporters of further reorganization: the current change merely acknowledges that structure should follow definition of function. Against this was cited the narrow function apparently perceived for public health by the Government—the tackling of health inequalities by promotion of screening, rapid access clinics and the like. Surveillance of disease, the need for stable population bases for calculating incidence or prevalence, and effective control and prevention of infectious disease have been effectively demoted in priority. But only if we let it be so, claimed supporters of the changes: the regional and PCT public health capacity will include large budgets for public health, and productive discussions across many sectors are already in progress.

An inevitable theme was whether this reorganization is politically based or evidence based. According to the proposers of the motion, certainly not evidence based: the plans were prepared hastily and with scant consultation. In their view the specialty, always vulnerable to political influence, would become effectively politicized, with practitioners suffering further loss of independence; there had been no published evaluation or detailed assessment of the earlier ‘reforms’, and announcements such as the NHS Plan in 2000 made no mention of the wide-scale structural upheaval now about to occur. Opposers argued for a more positive view of the inherent political nature of public health, pointing to international influences such as the World Health Organization's Alma-Ata declaration relating to ‘Health for All’7, which the current reforms address more closely than any previous reorganization. They pointed out that the repositioning of the public health function also acknowledges the need to work closely with those responsible for housing and social care. The counterargument was that these grand aims could have been achieved through modification of the existing public health structure; would PCTs be able to devote the necessary energy to the public health aims on their agenda, given the strong emphasis on secondary-care performance indicators?

There are different types of change, as well as varying attitudes and philosophies that may influence change outcomes: on both sides there was acceptance that management of change is a core skill for public health specialists. Proposers argued for slower, more considered, change based on evidence and evaluation; also that behavioural, not structural, change should be the core strategy. Opposers cited the history of public health and its perceived failures, as well as changing expectations, declaring that the time was right for revolution. There was no agreement on whether such rapid change would be destructive—for example, through loss of skills if experienced practitioners left the specialty. The question of out-of-hours cover remains unresolved following publication of the plans for the new agency for environmental and infection surveillance8 (already renamed the Health Protection Agency)—another major imminent change for public health. Yet there is scope for optimism. Opposers of the motion referred to new opportunities, renewal of enthusiasm and a structure to support the much-needed cultural shift. As for the threat of professional isolation in the new smaller units, electronic communications could provide the necessary networking.

Is all change good? Clearly not, yet the change rhetoric is a contemporary force and there is more emphasis on resilience to change than on clarifying how it should be defined and implemented9. This, in my view, was the essence of the debate—although, as a proposer of the motion, I must declare a bias. The motion was carried by 22 votes to 16, with several abstentions; and the frank exchange of views belied the accusation that our specialty is already irretrievably politicized. Even if, as the vote indicated, the NHS reorganization will damage the public health function, we can confidently expect another reorganization in a few years' time. People working in public health are certainly accustomed to managing change.