Description

Like other health authorities in England, we are now carrying out a baseline assessment of our clinical governance arrangements, as directed in HSC 1999/065. This has forced reflection on where the standards for the practice of public health come from and how we can develop better ones.

Standards are central to clinical governance, with the word appearing in the official definition.1 Yet setting standards in public health is harder than in clinical practice, as acknowledged in the recent White Paper Saving Lives.2 The White Paper mentions two difficulties with standard setting: the multi-disciplinary and multi-agency nature of public health work and the lack of a robust evidence base. Behind these factors lies a tangle of problems: the long time-scales for public health work, the intangibility of some of the outcomes, the vulnerability of initiatives to a change in the political climate and the difficulty for public health practitioners in operating as specialists in a specific field (such as mental health) and generalist workers in an allotted locality.

For example, I was once a member of a group developing an intervention for the secondary prevention of falls in elderly people. The group was diverse, including secondary care clinicians and health promotion specialists. The group was initially stymied by the anti-health promotion prejudices of some of the secondary care members. Other members of the group and I changed these attitudes, enabled the project to move forward and perhaps made it easier to run other health promotion initiatives for elderly people in future. Rajan Madhok discussed several complex aspects of achieving change in the first edition of Public Health Medicine.3 This kind of work is integral to good public health practice, but very hard to set standards for. Where is the evidence base for attitudinal change in this context (please – Id like to know)? How could one assess the contribution of different members of the group to achieving change (including those who looked embarrassed when uninformed views were expressed)? How could we measure validly the long-term results of such a meeting?

To this, the Department of Health1 responds briskly: “That does not mean that standards do not have to be set. They do” [2,para11.4]. The Department has acknowledged the scale of the challenge by creating a new organisation, the Health Development Agency, to advise on the setting of standards for public health and health promotion practice, among other tasks. The Agencys products will be added to the set of directions we will shortly receive on what to do and how to do it: the National Service Frameworks, the conclusions of the National Institute for Clinical Excellence and the General Medical Councils revalidation criteria. The Faculty of Public Health Medicine also has a standards committee.

Public health specialists have suffered in the past from a lack of explicit yardsticks with which to measure their own, and each others, performance. We are now moving from famine to feast before you can say “European Butter Mountain”. If all this adds up to a mutually compatible, balanced and achievable whole, then public health will be a stronger and more effective endeavour than it is now. The challenge for the future may be managing a surfeit of standards and selecting which to use to assess and improve practice.

References

1. Department of Health. A First Class Service: Quality in the New NHS. London: DoH, 1998.

2. Secretary of State for Health. Saving Lives: Our Healthier Nation. London: The Stationery Office, 1999.

3. Madhok R. Achieving change: an offer you cant refuse? Public Health Medicine JCPD 1999; 1: 31-3.