Examination of Witnesses (Questions 360
- 379)
THURSDAY 7 DECEMBER 2000
MR CHRIS
TOWN, MR
DAVID PANTER,
MR JOHN
RANSFORD AND
COUNCILLOR RITA
STRINGFELLOW
John Austin
360. May I follow this through. We all seem
to be agreed that we know what the key determinants of health
are, the economics and social requirements, all of that. We know
what needs to be done. You said you cannot legislate for relationships
and you indicated that relationships are improving within the
new structure. Are there any key changes which you think do need
to be made to ensure that what we know needs to be done, will
actually be done?
(Mr Ransford) One of the major changes is to ensure
that health is central to the agenda. I was on one of the modernisation
action teams leading to the NHS Plan. Chapter 13 was one of the
products. I do not think it is an LGA view, but I think it ought
to be, that it should perhaps not have been chapter 13. It ought
to have been a single number chapter. It should have been much
firmer and earlier in the plan. Everyone shares in an aspiration
and right to good health. Only some of us fortunately have disease
or injury or illness which needs to be treated at certain parts
of our lives. So I think it is incredibly important that health
is at the centre of the agenda. We should build our other services,
our curative services, in all sort of senses—not only health
ones, but intervention services for people in need—around
measures that create that healthier society. Our historical basis
for doing these things is based on different factors. I think
one of the most important things for local government in this
is the new power to be given to promote the social, economic and
environmental well-being of an area. Although the best bits of
local government have been doing that for years, it is now seen
as a positive role. It is not a bossy role. Local government cannot
do it on its own but it can bring together through community leadership,
local people, citizens, their representatives, the agencies, the
public agencies we have been talking about this morning, business,
and a whole range of interests, actually to improve health. It
is that change of vision and that change of priority which is
required.
(Mr Panter) I was going to add to that—again,
we have put it in our written evidence—in terms of a change,
this is about that joined-up working at the centre also relating
to the performance management arrangements. This is because I
think we are getting better across social care and health care
at joint performance management; but in terms of the broader objectives,
then to have consistency around the centrality of health in those
performance management frameworks and targets would be incredibly
helpful. All too often we find ourselves, at a local level, as
different public sector organisations trying to work for the collective
good, driven apart by the different demands in terms of performance
management from social government.
Mrs Gordon
361. Several times during this inquiry we have
heard the term "initiative overload". There is an awful
lot of different things going on. There seems to be a great interest
in experimenting in various new mechanisms, joint directorate
of health posts, other joint posts, other new ways of providing
health through management networks and joint health units, the
ones being developed in Manchester. May I ask the LGA representatives.
Do you consider these experiments to be useful, successful, worth
spreading? Are they to be positively encouraged or is there a
danger that the public get used as guinea pigs for some of the
ones that fail?
(Cllr Stringfellow) It would be good if we could always
predict success from the outset but the value of having different
ideas piloted is obviously that one can learn from them, take
what is best from particular models, and see whether that applies
to the local situation. The difficulty, as ever, is that what
we need are local solutions for local situations, local contexts.
They do vary enormously. For example, what I understand is beginning
to work very well in Manchester, might be wholly inappropriate
for a part of the country where there is two-tier local government.
So it is important that we actually have a range of models. I
do not quite see it as experimenting on the public in as much
as these ideas have been well thought through in advance and they
are seen to be appropriate for local circumstances. One of the
things we need to take into account, though it is incredibly difficult,
is that local government has that community leadership role. I
think one of the DETR consultative documents was called In
Touch with the People. Actually being in touch with local
communities to see what is going to suit them best is also very
important because the models might be great and we could sit around
for a long time as a bunch of professionals discussing this, but
it is what makes sense to people in their own localities that
is important. That is the responsibility that local government
has, along with health colleagues, to make sure that what is going
on actually does make sense; or, at least, if the structures are
very complicated, that they are seen to be seamless from the point
of view of the people using them. So I am not too concerned that
there is a divergence of ideas as to how we can deliver, as long
as we know what it is we are delivering on and that we have the
measures to be accountable for that.
362. There are two questions from that. How
do you evaluate some of these experiments? I think also that some
of the schemes we have seen were bottom-up schemes, they did start
from the community, so how do you actually facilitate that happening?
(Cllr Stringfellow) In terms of facilitating it happening,
we have a lot of experience in local government of community development
work. Certainly that is going on in primary care trusts. It is
very much about working with organisations, working with individuals
at a local level, and getting a sense of what is going to be important
to them. Sorry, the first part of your question?
363. How you evaluate.
(Cllr Stringfellow) Performance management is obviously
a step in the right direction and as schemes are being set up
there is a joint need to build in performance indicators and to
be constantly checking back. Of course, part of the way of evaluating
these things in the future will be through the scrutiny role within
local government. There are a number of ways in which that could
be approached.
(Mr Ransford) May I add a codicil to that, in a sense.
One of the most powerful of these initiatives is going to be the
New Deal for Communities, which is very locally targeted and is
not seen as a health agenda at all at first sight. It is seen
as a regeneration agenda. Of course, the benefits to the local
people and the community are exactly the same. What is being built
into that in the best of them is community evaluation. The second
point I want to make—I have spent virtually half my operational
career in single-tier local government and half of it in two-tier
local government—and in two-tier I always used to get told
off for calling it two-tier. When I worked in North Yorkshire
there were 650 units of local government. In my time the county
council had eight districts and over 630 town councils, parish
councils, parish meetings. Go to Filey Town Council on a wet December
night and you learn what people caring about their community is
about! So that sort of model is equally applicable in rural communities
at a very local level. There is a model which will deliver massive
health gains and is not seen, at the outset, as a health initiative.
364. A couple of the schemes we have looked
at. In one the GPs were very involved but in the other ones we
have seen they sometimes find it quite difficult to involve GPs
for various reasons: pressure of work, size of the list, etcetera.
May I ask what your views are on that: actually involving GPs
within the community projects.
(Mr Town) Where GPs add a value, it is terribly important
that they get engaged. One of the things primary care trusts are
starting to do is to look at the whole model of general practice
and say, "Could some of that time that GPs spend in face-to-face
contact be better spent on some of these projects?" If it
can be demonstrated that it can, then we have to find ways as
an organisation with the GPs concerned to free up that space.
There are a number of initiatives that are announced in the Modernisation
Plan that are on-going, which would allow those GPs to be freed
up to get involved. We have to be clear what the added value of
that involvement is rather than it is just a representative role.
365. The National Health Service Plan affords
opportunities for local authorities to scrutinise NHS organisations.
Do you think these powers could be directed toward ensuring that
the public health agenda is vigorously pursued by the National
Health Service? You talked earlier about this division—National
Health Service or public health. We know that if you improve public
health, then it takes the pressure off the acute services in the
long run. It is a long-term thing. How do you see that could be
pursued?
(Cllr Stringfellow) I would hope that this would be
at the heart of the scrutiny agenda because so much flows from
that. Also, that it would be a two-way process, so that it would
not simply be local government and public health, but also finding
ways of involving health to look at some of the local government
services that impinge on public health.
366. Have you any views on that?
(Mr Town) It seems to me that the important bit here
is in terms of scrutiny and in terms of performance management
in its wider sense, that we get a balance between the "must
dos" and the "here and now". So the targets that
were set by Government on waiting lists, waiting times, as important
as they are, that we try to determine some targets for the longer
term health care. One of the difficulties of this agenda is that
many of the results will not be seen for 20 to 25 years, so it
is terribly difficult to quantify those. So some of the performance
measurements at this stage would be based on a beliefs and evidence
base rather than necessarily the outcomes. Therefore, we have
to come up with something which says, "This is important
and we are being measured as organisations on this, not just on
the `here and now' stuff."
367. How can the proper scientific scrutiny
or investigation of the initiatives be managed at local government
and PCT level?
(Mr Town) The important bit is that we have a clear
understanding of what the anticipated outcomes are, so that there
is something to measure it against and for all parties, so that
if we are to be scrutinised, the party scrutinising us and the
party scrutinised have some agreement in advance as to what it
is that is being checked out. We need to agree some measures,
some milestones, that would at least demonstrate we are making
progress towards that target.
(Cllr Stringfellow) Could I also add that it is very
important when looking at what is going to be a new role for local
government scrutinising—although in my own authority we
have already got a health select committee that has looked at
various health issues quite effectively with health colleagues
and it has been a very challenging agenda—it is very important
that we take the opportunity to see that the initiatives, for
example, such as Sure Start, which bring together all of the things
that we are about to fix, sitting round this room, and to see
how we can learn from what is already going on in our localities,
and applying that to the health agenda. The other thing, which
is very important, is that if local government is going to take
this role seriously, that we make sure that there are experts
who will come in to advise us before we embark on some of these
scrutiny activities, so that we have the best possible starting
point. I am sure that there is a wealth of experience here in
terms of scrutiny and health but it is very important that we
do not just rely on our hunches and good ideas but have expertise
in there to advise us from the outset.
368. Do you feel there may be a conflict between
local authorities as partners in health and commissioners of health
services and scrutinies?
(Cllr Stringfellow) It is very important to acknowledge—and
the Local Government Act is very clear about this—that the
executive of the council will be taking a lead role in decisions
around commissioning and will be very clearly accountable for
that. It will be non-executive members (front-line councillors,
as I prefer to call them) who will be taking on the scrutiny roles.
So there is going to be a very clear separating-out but I do think
it is important that we are as rigorous with our own services
as we would be with services coming from other agencies.
369. You talked about having people with expertise
to advise, etcetera. How do you feel about the proposed demise
of Community Health Councils? That the new proposals, including
scrutiny by local authorities, will lead to better patient representation.
(Cllr Stringfellow) There are three strands to Community
Health Councils. In terms of scrutiny, there will be a much clearer
accountability with that role coming to local government. But
I do acknowledge that there is an expertise in Community Health
Councils that has built up over the years which the LGA nationally
is seeking to tap into and to work with. We are certainly recommending
that our authorities all have discussions with their current Community
Health Councils so that expertise is not lost. In terms of democratic
accountability, there is a huge advantage in having the scrutiny
resting with local government. I have to say, just as performance
might be patchy across local governments and health authorities
and primary care trusts, so it has been across Community Health
Councils.
370. I do not know if the NHS Confederation
has a view on CHCs and the proposals.
(Mr Panter) Again, it is about recognising that there
is a body of expertise and skill there. As Rita has said, it is
patchy around the country, but making sure we do not lose that
in the proposed changes and hanging on to that expertise. Particularly,
there is widespread feeling within the NHS that in terms of looking
at some of those other roles that will come out the demise of
the CHC, in terms of the patient advocacy and liaison services,
that there is an importance about that remaining independent in
some way. Certainly there are a number of proposals around the
country, one of which is in Hillingdon, where we are looking at
how we can do that, perhaps if we could set up an independent
body.
371. May I ask you about the Local Strategic
Partnerships. How do you see them working and how far would they
help to provide focused momentum for action to improve public
health inequalities?
(Mr Ransford) I think the Local Strategic Partnerships
are absolutely key to all this. They are probably the most essential
element coming out of the National Strategy for Neighbourhood
Renewal in terms of pulling all this together appropriately at
the right level. The health agenda, in terms of people talking
about it this morning, is absolutely essential to it, as is the
more traditional health agenda in terms of the health services
that apply to a community. Local Strategic Partnerships, when
working properly, can replace a lot of the confusion around this
which has gone on so far. The fact that the National Strategy
for Neighbourhood Renewal recommends that you use local authority
boundaries as building blocks—not necessarily local authority
boundaries but as building blocks—so, for instance, in a
county area you might have a Local Strategic Partnership based
on two or three districts coming together, and then another part
of the county might have another Local Strategic Partnership,
and the county council had to reflect both: that flexibility is
right. But if we all agree on one model for alignment, alignment
of responsibilities and alignment of intervention, this seems
to be the key to this because otherwise you tend to get dragged
down into organisational solutions, which certainly sitting at
this table we all know do not always work. Local Strategic Partnerships
do have that strength. They also have this inclusion agenda, which
is crucial to all of the things we have been talking about this
morning. If Government does back those, it is going to be very
important. There is evidence that it might because, of course,
the new neighbourhood renewal money is being distributed on the
assumption that you have a programme like LSPs in place first.
372. Do you think public health is an important
part of that?
(Mr Ransford) An essential part of it.
373. Do you think it is recognised at the moment
or does it need to have more emphasis?
(Cllr Stringfellow) It will be recognised in some
areas but there does probably need to be some awareness raising
of the public health agenda. In a sense, we can turn this on its
head because Local Strategic Partnerships will lead to a more
confident community and if those communities are able to participate
in training and skills and taking employment, that is going to
make a huge difference to the local economy and health and well-being
of the individuals in it. So it is absolutely critical. I am a
member of One North East regional development agency and we have
our regional economic strategy. Whilst we do not have an explicit
objective of public health, it really does underpin all of the
inclusion agenda. Particularly what comes from the north east
tends unfortunately to be scoring at the lower end of the indicators,
so promoting the raising of educational standards and good health
is absolutely crucial to what comes out at the other end in terms
of participation in the jobs market. Making the north east a place
where people have the skills that investors want to come and invest
in but more importantly than that—a real issue about well-being
and confidence—is that if we are going to be successful,
we have to grow the businesses which are there at present. One
of the issues around that is that we have 19 per cent of entrepreneurs
who would be seen to be women, which is about half the average
for the rest of the country, so we really have got to get some
role modelling here, so that it is going to make a sea change.
This is where I think projects like Sure Start need to become
a way of life and, if you like, that the idea of entrepreneurship
is not just confined to secondary schools but it is right down
the Sure Start agenda. That is why we are going to make a real
difference in the future.
John Austin
374. I do not disagree with anything said by
any of the witnesses, almost everything that has been said points
me in the direction of the written submission that has been made
by the Manchester Health Authority, who we will hear from later,
that we really need to bring together the community plans and
the health improvement programme. Is there not a case for having
a single plan? Should the responsibility for drawing that up be
with the local authority?
(Cllr Stringfellow) I am also a member of one of the
modernisation action teams, the same one as David, and one of
the things we rather hoped would come out in the plan would be
that it would be very explicit. There is a synergy between community
strategies, as we are going to the call them now, and health improvement
programmes. I think that in most areas health improvement programmes
are seen as an important subset of community strategies. It is
very difficult to separate them out if you look at that from a
public health perspective.
(Mr Panter) The work that is going on in Manchester
is not in isolation, there are other examples. In my own patch
we have already called the HiMP, the Hillingdon Health and Well
Being Plan, and that is lined up to be a chapter of the community
plan. The team who led on the development of that is a joint team
between health and local government, jointly appointed and jointly
funded. There are examples around of where the HiMP and the community
plan are coming together.
Dr Brand
375. You also take on board regeneration and
all of the other things through that common process.
(Mr Panter) That is correct.
376. Being coterminous is very helpful—as
my constituency is—but in those circumstances you can have
chief executives of either the local authority or the health authority
being accountable for their performance management on these plans.
There is clear vertical accountability. What happens with the
horizontal accountability? Should that be at local level or departmental
level, or both?
(Mr Panter) Could you clarify what you mean by "horizontal
accountability"?
377. You set out your objectives, your performance
indicators and then you get your bit of money, especially on the
initiative-itis bits. It is usually your department that is accountable,
it may be to the Department of Education and Employment, it may
be to the DETR, it may be to the Social Services budget, it may
be to the Health budget, or it may be to somebody in the region.
It is very confusing.
(Mr Panter) That is what I was referring to earlier
on when I referred to the Confederation's evidence, that more
thought needs to be given to that Central Government Performance
Management arrangement. You are absolutely correct, although some
elements of that have come together quite well recently. Certainly
in most initiatives around health and social care the performance
management is carried out jointly by the SSI and the regional
office, that is incredibly helpful but in terms of the broader
public health agenda, having that separation does mean that occasionally
there are perverse incentives and conflicts between some of the
local partners, because they are being performance-managed in
a different way to slightly different objectives or at least with
a different emphasis on the same objectives. That can get in the
way around some of these initiatives.
378. Presumably this is even worse in areas
which are not coterminous. Your community plan is different from
your HiMP. At which level should the plan be held? I am very concerned
that HiMPs are a health authority function rather than a PCT function,
which I would have thought would be more natural. Earlier you
said PCTs, ATOs and local governments should be coterminous, they
should then have the ownership of whatever you call the plan.
Is that not right?
(Mr Town) What we have been trying to do in Peterborough
is to localise the HiMP so we have the over-arching principles
agreed on a county-wide basis, which is also a health authority
basis, but at a local level we have looked at those specific issues.
For example, in my case I have the only "deprived" population
in the whole of Cambridgeshire, so our needs are somewhat different
when we are looking at coronary heart disease and mental health.
What we have done is localised that in conjunction with colleagues
in local government. We do have a local HiMP, we sort of call
it HiMP-let, a subversion, a localised version of the HiMP. Having
those over-arching strategies that are agreed on a county-wide
basis helps to inform that, that the real work and the real outcomes
are at a local level.
379. Is that the evidence of how people are
dealing with this across the country?
(Mr Ransford) It is certainly complex, but it need
not be confusing. Certainly having spent a lot of my career—
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