Examination of witnesses (Questions 40
- 59)
THURSDAY 20 JULY 2000
PROFESSOR LIAM
DONALDSON, DR
PAT TROOP
and DR RUTH
HUSSEY
40. Is this the TV or newspaper advertisements?
(Professor Donaldson) Would you like to comment?
(Dr Troop) Yes. For the tobacco programmes, a lot
of it was TV advertising programmes. The way that they are put
across is not necessarily for people to think this is a public
health programme. The tobacco advertisements, for example, had
case histories, it had people who were trying to give up smoking
explaining how they were trying to give up smoking because they
were aimed at people who we hoped were wanting to give up smoking
and needed that bit of help. There has been a television advertising
programme backed up by helpline and leaflets and very often in
areas that you and I do not see, they are in pubs and clubs and
things, aimed at this target audience where smoking is a high
prevalence. Individual programmes have that kind of back-up. Similarly
vaccination programmes have television back-up. We had it with
the Meningitis C programmes, and there were a lot of them around
at the time when mothers might be watching with their children.
They are very targeted kinds of programmes run nationally but
very much backed up locally because all the materials are then
supplied locally so people can run local campaigns to back those
up. It is that kind of national programme that is run and people
will not necessarily thinking of them as health programmes.
Mr Austin
41. Given that major determinants of health
are poverty, unemployment, housing, environment, etc., I am surprised
the words "public health" do not feature frequently
when we are talking about regeneration. Since the system of delivering
regeneration is largely now through the Single Regeneration Budget
which requires multi-agency working and involvement of the community,
are you aware that public health is a significant part of SRB
programmes or indeed of any SRB programmes which are public health
driven? How do you see public health in relation to regeneration
strategies?
(Professor Donaldson) I think it is very important
and a lot of health authorities are involved in the construction
of single led regeneration bids and budgets. Perhaps Dr Hussey
would like to give an example?
(Dr Hussey) Certainly in the current round SRB6, I
have personally been involved in developing the proposals and
influencing the way the programme shapes. I have encouraged the
local authority to use the tool of Health Impact Assessment to
enable them to look at the proposals coming forward to make sure
they are focusing on the health benefit of schemes. Just referring
to another initiative, New Deal for Communities as an example,
the New Deal for Communities in Liverpool has used Health Impact
Assessment as a framework for its decision making and the community
itself sent a resident on a Health Impact Assessment training
course recently so they could use health improvement as the outcome.
Some people use quality of life but I do not think the terminology
really matters, it is more to do with the principles of improving
the components that improve quality of life and well-being holistically.
My experience is that Health Impact Assessment is a useful framework
for people to use.
Chairman
42. Before I bring Stephen in on this general
area can I ask you, Dr Hussey, Professor Donaldson made reference
to an example—I think it was you who mentioned it—where
at a local level there was some suggestion that local people wanted
some more green space for children to play. If you had a practical
concern about some national policy area relating to the impact
on health in your locality— I will give you an example.
One of my personal concerns is not so much play areas in my part
of the world but the pressure on youngsters of academic achievement
and work outside school that means they do not have the space
in childhood and adolescence to use those green areas. I would
say possibly there is a lack of joined-up thinking somewhere between
health and education at a national level resulting in the pressure
that there is on particularly young people in secondary education—I
have got two teenage children—that does not enable them
to have the kind of exercise and sport involvement that the generations
of most of us around the table would have had. I say that as an
example but if you have a concern about national policy in some
area, what is the mechanism whereby you can ensure that concern
is taken up and acted upon?
(Dr Hussey) There are several routes that one could
take.
43. Like what?
(Dr Hussey) For instance, if it was appropriate I
would approach the Regional Director of Public Health and if it
was a significant concern I would approach Professor Donaldson
himself.
44. Even if it was in another Government department?
If it related to another Government department completely but
it was a concern that you had picked up, you would go that way
and then expect at his level that would be addressed with other
Government departments?
(Dr Hussey) The other way I would do it would be to
go up the other departmental route as well. For example, I am
regularly sent consultation documents from the Regional Assembly
and Development Agency. Again, the Regional Offices and the NHS
have staff working across that partnership as well. I can either
go up the route of the relevant Government department and/or go
up, the public health route and hope at each level there will
be some cross influencing.
45. You would feel free to do this not infrequently
on issues that concern you in Liverpool?
(Dr Hussey) I could not comment on how often I do
it.
46. You do it occasionally.
(Dr Hussey) I am regularly consulted. As part of the
post that I hold I am sent policy documents to comment on.
47. I was thinking more rather than you being
consulted, you actually initiating some representations about
an area of concern that you have got. I gave one example that
personally concerns me that relates primarily to league tables
and pressures on teaching staff in schools which in turn reflects
on youngsters. That was one example but there may be other examples
you can think of where you have felt it necessary to say "we
have got a problem here policy-wise, can we not do something about
it?"
(Professor Donaldson) If I might just cut in. That
is an example of health impact assessment really to look at a
policy. I suppose on the other side of the balance you would be
saying that the evidence shows that with higher educational attainment
people staying longer in education have markedly improved better
health than people who do not. I suppose there you would be balancing
the impact of that extra time spent on educational outcomes against,
as you say, the loss of opportunity for—
Chairman: I think there could be other factors
that we could debate that have a bearing on it. Peter.
Dr Brand
48. Can I pick this up very quickly. Do you
really think that the Minister of Public Health ought to be within
the Department of Health or should it be within the Cabinet Office
because we do seem to get most of this joined-up thinking coming
from the Cabinet Office now? I was extremely disappointed that
the ministerial role has been downgraded. There was a great fanfare
to set up the Minister of Public Health and it has rather faded
away.
(Professor Donaldson) It does not feel as if it has
faded away to us.
49. It does to us.
(Professor Donaldson) We have a very knowledgeable,
committed, energetic Public Health Minister. We worked well with
her predecessor and we feel the same about the present one. It
may be perceived in that way but that is not the way it feels
internally.
Dr Brand: The important bit you said there was
"internally". I fully accept that the Minister is a
very effective and knowledgeable Minister but she appears to be
functioning purely within the Department of Health. The point
I am making, and I think the point the Chairman was making, is
that so many other departments make an enormous impact on the
health of the nation but we do not seem to get this inter-departmental
high level presentation.
Chairman: It is a bit like the original question
I asked.
Dr Brand
50. It needs the Prime Minister to actually
interfere with what is happening rather than a Minister.
(Professor Donaldson) You will be seeing her later
in your programme of meetings but I do not think that is a fair
criticism. There is a cross-Government relationship. She leads
on Sure Start and she has been involved in a lot of the healthy
schools work. There has been a lot of joined-up Government on
health since the word go. Before I was in this constrained position,
where I have a national role, I would have loved to have seen
that when I was out in the field in public health but I did not
see the commitment. It is all very well for people to be a bit
cynical about it and say "we have not got enough" but
it is an incredibly strong position to be in compared to where
we were ten or 15 years ago when we really did not have any cross-Government
commitment to health. We have got declared policies on health
inequalities, we have got a Public Health Minister, we have got
Ministers who are working across Government departments and we
have got programmes like Sure Start in place. One of the roles
of Government in health is to create the conditions for health
out there at the local level. If we do have joined-up Government,
which over the years we have not had very much of, I think it
is a very strong position to be in now and we need to build on
it.
51. Can I just make absolutely clear that any
criticism of the present Government is not an endorsement of the
previous Government.
(Professor Donaldson) I am not making a political
point.
Chairman
52. It is a bid for the future, Peter.
(Professor Donaldson) I am simply saying that I feel
we have now got the tools to deliver the job.
53. I think the point that certainly I understood
Peter to be making was not so much a comment on the current occupant
of the ministerial role but whether the location of that role
is the right one. The first question I would ask is is the function
better in local government than in health? Would the function
be better placed elsewhere within the overall Government than
in your Department?
(Professor Donaldson) My personal view is that I think
it is better placed in the Department of Health for many of the
reasons that I spoke about earlier. I am the fifteenth Chief Medical
Officer and the first one was accountable to the Privy Council.
I think I am in a much stronger position working with a set of
Ministers who are at the coal face and who have got links with
their ministerial colleagues.
Mr Hesford
54. Just coming back to Health Action Zones,
if I may. I will invite Dr Hussey to listen to this and perhaps
advocate from Liverpool. Liverpool was a second wave HAZ and I
was involved in the setting up of that Health Action Zone. I know
the four drivers of the Health Action Zone. What I want to ask
Professor Donaldson is given the first wave and the second wave,
and at the moment there does not look to be a third wave, should
there be a third wave? Why is there not a third wave? What is
it, Dr Hussey, that we are missing out on in other areas if we
do not have a third wave?
(Professor Donaldson) I think at some point the expertise,
the experience gained from the Health Action Zones needs to be
main streamed, as we were saying earlier. I think that is one
priority, to gather together the evidence of the effective change
that has happened in the Health Action Zones so far having spread
them more widely through the NHS and the local authorities and
all the local partnerships that are around. We have not yet had
the formal evaluation, I am not quite sure when that is due but
we are due to have a formal evaluation. I am told it is 2002.
Before extending it further I think we need to have that evaluation
and a stock take of the effective action.
55. Dr Hussey, is that fair? Is that how it
feels? Are you just some sort of guinea pig and it is not really
an effective policy?
(Dr Hussey) These were set up to try and work in a
different way. To use the resources to change the mainstream which
I think is very pertinent and I would agree with Professor Donaldson
we need to learn from how successful they are in achieving the
goals they set out. It is important to reflect on what is coming
out of the first two waves of HAZs.
56. The Health Action Zone is to focus on the
short to medium term, three year gain, quick gain, if you like,
but it is a seven year programme. In what sense are you ever really
going to get an evaluation? Are we saying we cannot have another
round of the Health Action Zone basically for seven years, is
that what we are saying?
(Professor Donaldson) Well, I do not know that I can
give you a clear answer to that, that is very much in the hands
of ministers.
57. If you do not mind me saying, it is not
a political decision except that somebody has to sign off the
chit for the payment. From a professional point of view about
being one of the delivery mechanisms in theory, is it right to
wait another seven years? What are the issues around that?
(Professor Donaldson) I think the issues are it may
not be a purely political decision but it is a strategic decision
anyway in that you have to decide whether the present structure
of Health Action Zones sitting alongside or linked to existing
statutory structures—health authority, local authority and
so on—should continue in perpetuity or whether either by
disbanding the Health Action Zones and mainstreaming the policies
within existing structures or by creating new structures entirely
or by concentrating different structures in disadvantaged areas
compared with other areas, I think there are a number of choices.
I think it is very difficult within the context of this discussion
to say what the right answer is without clearer evaluation.
58. Would not one of the successes—I do
understand what you have just said and I appreciate what you have
just said—of the Health Action Zones be the fact they do
not have the incumbency of a massive structure? They have the
flexibility to range across an area which is massively important
in places like Merseyside which covers such a vast area, different
health authorities and different local authorities. What are the
issues there? Imposition of a new structure as opposed to flexibility.
(Professor Donaldson) I do not know that all of them
have created that very fluid arrangement. I think the emphasis
in different Health Action Zones is quite different. Some of them
have majored much more on health care rather than public health
issues. I think it is very difficult to generalise at this stage
until we have hard and fast data on the experience.
Mrs Gordon
59. There is obviously a lot going on at the
moment and there are lots of initiatives. That is good. I think
it is a recognition by the Government of the importance of preventative
health care and primary health care. There are so many of them.
I just read off the list there is the Health Action Zones, Employment
Action Zones, Healthy Living Centres, HimPs, Health Impact Assessments,
Primary Care Trusts, a whole list of initiatives. Is there not
a serious danger of "initiative fatigue" if you like,
a sort of committee overload, and a danger that with all these
new bodies, which are meant to be developing partnerships and
joined up working and thinking, that they will just be buried
in a mass of bureaucracy and just meaningless paperwork?
(Professor Donaldson) I think there is always the
danger of that, yes. I think what they have achieved—all
of those initiatives—is they have broken up traditional
ways of looking at things. They have created focus on the needs
of local people. They have brought different bodies, both statutory
and non statutory together in a way that has not been possible
before, and they are yielding concrete information about what
works and what does not work. There have been gains from it. How
long you allow that position to run, I think is a matter of judgment.
As I say I would not like to make that judgment here today or
even to say that one solution should fit every locality. I think
there have been gains but you do have to watch for making things
over complicated and bureaucratic.
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