Examination of witnesses (Questions 60
- 79)
THURSDAY 20 JULY 2000
PROFESSOR LIAM
DONALDSON, DR
PAT TROOP
and DR RUTH
HUSSEY
60. There was a Cabinet Office Report Reaching
Out which was critical of current arrangements as confusing
and fragmented and pointed to the need for better mechanisms to
link different policies across departments. The Report advocated
strengthened and higher profile Government offices in the regions.
I understand the Report has been accepted by the Department. If
so, what will this mean in practice in respect of public health
where many of the new initiatives have a key role?
(Professor Donaldson) I think the Department of Health
on that particular specific did not commit itself to any specific
organisational change but it is recognised that close links between
regional offices of Government and regional offices of the NHS
are very important. Already in some parts of the country there
have been exchanges of staff, public health staff from the NHS
side are working within the regional offices of Government and
vice versa. I think over time we have to look as to whether a
closer merger of some of those functions is the right way to go
because there would be many attractions to it.
61. Earlier you mentioned about Health Action
Zones, once the assessments have been done maybe they will be
taken to the mainstream, if you like. Is there room for that,
for some of the initiatives to become part of the standard care
we give and the primary care?
(Professor Donaldson) I think there is, yes, to choose
the right things, yes there is.
62. Do you believe that running initiatives
aimed at lessening health inequalities like research projects—with
a bidding process and short term targets—is likely to be
an effective way of influencing such a deep seated problem?
(Professor Donaldson) Our research programmes, some
of them are based on bids, but if you look at the research funding
bodies in the round, the Department of Health has a funding stream,
some other Government Departments have research funding streams
which can have a bearing on health and the Medical Research Council
has a budget and not all of that is directed towards specific
circumscribed bids. The Medical Research Council, for example,
can establish units which have longer term programmes of research.
I think you need a mixture because researchers or even practitioners
at local level often have good ideas about something which could
be looked at quickly which is perhaps on quite a small scale but
could bring a lot of benefit. I think you need to have a way of
funding that. Also you have to develop the research expertise
over time and make sure that it stays in Britain and does not
go off to America and other countries and we lose it. You do need
to put in long term funding to keep those people here and to allow
them to attract a strong team of researchers around them. I think
you need a mixture.
63. Do you feel, especially with bidding, that
it is the people who need the resources most who find it hardest
to put bids together and get them in because they are under the
most pressure?
(Professor Donaldson) I think that is right. I think
there is a more fundamental problem, it is not just a pressure
of time but people who have good ideas are not often trained to
design a research project to investigate that problem or pursue
that idea. One of the areas of action that has been taken is to
identify research experts locally within the Research and Development
Programme who can facilitate local people, help them to take forward
an idea without taking it off them, help them to have the necessary
skill and facilitation to pursue it. That is very important. Even
more fundamentally, I think that research needs to be a part of
the training of all professional staff, at least that they understand
the research issues and how to formulate research questions if
not becoming experts in research themselves.
64. Are you saying that is like a support network
really to get the bids in?
(Professor Donaldson) Yes.
65. Who is doing that?
(Professor Donaldson) There is an element of that
within the NHS R&D Programme. We have a Director of Research
and Development and we have eight Regional Directors of Research
and Development. Also, local university departments are identified
and researchers, people with ideas, can be directed towards them
for help and support.
Mr Austin
66. Can I go back to getting public health out
of the ghetto. The Chairman has referred to the fact that some
of us come from that glorious age when the MOH was a local authority
appointment. One of the points that has been made about that is
that it was not just a close relationship with social services
but with housing, with education, with all of those key services
which are so fundamental to public health. We have received a
lot of evidence which seems to suggest that a possible way forward
is joint appointments or joint teams of health and local authority.
I am wondering if you feel this is perhaps the road we ought to
be going down and whether it should be done more?
(Professor Donaldson) I too have some nostalgia for
the golden age of the MOH. As I said, my father was one. He used
to have his name painted on the side of the ambulance in Rotherham
and when his ambulance drove past the classroom I used to get
teased by the other children. Being in that position was a mixed
blessing. You are right, they did have those influencing skills
because they were sitting around the table with other chief officers
and could have a direct influence on those other policies. I still
think that the important thing, given that the function is placed
where it is now and it does have advantages, particularly with
the growth of chronic diseases and the amount of long-term care
and support and help that people need, is that we break down the
boundaries between organisations using some of the mechanisms
Dr Hussey has referred to, secondments, exchanges and so on, and
picking out within initiatives like the Health Action Zones where
good collaborations have been effective and trying to replicate
those elsewhere. I think it is absolutely vital. More than anybody
else I am a champion of public health being directed not just
at the lifestyle factors but at the underlying root causes. I
think that is where the evidence really shows that you will make
an impact in the long-term. By perhaps resisting the notion of
a return to the Medical Officer of Health I do not in any way
take away from the importance of doing that but there are other
ways to do it and we have to make those effective.
67. Where there have been joint appointments,
joint teams and joint initiatives what assessments have been made
of their value and success? Does working in that way lead to different
priorities and perceptions of the service that should be delivered?
(Professor Donaldson) I think at this stage, short
of having a formal evaluation of the Health Action Zones, all
we can do is give you an anecdotal impression. Certainly from
the Health Action Zones I have seen and the documents I have seen
there is a lot of evidence of that. Eighteen months ago I was
the Regional Director in the Northern Yorkshire part of the country
and in places like Northumberland and Tyne and Wear there was
already evidence of some of the boundaries between organisations
being broken down and some of the health programmes were being
led by local authority officers, not health officers. I think
that was very encouraging and shows that it can be done.
68. Can I come on to the role of the Public
Health Officer. There have been some suggestions that we should
have non-medically trained Directors of Public Health. The BMA
has reacted, somewhat predictably, as hostile to that suggestion.
How would you counter their charges that this would leave a dangerous
vacuum, for example, in dealing with communicable diseases?
(Professor Donaldson) I am in favour of a multi-professional
workforce in public health. The medical element is important but
it is only one of a number of important disciplines. In the White
Paper, A Healthier Nation, we set out the programme to
develop people becoming specialists who do not have a medical
training and who in the past—I think it was described as—had
to have a do-it-yourself career. We want to get a proper career
structure in place for people of all sorts of disciplines, including
medicine. I think the key thing is competency. Just as we were
talking about the need for protection from the Medical Defence
Union, there are important decisions to be made in undertaking
these senior roles, it is not just a matter of giving vague advice,
you have often to make important judgments about how money is
going to be spent, how it will benefit people and so on. You do
need people who are competent. I would not agree with the BMA
that the implication is it is only medical people who can ever
be competent, I disagree with that. Where I do agree is that it
needs to be done thoroughly and rigorously so that we have people
with the right skills in those key positions otherwise it just
perpetuates the idea that public health is a second class citizen
to patient care if we say "to treat patients surgically or
to treat patients as a specialist diabetic nurse you need proper
training and qualifications but do not bother about that in public
health, just give them the job and let them get on with it".
I think we need to maintain that rigour.
Dr Brand
69. When we lost the multitude of targets in,
I think it was, Health of the Nation we were assured that
although they would be targets defined nationally we would not
be losing sight of all the other issues and teenage pregnancy
was a very important one that had dropped off the national scale.
There is a lot of talk about whether targets are being delivered
and a new set is being produced on targets for tackling inequalities
for instance. This all revolves around the Health Improvement
Programme. When I asked Ministers three years ago I was told that
those targets would have to be approved by Ministers, there would
be a process of approval for each Health Improvement Programme
area, and that they would be aggregated nationally so the figures
would be available to see how we are doing as a nation. How far
have you got with that work? I asked last year and I was told
it was too early. I wonder when we are going to see some useful
figures.
(Professor Donaldson) The local Health Improvement
Programmes have to be signed off through the NHS management process
up through regional offices. I do not know that we have an aggregated
picture.
(Dr Troop) No, they are signed off at that regional
level.
(Professor Donaldson) I do not think they are signed
off and publicly available documents. I do not think an aggregated
description is being produced of their content.
70. So the Minister's undertaking that the aggregated
figures for the previously existing wider range of targets would
be available to the House of Commons' Library is not going to
be forthcoming?
(Professor Donaldson) No, I was commenting specifically
on the Health Improvement Programmes. There are clear targets
which are published both in the Public Health White Paper and
also in the priorities document that goes out jointly to health
and local authorities every year. The targets are clear. What
I thought you were asking me was how are people performing against
those targets and, as I say, that is something that is dealt with
through the management process.
71. You are telling me that we are publishing
the targets on a national basis but we are not publishing the
outcome of people's efforts in striving towards those targets.
Is that what you are saying?
(Professor Donaldson) There are some publications
of performance against targets but as far as a comprehensive stock
take in one place that I can point you to, I cannot immediately
point you to a single document.
72. It might be helpful if you went over the
evidence that was given by the then Director of Public Health,
and I think the Secretary of State, who gave a clear undertaking
that making these targets a local responsibility was not going
to make them less important and would not mean that we would lose
sight of the national picture.
(Professor Donaldson) I do not think we are losing
sight of the national picture.
73. I had always understood the Health Improvement
Programme was the basis on which local targets were going to be
delivered.
(Professor Donaldson) The Health Improvement Programme
is a plan for what will be done at local level but, as I indicated,
we have various mechanisms for monitoring, including the high
level performance indicators which were mentioned in one of the
other answers.
74. Throughout this morning we have said that
things work best if they are initiated or owned at as local a
level as possible. I always felt that the Health Improvement Programme
brought together the various players: the local authority, voluntary
sector, carer groups, patient groups and, of course, the health
economy. I understood that those Health Improvement Programmes
were required to set particular targets of what they were going
to achieve. Are you saying that there is another set of targets
which are being imposed on, say, Primary Care Trusts to deliver
outside their Health Improvement Programme?
(Professor Donaldson) No, I think I am saying that
there is a national set of targets which in the context of local
Health Improvement Programmes have to be addressed together with
any more local initiatives that the local people formulating the
Health Improvement Programme decide that they want to address.
75. You are saying that you are collating the
outcome figures for the national targets coming from the Health
Improvement Programme but you are not collating the local targets?
(Professor Donaldson) They are looked at at regional
level as part of the monitoring of the effectiveness of the Health
Improvement Programmes.
76. That is a significant shift in what the
Minister assured us when we produced the national targets. The
national targets were for national delivery. The argument was
,and we accepted the argument,that it was unreasonable to, say
in teenage pregnancy, have a blanket requirement to reduce them
by four per cent in each locality because in some localities you
might well be aiming at 30 per cent and in others one per cent.
It would still seem an overall aggregated picture—
(Professor Donaldson) We do for teenage pregnancy—
77. It is not only teenage pregnancy. There
were 22 targets being monitored previously and we went down to
five. Now you are telling me there are a few more that you are
targeting. I do not think we have ever had a list of what is now
available on a national basis.
(Professor Donaldson) Certainly we can provide that.
I think I may be slightly at cross purposes and I would not want
to go any further without being able to give you chapter and verse.
Nobody showed me any statement.
Chairman
78. Does Dr Troop want to add anything?
(Dr Troop) We do collect many targets. We collect
teenage pregnancies, we collect smoking figures, so many of those
previous targets we are still collecting. I think what we thought
you meant was when they were setting local targets were we aggregating
those which was not quite the same thing. Certainly I have across
my desk a number of targets you have referred to so we can certainly
go back and check the full list. Certainly, as I say, things like
smoking and teenage pregnancy we collect.
(Professor Donaldson) Coronary heart disease, cancer.
79. Peter Brand's recollection is also my recollection.
I recall in a TV debate we talked about this point exactly. Certainly
it was my understanding that there would be a national collation.
Accepting the point that you have made and you agree with, clearly
having national targets compared with certain areas does not make
any sense at all. There are fundamental differences in those areas.
Perhaps you would have a look at this.
(Professor Donaldson) Yes. As I say, I do not want
to say anything that would be in any way misleading but I do not
know exactly what form of words was used to refer to all this.
I think it is covered but I am very happy to go away and check.
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