Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 140 - 146)



Mrs Gordon

  140. I should have to disagree. We have just come back from visiting some projects in the South West, healthy living centre, community projects, health action zones, where people are working in partnerships with different agencies and different groups with an holistic approach to helping the health and environment of their communities. It is fair to say that one of the problems there identified to us was that within these partnerships it was very hard to involve the local GPs. The generous view was that they were just overwhelmed with their workload and just simply could not cope with any more. The less generous view was that they saw these initiatives as a professional threat and that they were too absorbed with healing the sick. They just did not have the time to devote to the whole population and this holistic approach. I wondered what your views were on this, whether you had identified this as a problem and how well equipped you feel doctors and other primary care practitioners are to tackle public health problems? If there is a problem, how can it be helped?

   (Professor Whitehead) General practice and primary care is in a state of change at the moment with the formation of primary care groups and primary care trusts. That obviously adds to the workload and the stress. There is a lot of thinking around how we can inject the population perspective, the public health perspective, into these wider bodies, primary care groups. Certainly they need to take a population perspective, so they will have to have a public health function built in to their arrangements and their structures. On the other hand, a debate is going on about the fragmentation of public health: that there is a danger of public health teams, which are located now in health authorities, being split up around different primary care groups and primary care trusts, then the individual members of those teams being (a) isolated and (b) losing the strategic vision referred to earlier. That is a problem. How do you build in a public health function without breaking up proper and adequate public health teams? It is an issue to be faced at the moment.

Dr Brand

  141. Is there any evidence of the effects of having a multiplicity of initiatives which have to be served usually by the same active people. We have health action zones, education action zones, employment action zones, IMPs, community plans, healthy living centres, single regeneration budgets, Sure Start, they all impact on what local people should be concerned about. Is there any evidence that this multiplicity of approach is actually more fertile or whether people are suffering from initiative fatigue?

   (Professor Whitehead) There is certainly plenty of anecdotal evidence from both sides. From the statutory sector side people are complaining that it is like being at the bottom of a silo, that all sorts of initiatives are coming down from the top and they have to deal with them. So statutory sector officers are complaining of that. Also disadvantaged communities are complaining of overload, the fact that they have so many initiatives and people coming into their communities, doing a quick needs assessment and then going away and that is an intrusion. It has reached the level of intrusion in some places and that is a problem.

Mr Austin

  142. From some of the projects we visited it was quite clear that the NHS had a major role to play in regeneration, not just economic regeneration but the whole regeneration of communities. It is in many areas the major employer but it is a major distributor of resources. Do you think there is enough recognition in the NHS of its role in regeneration?

   (Sir Michael Marmot) I do not know how to solve the problem and I am hoping you will make some recommendations which might solve it. The general point which comes across time and time again is that it is not just the initiative fatigue but the total lack of coordination. The health authority and the local authority are just acting as though they are occupying different universes.


  143. Would you subscribe to Sir Donald's assertion at the outset that perhaps shifting the focus of public health back to local government would not necessarily resolve the difficulty you have just described?

   (Sir Michael Marmot) I agree with Sir Donald.

  144. So how would you resolve it because it is a very important point.

   (Sir Michael Marmot) It is a fundamental change. Let us take the Social Exclusion Unit as an example in the centre. The Social Exclusion Unit has come out with a whole series of reports which are really interesting and very important. Health is not obviously a big part of them. I have sat in the room with people from the Social Exclusion Unit. When they hear people saying these things are important for health, they assume that somehow the doctors want to take it over. One could pull one's hair out and say what they are doing is very important to health but you still need primary care. People in the communities they are trying to improve still need primary care. These other actions on the wider determinants of health are still needed; whether it is Sure Start, the intervention with young children or these other initiatives, they are still going to need medical care. They have to intersect: the public health and health care, social services, social actions have to intersect. It seems to me that it goes all the way to the top and all the way to the bottom, that at the moment there is a profound lack of understanding about how these things relate together. People, not today I am happy to say, still think the inequality issue is all about health care inequalities. Health care inequalities are very important but they are not the whole issue. People think, yes, community developments, that is one issue and health inequalities are a different issue. We would argue that they are not. They are the same issue, but all the way to the top there seems to be a lack of understanding that these things have to be linked up, joined up, if that is the word. It has to start at the top and it has to be in the middle and it has to be at the bottom. I do not think simply shifting from one authority to another is going to solve that problem. I am hoping you will solve it, but something which will bring people together.

Mr Austin

  145. We visited one project which was involved very much in regeneration where the driver of the project was the health visitor. In your report you said that you recommended the further development of the role and capacity of health visitors.

   (Sir Donald Acheson) Yes.

  146. In what way?

   (Sir Donald Acheson) In this morass of projects and professionals, there is one professional, who we mentioned in the Report and that was the health visitor. This was because the evidence that a programme of home visits to women who are expecting a baby and then in the first two years of the life of the baby and the infant, has benefits which go into the second and third decade of life is really uncontroversial. It is very strong. It is not from this country, but it is from the United States and Canada. Nevertheless, we believe the evidence is sufficiently strong to justify action to develop further the health visitor's role. These people provide a light in a forest of difficulty, and uncertainty.

  Chairman: Do any of my colleagues have any further questions? Do any of the witnesses have anything to add that perhaps you feel we should have touched on but did not? If not, we thank you for your attendance. We are most grateful for your cooperation with this inquiry. Please feel free to remain for the rest of this session, if you want. Thank you very much.

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