• They have to be forthright in the advocacy of programs that improve health and to state clearly and openly the dangers and consequences of some actions, clinical, environment or political.

• They have to be able to influence the budget for public health activities and to ensure long-term public health issues are considered on a separate dimension from short-term clinical and practical issues which will otherwise always take precedence.

• they have to assume a clearly identifiable role in helping to influence and guide the policies not only of health authorities but also of schools, environmental agencies, housing departments, microbiological laboratories and practicing clinicians in hospital and general practice.

To be able to fulfill these tasks public health must work in close co-operation with other relevant disciplines and must take responsibility for the development, maintenance and operation of the information systems required to maintain first-class intelligence on the health needs of the population, disease control, including prevention and the outcome of public health and clinical policies.

As we have already seen, the present structure does not fulfill these important requirements. Public health practitioners have no control over the required information systems and do not have the practical freedom to report on the health of the populations for which they are responsible. Their power to influence and guide the activities of bodies other than health authorities is either absent, or rudimentary and informal. Change is needed. The present structure and powers of public health physicians are inappropriate and inadequate to fulfill the essential tasks.

There are, in our view, three possible options for a better structure:

There is a view that, since many of the factors that influence the health of the population are administered by local government, public health practitioners should be employed by local government, and their coordinating and guiding duties to Health Authorities, hospitals and general practice carried out on an agency basis.

There are two major obstacles to this solution. Firstly, most health information systems are administered by Health Authorities. Since appropriate guidance has to be based on accurate data and responsibility for information systems is essential if they are to be in a position to deliver that guidance, it is most unlikely that Health Authorities would be willing or indeed permitted to relinquish these functions.

Secondly, although clinical interventions are only one part of the way in which health is maintained and achieved, the role and authority of doctors is vital both in understanding, knowledge, and communication. One of the most important roles of public health is in the surveillance, prevention and control of disease, whatever its cause. It is important that highly qualified medical doctors are attracted to public health not only to cope with the public health problems, but also to communicate with the public, policy-makers and other practitioners. They play a central role in the planning of health services. If public health were not considered as a mainstream health activity, it is likely that the status of the subject and its attraction for medical graduates would diminish and public health and the health service in general would be the poorer.

This option envisages a Commission which would include the Public Health Laboratory Service, a central Toxicological Laboratory, the National Poison Centre and perhaps even the National Radiation Protection Board. The Commission would have a budget agreed not only for the expenses and staffing of these laboratories but also for the cost of all of the service public health practitioners throughout the country. Although the appointment and payment of public health practitioners would be undertaken by the Commission, most would be located in Districts or Boards. Each Health Authority would continue to have a Director of Public Health and several consultant posts as well as trainees. But all public health practitioners would be on the staff of the Commission and those at local level seconded there for fixed, renewable periods. Directors of Public Health would continue as members of Health Authorities, but would be ultimately accountable to the Director of the Commission and not to the Chief Executive of the District.

At all levels of staffing the need for multi-disciplinary working would be paramount. Consultant level appointments would be needed not only for those with a medical qualification, but also for statisticians, social scientists, health economists and so on. For all disciplines it would be essential to have a proper education and training program and not merely a university degree. For some posts, for example communicable disease control, medical training would obviously be essential. For others, this might be helpful but not mandatory.

The obvious advantages of this model are the independence that public health practitioners would have in both their action and reports, the recognition of the importance of a multi-disciplinary approach, and an acknowledgement of the clear differences between clinical services and the public health services.

There are however, various problems with this solution which effectively preclude its adoption as a practicable proposition. The most obvious of these are firstly that the establishment of a free standing commission, controlling not only action but also staffing and training might stifle initiative and secondly, it would be a bold and imaginative government who would be prepared to grant the commission the wide remit proposed or meet the full cost implications of the equivalence of salaries of all staff whether medically qualified or not.

The experience of such an organization for public health in New Zealand has demonstrated how easy it is to relegate public health functions and abolish independence when uncomfortable decisions have to be made.

A more realistic modification of the full Commission of Public Health option might be to reinforce the role of public health at district or board level - whether in health or local authorities - by the re-creation of expert regional institutes with a national institute, including micro-biological and toxicological laboratories. For public health to function effectively it needs access to expertise. This can be provided to a large extent through universities and research units, but there is also a need to have an identifiable practical resource with service responsibilities.

This option would retain a Director of Public Health and consultant grade public health practitioners in each District or Board. The function would be that of coordinator, with access to and responsibility for all public health information services as defined and the duty to guide with advice, not to direct, except in special circumstances.

Public health physicians should once again have specially secured positions as Medical Officers of Health had before 1974. Public health physicians should again be involved at both central and local level in the discussions of bodies concerned with the environment, social services, education, nutrition, and housing so that the influence, for example, of housing policy on health is fully recognized.

By requiring public health at local level to participate in and influence the decisions which in turn influence health, the wide diversity of different parts of the country could be recognized and a positive sense of local ownership encouraged.

If this option were to be introduced Local Authorities would again need to become involved in the appointment of public health physicians. This option emphasizes the fact that public health should be concerned largely with its own issues rather than with clinical service management and contracting. This model could also be used to promote involvement with general practice and hospitals locally and remove or reduce many of the current conflicts and difficulties between different specialties.