Select Committee on Health Minutes of Evidence



Examination of witnesses (Questions 260 - 272)

THURSDAY 23 NOVEMBER 2000

DR PETER DONNELLY, DR ROSEMARY GELLER, PROFESSOR JAMES MCEWEN, PROFESSOR SIAN GRIFFITHS, MR JOHN NICHOLSON and MR GEOF RAYNER

  260. Do you have anything to say about how you think they might be used more effectively generally and whether there is anything in their training that should change?
  (Mr Nicholson) I am going to give one word, I think the answer is no we do not use them as effectively as we could. My colleagues either side could say a lot more about it.

Mr Amess

  261. A question to Professor McEwen. In your memorandum you talk about the alternative public health model in Wales. I wondered if you had any views on the proposed Institute for Public Health in Scotland?
  (Professor McEwen) It has been moved beyond being proposed, the Director has been appointed and it will start functioning at the beginning of January. I think the key aspect is that is designed not to take over activities that other people are already doing, the Directors of Public Health, the academic departments or whatever, but to attempt to produce a co-ordination to ensure, whether it is education and training, whether it is service delivery, whether it is links between academic departments and policy, whatever these areas, there is hopefully for the first time going to be a much more co-ordinated approach within Scotland and it will be seen as a national. Facilitating I think is an unfair word, it is more than that. It will be responsible also for databases, for identifying areas of gaps where further research is needed and arranging for these to be commissioned. I think it should provide a unifying focus and actually perhaps pick up some of the things that we have been talking about earlier this morning of really ensuring that there is a concerted public health voice on key national issues which can be brought to bear on Government, on local authorities or at an individual level. I feel there is a great potential for it. It has a huge task. I have just looked at its remit, it has 11 areas it is supposed to cover. It will be impossible for it to do that. It is concentrating on two or three to begin with and I think it will then have to show how it can produce results within a relatively short time period. It will start on 1 January.

  262. A question to Mr Rayner. As a UK body can you compare how the various approaches to the public health function being adopted throughout the United Kingdom are impacting in practice?
  (Mr Rayner) Quite a large question. I will, if you want, give you a note on it. It is a big issue. You cannot really compare it around the regions.

  263. By all means send us a note.
  (Mr Rayner) Following up on Professor McEwen's point about Scotland. There are different structures there, there are different structures in Northern Ireland. Health and social services together in Northern Ireland. The situation in Wales is running on a new basis. I think the point I would really want to make is actually we should try to capture the variety around the UK and learn from what is being done, from the experiments in different places, and make sure that UK dimension is not lost and that the variety in the English regions is not lost. There are major benefits from devolution. Obviously you will be speaking to the Health Development Agency later. They will be looking at that practice in England. I think we want to make sure we are not losing the different practice around the UK as well.

  Mr Amess: If you would please send us a note.

Mr Austin

  264. Could I just ask a question about targeting need. There are a number of conflicting views about area based approaches to health improvement and the suggestion that many people may be left out if we merely target particular areas. What are your views on this?
  (Mr Nicholson) I think, to an extent, you are loading the question anyway in assuming that those schemes are probably not the best way to tackle everything structurally. I think I would share that view. We want to see the benefit of any schemes or initiatives that are being put forward applied so they can apply to everybody. I do not think any research in the last 30 years has shown that more people benefit from within one scheme area than would benefit outside and vice versa. There are always going to be poor people who are not captured and richer people within an area that is targeted as one of deprivation. I think implicit in your question is the answer to that specifically. What I would say, however, is that there are two or three other aspects to it. First of all, it is important to consider how large a population is going to be defined by any health strategic planning. That is a major problem. Somebody made the point to me that if the population we were trying to define was of those with lassa fever we might be looking at one person as a population, if the population we were trying to define was the needs of the whole of a region devolved as Geof was just saying it might be eight to ten million people looking at the general needs. As Sian was saying earlier, there are certain specialised services where, for example, people with HIV, who I have worked with for many years, have not got an even spread throughout the population geographically, they do live in certain areas and therefore the more you delegate to smaller units of defined population the harder a task you have of addressing specialism in an adequate way. I think I would answer the question more by considering what areas of population we want to make the best strategic planning we can, looking at what types of intervention we want to make that can be applied generally rather than too specifically, and seeing pilot schemes or initiatives as exactly that, and giving them a full rein to run in that time, without necessarily conditions or pre-conditions because otherwise you hamper them and at the end of them saying "Right what have we learnt? Let us apply that if it is beneficial and let us not if it is not". If it did not work we are honest about it and admit it, we are trying it and did not say it necessarily would work. I think the problem is that we have not got the structural shift but we have got quite a lot of initiatives. The initiatives are never going to be perfectly geographically located or cover all the population and they are not even being given a free rein within their own confines to do a job which might be possible.
  (Professor McEwen) I think it is not one or the other. I think public health has always been concerned with the population, the disadvantaged groups and the individuals, and how these all relate to each other. I think it is key that we do not go down any one route. The way we have been talking this morning I think has illustrated that.
  (Professor Griffiths) It is important also that evaluation is played in from the beginning of these projects and we take the risk on some things not working. That may take us a long time to understand whether it has worked or not. There is something about timescales, something about building in evaluations, something about accepting risk when we are doing something new which will support these areas of the schemes. I think at the same time they are are not either/or and if you think of the evidence on smoking there are things around smoking cessation, support at an individual level which are shown to be very effective and we use which are necessary as well as issues around tobacco advertising, selling cigarettes to school children etc. It is not either/or, it is about working together.

  265. Can I ask your views on the proposed national inequality targets?
  (Mr Rayner) To start, I think it is extremely positive. I think it is long term. There is a commitment from the Government to eliminate child poverty over I guess there are 18 years left, 19 maybe. I think it should be seen in a general span of things. What would be good also would be a commitment from all the parties present in Westminster to that sort of activity. As in Ireland, for example, where all the different political parties are united around the defeat of poverty, we know any different shape of administration is going to be committed to the continuation of those targets because it is a long term venture. There is consultation going on on what the targets will be and what the meaningfulness of those things will be. Clearly it should focus very clearly on things which are understandable and simple and the public can understand as well. We welcome the debate about what that target is.
  (Mr Nicholson) I absolutely back that up. I think the important thing is that these targets are put in place, that there is consultation as quickly as possible with as wide a range of relevant people as possible so they are as effective as possible and once they are in place they are then used, they are measured, they are effected. The worst thing we can do, having won I believe an argument here about targets, generally, having won that argument in principle, the worst thing would be if nothing then happens or if they are put in place in a local way and that is not then reflected in national decision making which follows on from it.

Chairman

  266. Do you feel there could be some political consensus around that? Do you feel that is realistic?
  (Mr Rayner) We are ever optimistic.

  267. Looking from the outside. That was a mischievous question.
  (Mr Rayner) What we want to say is it is long term. If you are going to have a long term measure you need everybody to sign up to that also.

  268. Coming back to the point Dr Donnelly made on politicians.
  (Professor McEwen) I think you get united support from all the professional organisations and all the ones represented here on something like this. We all support it solidly.

  Chairman: You may not get it from this Committee but we will work on it.

Mr Austin

  269. Is not the forbidden word "redistribution" obviously in that?
  (Mr Nicholson) Why is that a forbidden word?

  270. It is not forbidden as far as I am concerned.
  (Mr Nicholson) The UK Public Health Association is committed to tackling inequalities. In order to tackle those inequalities you have to look at targets that reflect what are causing those inequalities. You have got to be as tough on the causes of inequalities as on the inequalities themselves. In order to do that it is necessary to say that one of the biggest determinants for people's health is their income, what they have got to live on. When we have talked to the Minister of Public Health several times about the development of targets we have been quite explicit that that does mean tackling issues which include the Treasury, the Department of the Environment, Transport and the Regions and so on and so on. I think at the moment the view probably from the Department of Health is that health targets are not going to embrace something more widely and I think that is a view we have got to work on collectively to say that is not a wide enough view, we have got to bring in questions of income, employment and indeed, as we were saying earlier, all these other local projects which are demonstrating this much more widely than the NHS. I would share Geof's view that there is every reason to be optimistic. If we can turn the culture into longer term thinking to get some consensus on where people want to be in 18 or 20 years' time then it is possible to say if that is the target for that period then let us work backwards and say what would the target have to be in five years in order to be contributing towards that target in ten or 15 or 20.

Chairman

  271. Can I say that I am conscious we have got a second session to undertake and there are many questions we would like to have asked you that have not been asked. Do any of my colleagues have any points they want to make before we move on to the second session, or do any of our witnesses want to add anything which you feel we ought to have asked you but we have not? Briefly, please.
  (Professor McEwen) Very briefly. Just to say obviously we have updated our previous paper and we also have one on primary care. We have not had time to discuss these, so can we leave these with you?

  272. Please do, and any other information that you feel you would like to leave we would be very grateful for. Certainly the comparative work that was mentioned we would like to look at.
  (Mr Nicholson) Can I just ask a question about the dissemination of the findings of this Committee's work because you asked the question earlier on about how we could raise the debate and it seems to me that it would not be impossible for the findings of this Committee, in conjunction with organisations such as our own in the field, to be presented and disseminated and to try to put forward in a more effective way some of what comes out of the Committee.

  Chairman: I would certainly be happy to have a dialogue with you subsequent to the inquiry. We are talking about February. I think that is a very good idea. That is just before the General Election. Oops, sorry. Can I thank you all very much indeed for your evidence, it has been an excellent session. Thank you for your help.


 
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