Memorandum by the Local Government Association
(PH 62)
SUMMARY
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. INTRODUCTION
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. WHAT IS
HEALTH?
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. A DEVELOPING
ANALYSIS
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. THE CONCERN
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. LOCAL ARRANGEMENTS
DEVELOPED TO
MANAGE COMMUNITY
PLANS AND
HEALTH IMPROVEMENT
PROGRAMMES
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. WORKING IN
A VACUUM
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. INTERACTION
OF ACTION
ZONES
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. THE ROLE
OF THE
DIRECTOR OF
PUBLIC HEALTH
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. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
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. THE ROLE
OF THE
MINISTER FOR
PUBLIC HEALTH
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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