Letter

More than just purchasing

Dear healthmatters -- Charles Webster’s article (Public health in decline, issue 11) provides a useful critique of the role of public health medicine to date. I have recently published an article with a colleague which deals in detail with public health medicine’s entrechment in ‘purchasing’ since the NHS reforms (Public health heresy, British Medical Journal, 18 April 1992). This essentially supported Webster’s opinion of the likely increasing preoccupation with hospital administration.

But Webster leaves several major questions unanswered: how could a specialty as radical as he suggests survive in a state institution subject to such strong central control? And which public health interventions does he see such a specialty engaging in? Many would agree that public health physicians should be active in national lobbying on social and economic issues relevant to health. But little of the local intersectoral action advocated by the New Public Health movement has been evaluated, possibly due to the relative inattention afforded by mainstream pulbic health medicine.

What should public health medicine do in response to critique’s such as Webster’s? In my view, the first step is to stop the pretence: the majority of the current public health function is medical administration. Public health departments should be explicit about the number of staff dedicated to this role, and ensure that the broader public health function is adequately and explicitly resourced. And those resources must include multidisciplinary professionals who are better suited to the broader role than many public health physicians.

It must also address urgently the demands of the new administrative role, by drafting in additional clinical and other expertise before the specialty is embarassed by its inevitable failure.

Finally, public health medicine must be prepared to assess critically its progress in pursuit of public health goals -- a characteristic unfortunately lacking from many of the published responses to our own article.