Examination of witnesses (Questions 220
- 239)
THURSDAY 23 NOVEMBER 2000
DR PETER
DONNELLY, DR
ROSEMARY GELLER,
PROFESSOR JAMES
MCEWEN,
PROFESSOR SIAN
GRIFFITHS, MR
JOHN NICHOLSON
and MR GEOF
RAYNER
220. All the examples we have had just now from
Professor Griffiths have been purely medical or nursing examples
of the contribution to public health in the traditional prevention
of disease. I am really more interested in the much wider role
that I think you already have in housing, transport, education,
economic regeneration and that sort of thing and that is where
we do not see the evidence coming thorough.
(Professor Griffiths) I am sorry, I thought you were
commenting on the lack of prominence in the NHS, which was one
of your points in your question, and I was commenting on that.
Increasingly there is a public health presence in areas around
the regeneration agenda, around housing, homelessness, the health
needs of asylum seekers for instance, requiring them to work with
social services, housing, the voluntary sector to address them
together as we have done in Oxfordshire. I do not know that you
need to be labelled "public health" to do some of this.
That is the dilemma. I am not sure the Public Health Director
has to necessarily be the key person. There are many people in
public health in local authorities who can lead in this area with
the support of the Public Health Director rather than leadership.
(Mr Rayner) Can I raise an issue that goes back to
things that have been said earlier? It is about definition and
scope. Until reasonably recently Directors of Public Health or
Consultants in Public Health were specialists in community medicine,
so there has been a change in title and you can get confused about
their scope. That is one thing, but the second thing, as Sian
has just said, is it does require action across authorities and
with communities. Just going back to the point about the voluntary
and community sectors, if I can just expand a bit, it is not just
the formal voluntary sector, it is local communities as well and
building up relationships which are not just based on bureaucratic
reporting, top down ways of working, but really are a yeasty model
in local settings where people work together in a much more inspired
way. I think we have to open up that scope for people to see themselves
as part of public health in a broader way which brings in local
Agenda 21 activities, strategic partnerships, building things
up from the bottom, and that is a much broader definition of health.
221. Can I just ask you whether you feel it
is a happy combination to have this strategic, more visionary
role being combined because of tradition with the very specific
and slightly more obsessional public health medicine/communicable
diseases role?
(Professor Griffiths) I think it is entirely possible.
222. Yes, but is it desirable?
(Professor Griffiths) I think it is desirable because
communicable diseases is an aspect of health care practice. You
need doctors but you also need nurses, environmental health officers,
health visitors, you need the whole community involved. I think
it is a good thing to have communicable diseases within the broader
public health field and not separated out and I think that is
one medical function where it is very clear what the medical contribution
is, although I might say that the on call rota may now covered
by a variety of people who are appropriately trained. It is about
appropriate training, appropriate skills and competencies rather
than necessarily a professional background label.
(Professor McEwen) I think our key emphasis just now
would be on building up a multi-skilled team which is available
to contribute in a whole host of different areas, whether it is
communicable disease, whether it is working towards reducing inequalities
in health, whether it is working on the whole spectrum of heart
disease or cancer or whatever it is, ranging from environmental
issues right through to treatment. This is where we see a highly
skilled team of people bringing their different expertise, encompassing
the whole range of public health practitioners including people
in primary care who are not formally trained as specialists in
public health but have a commitment to public health—health
visitors, GPs, people who have come from housing environments,
many others. All these people are the wider public health team
and into that you put a central group and to some extent I think
it is what is appropriate in a local setting, what is the best
administrative structure in a local setting because we have broken
down all the formal structures of the past and we cannot go back
to one system. I would suggest, that you get a means of providing
the skills as they are needed in different settings.
Dr Stoate
223. You talk about consultation, you talk about
joint working, you talk about wider teams. These ideas have been
around since the 1970s and certainly since the submission of the
Black Report of which we are all only too aware. The idea of a
wider function of public health has been around for a very long
time, albeit with a chequered history. Why has it been so patchy
and so slow?
(Professor McEwen) I was discussing this at a meeting
last week. I am no believer that rhetoric is sufficient to get
people to work together. We need far more than just a commitment
saying we must work together. That is not sufficient. I would
argue that we do need local appropriate structures which actually
put people in situations which do work together, whatever that
happens to be, whether it is a managed network, whether it is
the sort of arrangement that Rosemary had where you can have direct
links with local authorities and health authorities. I do not
think exhortation is nearly enough. You need a proper functioning
local structure, whatever is appropriate in that locality.
(Dr Donnelly) I want to make a brief point about the
interesting issue that Dr Brand has raised which is where is the
evidence, in a sense, that public health within health authorities,
health boards is moving things forward? What is the evidence of
its effectiveness there? I was asked a very similar question when
I did a similar thing with the Welsh Assembly when I was working
down there and the answer I gave them is the answer that I will
give you. I actually think that you as our elected representatives
have some responsibility in terms of setting the agenda here because
what happens is that health authorities as statutory boards with
their corporate executive members will deliver on the agenda that
is set for them. This is not a party political point but it is
a political point. If you can win collectively the political argument
that actually says that prevention is as important as cure, that
the long term is as important as the short term, that it is not
all about intensive care beds, it is not all about waiting lists,
it is also about all the things that go around healthy lifestyles,
healthy living and healthy lives, then of course Directors of
Public Health and health boards will deliver on that. But when
you go to the annual review you do not get beaten up because your
statistics on smoking and your statistics on the consumption of
food or exercise are bad; you get beaten up over waiting lists
and issues such as that. There is a sense in which, collectively,
I think you have the opportunity to change this, but it is more
in your hands than in ours.
Chairman
224. I think you are preaching to the converted,
frankly.
(Dr Donnelly) Always the safest thing to do, Chairman!
(Professor Griffiths) Can I add on the back of that.
Our Healthier Nation was a very good public health strategy.
There were some very good ideas within that about how to take
partnerships forward and responsibilities at different levels.
It would be a shame if they got lost within a reformatting of
the NHS plan, particularly the issue about workforce capacity,
particularly about building up skills in communities and amongst
people other than doctors, and I think one of the things that
Faculty would like to see taken forward is Our Healthier Nation
as a strategy. It came out a year ago. It came out in July and
we have had other things since then but we would request that
it is given a greater profile. I think my colleagues in their
submissions agree with that.
Dr Stoate
225. We have known for 25 years at least that
the wider issues of public health such as housing, poverty, social
exclusion, all the things we have already been talking about today,
are crucial in bringing about public health and it is not just
a clinical model, as Dr Brand quite rightly said. What I am asking
is why should it be any different now given that 25 years of history
have got us not very far?
(Professor Griffiths) I think the political climate
is more positive for public health. I think the whole focus on
urban regeneration, social exclusion and the ideas in local strategic
partnerships are very encouraging. I do think there are some new
things coming through and I think we need to work with them. I
think what we need is some sustained work and we need some resources.
One of the things, just to go back to the voluntary sector, that
bedevils us is short-term funding and the bidding culture, and
we need some sustained programmes that recognise that this is
going to take time and that it is important for us to do it. That
is what I really want to see.
226. That is very important but I would like
to go slightly further from there. You have given us one or two
ideas about what we can do but if we are going to make this work
this time (clearly it has not done in the past) can you give us
what we need to do now, what we need to recommend as a Committee
to make sure that the future is an awful lot more encouraging
than the past? I want some specifics so we can then hopefully
bring these into our report.
(Mr Nicholson) Some of those are about reducing some
of the barriers because what is being said by all of the last
few contributions is that there is a lot of goodwill at local
level to work together and a lot of willingness to do it, but
in fact there are a plethora of initiatives that are coming down
from central government rather than some concerted initiatives
in which everybody can join together and respond to. "Joining
up" is a favourite phrase of the Government and at local
level people are joining up repeatedly, but the problem is joining
up within the square mile here which would help a lot of the regions
outside of this city. In answer to Howard's question about direct,
practical issues, it is a problem at local level to have so many
initiatives without it being clear which is the highest level
priority issue. This Committee has got the capability of saying
that one particular form of partnership is the one that we recommend
and the others are useful and optional but not necessarily the
main one. That is one thing to do. It is possible for this Committee
to ask for the planning work and the thinking that went into the
NHS plan looking at prevention and inequalities, which spent probably
50 per cent of its time considering community development, the
input of the voluntary sector, health visitor-led projects at
local level, none of which surfaced in the eventual documentation,
to be made equally public so that people can be guided by that
and use that in practice at a local level. It would be possible
for this Committee to say that voluntary sector involvement at
each of the local planning levels should be some sort of mandatory
requirement, in not necessarily a specified number of places or
otherwise, but with the loss of the joint consultative committees
and the directly elected voluntary sector, with the loss of community
health councils and the directly elected voluntary sector places,
there is the potential for a vacuum. Not everywhere is guilty
of this but there is the potential for a vacuum where voluntary
organisations and community organisations are not involved in
that planning at local level. I hope those are some simple practical
points that the Committee could put forward.
(Professor Griffiths) I would like to add in the word
"coterminosity" because I think the barriers that are
caused by non-coterminosity must make it really difficult to work
with. I would also like to say, as I think Rosemary said earlier,
that unless we get HImPs to be part of the community strategy,
which is part of the same thing as a local strategic partnership
plan, and we try to have a single shared plan that looks at all
the broader aspects of health as well as health services within
the context of the whole population, those two things alone will
help us in the way we work and the longer time scale, which I
know is rather difficult to ask.
227. Is it fair to say that you think the future
can be different from the past and that you can make a difference
this time?
(Professor Griffiths) I have seen enormous changes
in the way that primary care and local authorities in my patch
are working together. It will be difficult if the short-term funding
is not sustained in the longer term. I think there has been a
huge sea change. I think projects are a good thing and do enable
community involvement. There has been a greater recognition of
the health impact of what local government does and the powers
of scrutiny and the opportunities it can create, and we need to
actually use those. Another point is we should use the powers
of scrutiny of local government to assess health in populations.
(Mr Rayner) Sian raised the point about Saving
Lives and other projects around the United Kingdom which may
be sidelined by the national plan. I almost think there is an
opportunity for the Government to re-visit things to pull back
the public health side into an integrated perspective with the
NHS; maybe we should be talking about a national plan for health
and not just a national plan for the NHS. I think there are a
lot of lessons that have been learnt. I think we also need to
go further and possibly the criticisms we have had on Saving
Lives—and it is mostly good—should be redressed
in a later document called the National Plan for Health
which incorporates the sent perspectives, whether it is public
health medicine, multi-disciplinary networks and so on, but also
issues of governance locally, and there are many other issues
that can be trapped inside a new document which is about energising
the country and not just the Civil Service or the NHS.
(Dr Geller) I have got some very brief specific measures
to suggest. Join up the policy and the "motherhood and apple
pie" with the money and the finance. That is one of the key
things that gives the message to health authority chief executives
and local authority chief executives that the Government does
not mean business so much on some of its priorities as it does
on others. A similar sort of point—join up what you are
expecting with accountability, which picks up on the point you
were making about the regional reviews that we are not asked about
these things very much and not held accountable. Also, do not
forget the accountability and having somebody in charge or responsible
for delivering because I think that is another reason why things
float around in the ether with lots of goodwill but maybe not
the delivery of the goods for the population at the end of the
day. Those would be my three key ideas.
228. A final question to Dr Donnelly and that
is how can the annual report of the ADPH enter the planning process
to try and make more sense of the whole picture?
(Dr Donnelly) There are two ways of using an annual
report broadly. What some people do is they have it as a retrospective
document so it is almost a record of the year and therefore it
tends to come out two or three years after the fact. I can see
why people do that. It is nice to have a chronological record
to see what is happening in terms of health plans. I personally
do not think that is the best use of it. What I think you should
do is publish it in year, it should be forward looking, it should
draw on a lot of different sources not simply those employed by
statutory health organisations, and what it should do is lay out
public health and the health agenda for the next year or 18 months
which sets the direction of travel for the board, for the trusts,
for the authorities which says these are the things that you all
need to be doing in pursuance of public health. I think that is
the way it should be used.
Mr Amess
229. Dr Geller has sort of answered one of my
points. I really enjoyed what Mr Nicholson had to say so I would
quite like to return to his earlier remarks. Mr Nicholson, you
were telling us politicians in this square mile to pull ourselves
together, give some leadership and all that and you basically,
if I can paraphrase what you said earlier, said there were too
many of these initiatives. First of all, Mr Nicholson, why do
you think there are all these initiatives?
(Mr Nicholson) Why do I?
230. Yes.
(Mr Nicholson) I had always understood that it was
the prerogative of this place to put forward the initiatives.
231. Come on, you are not a shrinking violet,
you have got strong views; why do you think there are all these
initiatives?
(Mr Nicholson) The determination of the Government
to ensure that the inequalities in health which exist in this
country are tackled is something which the UK Public Health Association
welcomes. From the first moment where it became possible to talk
about inequalities, because for a very long period of time in
this country it has been difficult to talk about inequalities,
we can now talk about it, and we would welcome that entirely.
We believe that the responses to the structural inequalities which
exist in society and which cause people much ill-health have been
well-meaning but often individual, anecdotal attempts to create
small solutions that may lead in due course to more structural
solutions but which often have not had much time to test out whether
they do or not. In reality what we would argue is needed is the
strongest shift possible from those who are healthiest and often
wealthiest towards those who are experiencing least health and
probably have got the least wealth. That is a very big and structural
shift and one that would take a lot of courage by Parliament to
put forward in any financial climate. All we are saying as a voluntary
organisation with members across all the regions throughout the
United Kingdom is that the experience we have got of our members
and of real health in those regions is one that argues for more
than a lot of initiatives, argues for some very central direction
about the most important points and enables people to work together
as flexibly and as co-operatively as they can at that local level.
That is what I was trying to reply earlier. It is the removal
of some of those barriers. If people were free to be flexible
at local level to join the plans up, to join the thinking up and
to put forward local responses to nationally set targets of tackling
inequalities for example, if that was possible I think we would
see some real progress in the way that Sian was describing.
232. So in all these initiatives then is not
the Public Health Association closely in contact with the Government
and Government Ministers regarding them?
(Mr Nicholson) We speak to Ministers on a fairly regular
basis—
233. Of course you do.
(Mr Nicholson) And we do try and make the same point
to Ministers that I hope we are trying to make to the Committee
today, and that is that we want to—
234. But we are not the Government, are we?
(Mr Nicholson) Indeed, which is why we will be glad
to have your support as a Committee.
235. Well, you might get our support but whether
the Government listens to any of our reports since I have been
a member is a different matter. But you must be frustrated at
your lack of influence with Government Ministers?
(Mr Nicholson) On the contrary, I am delighted in
your confidence in the UK Public Health Association that we have
so much influence over Government in comparison with yourselves
on this Committee. We will take that in good heart. We are an
organisation which has existed for just over one year and we are
holding a national conference next March. I will continue to plug
the Association for many more minutes.
Mr Amess: You are well-known to us and you are
getting lots of publicity!
Mrs Roe
236. Chairman, I have been listening very carefully
to the questions and answers up to now. We have all been talking,
basically, about the process but I would now really rather like
to talk about results. I wonder if you could actually tell us
who really gets into trouble when perhaps there is evidence that
things are not going well and whether there is a way of showing
that the local public health is actually improving? I do not think
the health authorities are judged on this and I would like your
comments on this. Who picks up the tab? Who is going to say "It
is getting better and this is why"? I would like to hear
your views on this.
(Professor Griffiths) I think that is exactly the
problem. The point we have all been making is the lack of shared
accountability for the population for the health statistics. We
have got the NHS arm being accountable for health service delivery,
and that is what they are held to account for. Local government
are held to account for a variety of other things, not necessarily
the health of their population. I suspect that our shared view—I
am looking for nods from my colleagues—because I have read
their evidence, would be that actually we need to see very clear
accountability for health. Health impact is one of the things
that has been promoted, both through our Healthier Nation and
also other groups, such as ourselves, as a way of saying "This
is a way of demonstrating that impact on health through certain
activities". I think there are suggestions there. I go back
to John's previous point, we would value your support for our
initiative, and maybe mutual support may deliver some results.
237. Sanctions?
(Professor Griffiths) Sanctions are needed wherever
you have a performance indicator. The Government has moved towards
sanctions in the NHS, the Traffic Light Scheme. I have not given
any thought to how you might do this across the population but
it is possible that if health is not seen to improve there should
be sanctions, just as there should be rewards.
Chairman
238. Performance related pay: your teenage pregnancies
go up, your money goes down.
(Dr Donnelly) Can I say, it is actually a very important
point. I think there are some very simple things you can do. The
first thing is you can recommend that the Director of Public Health
always goes to the annual review because that is not universal.
You may be amazed by that but that is not universal. Sometimes
the Director of Public Health does not even attend the annual
review. The first thing you can do is make sure the Director of
Public Health goes. Number two, you can make sure that health
status of the population is an agenda item. You may be amazed
that is not the case but often that is not the case. If you simply
achieve those two things, you get the DPH around the table and
get the health status of the population on the agenda, you have
actually made quite a lot of progress because that is how you
then begin to say "All right, Dr Donnelly, what are you doing
about the number of people who are smoking in your community,
the number of people who are contracting HIV Aids, the number
of people who are homeless and on the streets?", etc, etc.
You actually then have the right person to speak to and you have
it on the agenda. That does not happen at the moment.
Mr Burns
239. Very briefly, would you agree then that
one of the problems of the Health Service is the culture of an
over-reliance on inputs rather than outputs? If you agree with
that, how can one break down that culture and concentrate more
on outputs which are ultimately the most important thing?
(Dr Donnelly) The one word answer is yes.
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