Select Committee on Health Minutes of Evidence

Memorandum by the Local Government Association (PH 62)


  The LGA fully supports the government's comprehensive public health strategy and the recognition of the importance of prevention within the development of the national plan for the NHS. We hope that the report of the Modernisation Action Team on inequalities and prevention will receive prominence within the national plan for the NHS when it is published later this year. Within our position of broad support for the strategy, we have the following concerns.

  1.  The LGA believes that the current framework for public health as set out in Saving Lives' Our Healthier Nation is unhelpfully dominated by medical thinking. This medical dominance leaves the framework inadequate as a way of understanding and responding to the broader issues involved in improving and sustaining the public's health.

  2.  Local Authorities through their community leadership role and their power for social, economic and environmental well-being should be required to lead the public health agenda.

  3.  The key strategic plans for a local area are the community plan and the health improvement programme. The community plan with its wider focus, is, in many areas used as the over arching strategic plan with the HiMP a critical subset of it. However the LGA recognises that in some areas the HiMP is used as the overarching plan. For this reason the LGA believes that NHS bodies and local authorities should be issued with clear guidance requiring a direct read between the community plan and the HiMP.

  4.  The LGA welcomes the development of Primary Care Trusts. However the LGA believes that the lack of elected member representation by right on local PCTs undermines the strategic link between local government and the NHS and removes an important line of accountability back into the local community.

  5.  The lack of co-terminosity between NHS and local authority boundaries remains a major obstacle to developing integrated action for public health. The LGA would like to see specific guidance given to the emerging PCTs requiring them to establish co-terminous boundaries with their local authority.

  6.  The overwhelming majority of authorities report a helpful relationship with the Directors of Public Health. However they are seen as strongly allied to the NHS agenda. The LGA believes that the advent of PCTs and the changing role of health authorities offers an opportunity to rethink the organisational home for this important function.

  7.  It is early days for the HDA. The LGA hopes that the agency will develop a strong focus on supporting local authorities and Regional Development Agencies in developing strategic plans to tackle health inequalities.

  8.  The LGA welcome the acknowledgement of the importance of public health with the creation of a ministerial portfolio. However there is widespread concern amongst our member authorities that this post has recently been downgraded in recent government changes. The LGA believes this ministerial post is critical to the delivery of the public health agenda and the maintenance of the profile of tackling health inequalities and the wider public health agenda.


  1.1  The LGA welcomes this opportunity to provide evidence to the Health Select Committee on public health. We would be delighted to have the opportunity to supplement this written evidence with verbal evidence to the committee.

  1.2  The LGA welcomed the recognition of the importance of prevention within the development of the national plan for the NHS. We hope that the report of the Modernisation Action Team on inequalities and prevention will receive prominence within the national plan for the NHS when it is published later this year.

  1.3  We begin by stating our support for the Government's comprehensive public health strategy. We are particularly supportive of:

    —  The focus on inequalities in health including a detailed response to the Acheson Report;

    —  A recognition of the broad social, economic and environmental determinants;

    —  Clear recognition of the need to regenerate health in local communities;

    —  Promotion of inter-agency and multi-disciplinary partnerships at local and national levels;

    —  Incentives for practical innovation;

    —  Coherent linkages with several new programmes and policy streams, a "joined up" approach;

    —  Forthright analysis of key areas of harm including tobacco.

  1.4  Within our overall position of broad support for the new strategy, we have a number of concerns about the priorities and focus of the public health strategy and of the implementation framework that it proposes.


  2.1  Debates about the definition of health have long bedevilled health policy. It is clear that Saving Lives: our Healthier Nation, the public health white paper accepts the premise that health is, to a large extent, politically and socially constructed. It is forthright in stating that:

    "In our new approach to better health, we want to break with the past. We want to move beyond the old arguments and tired debates which have characterised so much consideration of public health issues, including those who say that nothing can be done to improve the health of the poorest, and those who say that individuals are solely to blame for their own health."[1]

  2.2  We do not believe that the White Paper has broken with the past as comprehensively as these words suggest. The four identified priorities, cancer, heart disease and stroke, accidents and suicide prevention, are important in addressing major causes of ill health and premature death.

  However in isolation they reflect a somewhat constricted view of health carrying with it the imprint of old debates about whether health is more or less than the absence of sickness.

  2.3  The LGA has long promoted a view that health is demonstrably more than this. We believe that enabling people to maximise their potential for health and increasing the quality of life for individuals and populations is as important as increasing the number of years free from disease. The public health strategy may be the catalyst for analysis and action at local level but this cannot be taken for granted, particularly in the absence of coherent structures for delivering the national policy agenda at local level.

  2.4  We are convinced that the public health strategy would be more likely to achieve its aims if national and local government takes a forthright approach to addressing all of the factors that influence health, and not merely concentrate on the diseases and accidents which are the downstream manifestations of ill health and early death.

  2.5  We would have wished to see Saving Lives focus on the root causes of ill health, analyse their impact on distinct population groups and propose radical, comprehensive and multi sectoral action for reducing and eliminating them. We are disappointed that the many initiatives undertaken through Local Agenda 21, for example, have not been acknowledged within the White Paper and more importantly, that these have not been proposed as examples of how to develop effective approaches to improving and sustaining health at local level.

  2.6  Many of these are examined in detail in the Local Government Association publication Community Leadership and Community Planning: towards a community strategy for wellbeing,[2] which is an important supplement to the White Paper, providing detailed advice to local agencies in developing a community leadership approach to local health improvement.


  3.1  The White paper clearly promotes a understanding that health is much more than the mere absence of disease, yet its proposals fall considerably short of being an effective blueprint for achieving individual and population well-being.

  3.2  This is less a criticism than a recognition of the considerable work still to be done in translating our contemporary understanding of the conditions which create and sustain health into effective practical proposals and real innovation. It is of vital importance that all of those interested in public health are involved in developing this analysis. This is a challenge for the LGA and other bodies interested in improving and sustaining public health as well as for Government.


4.1  The "medicalisation" of the analysis and the framework

  A consequence of this evolving but still limited analysis is that the White Paper proposes a framework, which is still too focused on disease. We do not agree with those critics who suggest that all the priorities are disease areas. Indeed, it is hard to understand how accidents could be construed as a disease. However, the framework within which the key public health challenges are conceptualised is still dominated by medical thinking. Important as this is in the treatment and control of disease, it is inadequate as a way of understanding and responding to the broader issues involved in improving and sustaining the public's health.

4.2  A Focus on the NHS

  Saving Lives needs to be understood and appraised in the context of its links to its predecessor strategy, The Health of the Nation, (HoN). It has been suggested that Health of the Nation failed to achieve its full potential. It had negligible impact on national or local policy and was seen primarily as a health service initiative, which had little relevance or meaning to local government and other agencies. Nor did it cause any shifts in the behaviour of health authorities such as to bring about any major readjustment in investment or other priorities.[3]

  4.2.1  This failure to improve the publics' health, which is surely most dramatically expressed in the ever widening health gap between richest and poorest in the UK. Most of the current public health targets, the language in which the whole strategy is discussed, leadership and incentives relate to medical thinking and to the NHS. As a consequence the White Paper continues to reflect the "medicalisation" of thought and action in public health. Many of our most serious reservations about the strategy relate to this, and in particular, those which are to do with local planning structures.

  4.2.2  Against this background and specifically in relation to the specific concerns of this inquiry we offer the following information.


5.1  Community planning—a practical expression of leadership

  5.1.1  The community planning process provides a key practical mechanism for demonstrating effective community leadership for developing a sense of vision or direction and for integrating or "joining up" the work of various agencies at the local level. It is the vehicle for making connections, to promote long-term sustainable development.

  5.2.1  The NHS White Paper "The new NHS Modern—Dependable and the Public Health White Paper "Our Healthier Nation—Saving Lives" set out a statutory duty for health authorities to take lead responsibility to improve health and tackle inequalities for the people of their area.

  5.2.2  The Health Improvement Programme is the vehicle through which Health Authorities fulfil "their overall role to protect and improve the public health".

5.3 Similarities and differences

  There are some key difference as well as similarities between HiMPs and community plans. These can be summarised as:


    —  Both are developed in partnership with communities and other public sector partners and the wider community.

    —  Both processes should be as inclusive as possible.

    —  Both should focus on the broader determinants of health and aim to enhance well-being.


    —  the Health Improvement programme covers the geographical area of the health authority, this often encompasses more than one tier of local government or more than one local authority.

    —  HiMPs have a specific focus on tackling health inequalities while community plans to address the overall economic and social conditions which impact on community well-being.

    —  Progress against HiMP targets will be monitored by NHSE regional offices jointly with the social care regions and the government offices of the regions.

  6.2  Unfortunately too often community plans and HiMPs are developed in isolation from each other.

  6.3  The LGA believes that the HiMP process is a major opportunity for local authorities to create or strengthen partnerships and to achieve further influence over a range of health priorities. HiMPs and community plans together have the potential to direct the bulk of public sector investment at local level to actively create the conditions and opportunities to deliver well being for a community.

  6.4  For this to occur there must be rationalisation and streamlining of the local planning process and clarity about leadership of various parts of the agenda. It is clear from our earlier comments that we believe that local authorities, through their community leadership role should be required to lead on and take ownership of the broad public health agenda whilst NHS agencies should continue to lead on those issues which are their traditional concern and for which they have expertise.

  6.5  We believe that this would be a rational and appropriate division of labour, enabling the NHS to continue to do what is best and ensuring that local authorities bring all of their formidable resources to bear on delivering the public's health.

6.6  Current Arrangements

  6.7  A wide range of mechanisms are beginning to emerge at local level to ensure synergy between the development of local HiMPs and the Community Planning process.

  6.8  A major issue is the lack of co-terminosity of Council boundaries with those of health authorities, and the emerging PCTs. This is often forcing a division of labour within local arrangements with for example Health Authorities providing an overarching strategic framework, frequently focused on disease group priorities through the HiMP whilst local authorities within the health authority area focus on health inequalities and client groups at Borough level. (Hammersmith and Fulham, Welwyn, Hatfield)

  6.9  The arrangements that are beginning to emerge for managing this division of labour can be broadly categorised as:

    —  Those relying on existing joint planning structures in which work on both local plans develops as two separate streams of activity but including varying levels input and development from other agencies. (Hackney, Nuneaton and Bedworth) Within these arrangements, it is clear that many localities are finding it necessary and useful to pull together some aspects of their planning and are attempting to ensure coherent linking of community plans with HiMPs. (Kingston, and Haringey) However, in many cases the HiMP and the Community Plan are developed separately and are not formally connected. In addition, arrangements for representation of local authorities on HiMPs Planning groups are not yet robust and in a number of cases, local authority input has yet to be agreed.

    —  Those which have developed new, integrated structures for developing and combining local plans. Several Councils are now involved in variants of Partnership Boards or Community Leadership Forums, involving all sectors of the community to develop action to improve local population health and to ensure integrated planning and delivery of essential services. These new structures effectively abolish existing joint planning arrangements, replacing them with new powers of partnership and new structures for delivering the partnership agenda. These new structures assume a number of local formations, but share the same objectives. Partnership Boards or variants of them exist in eg Brighton and Hove, Kirklees and Kingston.

  6.10  Within both sets of local arrangements many authorities are leading the community involvement at a neighbourhood level establishing joint local "fora" to develop particular aspects of the Health Improvement Programme in consultation with local people and community agencies.


  7.1  Notwithstanding progress on developing effective local arrangements, local authorities overwhelmingly report that they are attempting to work within local HiMPs partnerships in a vacuum, with no feedback from central government about processes or performance on targets as this is fed through health authorities. As a consequence, local authority members are distanced from HiMPs, seeing it a "health service issue", which has nothing to do with local government. The lack of any guidance for the NHS on the appropriate levels of involvement for the three tiers of local authority—County, District and Unitary—reinforces this feeling. As a consequence, there is a lack of synergy between the HiMP and the Community Plan in many cases.

  7.2  The proposal in the Social Exclusion Unit's National Strategy for neighbourhood renewal for Local Strategic Partnerships, based on local authority boundaries provides a useful approach to across the board planning at a local level.

  7.3  There is a strong case to argue for more concrete links between health and other Government priorities, particularly education, regeneration and social inclusion and a suggests a number of developments at local level to make this linking a practical reality.


  8.1  The proliferation of local area initiatives and geographically based "zones" reinforces the need for the community planning mechanism to provide a clear strategic framework within each local area. The LGA does not believe that the multiple bidding processes and the proliferation of different targets and outcome measures involved create the environment or the wider strategic framework for maximising the benefit from the large amount of resources being made available to local areas.


  9.1  It is clearly of critical importance that Direction of Public Health and senior local authority members and chief officers regularly meet together to discuss and agree local strategies. However, local arrangements are once again very variable, dependent on the commitment of key individuals.

  9.2  Local authorities report generally good relationships with the local DPH. However the role is seen as strongly allied to the NHS agenda. The advent of primary Care Trusts offers an opportunity to rethink the role and organisational home for this important function. The LGA would be happy to expand on this point in verbal evidence to the committee.

  9.3  Local authorities are developing new skills and new capacity to pursue the public health agenda effectively, including skills in health needs assessment, evaluating the health impact of strategies, projecting future needs and evaluating evidence of effectiveness. These are not currently held within the repertoire of local government but are seen to be core to the health function. It is vital that these skills are placed at the disposal of local authorities as well as health authorities. In this sense, local authorities are concerned with their relationship to the public health function rather than to the DPH as an individual.

10.  PCTS

  10.1  The LGA welcomes the development of Primary Care Trusts. Some authorities report active involvement from PCG/Ts particularly in relation to citizen involvement. The LGA believe that the public health agenda is undermined by lack of co-terminosity of PCTs with local government boundaries. In addition the lack of elected member representation on PCTs by right significantly undermines the strategic links between local government and the NHS.

  10.2  The LGA believes that clear guidance is needed for PCTs to work with their local government colleagues to develop citizen involvement and consultation mechanisms. In some areas this is already developing, however it is essential that this work is developed to underpin the development of the community plan and the HiMPs.


  11.1  The LGA welcomes the shift in focus signalled by the establishment of the HDA. However a number of authorities have expressed concern that some of the HEA programmes, such as action around mental health may be lost in the transition. The LGA hope that the focus of the HAD will be on supporting local authorities and Regional Development Agencies in the development of strategic plans to eradicate health inequalities.

  11.2  The LGA believes that there is a real danger that the HAD will become focused on activity within the NHS. The proposal for the regional HAD posts to be reporting to the regional directors of public health is a cause for concern.


  12.1  The LGA welcome the acknowledgement of the importance of public health with the creation of a ministerial portfolio. However there is widespread concern amongst our member authorities that this post has recently been downgraded in recent government changes.

  12.2  The LGA believe this ministerial post is critical to the delivery of the public health agenda and the maintenance of the profile of tackling health inequalities and the wider public health agenda.

November 2000

1   Saving Lives: Our Healthier Nation (1999) page 6. The Stationery Office, London. Back

2   Ibid. Back

3   The Health of the Nation-a policy assessed. (1998) The Stationery Office, London. Back

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