Ian MacArthur argues that the environmental health profession needs to do more than just deliver on targets, it needs to engage with the wider public health agenda

In 1997, when the Commission on Environmental Health published its report Agendas for change, the country was full of optimism, radical hope and content in the fact that "things could only get better". At its launch, on a hot July day, equally warm words were exchanged on the bright new future for environmental health. There was the promise of a rebirth of public service and new and better ways in which we would work in the future. With the millennium tantalisingly close, Agendas for change caught the public's mood for a bright new dawn. It is only four years since the ink dried on the report, yet the memory of those seemingly significant times already assume the rosy glow of the "good old days".
Agendas for change stated that environmental health was at a cross roads - it could either reconnect with the public health mainstream, or it could continue to deliver a collection of distinct services connected through historic and professional ties.
In reality, the choice was perhaps not as stark, but the Commission's report made an impact. For a brief period thereafter, the mood for change was pushed along by the fury of activity of the New Labour administration. New ministers throughout Whitehall, including for the first time a Minister for Public Health, rushed around revising and reviewing policy, each trying to out-do the next. But speed alone cannot deliver meaningful change.
The early drafts of Our healthier nation promised much, but in the end delivered little; while the national sustainable development strategy Opportunities for change, which echoed the title of the Commission's work, also seemed to offer a paradigm shift in Government thinking. Alas, economic growth remains the "golden fleece".
A report was commissioned on health inequalities, a term banned in Government for sixteen years, but its impact has been limited to one department's efforts and it has not yet led to a joined-up and cross departmental effort. The bright and shiny ideas soon became tarnished with the daily distractions of running a country.
The Agendas for change report advocated a number of structural changes to reconnect the health sector with local government. It highlighted the need to plug some of the local democratic voids and it argued that new and increased "all encompassing" powers and freedoms were needed at the local level to deliver the changes communities wanted. At the time they sounded radical - a great departure from the status quo, good for debate but unlikely to go anywhere.
However, we did not count on this Government working on two levels at once. For despite the froth and spin of initiative fever, some very significant, quiet structural changes have been taking place right under our noses. The governance landscape of the UK today is barely recognisable from that of the mid-nineties and much of it reflects what Agendas for change advocated.
The Commission recommended new all encompassing duties and powers for local authorities to deliver on sustainable development, and furthermore that they must consult with local communities in preparing their strategies. Today, local government is challenged with developing community strategies that promote the social, economic and environmental wellbeing of their communities and reflect the needs and desires of the local population. Local authorities have also been provided with the new "power of first resort" - the ability to do anything (within reason) to promote the social, economic and environmental wellbeing of their communities (coda for delivering sustainable development).
The Commission believed that interagency working was essential to deliver the new approach to environmental health improvement. It advocated the need for statutory partnership working between all sectors to deliver local sustainable development. Today we have local strategic partnerships to fulfil that very role.
The Commission further argued that local government and central government needed to work closer together to agree common priorities and for local government to be given greater freedoms to provide relevant services. Today we see the rolling out of public sector agreements enabling concentrated efforts and incentives to deliver real and sustained change.
Crucially, the Commission recommended a return of public health to the fold of local government. Not surprisingly this stuck in the gullet. Too much had been invested in the NHS system, and too many bad memories from before the reforms of 1974 were still around, to allow this one to run too far. Yet by stealth and blindingly quick reform, public health is once more returning to the local government agenda.
The Government's publication on Shifting the balance of power within the NHS, published in the summer for little more than a month's worth of consultation, has placed public health as close to local government and the traditional environmental health service as it is likely to get. The Primary Care Trusts (PCTs), now coterminous with local authorities, are the new health leaders and will receive 75 per cent of total NHS funding by 2004. PCTs will be responsible for a strengthened public health function to support needs assessment and to ensure public health surveillance and population screening are carried out across local communities. They will be the lead NHS organisations for working with local authorities and other partners to improve the health of local communities and to deliver wider objectives for social and economic regeneration.
In addition, strong regional public health groups co-located in the nine regional offices of government, led by a Regional Director of Public Health, will be established. The groups will concentrate on, among other issues, the development of an integrated multi-sectoral approach to tackling the wider determinants of health.
Upon reflection, we may doubt that the quality of life has actually changed much and that if it has, it is probably down to the Treasury. Yet real reform has and is taking place. Furthermore, most of this reform is in line with the thinking of the Environmental Health Commission. The structural and legal base has changed in favour of meaningful environmental health action and delivery. It is now up to the profession to seize the opportunities presented - and soon.
The recently published Public health skills audit served as a poor reflection of the skills, knowledge and capacities of the environmental health profession to contribute to the public health agenda. This research, however flawed and disappointing, will go forward in the development of a national public health workforce plan. The CIEH is addressing this issue directly and has highlighted the exemplary and Beacon Status work already carried out by environmental health professionals in local government. The profession more than ever needs to unveil its much heralded adaptability and begin to engage and work on the public health outcomes, rather than just the delivery of Agency imposed targets.
We must also promote and commend the work undertaken to protect as well as promote the public's health. This too will remain a key function for the local government service and must be seen as a key element of the national public health service. For here lies the problem - new powers and opportunities for different ways of working are of little value if we do not have the political freedoms and the resource flexibility and capacities needed to raise our heads above the parapet. Brave, bold decisions are waiting to be taken.
In summary, and in today's policy context, the environmental health service and profession continue to face new challenges and pressures. Since 1997, the Government has promoted a strong emphasis on the social, economic and environmental policy nexus. It is a theme that runs through much of the Government's "joined up" initiatives and very closely reflects the CIEH's declared approach to the problems society now faces.
Nevertheless, the environmental health service within local government has continued to be pushed to the margins of mainstream public health work at a local level, through an increasing centralisation of the direction and management of service delivery. More and more, the work which environmental health professionals deliver, in terms of food safety, occupational health and safety, and to a lesser extent, environmental protection and housing, are driven by national edicts and performance management frameworks. Such pressures, coupled with increased public expectation and diminishing resources in the quest for "best value", have stifled innovation and any enthusiasm for partnership working. Exceptions do exist and openings and opportunities have been created, particularly in the creation of new PCTs and the prospect of genuine partnership working they bring, yet the majority of environmental health services are now viewed, both nationally and locally, as delivering national enforcement rather than community empowerment.
I am convinced that such trends do not make best use of the core skills of environmental health professionals, nor do they necessarily make the greatest impact on the public's health. This year has witnessed a radical change in the operation of the CIEH, with a new, more broadly based Policy Development Board and approach. As a result, I hope that the CIEH will drive a more progressive and outcome-focused agenda. Taking hold of the new opportunities at the local level will require support and leadership from the professional body.
In truth, we have come a very long way in a very short time. The agenda has changed - whether it has changed for the better is our challenge and will be determined by the profession's capacity to take and develop the opportunities now presented.

Ian MacArthur is policy co-ordinator for the Chartered Institute of Environmental Health. These are the personal views of the author and they do not represent the views of the Chartered Institute.