The Review’s preference for locating the local public health function within Health Boards is driven by an understanding that health improvement will be their raison d’être. Earlier sections of the Review have considered the enhanced role of Health Boards as public health organisations and discussed issues relating to governance and accountability. This section expands further on some specific issues but begins with a restatement of the purpose, function and accountability of Health Boards:
The Board should provide high profile leadership for public health, developing effective well-managed multi-agency partnerships for health. Clear and shared public health goals and responsibilities will be reflected in the corporate activity of the Health Board and its partner local authorities;
The Board’s work to improve health will involve both the NHS and wider partnerships, all of which will contribute to an effective public health function;
The Board’s organisational development will reflect public health values and methods and many of its resources will be devoted to the public health function. Its business and decision-making will be driven by public health principles, and informed by the best possible public health intelligence;
Health Boards will be accountable for their role in health improvement and will have a framework for public health governance;
Board organisation and development
The relationship between the general manager and the DPH is crucial and their roles are complementary. The DPH heads the team responsible for analysing the population’s health needs, provides leadership for the development of health strategy, ensures that assessment of health needs drives health and social care planning, provides public health input to partnerships, and undertakes a number of statutory responsibilities on behalf of the Board. Meanwhile, the general manager is responsible for marshalling public health resources, ensures that the Board achieves its objectives, gives momentum to the implementation of public health strategy, and has a raft of NHS responsibilities that are not directly related to public health matters. In the same way that DsPH benefit from a broad understanding of management so the Review believes that General Managers benefit from an understanding of public health principles and practice. The Review heard arguments in favour of adopting the title of "Director of Health Policy" to underline the DPH role in the Health Board and can see virtue in the practice of some English Health Authorities whereby the DPH post is styled "Director of Public Health and Health Policy".
The Chairmen and non-executive Directors of Health Boards also have a crucial role in discharging the public health function. They bring a wide range of perspectives to the process by which public health strategy is determined and implemented. They also have particular skills and interests, and their knowledge of networks (for example, in the private and voluntary sectors) may help to further the public health agenda.
The Review notes with great interest the ongoing development of Health Improvement Programmes (HIPs), the organisational development being undertaken by the Management Executive, and the plans to develop a performance management framework for the public health role of Health Boards. To assist Boards in their further development as public health organisations, we suggest that the DPH group and the general managers group work together and with other key stakeholders to develop standards for the public health function within Health Boards, the work to consider staffing, resources and ways of working.
Public health within Health Boards
Staffing and resources
The first priority is adequate capacity, including staff and resources, for the tasks in hand. The model public health endeavour within Health Boards is multidisciplinary, its disciplines and range of skills reflecting its core functions. A critical mass of public health expertise enables the Board to provide sufficient expert input to priority areas and allows professionals to maintain effective networks with key colleagues and stakeholders. An effective response to public health emergencies is ensured with formal arrangements to provide year-round 24-hours a day management and cross-cover arrangements that take appropriate account of leave. Adequate administrative support is available. The Review appreciates that in these considerations, small Health Boards are denied the economy of scale afforded to their larger counterparts.
THE MODEL PUBLIC HEALTH FUNCTION WITHIN HEALTH BOARDS — PERSONNEL
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Ready access to a full range of library services includes on-line access to relevant databases and search facilities. Computing resources with appropriate support are backed by the ability to exploit electronic communication to the full. Necessary research can be commissioned, but collaboration between Boards and other agencies can avoid unnecessary duplication of effort.
The model public health department has good surveillance systems for both communicable and non-communicable disease and can monitor the key determinants of health and ill health. A common public health dataset is available to the organisation and its partners. The dataset is regularly updated, capable of ready interrogation, and populated with relevant data from health, health services, and local authority information systems. The proposed Public Health Institute could have an important national role in developing this dataset.
Ways of working and structure
Work which addresses the public health agenda is fully integrated with the rest of the work of the Health Board and public health professionals are engaged fully in key areas such as priority setting, formulation of HIPs and commissioning of services. Some respondents argued that commissioning and resource allocation are an inappropriate use of public health doctors and dentists. The Review sees involvement in such activities as essential if these professionals are to exert a major influence on the use of health resource (‘for the greatest good of the greatest number") and play a leading part in realising the vision of Boards as public health organisations.
The culture of the model public health organisation is as important as its structure. Its members are approachable, work closely with partners in other organisations in ways that are defined and widely understood, and operate as a cohesive unit with common purpose. There are good working relationships within the organisation, and with the NHS and other organisations. Members of the organisation work coherently to clarify and communicate its objectives, maintain its high profile locally, and undertake emergency or priority tasks.
Within the model department of public health, the DPH provides the inspirational leadership so critical to team building and development and there are excellent relationships between the DPH, General Manager, Chairman and Board members. The Health Board leadership supports and values all staff, appreciates their skills and perspectives, and allocates tasks appropriately. Public health professionals feel that they are working towards objectives that are common to the Health Board as a whole.
The model public health department is aware of all major pieces of public health work in the region and has a clear overview of the ways in which they contribute to overall health improvement. The organisation ensures that effective links between initiatives achieve good coverage of priority topics and avoid unnecessary duplication. It understands who its ‘customers’ are and takes account of their views when developing its services.
Sufficient time is available for proactive strategic public health work. Many consultants in public health medicine and dentistry told the Review that they spend much more time on reactive or "firefighting" tasks than in strategic and preventive activity to improve the public health. This said, the reactive elements of public health work must not become detached from planning and strategic work. For example, disease surveillance informs strategy as well as prompting a response to outbreaks or incidents, and the organisation’s CD&EH function is fully integrated with the rest of the public health department. While much of the day-to-day work of CD&EH staff inevitably addresses immediate issues, the department must not lose sight of the more strategic elements of the CD&EH function; this is helped if day-to-day CD&EH cover is shared between two or more CsPHM.
In defining the responsibilities of individuals the challenge is to allow enough flexibility to respond to the issues of the moment while allowing staff to develop specialist knowledge of topics and local knowledge of people and organisations. One solution would be to have lead public health professionals for each local authority and/or LHCC and/or Trust. However, while this might aid communication and the development of strong working relationships, it militates against the development of specialist expertise, is demanding in terms of manpower and reduces the likelihood of a cohesive public health policy being developed across the Health Board area.
An alternative is to have lead professionals who deal with broad client groups and topics which cross boundaries between organisations. This model favours network development and the growth of topic-based expertise which can be valuable at national level. It remains an open question as to whether individual members of the department should retain a given area of involvement or rotate through different responsibilities. Rotation gives individuals a broad range of knowledge, skills and experience, and enhances departmental flexibility. Individuals vary in their attitude to the balance between increasing specialisation and the retention of a broad range of skills. We take the view that the needs of the population served are paramount but that judicious organisation by the DPH will go a long way to reconciling organisational needs with individual aspirations. Whichever model is adopted, there should be allocation of enough time and expertise to priority areas with regular review of priorities in the light of available skills and resources.
The model public health organisation attaches great importance to training, continuing education and professional development. Individuals have annual objectives and job plans that are reviewed as part of an organisation-wide appraisal system that is valued by staff. The public health function operates within a clear clinical governance framework, audits both its long term strategic work and reactive work regularly, and heeds lessons that have been learned. Its organisation and function are reviewed frequently, and every member has the opportunity to contribute.
Towards a Healthier Scotland emphasises the importance of the DPH as an agent of strategic change in delivering the public health agenda; he/she needs to be much more than the ‘chief medical adviser’ to the Health Board. Management expertise in conjunction with the ability to "see the big picture", identify the priorities for health improvement, and operate at a strategic level are key attributes. The Review believes that the DPH role must evolve further if Directors and their teams are to respond effectively to the public health agenda of Boards and provide region-wide leadership. A coherent and concerted approach to strategic public health issues by Scotland’s DsPH could make an immense contribution national public health leadership.
The ideal DPH needs to be well informed, have excellent communication and influencing skills, and be able to delegate appropriately. He/she will have broad public health experience and be able to relate with authority to all consumers of the public health function. Because of these prerequisites, and because of the importance of the relationship with senior clinical doctors, we believe that for the foreseeable future the DPH needs to be a medically qualified public health specialist. Given the development of specialist training and accreditation for other professionals the future may see a new cadre of professionals able to undertake many of the current DPH roles. The Review believes however, that accredited public health doctors with suitable experience and aptitude will always be optimally placed to act as DsPH.
A number of respondents called for management and leadership training as an integral part of preparation for the DPH post. We recognise the value of such skills and recommend that opportunities to acquire them are built into the career development of Specialist Registrars and CsPHM. We see an important role for the proposed Public Health Institute (paras 349-357) in such developments. Collaboration with the English Department of Health is recommended in the current initiative to develop public health leadership courses and learning sets for DsPH.
The DPH must have the support and confidence of the public health department. This has led to some calls for the DPH to be nominated from among the department’s CPHM staff. While we see value in consulting one or more senior members of the department in the appointment process, we can see huge disadvantages in ‘internal democratic’ appointments. The DPH must also command the confidence and respect of the Board for whom he/she will work and to whom he/she will be responsible. As discussed earlier, we see merit in involving other key stakeholders in the appointment. In particular, we recommend that a senior representative of local authorities should serve as a member of the Advisory Appointments Committee. In England, a number of Health Authorities have made joint appointments with local authorities, a model that deserves consideration in Scotland.
To function effectively, the DPH should serve as an Executive Director of the Health Board, as a Designated Medical Officer to local authorities, and as head of the Board’s department of public health. The Designated Medical Officer role of DsPH should be clearly specified and understood by both the Health Board and local authority. The department of public health which the DPH heads should have appropriate capacity, resources and ways of working (paras 251-267).
Directors of Public Health in Scotland still carry the additional title of Chief Administrative Medical Officer (CAMO). Given that medical administration is no longer central to the purpose of the post, we recommend that, with the necessary legislative and regulatory alterations, the title of CAMO is removed. Furthermore, many of the administrative tasks currently undertaken by DsPH, (including operational elements of medical re-housing; appeals against discharge from hospital) could be transferred to others within the NHS. As indicated earlier, we can see attractions and logic in having the DPH styled as the Director of Public Health and Health Policy.
The DPH Annual Report
The DPH is required to produce an Annual Report on the health of the population. The Review heard that the Report is often under-utilised and may not influence significantly the corporate forward agenda of Boards or local authorities. In some areas it excites little comment, being formally received by a Board which then fails to act on its recommendations. The degree of interest shown by local authorities and the media also varies considerably.
The Report must be a tool to inform corporate planning and drive public health activity; it must not just be a report of past action and events. It should be concise, strategic and focused, grounded in partnership working, and with a clear target audience(s) to whom specific actions are recommended; these will usually be bodies that have power to allocate resources. The Report should be the central influence in the formulation of HIPs and Community Plans. In turn, it will be greatly influenced by LHCC-based assessment of the needs of local populations. As an integral part of the planning process, it should be seen as an ‘annual plan’ as well as an annual report. Timely delivery, quality and relevance will be the ultimate determinants of the impact and utility of the DPH report.
A number of respondents spoke of the need to retain the ‘independence’ of the DPH Annual Report. However, viewing it as an independent ‘quasi-external’ commentary on the work of Health Boards (and local authorities) could significantly erode the ability of the DPH to influence and drive the public health agenda. We believe that while the DPH should remain responsible for the Report’s content, this must be linked with the Board’s performance framework and could be used in its annual review. This view is consistent with recent FPHM guidance on "The Future of the Director of Public Health’s Annual Report".
The DPH is accountable to the public and the Report should be formally received and considered at a public Health Board meeting. Primary Care Trusts and their LHCCs must also receive the Annual Report, and its influence would be increased if local authorities, Health Boards and NHS Trusts also respond to it in public session. As a measure of the department of public health’s performance within the Health Board, audit and appraisal of the Report could form a key component of clinical governance.
The public health will be best served if the specialist public health workforce is multidisciplinary and able to bring a wide range of experience and perspectives to the understanding and solution of public health problems. We heard many calls to foster the development of this multi-disciplinary workforce, including written comments from the Chairman of the National Co-ordinating Group of the UK Multidisciplinary Public Health Forum (MDPHF). A separate meeting of the Review group (12 May 1999) was held for public health practitioners other than doctors and dentists.
We appreciate that public health practice in Scotland is increasingly multi-disciplinary and recognise the added value provided by public health specialists with qualifications in disciplines other than medicine or dentistry. We can see considerable room for improvement in the allocation of responsibilities and tasks to appropriately skilled people if the available resource is to be used optimally. Public health doctors and dentists could be freed to concentrate on tasks that only they can undertake, while on the other hand, specialists with other professional backgrounds may be better equipped than doctors or dentists to undertake certain public health tasks. In partnership work, where there is usually input from local authorities, the entire resource available for the task in hand should be identified. Effective working demands appropriate delegation, co-ordination and accountability, and could benefit from joint audit.
When public health practitioners who are not doctors and dentists become part of the public health function it is usually assumed that they are fully trained and ready to be immediately effective. In contrast, recruits in public health medicine and dentistry are regarded as specialists in training until they are accredited and appointed to consultant posts. Although some non-medical/non-dental professionals undertake a Masters course in public health they often have to rely on in-service training. As well as being unstructured and unco-ordinated, such training may place a strain on other resources and manpower unless it is explicitly taken into account in the department’s work plan. Once skills and experience are gained, the absence of a career structure means that these professionals are often lost to the public health function.
It is beyond the Review’s remit to make detailed proposals for professionals other than doctors and dentists. However, it supports the view of the FPHM that all public health specialists (including those without medical qualifications) should be properly trained, accredited and subject to CPD. It sees a pressing need to consider the overall size and composition of the workforce needed to deliver the public health function in Scotland, with description of the training needs, development, salary structure and career pathway of those who are not doctors and dentists. It appreciates that the Chief Nursing Officer’s review will consider nursing interests and that collaboration between the UK Multidisciplinary Public Health Forum, the Royal Institute of Public Health and Hygiene and the FPHM is already underway to describe standards for specialist public health practice in the UK. This important work will inform the future development of the specialist multidisciplinary public health function.
The Review acknowledges that national appraisal of the multidisciplinary workforce must not restrict the ability of Health Boards (and others) to recruit and develop a workforce that is appropriate for their needs. Nevertheless, a national collaboration between Boards could provide helpful clarification in a Scottish context. The Review appreciates that there are precedents for considerations of this kind to be placed within the remit of the Scottish Council for Postgraduate Medical and Dental Education. However, it sees the area as a primary concern for Health Boards, the organisations that employ most of the individuals concerned. Health Boards will also wish to take account of the work being undertaken in England to study the capacity and capability of the public health function.
Many respondents stressed the importance of working in networks if the aspirations of Towards a Healthier Scotland are to be realised. Networking permits the optimal deployment of resources and skills, avoids unnecessary duplication, allows more uniform provision of essential services and specialist expertise, and can improve training, professional development and job satisfaction. National and supra-regional networks can maximise the efficiency and effectiveness of the public health function while retaining crucial local knowledge and input. Such networks also facilitate peer review of standards and could form an important part of the clinical governance framework.
The Review strongly advocates that networks should be multi-professional, pragmatic, flexible and not constrained by existing geographical boundaries or barriers between disciplines. Multi-professional networks allow the appropriate deployment of personnel so that tasks are matched to particular skills, knowledge and expertise. For consultants in public health medicine and dentistry this might mean that they undertake fewer tasks that do not require their particular skills while allowing them to concentrate on more of the tasks and areas which do.
Existing public health medicine and dentistry networks
The Review appreciates that networking is already a significant factor in the delivery of the public health function in Scotland. It recognises that networks have been formed by;
Directors of Public Health (meeting as a group and with the CMO);
Those involved in the Scottish Needs Assessment Programme (run at present from beneath the umbrella of OPHIS);
Consultants in communicable disease/environmental health with participation by SCIEH;
Service and academic consultants in dental public health together with the Chief Dental Officer have developed guidelines and co-ordinated national work in epidemiology and primary care;
Heads of Academic Departments;
Consultants with a specific interest in information (in concert with ISD);
Consultants with a specific interest in public health in primary care;
Trainees in public health medicine.
The Review encourages the continued development of networks, and sees them as a means of addressing some present and emerging needs. In some cases, networks will be Scotland-wide (e.g. communicable disease) while in others they may have a UK dimension (e.g. the National Screening Committee).
Multi-professional and multi-agency networks
Pragmatic local multi-professional networks are already contributing to the public health endeavour. They may be seen as the best way of meeting the needs of particular groups such as children, people with cancer, those with mental health needs, and substance misusers. They may assist planning or provide a means of implementation. Many take forward work on service development and/or quality assurance issues. Some have developed innovative joint approaches to improving the health of particular groups. Some groups established under the Health for All or Healthy Cities banner have developed strategy that is based on a broad vision of health before focusing work on locally determined priorities.
Local multi-agency networks
Local Multi Agency Networks
Consultants in public health medicine and dentistry are also increasingly involved in the development of managed clinical networks established following the Acute Services Review. The Review recognises the importance of this activity and the value placed on it by clinicians.
The purpose of networks
The public health networks already in existence or developing in Scotland illustrate the breadth of possible purposes. Networks can:
Reduce duplication of effort;
Provide back-up expertise to cover absence of staff;
Contribute to the development of high quality public health work;
Facilitate the sharing of experience and ideas;
Provide a greater range of expertise than is available in a single Health Board area;
Share expertise with non-experts who have an important role in health improvement;
Increase the commonality of health policy across Health Board areas;
Ensure inclusive development of strategy and facilitate joint implementation and monitoring;
Ensure that public health considerations and expertise are brought to bear in the development of managed clinical networks;
Achieve economies of scale in the provision of information science, statistical support and other specialist input;
Provide a point of contact with public health networks in other areas.
What makes a good network?
An essential prerequisite is joint ownership of the network and its work by all stakeholders, or a clearly identified "client". If there are a number of stakeholders, the purpose of the network must be jointly agreed; it should have clearly defined aims and set out a strategy to realise them. Its activities must form an integral part of the work of each stakeholder organisation; there must be co-ordination and a clearly identified lead individual. It is demoralising for a network to see its work ignored by partner organisations (and even more demoralising if, after a significant time lapse, individuals are asked to revisit the same areas of work).
Members of the network must be clear as to their individual role; the best networks have no "passengers" and make best use of all the skills and expertise of all those involved. Appropriate commitment and protected time is essential, and for many members this will mean much more than simply attending meetings. Continuity of commitment is also important. The Review heard from several CsPHM of the difficulty of establishing and working in local partnerships when members from partner organisations are not sufficiently senior to operate effectively, commit resource or commit their organisation to action.
Networks need appropriate resources and support. Without the expert time needed to undertake tasks outwith meetings, networks may become nothing more than "talking shops". Without adequate support (administrative, secretarial and information support), either the work is hindered or members take on additional and inappropriate tasks. We were told on several occasions that much CPHM time is taken up with tasks that do not require a consultant simply because support is not available. Networks whose members are separated by considerable distances need good communications; e-mail and phone/video conferencing are obvious solutions.
Core public health data sets and easy access to ISD data (to allow local and national comparisons) will help public health networks considerably. Many local networks are working on health inequalities and need access to advice on how to monitor them. Similarly, it would be helpful if information about the effectiveness of health improving interventions is readily available in a useable form. Such support could usefully be provided on a national basis.
Links between networks and access to external expertise can be crucial. While much depends on the personal knowledge of network members, a national database of expertise and network activity could help to save time and avoid duplication of effort.
Finally, networks must be evaluated. The acid test is whether they "add value" at reasonable cost. A network should make a greater contribution to the public health function than if its constituent agencies and organisations functioned separately, and should do so in a cost effective manner. Ideally, the anticipated added value should be specified when setting out objectives for the network, and its work should be appraised periodically to allow any necessary amendments.
Managed public health networks
The Acute Services Review described managed clinical networks (MCN) as linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, unconstrained by existing professional and Health Board boundaries, to ensure equitable provision of high quality clinically effective services throughout Scotland.
As described in MEL(1999)10 (Introduction of Managed Clinical Networks within the NHS in Scotland), networks can be developed locally, regionally, supra-regionally or nationally, but regardless of their size, scope and extent, each must have clarity about its aims and organisation, and leadership from a defined ‘lead clinician’ or manager. Each network should have an evidence base, use its multidisciplinary education and training potential to the full, and participate actively in audit, surveillance, research and development. Although developed as a model to deal with service organisation and delivery in the acute sector of the NHS, the concept can be applied readily to various aspects of the public health function. In time, professionals might be appointed to Managed Public Health Networks rather than organisations such as Health Boards; in other cases an individual’s contribution to a network might be defined in their contract, job description or work plan.
The Review believes there is particular merit in developing managed networks for communicable disease, for health impact assessment and for remote and rural areas, with specific reference to the North of Scotland. The following sections outline the way in which these networks might develop.
Communicable disease network
The Review is aware of the strong network formed by consultants in CD&EH with support from SCIEH and public health doctors from the Scottish Executive Department of Health. This network already serves an extremely useful function in terms of information exchange, formulation of protocols, continuing professional development and improved surveillance of disease. Co-operation between neighbouring Health Boards is of great importance in providing an adequate manpower response to major outbreaks of communicable disease or major environmental threats, and in sustaining emergency on-call rotas. Continued development of this network is vital to Scotland’s ability to prevent and control CD&EH threats and will be discussed later in further detail (paras 310-320).
A Health Impact Assessment network
Health Impact Assessment (HIA) is a relatively new tool that will be used increasingly to inform national, regional and local policy. The methodology is relatively untried but from the outset it is clearly desirable to identify the full range of expertise needed for each specific application. A national HIA network could avoid wasteful duplication of effort as well as having an important developmental, training and education function. It could undertake priority work for national and local government, Health Boards, or any of the organisations that need to define the health impact of their activities. The network would need input from public health professionals, from academic and research sources, and from a range of contributors in local authorities, voluntary agencies and other organisations. Useful developmental work is already underway as part of the Scottish Needs Assessment Programme but we see further development of HIA as a potential sphere of activity for a Public Health Institute (paras 349-357).
Networks for remote and rural areas
The problems faced by remote and rural areas in terms of their public health function were discussed during the Review meeting held in Inverness. We are grateful to all those who participated and acknowledge the helpful paper from Dr Norman Waugh describing a potential public health network for the Northern Health Boards (Grampian, Highland, Orkney, Shetland and Western Isles Health Boards). Each Island Health Board has a DPH and a service level agreement with Grampian Health Board to cover absence of the DPH and provide specialist advice in areas such as CD&EH and breast/cervical screening. At present Western Isles have a part-time DPH (but will consider a full-time appointment in future), Orkney have just appointed a DPH, and there is a vacant post in Shetland. A proportion of the workload of the DPH in Orkney and Shetland concerns the management of the directly managed units; in Western Isles these duties are undertaken by a separate Medical Director.
the difficulty (impossibility) of one person retaining competence and expertise in all sub-specialty areas of public health medicine;
diseconomy of scale when providing public health functions to populations of less than 30,000 people (this including the need for unnecessary replication of activities in all three Boards);
professional isolation including the demands of round-the-clock on-call duties;
the difficulty of not having a second public health medicine opinion in the event of personality differences;
the need for service level agreements with a mainland Board to cover absence of the DPH.
Even if all three Island DPH posts were filled, there is a strong case for collaborative working to overcome some of these disadvantages, and there must be particular concerns about the ability to respond to a major communicable disease outbreak or environmental health disaster . A North of Scotland public health network would go a long way towards resolving some of the difficulties and strengthening the public health function. It could provide a substitute for the presence of a full-time resident DPH in Island Boards, the objective being to increase the quality, capacity and sustainability of the public health function, not to save money.
In summary, the aims of a Northern public health network would be to:
share work, reduce replication of effort and achieve greater economy of scale in the provision of information science, statistical and other specialist support;
add value by improving the capacity of the five public health departments concerned and the volume and quality of their output;
provide all five Boards, and in particular the Island Boards, with access to a greater range of expertise in all aspects of the public health function;
provide cover for annual leave and other absences;
increase the commonality of policies;
provide a uniform quality of public health input across the whole Northern area;
provide a single point of contact with clinical networks (recognising that many patients from Island communities are referred to Aberdeen or Inverness for hospital treatment or dealt with by clinical networks based on these centres).
While the impetus to develop a Northern network comes principally from the difficulties faced by smaller Island Health Boards, expertise would not necessarily flow centrifugally. A DPH based in an Island Board might have particular skills that would be helpful to the larger population served by the network; furthermore, his/her involvement with a larger population would help to maintain, hone and develop such skills and enhance job satisfaction. Capitalising on the skills of all public health specialists in this way would have obvious benefits for public and professionals alike. In developing the network, we recognise the existing and potential contribution of general practitioners to the public health function in remote communities.
A series of options can be considered. The present informal system in which support is offered on an ad hoc basis with some underpinning by service level agreements is undesirable, insufficiently robust and difficult to sustain. A single department of public health for the north of Scotland has some attractions but has the overriding disadvantage that it could be seen as detaching public health professionals from their parent Health Board. The Review sees most promise in a flexible network established under the umbrella of the Northern Planning Group and run on a day to day basis by the DsPH in the five Health Boards. The fact that public health medicine specialists would contribute to the work of the network, and not solely to the work of their parent Board, would significantly change lines of accountability and working patterns and relationships. However, existing arrangements for some Consultants in Dental Public Health and Chief Administrative Pharmaceutical Officers offer precedents for changes in working practice.
The current moves to develop a Remote and Rural Areas Resource Initiative and a Highlands and Islands Research Institute, both based in Inverness, have obvious implications for any Northern public health network and offer major opportunities for developmental work. We recognise that there will always be some networking issues that require Scotland-wide rather than regional consideration, and do not see the proposed regional network arrangement as in any way weakening national networks in areas such as communicable disease. Rather, it sees the two as mutually supportive.
The Review appreciates that there are Health Boards other than those in Northern Scotland that have remote and rural areas. Borders and Dumfries and Galloway in particular have relatively small populations (100,000 -150,000) spread over relatively large areas. While per capita staffing levels may seem higher than those of large Boards, problems with economy of scale loom just as large as those just discussed in Island Health Boards. In the case of Borders Health Board there are ties with the nearby adjacent Lothian Health Board and arrangements for emergency cover in areas such as communicable disease; this is not to say that a more formal networking arrangement would not be beneficial. In the case of Dumfries and Galloway, more formal linkage with neighbouring Ayrshire and Arran could be mutually beneficial.