Flattening the national health service hierarchy: The case of public health

Recent re-structurings of the National Health Service (NHS) in England have illustrated the British government's commitment to a policy of devolving resources and responsibilities to local levels. As a result, public health teams are now located in 303 primary care trusts, and are more numerous, and much smaller, than previously. These changes have coincided with a number of other changes within public health (the introduction of an accreditation process for non-medical specialists, and the reorganisation of health protection). The re-organisation has exacerbated existing anxieties about the capacity of the public health workforce. Two recent studies found public health practitioners to be very concerned about the fragmentation of their profession and the resulting isolation in which individuals would work. Directors of Public Health feared that their primary care trust responsibilities would limit the time for their public health work. Multiple local organisations are not well-placed to try to address strategically the long-term problem of an inadequate national public health work force. It was recognised that bringing resources nearer to local communities and the rest of the NHS offered great opportunities for public health to be more responsive to local needs and to harness local resources. Nevertheless, it appears that, not for the first time, the re-organisations of the NHS have not been designed with public health in mind, and it is not yet clear how the challenges of inadequate capacity will be met. © 2005 Taylor & Francis Group Ltd.