Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 147 - 159)




  147. May I welcome our new witnesses? We are very grateful for your cooperation with our inquiry. Could you each briefly introduce yourselves to the Committee?
  (Professor Wilkinson) I am Richard Wilkinson, Professor of Social Epidemiology, Sussex and Visiting Professor and Associate Director of the International Centre for Health and Society at University College, London.
  (Professor Macintyre) I am Sally Macintyre. I am a sociologist. I am Director of the Medical Research Council's Social and Public Health Sciences Unit, which is based in the University of Glasgow.
  (Professor Popay) I am Jennie Popay. I am Professor of Sociology at the University of Leeds, just, a week ago. Before that I was at the University of Salford. I am a public health specialist and sociologist.

  148. You will feel much better for coming over the top to the other side of the Pennines I am sure.
  (Professor Popay) I have to hide my rose.

Mr Burns

  149. Could I ask each of you if you could define for us your view of what public health is?
  (Professor Popay) If I were on Who Wants To Be A Millionaire, I would ring home for advice. For some people, and the discussion earlier this morning has reflected it, it is about professional groups. For others, and I suppose that is where I would position myself, it is about both type of work and a philosophy or an approach to work. On the philosophy and approach to work, it is about taking a population or macro perspective rather than an individual one, although I do not discount the fact that public health work can go on and does go on at an individual level. In terms of types of working, certainly traditionally, the roots of public health have been in social reform, in altering the social, economic and physical environment to promote population health. That is one of the key elements of the type of work for me. A second key element is that it is about amateurs as well as professionals. Many different types of people get involved in doing public health including lay people. Traditionally of course it was an amateur activity. Maybe we lost a lot by the professionalisation of it. The third element would be multi-sectoral working, again an enduring aspect of public health.
  (Professor Macintyre) I agree with all that. I just wish to add that it is unfortunate that sometimes public health is taken to mean public health medicine practice as practised in health authorities. It is interesting in this respect that the Medical Research Council in its most recent initiative has deliberately talked about the health of the public rather than public health. Every time it talked about public health it was assumed it meant public health medicine. I take public health to be the health and wellbeing of the population in a broader sense.
  (Professor Wilkinson) There is often no need to distinguish between the health of the individual and what sums to the health of populations. There are a few important areas where perhaps factors which improve the health of individuals, things we have become aware of through studies of large numbers of individuals, may not sum to better health of the population. For instance, if the effect of income on health is mediated by social position, then improving everyone's incomes in an affluent society like ours may not improve overall standards of health. You get curious differences between patterns which you see internationally where amongst the developed countries it is not the richest who have the best health. Within countries where there are these steep social gradients maybe moving everyone's income up or maybe even moving everyone's education up, will not produce the expected benefits at the population level. In those sorts of areas one needs to be very aware of the distinction. Another point I would add is that public health is defined by its content. In the nineteenth century clearly that was sewers and water supplies and housing and so on. Now increasingly we are thinking about the other factors you have been talking about, a whole range of issues to do with the relationship between the material or economic circumstances and the social environment. It is this area which modern research is telling us that public health has to address.

  150. Broadly, if I have understood what you all said correctly, you basically agreed with each other and maybe fleshed out areas which are of particular interest to each of you. However, there is broad agreement. Do you think the Government has a clear definition and that that definition is understood and agreed across the range of Government where involvement is needed in the public health arena, whether it be the DETR, the Cabinet Office, the Social Exclusion Unit, the Department of Health or wherever.
  (Professor Macintyre) I cannot answer for what the Government thinks. There is still a notion that health is the province of the Department of Health and of doctors and some of the issues, such as urban regeneration which was discussed this morning, are crucial for public health. Sometimes a compartmentalisation means that is not taken into account.

Mr Amess

  151. Increasingly Government departments have changed; we have shut some down, we have joined others up, we have this ridiculous huge department, DETR, at the moment. Specifically on the thing we are talking about at the moment, do you think the public health function and the Minister should be moved out of the Department of Health? Do you think the title Public Health is important? Do you think the whole thing should be rejigged? How do you think we should, through the Government branch, try to improve people's public health or do titles not matter?
  (Professor Popay) There is a slight problem. We are talking about the public health function. One of your advisers talks about public health being everywhere but nowhere. It seems to me that if we continue to think about it as a function, then we get parallel lines and then you get stuck with where to put the national leadership and where to put the team around the national leadership and what flows from that in terms of local organisation. It seems to me that you do need leadership at a national level, but thinking about that in terms of a single Minister with that brief, or a single civil servant with the lead in a single department, is quite problematic from a perspective where many, many different people, many, many different departments have key roles in the public health agenda. I should think it is more about how you put the responsibility for health into whatever the mix of Government departments is at a national level. Similarly, how do you build that at a regional level and at a local level rather than where should you put your DPH?
  (Professor Wilkinson) I would argue for a more fundamental re-jigging. It seems to me that a lot of the social determinants of health which we are interested in involve very similar pathways and factors to things which influence crime rates, perhaps, particularly violent crime, which affect educational performance of schoolchildren, educational failure. There is no evidence, but my guess would be all sorts of other problems like drugs and vandalism and so on are all rooted in relative deprivation, they all involve the social environment associated with that and it seems to me that rather than doing things simply in the name of health, one needs to be trying to think how Government could encapsulate work related to all of these issues in slogans like tough on the crime and the causes of crime; we can be hard on disease but we also need to be hard on the causes of disease and the same with educational failure and so on. It is very clear that a number of the pathways, particularly the psycho-social pathways linking relative deprivation to health, also link relative deprivation to educational failure and violence and a number of other problems. It really is not a matter of thinking where the Minister of Public Health should be, but of thinking how a Government can take on board these broader issues affecting a number of different areas.

Mr Burns

  152. Is there not a problem, given so much inter-reaction towards housing, financial background, the environment, the quality of life, that it is across the Whitehall departments and there are turf wars in all Government departments and all Governments? There are budget battles. Is there not a worry—and you may well disagree—that if you do not have one Minister who is completely committed to the promotion of that interest and has the powers to coordinate across Whitehall, what you will do is fall between two stools and there will in effect be no-one and the turf wars and the budgetary battles can continue and public health will get pushed further and further behind and almost forgotten because of other issues which may be politically of more concern or demanding Ministers' attention at any given time.
  (Professor Popay) I am not expert on how Whitehall operates and whether Ministers have ever been that, but if that is the case, then I believe one gets in a mess if one starts thinking about which department that super person should be in, rather than perhaps in the Cabinet Office or somewhere beyond; a single Whitehall department seems to me to be quite important.

  153. Are you familiar with children's health?
  (Professor Popay) Yes; a little.

  154. The Department of Health, I assume still, is the lead Ministry for children's health but that has a knock-on effect in many other Government departments. I can tell you that certainly up until three years ago it was a constant battle because the Department of Health certainly had a very proactive and interested agenda to help enhance and improve children's health but it was literally a constant battle with other departments who either failed fully to understand the implications of their policy areas on children's health or because of budgetary problems or other priorities within their department, although they had a coordinating role. I just fear that if you do not have a lead Minister who can constantly be prodding and keeping their eye on the interests of that subject across Government then it will get submerged.
  (Professor Popay) It seems to me that there is an important difference between somebody with a lead to keep something on an agenda and fight the battles, versus a function, leader of a function, which is the drainpipe type of perspective really. It is the visionary rather than the anorak. Then there is the issue of whether that leader is best placed in a single department, if so which one, versus outwith the departmental structure somewhere. There are those three separate issues really.

Mr Amess

  155. So it does not seem wonderfully focused at the moment. It is all to do with wellbeing really, you clearly all think.
  (Professor Wilkinson) Yes, I suppose I feel that there must be a problem of how much clout anyone responsible for public health in the Department of Health has, or indeed wherever they are if their responsibility is for public health, in addressing departments responsible for transport and education and so on. That Minister for Public Health will be seen as fighting a separate wicket. If you move in the sort of direction I was suggesting, maybe having some Minister without Portfolio, responsible for social development, seen as contributing to all these different fields equally, crime, educational failure, health and so on, I should have thought there might be a chance of their concerns being treated more seriously by different departments.

Dr Brand

  156. I was fascinated by Mr Burns agreeing that you all gave a similar definition of public health. It was very similar but none of you actually defined its boundaries. This is where we are really struggling. Until you define where the boundaries are, you do not know which Minister should be responsible and there clearly is the public health medicine function which is frightfully important and really has to be carried out and that clearly is the Department of Health. However, there is the wider function which we discussed in the earlier session and you have just come onto again, on the socio-economic gradient effect and how we deal with that. Is that a public health function per se or are the public health academic world and the real world of Directors of Public Health merely informants on that scene? If it is merely a function of getting the data, then presumably we do not need a Minister of Public Health in the wider sense, it can be done by whoever runs the Social Exclusion Unit I suppose. Is there an agreed definition of the wider visionary role of public health.
  (Professor Macintyre) The problem was that the question we were asked was: how would we define public health? We all responded in terms of the outcome.

  157. You all ducked.
  (Professor Macintyre) We were not asked what the public health function was but how we defined public health. We all define it in terms of the desired outcome which is improving population health. It seems to me it is a different question to ask how to do that or who should do that. We have now moved onto that. The difference is between thinking about inputs and outputs and, if the desired outputs are to do with improved population health, all age groups and using all measures, morbidity and mortality. But I am not competent to discuss the operational question of function because I do not know enough about the operation of Whitehall or indeed about health authorities. I would just point out that coming from Scotland we actually have a different system.


  158. Could we learn from different systems? The first question I asked of the witnesses earlier on was about the system which applied in this country and as I recall in Scotland prior to 1974. We talked about the leadership role at Government level but I am not clear where you see the leadership role at local level. Do you broadly support Sir Donald's view of the process of change since 1974? My perception is, having seen the old MOH in operation, having been a councillor on a public health committee, having seen the impact upon local authority policy, that that system, the change to the system in 1974, sidelined the public health function, removed it from a key area of change and improvement. I still feel we have not yet made up for what I believe was a policy mistake. I am not saying necessarily we move that function back into local government; things have moved on since then and we have the RDAs, a huge number of other factors coming into play now. We have not come to a conclusion about the national leadership role. What about the local arrangements? What are your thoughts?
  (Professor Popay) More thinking about local public health systems is really important to the future of health improvement and the reduction of inequalities. In a way there is almost too much preoccupation with the national level and it is about how it plays out locally that is really important. My sense is that the Directors of Public Health have performed very variedly since 1974 and before 1974 Medical Officers of Health performed very variably. Salford has a rich tradition of very, very effective Directors of Public Health; Leeds less so over the last 200 years. There is a problem with the charisma and ability of individuals in any leadership role. It seems to me we might get further by thinking about the type of leadership we need and where that is located within local systems. The local health systems are in a period of turmoil and transition at the moment. My personal view is that locating leadership for public health with primary care trusts is a mistake and could be a very serious mistake in the future. As a person on the margin of the national policy discussions I do not know where local health authorities are going, but if they go into simple performance management, that would be a local disaster for public health, if nothing is handed to the local authority.

  159. Is that view shared by our two other witnesses?
  (Professor Wilkinson) Yes. I disagree with Sir Donald and move more in the direction I think you were suggesting. One very often comes across work done by directors of public health in health authorities where they are charting, drawing up tables, measures of health inequalities between small areas within their patch, looking at the rates of different diseases. You know that the local authorities they are working for do not control these things, that they are not the primary influence on the rates of disease or scale of health inequalities in their area. Obviously they can do something about them. Although perhaps it is good for health authorities and the consciousness of these problems that there should be directors of public health within the health authorities, logically in terms of what we understand the determinants of population health to be, it would seem more sensible to put it with the local authorities. What the old directors of public health in the local authorities saw as their job then would be very different from what similar people think is their job now because our understanding of the determinants of health has really changed. How they might mesh with all sorts of other areas of local government policy might be quite different from what it was in the past. I do think that a similar area and similar set of issues might arise as we have just been talking about. Where in national Government do you put such a person, where in local government do you put such a person, how do they relate to housing and transport and education services locally?

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