Examination of Witnesses (Questions 340
- 359)
THURSDAY 7 DECEMBER 2000
MR CHRIS
TOWN, MR
DAVID PANTER,
MR JOHN
RANSFORD AND
COUNCILLOR RITA
STRINGFELLOW
340. It is interesting that you mention the
health visitors, because we have discussed at some length the
health visitors. I certainly recall working in Social Services,
as you did, Mr Ransford, before 1974 when health visitors had
a very important role in the community, and I have often asked,
"Whatever happened to health visitors?" We actually
discovered a few in this inquiry and it is interesting that you
make that point. Going on to the issue of the medical model, one
of the arguments that we have had put to us, relating not so much
to the local organisation, but the national organisation, is that
the location of the Public Health Minister in the Department of
Health needs that public health function and is dominated by that
model within the Department at national level. How do you each
see the role of the Public Health Minister currently—I do
not mean the person, I mean the actual function—to be located
within the current Department, for argument's sake it ought to
be a Cabinet position, free ranging across the departments rather
than being located in one specific department, would you share
those concerns and if so, what would be your ideal location for
the Public Health Minister?
(Cllr Stringfellow) I think just as much as it matters
at local level that Government is joined-up, so it does at national
level, and that the Public Health Minister has a very strong influence
on colleagues across other departments. To some extent I think
where the Public Health Minister is located should not matter
if that is actually happening effectively, but we obviously do
not know whether, perhaps, after the election there might be some
change in the make-up of Government departments and there might
be some opportunity, perhaps, to look at that in a slightly different
way than we are able to do at the moment. I think what is important,
and the LGA thinks is important, is that there is that capacity
for joining-up and that there is an influence across all departments
and that departments actually engage in the public health agenda.
Maybe the bigger task is actually awareness raising around the
importance of public health.
(Mr Panter) From the Confederation's point of view
I think that what we are learning to do within the NHS is increasingly
becoming focused on outcomes and then putting the structures in
place to deliver that outcome. So our concern would be that the
Public Health Ministers needs to be in a position where the Government's
outcome that they desire can be best delivered, but that is for
the Government to decide where they can be delivered to achieve
the outcomes that they want. Then it is reiterating the LGA's
perspective about the joined-up nature.
(Mr Town) I think only to add to that that in terms
of the performance management of the way we tackle these public
health issues, again, a joined-up approach which could be focused
in on one minister would be very helpful to the Service.
Dr Brand
341. Do you think it is helpful that that minister
is always going to be subsidiary to the Secretary of State for
Health, we are talking about resources as well? What are the priorities
of the Secretary of State for Health, that is really the question?
(Cllr Stringfellow) I would hope, Chair, that the
Secretary of State for Health, indeed, does and would have a very
strong view about the importance of public health. How that might
happen in the future is difficult to predict, but that is the
important point, not so much the status as the importance of the
issue.
342. I asked that question of Frank Dobson when
he was Secretary of State for Health and he said he was the Secretary
of State for the National Health Service. Now, that is an acute
service. As in illustration of the medicalisation of the public
health role, I think it is pretty negative to leave it under the
Health Service. There is a problem which I think one of you has
touched on which is that the public health role, 78 per cent is
to do with the visionary joint working and influencing of other
departments, but of course there is a very distinct element which
is control of communicable diseases and immunisation policy and
that sort of thing. Do you think that those two roles traditionally
have gone together under a medical model is now stopping further
progression? I have described it as the visionary verses the anorak
function or directors of public health.
(Mr Ransford) It is certainly why we submit that the
medical model is very important, because, of course, there are
essential functions for the health and safety of the public really
which must be preserved. It does not necessarily mean that the
same person or the same function has to do both things, as long
as the links are explicit and clear. I suppose our experience
is that so often the skills and the experience needed for the
specific functions have dominated some of the visionary stuff
which can only be done on a horizontal basis across communities,
across services, across Government. Whilst, in terms of your earlier
question, I think it is very important that the Secretary of State
for Health has a view of public health and how to resource it,
so is it essential for the Secretary of State for Education and
Employment to do that, the Secretary of State for Environment
and Transport and the Regions to do that, and so on, because it
is so essential to the society in which we live. So, yes, of course,
the function is important, but does it need to be linked to the
same person in the same place?
343. Basically you are saying that, for example,
the control of a meningitis outbreak does not need to rest specifically
with your Director of Public Health if he is employed within the
local government system?
(Mr Ransford) That is right. You can have responsibility
and accountability in different places from actual action. I think
we have got away, and will increasingly get away, from the strict
organisational boundaries to task and function. Some of the best
examples are in joint working between health and local authorities
about ensuring that partnership achieves the outcomes, as David
Panter was saying, and not get tied up with the organisational
process and culture which leads to it.
(Mr Panter) If I can just give you a practical example,
again, from my own patch, Hillingdon. A key feature of it is Heathrow
airport, so we are a port health area having particular responsibility
for health control. We are currently exploring the use of Section
31 of the Health Act flexibilities to bring together the environmental
health component of the local government and the communicable
diseases component of the Public Health Department. Actually at
Heathrow airport those two groups of staff work side by side—they
are employed by two different organisations—and it would
be far more effective if they are working together. I think what
we are trying to recognise is that actually, like with most medical
specialties, public health has sub-specialties of communicable
disease, and, in fact, the lead in my part of the world on communicable
disease has very little to do with that broader health agenda
because all of their time is about communicable disease, which
is a very tiny sub-set. So we are exploring using the Health Act
to merge those two elements together.
Dr Brand: Perhaps when we are exploring the
position we should be more specific about what functions of the
Public Health Department we are talking about. There will be some
which are comfortable across departments and some which will remain,
presumably, the responsibility of the Secretary of State for Health—communicable
diseases clearly should be—but if it is a shared concern
with the Secretary of State for Education, it is difficult to
know which should take the lead.
Chairman
344. Can I just ask a specific question? With
the future control of health authorities being uncertain, what
would be your objections to shifting the current remaining health
authorities' functions into local government, and in a sense,
getting back to partly where we were pre-1974?
(Cllr Stringfellow) There must be an issue about whether
it is good to go on having more and more changes.
345. We are moving now towards PCTs, PCT function,
on-going work of district health authorities. Certainly in my
part of the world there is a huge debate going on, a heated debate,
about the future role of health authorities and certainly whether
their role should cover a much wider area than currently is the
case. I wonder what your objection would be to what I have just
proposed, particularly as the Government are looking at strengthening
the role of local government in monitoring the operation of the
NHS?
(Cllr Stringfellow) One of the things I was going
to say is that there is a move to merge health authorities and
have wider commissioning organisations and, of course, commissioning
is going to pass to PCTs ultimately. I just want to make it clear
that from the LGA's point of view what we are not seeking to do
is poach a particular territory, but simply to say that we can
see that working across, as we have described, with health colleagues
and working in partnership, working in a joined-up way, may well
achieve the same objective as actually having health authority
functions moved into local authority. I think we want to keep
an open mind on that.
346. So you are not arguing for the possibility
of moving a function into local government, which, of course,
was the position of your predecessor organisation some years ago,
as I remember? So there has been some fundamental change. Why
has there been that change?
(Cllr Stringfellow) I think the whole modernisation
agenda has led to, perhaps, a different attitude, a different
context about being less constrained by the organisational dictate
and structures and actually looking very much at what works best
and what is going to be appropriate in the local situation. I
do not think that right across the country simply moving health
functions into local government would necessarily resolve some
of the issues and barriers that there may yet be. It is about
working together wherever people are placed.
347. We have looked at the future of NHS and
the argument we are getting very strongly is that public health
is a much wider issue than health as we define health. I cannot
see any argument against looking seriously at shunting the entire
function back into local government, which takes account then
of what is in the national plan about the local government health
service, they will then have a clear function which will surely
resolve some of these anomalies in the whole operation of public
health?
(Mr Panter) If I can again just to try to illustrate,
I think the concern of the Confederation has been that we need
to make sure that there is the appropriate critical mass of public
health expertise and, therefore, much more inclined towards looking
at a public health resource centre type of approach. In my own
case, in my own area, there is a health authority, there is a
PCT and the health authority is en-route to merge with other health
authorities, but we only have two public health consultants and
a communicable disease consultant. Those two public health consultants
draw upon a broader group of consultants across west London to
share expertise and network, and what we are looking at is creating
a single public health resource centre for all of west London
which could then support all the boroughs and the health organisations
within west London. I think there is a danger that if public health
is confused with the public health individuals, those medical
consultants, there is simply not enough of those consultants to
go around in terms of providing adequate support. So there is
something still in there, for me, about how you separate out the
public health function from the public health individuals, particularly
medical consultants.
(Mr Town) I will just confirm what my colleague says.
I think there is certainly a need for strategic planning authorities
within the National Health Service as we develop services, as
we introduce the modernisation plan, and I sense equally that
we have very limited resources and there would be some confusion,
I think, if we were to split it up into the current structure
of local government.
John Austin
348. Are the local health authorities not now
redundant? What do you perceive as their role? I do not think
the NHS plan talks about the performances management of the modernisation
agenda, whatever that means, but what is their role?
(Mr Panter) I think, as somebody who has moved from
being a health chief executive to being a Primary Care Trust Chief
Executive I have seen both sides and I believe very strongly that
the majority of the current role of health authorities quite rightly
migrates to Primary Care Trusts, and health authorities need to
pick up a new mantle around a broader strategic planning role,
partly performance management, but with that broader strategy.
If Primary Care Trusts are going to work well they need to work
well on smaller populations, ideally co-terminus with local government
structures, to get the integration with social care. Health authorities
need to pick up those strategic issues which require much bigger
populations. So I think, as the modernisation agenda sets out,
creating health authorities covering one and a half million population,
there are bigger strategic issues that need that size of population
and the PCTs cannot pick those up, it is beyond their scope. I
think there is a clear role for that structure. One could then
argue about how that fits with the current regional arrangement
within the Health Service.
John Austin: The local role is the inter-relationship
between the local authority and the PCT and not the health authority,
which does beg a question; if you say that the health authorities
are too small for the strategic planning role you are suggesting,
therefore, amalgamation of health authorities. What is the role
of the region?
Chairman
349. That is a tough question, John.
(Mr Panter) I think from the Confederation's point
of view it is a legitimate question that is still to be explored,
because until we can define—
350. It is a diplomatic answer as well.
(Mr Panter) The problem at the moment is that we are
still trying to explore what the role of the health authorities
are beyond the broad headlines that are set out.
John Austin
351. Could the region be the one responsible
for the strategic planning and the oversight of performance management,
and the local authorities, in collaboration with the PCTs, is
delivering the local plan?
(Cllr Stringfellow) In relation to the point that
you have just made about the region, can I say that we do have
a problem about regional boundaries, because if we are looking
at public health and bringing all of the strands of services and
planning together. Of course, for example, in the north the government
office boundaries are quite different from the NHS executive boundaries,
which has been further compounded recently with the National Care
Standards Commission and Social Services' inspectorate functions
mirroring the NHS executive boundaries. That is not a direct answer
to your question, but it does make the point that it would be
very helpful if we had co-terminosity at a regional level. If
I could, perhaps, pick up more specifically, I represent residents
in north Tyneside, which is part of the Tyne and Wear conurbation.
Under regional arrangements at the moment there are four sub-regional
partnerships—Tyne and Wear is one of them—and I have
to say that I am not making a bid for there being wholesale merger
of health authorities, but there is certainly some sense in looking
at health on the same basis as we are looking at learning, and
skills councils, connections, small business service, single regeneration
budget funding from the Regional Development Agency and European
funding, so there is a synergy at that level that health could
do well to be part of.
352. I am still not convinced about the role
for the Health Authority, because I think the example that you
put forward is a coming together of agencies who are responsible
for delivering services. It seems to me that the Health Authority
does not have that role. Why not? It cannot be agencies coming
together.
(Cllr Stringfellow) It is delivering and enabling
as well. It is not simply delivering a role for all of the agencies
that I have just mentioned. A lot of that is about enabling and
providing the glue for things to stick together.
353. Then my question is: If that is the role
of the Health Authority, are they equipped and do they have the
necessary skills to do so?
(Mr Ransford) Certainly it is
not the Local Government Association's position to comment directly
on the role of the Health Authority except in as much, of course,
as it impacts on local government and local government responsibility.
Of course, all of these organisations at that strategic level
are multi-faceted. Yes, they are delivery agencies, but they are
also planning agencies, they are also relating the needs of the
population to the services they have provided, they are responsible
to work together to get more from the whole, and clearly health
is a player at that table, and an essential player at that table,
and with some of the more local partnership as well, community
safety and drugs and a whole series of other joined-up bodies.
What organisation the Health Service has as to support that is
a matter primarily, I suppose, at the beginning, for the Health
Service, but it is very, very important that health is a player
at all of those tables.
(Mr Town) I think the issue at the moment is that
the existing regional health authorities are very large in terms
of the population that they serve and Primary Care Trusts are
very small in terms of the population that they serve. I would
certainly feel that at the time being there is a need for an intermediate
organisation which brings together things like clinical networks.
We are starting to see significant specialisation in a number
of areas of medicine where we need to get teams of people working
together across existing NHS organisational boundaries. The health
authorities certainly have a role to play in that. Currently they
have a significant role to play in managing the Family Health
Service function, the GPs, pharmacists and people like that who
have separate conditions. There are complaints functions and there
are a number of statutory functions that, in my view, would be
lost if it was too remote and became part of an organisation that
was looking at four million population.
Dr Stoate: Mr Austin is not totally convinced
about the future of the Health Authority.
John Austin: Going by his own experience.
Dr Stoate
354. I would like to look more at the Primary
Care Trusts in that case, because if we are going to have structures
we need to make sure that these are robust, particularly as the
structures are clearly changing rapidly and it is very important
that we ensure that there are no gaps and problems. I would like
to start with Mr Panter and pick up on something from your own
Confederation's submission to us. You said; "Before the establishment
of PCGs and PCTs, primary care in the NHS had neither the structure
to enable a more forward looking approach to address wider community
health needs, nor the mechanisms to meaningfully influence strategic
planning." That was from your own comments. How successful
are the PCTs likely to be in the reduction of the qualities? You
are saying in your submission that GPs surgeries previously could
not really deliver a public health function, which is fair enough,
so what makes you think that PCTs can do what the old GP service
could not?
(Mr Panter) I think it is still early
days, but certainly what is beginning to happen is that Primary
Care Trusts start to put a support framework around general practice,
which enables them to work collectively with each other, drawing
upon their practice experience, but pooling that to get a wider
perspective. Also we are clear that a key role for the GP is not
necessarily to focus on public health, there are a lot of other
important things that they have to do. So, again, it is those
GPs working as part of a broader team that, as I say, in our own
experience in Hillingdon, are the real champions of public health
and keep them on the agenda and keep raising it and forging ahead.
They are now feeling liberated and empowered in an entirely different
way than they have before. When you start to combine that with
some of the potential we have through the Health Act to work across
into local government, again starting to do things differently,
then I think that that does put general practice and GPs in a
stronger position to influence. Clearly it is still early days,
but so are the nine months in Hillingdon, then we can start to
see some of those things that are starting to have an effect.
355. I accept what you say, except even your own bit evidence
seems to slightly contradict that, and it says, "It should
be recognised that it is entirely reasonable from new primary
care organisations to concentrate their main efforts on developing
and improving primary and secondary care services and delivering
clinical governance", which rather damps down this function
of public health. I am a little bit concerned about the those
two slightly contradictory statements.
(Mr Panter) I think what that contradiction encapsulates
is that there is inevitably, in the way in which the modernisation
agenda is structured, room for flexibility to meet local circumstances.
I was giving you an example of my experience from Hillingdon where
we are currently the biggest Primary Care Trust in the country
with a quarter of a million population, we are-co-terminus with
a borough of London, we have taken into to the Primary Care Trust
about 95 per cent of the staff and functions of the Hillingdon
Health Authority, so we are in a very different position to engage
in some of that agenda than a much smaller Primary Care Trust
that might be around a rural town or community who is working
collectively, and my colleague may give you an example of where
two or three Primary Care Trusts are working collectively on a
very similar agenda.
356. I understand that, but my worry is that
you talked about Primary Care Trusts being a collection of GPs
and health visitors and so on, which is fine and you have also
talked about some functions of the Health Authority, which is
also fine, but how good are the links between your PCT and the
rest of the Government, because we have heard from the LGA, quite
rightly, that the real public health agenda is only very marginally
related to health delivery and it is much more related to education
and Social Services provision, housing needs, employment and social
exclusion? How closely can your PCT realistically influence those
agendas?
(Mr Panter) I think that we are currently waiting
on a decision on whether we can have beacon status for the work
that we have done with the local government on health strategy.
Because we are co-terminus with the borough and because they have
been a key partner in helping to shape the Primary Care Trust,
we have a series of connections across those other areas. For
example, we now also established a Scrutiny Committee for Health
in the borough, which is not only looking at the role of the Health
Service in the borough, it is also a way in which councillors
can scrutinise the other decision making of the local authority
around housing, education, leisure, environment in terms of health
impact to see whether or not it is in line with the overall objective
of the health within the population. So I think our first statement
as a Primary Care Trust has been to say we are very keen about
supporting that broader health agenda with local government and
we recognise that we are a small part of that.
357. It all sounds very warm and cosy. You say
you can scrutinise the other policies of the local council and
authorities, but how much can you influence them? It is all very
well saying, "We are looking at the housing agenda and we
are looking at what local authorities are doing about raising
taxes and spending", but how much can you influence those
things, because unless you make any actual impact on that you
are not actually going to change public health at all?
(Mr Panter) I would hope that we will have an influence,
because the way in which our Primary Care Trust is structured
does involve local elected members. It also has an internal structure
which is co-terminus with the Parliamentary constituency boundaries.
We have worked very hard to engage local elected and nationally
elected politicians into the structure so that they also enhance
their understanding of both the Health Service and that broader
health agenda.
358. How much do you feel that your local government
function is genuinely influenced by a PCT? How much notice do
you take in local authorities of what the PCTs say? How much do
you let them influence what is decided by councils?
(Cllr Stringfellow) I can say that across the country
it is very patchy and local government, in terms of its progress
and modernisation, is at different stages, as is the maturity
of Primary Care Trusts, and not everywhere in the country will
have Primary Care Trusts come April 2001. If I can just speak
to you about my personal experience in north Tyneside, we have
a Health Partnership Board that has been established for three
or four years and it takes time to evolve. It is important that
good relationships are built up and there is mutual trust. The
difficulty is that one cannot legislate for that, it is an evolutionary
process, but one of the things that we are looking at in terms
of scrutiny is that, yes, we are going to have the duty to scrutinise
health colleagues, but also how do we actually make sure that
health colleagues are a part of our scrutiny process in any event
so that we can pick up on the point that David Panter has made
in terms of looking at how housing, environmental or other policies
impact on health and where we can make changes? There is some
evidence of that. There has certainly been some evidence of that
in terms of how we have taken the health improvement programme
and there has been mutuality about those discussions. It can be
very effective, but I think we cannot simply say that there is
a set of rules to which everyone must work and it will happen,
it is more complicated than that.
359. Are you not worried then in that case that
if you say it all depends on mutual trust, mutual organisation
and so on, maybe in some parts of the country it will quite clearly
work very well but, equally, in other parts of the country it
may be a total disaster. The way you have said it, if it all depends
on mutual trust, etcetera, we know—I have been in local
government for a long time—it does not always work. There
is not always mutual trust. It cannot be legislated for. Perhaps
it should be. Maybe we do need statutory influence on each other
to ensure that this function does occur.
(Cllr Stringfellow) Relationships, in a sense, cannot
be legislated for. That was the point I was trying to make. In
fact, if we look at the National Service Frameworks which are
coming through and best value, as it applies now to local authorities,
if it is going to be duly best value within health, it comes to
a point that Dave made earlier about outcomes being so important.
The bottom line is that we are all accountable—in local
government, at any rate—to the electorate for making sure
that those outcomes are transparent and are successful. If they
are not, then there is an electoral price to pay. Equally, the
scrutiny role is going to pick up with health and create a greater
transparency there. So the frameworks are coming along. We are
all keen to end the post code lottery, whether it is in social
care or education or housing, because Members will have seen,
for example, in the press today, the results of Key Stage 2 in
our schools. We see this as one of the critical priorities that
we have in local government, in terms of equipping our young people
to have the best possible life chances, which also impact on their
health status in the longer term. It is very complicated, I think,
but nevertheless the frameworks that are coming forward are welcome,
because we can work locally to meet local objectives within that
framework. I think that means that we are working with health
colleagues who, equally, are going to be very much more accountable
because the league tables and the other information is coming
and being made very public.
(Mr Town) If I could add to that. For mutual distrust
I would read mutual misunderstanding. I think there has been a
huge misunderstanding between local government and health, both
at an organisational level but also at an operational level. Although
we are only eight months old, we have to reflect that PCTs are
very new organisations, and that we have made significant progress
in engaging GPs as advocates of the local public health. I agree
that they may not be the experts, but they are advocates in dealings
with local councillors. They are seen as very influential people
locally. They are listened to. They have now taken the time to
talk to local councillors about local health issues. We have held
conferences about mental health issues and learning disabilities
issues, at which councillors and GPs have sat together. In my
experience—and I have been in the National Health Service
for nearly 30 years—this is probably the first time. There
is the beginning of a significant change at a local level. We
deal with the unitary authority and I certainly find that is easier
because there are two PCTs and one unitary authority, so we have
a very strong bond, a very strong relationship at a local level.
It increases and improves on a weekly basis almost, as one contact,
one bit of trust leads to another.
Dr Stoate: Fair enough. Thanks very much.
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