Examination of witnesses (Questions 140
- 146)
THURSDAY 16 NOVEMBER 2000
SIR DONALD
ACHESON, SIR
MICHAEL MARMOT
and PROFESSOR MARGARET
WHITEHEAD
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.
Chairman
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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