EHJ September 2003 page 268-269 When it comes to predicting the future direction of the public health agenda in Northern Ireland there is no crystal ball. Heather Moorhead suggests that co-operation and a pioneering approach is the only way forward

Local government in Northern Ireland is entering a new phase of development following years of under-funding. Starved of any real power for the last 30 years - due to the stripping away of powers for reasons of equality and politics - a review of public administration is currently considering the future role of councils and the development of an appropriate structure for the entire public sector.

Councils must have a renewed role in public health. The new Northern Ireland Local Government Association (NILGA), established in 2001, has already identified the key role of local authorities as that of civic leaders. In other words, councils should be at the hub of civic life. Members feel it is only then will they be able to achieve the social, environmental and economic developments required in their areas. Local authorities should be at the forefront of assessing local issues and brokering local solutions. It would be my contention that this is the same as "good old-fashioned public health". There is broad agreement with this stated function, but how this will be performed in practice is the critical question.

Lack of understanding

Many people do not understand their role. A charge could be made that we have "professionalised" to such an extent, we tend to think only from our own narrow professional viewpoint and that we do not perceive where our work fits into a holistic picture, or perhaps why it is important at all. Let me give you an example.

Have you ever suggested to an economic development officer that they make a significant contribution to health? "Oh no - we support business," they will say. My understanding is that you need a thriving business community to generate enough money to pay for daily living and, indeed, public services. This is clearly an important public health issue. The fact that we live in a fragmented world and understand it in these terms is an endemic issue.

This situation is exacerbated in Northern Ireland by the fact that it tends to be extremely factional - people want to get on and do their own thing. Competition is often seen as being more attractive and less complicated than collaboration, especially in the long term. But competition is a great deal less effective.

Language barrier

Part of the same problem is that we have no language for "joining up" - or at best it is very limited. People only seem to recognise their own "label".

About three years ago, I spent a frustrating summer involved in setting up a public health network for Northern Ireland at the same time as an environmental/sustainable development network. The two agendas were more integrated than specific and it seemed obvious that the best way to progress would be to have one network.

Unfortunately, I was unable to broker this as each "side" perceived that they had different agendas - public health and the environment - and yet the key issue on each agenda was integration. If we are to achieve our long-term goals we will need a language that is inclusive, buying in support and not excluding people before work has even begun. Public health can only be achieved where public policy is coherent.

Accountability

Individuals are made accountable through a business plan with targets, the majority of which are frequently process driven. This means that we need to deliver set tasks with limited flexibility. Often the business plans are flawed and we see people working extremely hard but doing the wrong things.

Perhaps a more innovative approach to business planning - one that involved stakeholders - would lead to better public health outcomes. Perhaps professionals could be appraised on an integrated basis. This would encourage greater risk taking (on a managed basis) and allow for different outcomes.

The future is clear

It is clear that councils should have a stronger role in public health, particularly in regard to taking a long-term view, designing integrated solutions, in capacity building between sectors and as influencers for "healthy behaviours". For this to happen as effectively as possible, a new paradigm is required where each professional grouping considers not just what it does, but how it relates to others. Flowing from this we need a new language and new business management techniques.

Although there is an uphill struggle against "the way we do things" and "institutionalism", we are on our way. There is everything to play for in Northern Ireland at the moment and we are likely to see significant changes after this review and in the coming decades.

Who knows, perhaps we in Northern Ireland can pioneer solutions for others? We are building from a different foundation, with years of significant community development and conflict resolution experience - so watch this space...

Heather Moorhead is chief executive of the Northern Ireland Local Government Association.

See www.nilga.org and www.rpani.gov.uk for more information about NILGA and the review of public administration in Northern Ireland.