Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 200 - 219)



  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.


  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.


  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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