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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