Examination of Witnesses (Questions 332
THURSDAY 7 DECEMBER 2000
332. Can I welcome you to this morning's session
of the Committee and begin by welcoming Siobhan McDonagh to the
Committee. Can I also welcome our witnesses and thank you for
submitting your very helpful written evidence. I would ask you
each to briefly introduce yourselves to the Committee.
(Mr Town) My name is Chris Town. I am
Chief Executive of North Peterborough Primary Care Trust, but
I am here today representing the NHS Confederation.
(Mr Panter) David Panter, Chief Executive of the Hillingdon
Primary Care Trust, again representing the NHS Confederation.
(Mr Ransford) I am John Ransford, Head of Social Affairs,
Health and Housing from the Management Board of the Local Government
(Cllr Stringfellow) I am Rita Stringfellow, Chair
for the Social Affairs and Health Executive of the Local Government
Association and I am also a North Tyneside Councillor.
333. Can I begin by basically exploring the
definition of public health and, particularly to the LGA, ask
you about your evidence where you state in paragraph one of your
evidence that the current framework for public health set out
in saving lives is "unhelpfully dominated by medical thinking.
This medical dominance leaves the framework inadequate as a way
of understanding and responding to broader issues involved in
improving and sustaining the public's health." Can you explain
what you mean by that and what the implications are of that assertion
for where we go from here?
(Cllr Stringfellow) One definition we might look at
is something like a society movement to improve the health of
the population and, therefore, that action on all parts of society.
I think we see that there are very many things that influence
people's health and perhaps 70 per cent of the health impact in
people's lives is not directly to do with a medical analysis.
I think we see the value of joining up all of the things that
impact on health, for example, education, leisure, housing, transport,
environment, planning, safe community issues, and certainly there
are many examples across local authority where the concerns that
people have are about environmental factors that do have an impact
on their lives.
334. Certainly your Association has set out
an argument in respect of rolled-up Government on public health,
and one of the debates we have had is whether it was wise in 1974
to shift the public health function away from local government.
Some of the witnesses that we have had in the inquiry so far have
said that moving the public health function back into local government
would not be particularly helpful, because local government has
changed since 1974. How do you react to that?
(Cllr Stringfellow) I think the whole world has changed.
I think the Local Government Association's view would be that
we do not seek to take over the management of public health, local
solutions are going to be most effective, but certainly we see
ourselves as having a very strong community leadership role in
bringing together all of the strands that I mentioned in my previous
335. How do the Confederation feel about this
(Mr Panter) I think, again, we would agree that the
public health agenda has to be carried forward on a partnership
basis and we have to separate out the public health awareness
and responsibility from the very narrow public health function
represented by public health doctors. In essence, where the management
of public health function sits in some ways is neither here nor
there. There are going to be different local solutions for that,
but that function must be supporting the broad range of organisationslocal
government, health, the voluntary sector and the business sectorin
helping to carry out their role in promoting public health.
336. Do you see, within your own membership,
different models from one area to another? We have Manchester
later on who have developed their own particular model. Do you
see it as being helpful that people can explore locally what is
most appropriate in their areas? From what you see developing
now do you see models that, perhaps, offer more merit than others?
(Mr Town) I think experimentation is always helpful
and this is a very complex area. I think the important bit is
that we recognise that it is not just about the medical aspect
of public healthpublic health consultantsbut the
wider public health input into the agenda, and that is around
health visitors, community development workers and people like
that. I think it depends on where you are. Certainly where I work
in inner cities it is about engaging all those people and using
the expertise that is available in the public health directorate
to support that rather than necessarily be the only people involved.
337. What about the specific role of the Director
of Public Health, because, again, in some areas, like my own,
the Director is based primarily in the Health Authority and some
of them have been talking about joint appointments and some have
joint appointments? What are your views on whether that role might
be more influential back in the local authority? I can recall
the very important role of pushing individual local authority
departments in a direction they would not otherwise have taken.
Should we be looking at that role in a new light?
(Mr Ransford) Certainly the important thing is how
they carry out that role most significantly and most essentially.
I think that is much more important than where they are based,
and that will vary from locality to locality. We see that as a
strength of the system. You are quite right, I can remember the
pre-1974 situation too, and the Medical Officer of Health was
not only a senior officer of the local authority but one of the
senior officers of the local authority with statutory powers,
the annual report was an extremely influential document and could
brigade resources, and that was clearly one of the major priorities.
I think we have all moved on considerably in the last quarter
of a century and it is quite possible to have that sort of influence
in different places, because organisations are so much more fluid.
As others have said, the concept of partnership is so important
that the individual organisational base should not be as essential
as it was. Including public health is such a long-term agenda,
so you have to look at distant horizons as well as immediate ones
in order to make things work.
338. From the LGA's point of view how do you
see the medical model folding back addressing the wider public
health issues, because this, in a sense, links to the previous
(Mr Ransford) Quite simply, in a way, the medical
model comes with a series of culture, of understanding, of knowledge,
of practice, which are absolutely essential to the processno
one would argue against thatbut are only part of the process,
because health, as Councillor Stringfellow mentioned earlier,
can only be proved by a range of functions working together. So,
again, it is about the way in which those essential skills are
practised and that role is seen as part of a team work approach
and not as something which is separate from the rest of the organisation.
Again, it seems to me it is getting the purpose of that right
and seeing the essential and appropriate place of the medical
model within improving public health. It is almost as ludicrous,
it seems to me, to say that a medical model is what should determine
public health as that health is an NHS agenda. Of course, health
is part of the NHS agenda, but it cannot deliver better health
on its own.
339. The Confederation would agree with that,
(Mr Panter) I think that is absolutely right, and
I think certainly from my own experience and my own new organisation,
the group of staff that are finding a new lease of life is the
health visiting workforce. They have training in public health,
they are doing public health on the ground at a micro level on
housing estates, and yet they have often been excluded because
they have a different approach to that medical model. So, I think,
even within the health sector itself the medical model is only
part of what is required.