Examination of witnesses (Questions 200
- 219)
THURSDAY 23 NOVEMBER 2000
DR PETER
DONNELLY, DR
ROSEMARY GELLER,
PROFESSOR JAMES
MCEWEN,
PROFESSOR SIAN
GRIFFITHS, MR
JOHN NICHOLSON
and MR GEOF
RAYNER
200. You would argue for a more free-ranging
involvement with Cabinet status?
(Professor Griffiths) Yes.
(Professor McEwen) We would wish to support that very
strongly. I think part of the problem is perception. With the
present set-up there is a perception that public health is limited
to what goes on in the Department of Health. A wider remit would
provide a more enhanced function and allow all that we have been
talking about in the last few minutes to be more easily achieved,
possibly within a Cabinet setting.
(Dr Donnelly) I would agree with those comments. I
think the difficulty we have is that public health is, by definition,
a topic that crosses many different areas and that does not necessarily
neatly fit into the Whitehall model of running the Civil Service.
I think it is almost for you, collectively, to think about which
is the positioning of the Public Health Minister which would give
him the greatest likelihood of linking up with the various Whitehall
departments that need to be involved in public health initiatives.
Yes, it would be great if that was a Cabinet level post but falling
short of that something perhaps linked to the Cabinet Office would
seem to me to have some attraction. However, I would not claim
to be an expert in the organisation of government.
201. Taking this same argument to the local
level, some of us who are well into middle age go back far enough
to remember the old MOH and the local government involvement in
public health committees—and I served as a councillor many
moons ago. What are your thoughts on the role of local government?
Coming back to the evidence from the UKPHA, I notice your argument
that the role of the Director of Public Health be given greater
status, perhaps even based in the local authority. One of the
worries I have had over the years is about the way in which we
have, in a sense, lost direction in public health at the local
level for a variety of reasons. One of the reasons for me is the
way it became detached from local government in some key policy
areas that genuinely do impact directly upon public health. Perhaps
we could explore further your arguments on the role of local government
here and perhaps we could see whether our various witnesses agree
on this as a possible direction in future?
(Mr Rayner) Since 1974, when that relationship ended,
much has changed in local government, much has changed in local
governance and our arguments are about restoring local governance
and not simply local government. On the issue of local government's
functions, which are in fact being rejigged, there is new oversight
responsibility now towards the NHS, there is the issue of the
strategic partnership, there is an attempt to create a genuine
partnership role between bodies. I think the public health function
should be located either among those bodies, or maybe in one,
and that is an exploratory issue. There are opportunities for
testing new relationships around the country and in different
parts of the United Kingdom even. So I think that while we want
to see an enhancement of local governance, better partnership
working, sharper focus and less people tripping over each other
between different roles, we also want a real focus on our public
health `joining up'. In some places that might be local government
taking the lead. It goes back to the boundaries and the issue
of the lack of coterminosity is a major one and we do not under-estimate
the difficulties of those sorts of issues. If we say the issue
is about local government, about prominence, we would say that
the same issues that we have raised at a national level are also
true at the local level.
(Mr Nicholson) The fragmentation and the potential
loss of accountability through the direction towards primary care
trusts and following primary care groups raises an uncertainly
for public health. I will not put it stronger than that because
it is untested territory, but it seems to us that the smaller
a population base you are addressing the more difficult it is.
The difficulty for public health is being able to address in a
strategic manner a large enough population. The fragmentation
into the trusts at local level, the potential for local government
only volunteering perhaps social services' representatives rather
than local government representatives overall, all of this adds
up to a feeling that maybe the local authority is a more secure
base with a larger base of population which could, as Geof says,
be one of the models in which the Directors of Public Health or
a public health function could be considered.
202. Before I bring the other witnesses in,
obviously there are a number of options being explored at local
level, as you are all well aware. We are aware of the managed
public health networks, the joint health units between the different
authorities, resource centres sometimes attached to universities,
the PCTs, which I want to explore again in a moment, and the suggestion
of HImPs and community plans being combined. These come through
in evidence that we have got. Going on to the PCT issue, can I
explore the Faculty's view on this. You say: "To ensure that
the role of the Director of Public Health does not become sidelined,
it is important that public health attachments to the PCTs should
be done on a single employment base." Can you explain what
you mean by that and what your reservations are about the role
of primary care because it certainly seems to us as a Committee
that primary care has really never had a role driving forward
public health in a way it does in some of the other countries
that we have looked at.
(Professor Griffiths) Perhaps I can just explain some
of the context of that remark. I do not disagree with larger populations
and strategies. There are times when public health needs to work
across millions of people, for instance specialised services.
I think it is about getting the right public health skills at
the right levels to enable us to deliver the public health functions
to populations. It is about us all putting aside our structural
barriers and saying how do you do this best. The problem with
coming up with a single model is that if you take a shire county
like mine you have districts, you have non-coterminous PCTs and
you are splitting the public health department five ways anyway
and another five different ways if you go to local government.
The concept behind the network is a co-ordinated, facilitated
function. I would stress that the DPH is not about maintaining
control, it is about co-ordinating and facilitating the public
health function of the population, which will be different in
different parts of the country, with the different resources available,
with the different initiatives such as healthy living centres.
What we are really saying is that we need a population base which
needs to be large enough to have the skills available to do things
like health impact assessments, and to really make sure that we
can strategically combine the HImPs into local strategic partnerships,
which is the newest document which we fully support. It is about
how do we find our way through this morass of new ideas and innovations
in a concerted way, and our major concern is to make sure that
we have the right skills and the right training. This is not just
for public health doctors, it is for everybody in public health.
So then you come to joint units, resource units, etcetera, and
secondments and actually thinking about who you are working for
and why you are doing it rather than which organisation public
health is sitting in, which takes you back to governance rather
than government. If it is more appropriate to sit in local government
and do that, that would be fine. For me it would have to be a
county and not each district because there are not six of me.
So a simple phrase like "go back to local government"
is actually more complicated than it sounds.
203. Dr Geller, what are your thoughts on this?
(Dr Geller) I do not think there is a perfect place
to put a Director of Public Health just like there is no perfect
place to put a Minister for Public Health because public health
is so wide-ranging, and our challenge is to work with all these
agencies and make sure that they are all contributing in a co-ordinated
and effective way towards improving the health of the population,
which is why I get up and go to work in the morning incidentally.
I think that is a very important passion and mission to put across
to all agencies. I personally would support the Director of Public
Health and the Department of Public Health staying in health authorities.
I think it is a secure base. I think you have more independence
for your annual report.
204. I put it to you—and I go back long
enough to remember the old MOH putting the boot very much into
some departments in the local authority I served on—that
there was no restriction on what that officer did at that time,
as far as I could see.
(Dr Donnelly) What has happened, I would argue, in
the interim (because I also have spent time as an elected member
of a local city council) is that there has been a change in the
way local government runs and works. I have to tell you that my
fellow officers in local government look at the degree of freedom
I have as a Director of Public Health in the health authority
with jealousy and with amazement, and I would be very loath to
give up that degree of freedom, which allows me, for example,
to write entirely independent annual reports, by going back into
local government.
Chairman: I would have thought that if such
a move were contemplated today then there would be a very strong
argument in this place to ensure that the new Director of Public
Health or MOH had similar powers to what the old MOH had to allow
a free rein over all of local government, otherwise there would
be no point in giving them that function. Stephen?
Mr Hesford
205. I am interested in what you just said,
but freedom to roam around an ivory tower is no great freedom
at all.
(Dr Geller) There needs to be a degree of independence.
I do not think you should have a free range and, anyway, you would
become detached and no-one would take any notice of you.
206. That is what happens, is it not, no-one
takes any notice of you?
(Dr Geller) Not where I am in Shropshire. I feel it
has been quite successful. If I can just give you an example there.
I am the Director of Public Health for Shropshire Health Authority
and, like Sian says, we have seven local authorities altogether,
one unitary council and one county council. I have been appointed
to both the councils as their honorary Director of Public Health
as well as the health authority, so I am Director of Public Health
in three organisations and I am also working very, very closely
with the primary care groups as they emerge into primary care
teams. Influence is not necessarily about hierarchy or independence
or any of those things. At the end of the day it is down to good
networking, charisma and developing trust and working relationships
with others.
207. What is the difference between influence
and delivery, actually doing something?
(Dr Geller) I think you can influence others to deliver.
I am one person and I cannot do every job myself so I think leadership
and influence is the key. I am finding in Shropshire that there
is a lot of excitement among the key players in the NHS and the
other authorities about improving health. This is growing and
the enthusiasm is very exciting and that is what I am talking
about in terms of delivering and improving public health—all
the services working in a co-ordinated way. I hope to be going
on a bit later to mentioning health improvement programmes because
we are working on multi-agency project teams around the priorities
within the health improvement programme and they are really starting
to deliver results.
Mr Burns
208. Can I seek some clarification from Dr Geller
and Professor Griffiths to two questions, and I will phrase the
first one very carefully. Since 1972-74 local government has become
fairly politicised in a way that many people would argue it was
not beforehand. If one has a public health official within local
government, how can they protect their independence from the politicians
at a local level who might in certain instances be on a different
agenda?
(Mr Nicholson) Can I say, Chairman, that I think we
are in danger of not comparing like with like here. The local
government that some of us might romantically wish to put public
health "back into" has changed dramatically and, likewise,
the health authorities in which Directors of Public Health are
presently located are themselves changing as a result of the directions
towards the primary care trusts. It seems to me that what we need
to be focusing on is what we would like to see the function of
public health at local level being and how we would like it to
be carried out. In that sense I agree with much of what Sian is
saying, that there are a number of mechanisms that can be sought
here. The issue is about ensuring that all the sectors, including
local government policies for public health, are combined within
that.
Mr Burns: Can I have an answer to my question.
Chairman: I was going to come back to Dr Geller
to answer that point. In a sense, she works jointly with local
authorities. Do you find that a problem?
Mr Burns
209. That is why I asked. Professor Griffiths
will answer the second question.
(Dr Geller) Personally I have very good working relationships
with all the organisations and I do not have too many difficulties
in promoting the public health agenda and getting some action
on it, but I think what we need to do is to make sure that the
systems and the structures are as supportive as possible. I do
not know if I am answering your question directly. This has not
arisen for me, but there is a possibility, as Peter was saying,
that if a particular politician had a particular agenda which
was not in the interests of public health, how easy would it be
for me as an officer within the local authority, and again which
local authority in some of the areas, to be able to stand up against
that? I think personally I would find that difficult. I have not
come across that, possibly through developing trust with networks
ecetera, but I think we have to have structures that guard against
that situation because it will happen; it will happen to me, it
will happen to all of us at one point in time.
210. Professor Griffiths, you, as I remember,
are basically health in Oxfordshire?
(Professor Griffiths) That is a slight over-statement
but I am Director of Public Health in Oxfordshire. There is rather
a lot of health in Oxfordshire.
211. Presumably in your role in the furtherance
of public health in that county you will have had a view on the
closure of Burford Community Hospital?
(Professor Griffiths) Yes. Can I just explain to the
rest of the Committee that Oxfordshire Health Authority has over
the past five years had a programme of reshaping its community
services more in line with developing intermediate care. One of
the parts of reshaping the services was to open a new hospital
in Bicester but to actually close the community hospital in Burford.
So when you take a county-based view what you need to do is look
at the needs of the population and where the services are most
needed and where the limited resources will be targeted. That
is what we did as an authority when Burford was closed. However,
as Public Health Director, I can assure you that the health statistics
for that part of the county are good. We have been engaged in
working with the new organisation that is looking at the voluntary
status of Burford Hospital and we are doing our best to make sure
that nobody is disadvantaged by the changes we have made in the
community hospitals, particularly in relation to new schemes such
as the MIU, which is an emergency unit which allows the people
in Burford to get emergency care nearer to home rather than going
to Oxford. I think there are two sides to every story. I have
given you a few facts there.
Mr Burns: Would you confirm that this decision
on Burford Community Hospital was not met with universal support
and agreement by the local population there, or indeed by many
of the Members of Parliament in Oxfordshire, including not simply
Conservative Members of Parliament but also the Labour Member
of Parliament for Witney.
Chairman
212. You know I let you range wide over all
sorts of areas, but I think we are getting a little bit outside
our remit today.
(Professor Griffiths I am happy to continue this conversation
outside this Committee.
Mr Burns
213. Just a brief yes or no?
(Professor Griffiths) Of course I am aware that any
closure brings with it opposition and opponents. I am very happy
to talk to you outside this Committee.
214. My final question makes the point which
is the opposite to the one to Dr Geller. Of course, though, it
was the health authority that came up with these proposals and
you are basically working within the health authority, so how
much do you feel on a contentious issue like that that you were
bound by what the health authority wanted to do rather than possible
other interests, or do you feel there was not a problem?
(Professor Griffiths) I think Mr Burns probably knows
that there were long hard discussions and consultations and difficult
decisions to make over the population of Oxfordshire and at the
end of the day you go with the majority decision. To try to tie
it back into the role of the Director of Public Health if I might,
there are issues there about where the Director of Public Health
sits being influenced by the organisation within which he sits.
The Director of Public Health has in the past been a corporate
member of the board. In the market system we were a corporate
member of the board, so there was an actual obligation, once the
majority decision was made, to work with that decision. I would
not like people to think it is all bad or good in either position.
The role of the Director of Public Health is inevitably influenced
by where you sit, and that is why I think we need to be very clear
about the future role of the Director of Public Health across
all organisations so they have independence across all organisations
to comment freely on services whichever sector of the patch they
are in, which may equally well include the voluntary sector and
local employers. I think that is the role we are trying to develop.
You get into difficult positions. My view on coterminosity is
that it is extremely important and yet we have not chosen, through
consultative processes, to go for coterminosity in Oxfordshire.
If that decision is made, you stick with the majority, consulted
on decision.
Mr Burns: Thank you very much.
Mrs Roe
215. Dr Donnelly, we all know that the Director
of Public Health has a crucial role to play in co-ordinating public
health. If public health is everybody's business, could you tell
us how the DPH can assist in ensuring that this happens in practice?
In particular, I want you to focus on the role of the voluntary
sector and how they can also be brought into the picture.
(Dr Donnelly) That is a very fair question. One of
the difficulties with the term "public health" is that
it means different things to different people. If I can use an
analogy, it is almost like the term "environmentalism"
Public health can span everything from a medical specialty to
a specialty which is an awful lot broader than medicine, quite
rightly, to almost a philosophy rather akin to the way environmentalism
is seen as a philosophy. So you can have a public health approach
to certain problems. The difficulty with that is that when something
like public health becomes everybody's business, what is distinctive
about those people who claim to practise public health and what
is the added value that they actually bring to that? I think what
public health practitioners can bring is a mixture of very relevant
skills. They have a mixture of hard analytical skills with softer
political and managerial skills. If you take just, for example,
the training that someone who becomes a Director of Public Health
has currently been through, it is very extensive indeed. They
will start by spending five or six years at medical school. They
will then spend a minimum of three years doing clinical medical
jobs and often for very much longer. They will then undergo training
in public health which takes five years and will probably have
been a consultant in public health for at least five years before
they become a Director of Public Health. So you are dealing with
somebody who has around 20 years' post-graduation or 15 years'
post-graduation experience and training specifically for the role
that they then fulfil. I think that blend of skills and experience
makes them ideal individuals to advocate across all the various
sectors, to co-ordinate a team that, yes, of course, has to include
all sorts of people from all sorts of professional backgrounds,
absolutely not just from medicine, and I think those are the distinctive
things the Director of Public Health, if you like, brings to the
role.
216. And can you touch on how you can ensure
that the voluntary sector is also engaged in that?
(Dr Donnelly) We spend an awful lot of time working
with the voluntary sector. They are a tremendous public health
resource in this country. They bring creativity, they bring the
ability to react very quickly to public health problems, and they
also bring a way of energising communities and getting people
engaged in public health problems. So Directors of Public Health
are very well used to working with voluntary agencies and, for
example, this year I have had them write chapters in my annual
report because I think we can give them a platform to spread the
good practice that they are undertaking.
Mrs Roe: From my experience, the voluntary sector
has a great deal to contribute because they are operating at the
real grass roots level and I am very pleased to hear that you
recognise the part that they have to play.
Chairman
217. Can I go on on that point because we have
looked in this inquiry at some interesting local projects, as
you are aware, and certainly one of them was in Cornwall. The
entire project was initiated by a health visitor from the bottom
up. The impression we gained was the need to somehow harness that
energy and enable people to project their concerns in a similar
way. It was not top down, it was very much bottom up, and we saw
it and we were very, very impressed.
(Dr Geller) I will be brief because Peter has already
answered the question but I think the annual report again is very
useful here. I use my annual report to highlight important health
problems which we can all work on together and I also use it as
an opportunity to visit all the organisations and stakeholders
once a year to discuss the issues within it and to hear their
views on that and ways in which they feel they can contribute
and take part. The other point is to involve all those who will
have a lot to offer in policy construction right at the beginning.
I would see the health improvement programme as the vehicle for
that and in Shropshire we have these priority project teams around
teenage pregnancy, coronary heart disease, or whatever, and on
some of those teams we have a voluntary sector representative,
quite often from all the different agencies who can contribute
and, indeed, the enthusiasm generated by planning in that way
(it is rather a bottom-up approach) is delivering results, I feel.
Dr Brand
218. Dr Donnelly pointed out the wide range
of skills that are acquired by Directors of Public Health. I was
very interested when Professor Griffiths pointed out that one
of the major strengths of being in the medical health authority
model is that you are a corporate member of a board.
(Professor Griffiths) Yes.
219. Although there is clearly a need to have
a medical/public health medicine function, and perhaps that is
something we might explore later on. I have been impressed by
how effective Directors of Public Health are at influencing local
authorities, but extraordinarily disappointed over the influence
that they have over health authorities. I would like some comments
on that because I think you do have a constraint in your formal
officer role in the health authorities. I would like to know how
we can protect that?
(Professor Griffiths) I think it goes back again to
being clearer about the role of the DPH in the changing world
of local government and health services. I think primary care
does offer us an opportunity because there are many people in
primary care who are public health professionals. Public health
is only seen as the health authority and as the DPH and consultants.
We were seen mainly during the market time as advisers on commissioning.
There is still some of that image that sticks to the label "public
health", whereas in fact there are many people in trusts,
for instance some of the nurses who work in prevention in cardiac
wards, who are public health practitioners, and they may also
be working out in the leisure sector to the same people so they
are working across the sector on a particular issue. A lot of
health visitors, school nurses and community development officers
have key roles to play in primary care in public health, so their
influence mill be more on the patients and patient care. I would
agree that sometimes the structure of public health may not be
seen to have a major influence on NHS policy decisions, but in
the national service frameworks there are a lot of things that
we now have to deliver on locally, and I think we need some help
centrally in saying that we must look at the health aspects and
not just the service delivery aspects of the NHS. I think it is
probably more about image and perception than it is about what
is going on and the way we are working across with our colleagues
through the hospitals in terms of promoting health. Public health
is much broader than public health departments. We may be influencing
things in a quieter, more subtle long-term way. It may not be
seen because health authorities are consistently talking about
"winter crises", but ever in that area our contribution
has been implementing the flu vaccine programme and now the implementing
advice on the prescription of Relenza, and we may be implementing
things like that in the background.
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