Examination of witnesses (Questions 80
- 98)
THURSDAY 20 JULY 2000
PROFESSOR LIAM
DONALDSON, DR
PAT TROOP
and DR RUTH
HUSSEY
Dr Brand
80. One final point. Where do you think the
Health Improvement Programme should be owned? Should it be at
health authority level or at Primary Care Trust level or indeed
in the local authority area? It is a silly question for me to
ask because the Isle of Wight is as coterminous as you could possibly
get. You need to have a unit of population which can feel they
are participants in this programme.
(Professor Donaldson) I think the leadership of the
Health Improvement Programme rests with the health authority to
bring all parties together who have responsibility for that population.
Increasingly, I think the Health Improvement Programme is regarded
as jointly owned. I do not think we have a hierarchy in the way
that we look at the health, local authority and other partners
together.
81. What is the ideal size of population? You
are talking about Primary Care Trusts or Groups being 100,000.
I think health authorities are getting bigger, they seem to be.
You are talking about health authorities being a few million.
What is a reasonable size for a Health Improvement Programme?
(Professor Donaldson) I would not like to put a figure
on it but certainly it needs to be bigger than a Primary Care
Group because there are needs in the population which will not
be present in large enough numbers in a population of only 100,000.
I would not like to put a precise figure on it.
Mr Austin: Can I just come in on that. With
the changing structure and the move to PCTs, Dr Brand has referred
to the increasing size of health authorities. I would like to
pose the question do we need health authorities at all? Is their
function completely redundant now? Could not everything they do
be done perfectly well by the PCTs working with local authorities?
Dr Brand: You would have to have more active
regions.
Chairman: Any comments from anybody? We can
debate this in the Committee but we would like your comments?
Mr Austin
82. It seems an unnecessary tier of bureaucracy.
(Professor Donaldson) I think the point is that you
have to take into account the regions as well if you are going
to change. I believe you do need a strategic body and I think
there are planning functions, there are multi-agency functions
which are larger than would be present at the PCT level. I think
you do need another tier. I think we are in the fortunate position
of being able to see how these new bodies develop and judgment
about that does not have to be made yet.
Mr Hesford
83. In terms of HImPs and the planning cycle
around HImPs, the backbench group on Primary Care Public Health
here took evidence on the effectiveness of HImPs. One of the points
which came across very, very strongly was running the HImPs along
with community plans, the planning cycle should be the same three
years. In effect the community plan and HImPs should be merged
into one and the same thing. Do you have any comment?
(Professor Donaldson) I think there would be great
advantages in doing that.
84. Is that likely?
(Professor Donaldson) I do not know but I think there
would be great advantages in doing that.
85. Just on something slightly different. This
is to Professor Donaldson. Public health infrastructure, what
has happened to the review of public health infrastructure, an
interim version of which was published in 1998?
(Professor Donaldson) The report has been completed
and it is with Ministers.
Mrs Gordon
86. Many of the memoranda put the case for fluoridation
of water supplies as an extremely effective way of improving oral
health and reducing oral health inequalities. I am sure there
is still quite a lot of controversy about this. To what extent
is this a real priority of Government?
(Professor Donaldson) The Government, as you know,
has flagged this up in the Public Health White Paper and has commissioned
a review of the evidence from York University. That is due very
soon, we think certainly within the next month or so, and then
decisions will be made about it after that.
Mr Gunnell
87. To what extent do mechanisms of surveillance,
monitoring and rapid response remain in place for tackling communicable
diseases?
(Professor Donaldson) I think we have a good system
of surveillance for communicable diseases but it is in need of
some change and modernisation. I am chairing a Communicable Disease
Strategy Group and that will be one of the strands of work that
we will be making recommendations about. Our basic system of surveillance
is through the Public Health Laboratory Service. It has two branches,
one to do with the running of laboratories themselves and the
other is the Communicable Disease Surveillance Centre based in
Colindale. The Communicable Disease Surveillance Centre is internationally
regarded and over the years has provided very, very good information
on communicable disease problems in the population and on occasions
has been able to help in the solution of international outbreaks.
The main issue is to make sure that system of surveillance does
not get left behind in all the changes which are occurring in
the diagnosis of communicable disease and so on. There are a lot
of developments in that field. Within the next few years it may
be possible for a general practitioner to be able to test for
the presence of an infection using a microchip and maybe to get
a genetic profile of that organism. With those changed ways of
diagnosing and capturing information we need to make sure that
we have a surveillance system that is connected to that. That
is one of the aims in the Communicable Disease Strategy. The short
answer to your question is I think we have very strong foundations
in this country, much better than some other countries, but we
need to make sure that we continue to invest and develop it.
88. Let me just ask as an example, what about
Hepatitis C?
(Professor Donaldson) That is a relatively new disease.
It is not a new disease but it has been recognised relatively
recently. One of the areas of Colindale's work is monitoring blood
borne viruses and you need quite specialist laboratories to be
able to profile those organisms. That is one of the things that
is well covered. An area which I think has been less well covered
is antibiotic resistance, we do not have particularly good surveillance
on that, so that is an area which needs to be strengthened.
89. Thank you. You are satisfied that the structures
are in place for you to do what you want to do and to develop
what you want?
(Professor Donaldson) Yes, but the importance of the
strategy will be to make sure that they are developed further.
90. That is nationally funded from the centre?
(Professor Donaldson) Yes.
Chairman: Do any of my colleagues have any further
questions?
Mr Austin
91. Can I ask a quick question about accident
prevention. It seems to me that there is a disjointed approach
to accident prevention with prime responsibility being with DTI
because that is where the safety officers relate. Is there an
argument for a Government department, a single department, having
responsibility for Government strategy in relation to accident
prevention and, if so, where should it be?
(Dr Troop) This is one of the areas where there is
a lot of joint working across departments. We have people in the
public health group in the Department of Health who work closely
with colleagues in DETR and DTI. Although there are different
strands to the programme there is very much joint working. Because
different parts of the accident programmes have different facets,
for example there is the Walking to School Initiative, we work
closely with the DfEE and in areas where we work with the elderly,
for example, we work closely with the DETR. We also work closely
with the Health and Safety Executive. It is one of the areas where
a number of different organisations need to be active in the programme
and so we do work across different Government departments. It
could be lodged in any one of those departments but, in fact,
that close working seems to bring those issues together.
Dr Brand
92. Can I just pick that up in relation to the
Health and Safety Executive. Is there now a little bit more joint
working between the Department of Health? It was quite clear when
I had an Adjournment Debate the risk that people run of being
exposed to agro-chemicals was very difficult to determine because
the right tests were not done at the right time people were exposed.
I was told that there was a Red Book which gave all the answers
but there was not one available in my constituency. Obviously
in theory there are working parties but in practice the practice
is not disseminated enough to patient level.
(Dr Troop) We are strengthening those relationships.
I now meet on a regular basis with the Chief Executive of the
HSE so we are beginning to identify those areas where we need
to work together. We have very close joint working on the Health
at Work Initiative, which has been a joint initiative so again
that is beginning to work across different sectors of industry
to identify where we need to work closely together. As you know
they have now set up the new Occupational Health Programme and
they have set up a board and I am a member of that programme board
which is just about to be set up. We are working very hard to
pull all those different initiatives together. We do have strong
advisory networks at that national level but that, if you like,
implementation level we are just beginning to strengthen.
93. You will make sure that the information
gets down to patient level?
(Dr Troop) Very much so.
Mr Austin
94. Is the Accident Task Force up and running
yet?
(Professor Donaldson) We have identified members.
We have not started work yet.
Mr Hesford: It may be thought that if there
was a person on the Clapham Omnibus listening as a third party
that we have concentrated a lot on structures this morning. Perhaps
that was inevitable.
Chairman: We like structure on this Committee.
Mr Hesford
95. Understandably we have concentrated so far
on structure , rather than reality of determinants and inequality
in health. Taking income inequality, would you accept that is
a major determinant in inequality in health? I understand from
listening to Professor Whitehead, for example, on the continent
the model over there is to basically avoid looking at income inequality
and they look more at structures which might be one of the areas
of difficulty we have looked into this morning. Could you tell
the Committee more about what cross Government action there is
on income inequality, looking at what actually affects people's
day to day lives?
(Professor Donaldson) The research evidence shows
that internationally income inequality and health inequality are
very closely associated. I do not think I am in a position to
comment on economic policy.
96. In terms of, for example, the New Deal,
would that tend to have an effect on income inequality in the
sense formerly long term unemployed are now working; Sure Start,
disadvantaged children who otherwise would not have accessed education
in the way they might otherwise access education; the minimum
wage, people working on poverty wages who might now have economic
activity they formerly did not have. Do you see those are important
policies in determining long term inequality in health?
(Professor Donaldson) I think they are very important.
They are examples of the sort of other Government department initiatives
which have a bearing on health. There is no doubt that if education
or employment income opportunities are increased then more people's
health will be improved, yes.
97. Would it be a professional view that those
are as important as any of the structures that we have talked
about this morning?
(Professor Donaldson) I think the structures are the
least important thing. The two areas which are important are the
underlying factors that you have mentioned and some of the ones
that we mentioned earlier, adding in the environment, education
and so on, and the individual risk factors and things that affect
people's health directly. As you say, it is the way in which we
work together to address those things, not the structures, that
is important.
Chairman
98. Are there any further questions from colleagues?
Are there any areas that you want to add that we have not touched
on that are relevant to this inquiry?
(Professor Donaldson) No, Chairman. If it is not presumptuous
of me—I am sure you have already decided your list of witnesses—as
far as somebody who has a very great knowledge of the research
and factors in the area of inequalities, Sir Michael Marmot is
one of the national figures in this field. I would recommend that
you take some evidence from him.
Chairman: We are so well organised he is on
the list already. You have undertaken to drop a line on one or
two points. Can I thank you once again for your evidence and for
being here today, we are most grateful to you. Thank you very
much.
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