Select Committee on Health Minutes of Evidence

Memorandum of Evidence


  1.1  There are many definitions of health, For the purpose of this memorandum we shall use the following definitions:

    —  Health is the strength to be fully human.

    —  Health is to have the opportunity to lead as full and as happy a life as possible.

    —  Neither definition regards freedom from all illness as an essential prerequisite for health and both definitions recognise that each individual is unique as is their experience of health. Both definitions recognise that to be born or become disadvantaged or diseased should not necessarily mean that an individual will be unhealthy.


  2.1  The factors affecting health will be well known to the Committee. In our work we try to keep in our minds all the factors listed in Appendix 1. We are delighted that there is now an open acknowledgement of these factors including poverty and unemployment.


National Government

  3.1  Many areas of national policy have a profound effect on health including economic policy, social security, taxation, education, crime and disorder, and food safety. Reductions in poverty and unemployment would have a profound impact on the health of our people.


  3.2  Local government has a considerable influence on the factors that promote or undermine health.

Public Health Services

  3.2.1  Environmental health services, consumer protection and waste and refuse services are the cornerstones of health protection and promotion.

Environment, housing and planning

  3.2.2  The safety of what we breathe, eat and drink is of paramount importance. The quality of the environment in which people live has a profound effect. Noise, pollution and visual impact are all important.

  3.2.3  Control of the physical and built environment is of profound importance. Poor housing can cause respiratory disease, promote mental illness, lead to injury through accident, and constrain the lives of those who suffer physical or psychological illness or disability.

  3.2.4  The planning, design, construction and maintenance of the physical infrastructure of day to day life is also vital. Roads, footpaths, leisure facilities must be built and kept fit for their purpose.


  3.2.5  Access to educational opportunity at all stages of life influences each individual's ability to be socially, economically and personally effective and able to best determine and control their own future.

Economic Development

  3.2.6  The creation of wealth in general supports and underpins health. However, inappropriate economic development can have adverse effects for example on the environment. Anticipating and addressing changes in economic opportunity is essential for a healthy society.

Social Services

  3.2.7  Personal social services both promote health and ameliorate the effects of ill health particularly for the most vulnerable in society.


  3.3  Within the health service many public health functions are discharged, some are easily identified as public health functions, some are less easily recognisable as such.

Public Health Functions

  3.3.1  The most important, is the duty of the Directors of Public Health to independently assess and report on the health of the population for which they are responsible. Before the 1974 reorganisation of local government this duty was discharged by the Medical Officer of health of local authorities. This longstanding process underpins the setting of local health policy.

  3.3.2  The NHS has shared responsibility (with local authorities) for the control of communicable disease and environmental hazard. Other population-level interventions include providing immunisation and screening services.

  3.3.3  Much of local health policy is led from within the NHS, for example, planning the implementation of National Service Frameworks and ensuring the provision of health services.

  3.3.4  In most places, the majority of specialist health promotion services are based in the NHS. Functions include the leadership of important programmes such as tobacco control, reducing teenage pregnancy and promoting physical activity. Health promotion programmes require the active participation of other agencies, especially local government.

Primary Care

  3.3.5  Primary medical, dental and ophthalmic services and community pharmacy provide, directly to individuals, interventions that not only treat illness but also promote and secure health. Certain groups of health care professionals have particularly important roles, including health visitors and community, practice and school nurses.

Hospital Services

  3.3.6  Whilst hospital services are predominantly curative, services such as maternity and microbiology services have a prevention and public health focus. However, it is easy to forget that when needed, access to safe and effective health services are perceived by most people as essential to a feeling of well being.

Other Local Agencies


  3.4  Crime and disorder have a profound effect on health and well being, particularly for the less well off, the young and the elderly. The police contribute to other important public health functions, through speed control, minimising the detrimental effects of alcohol and illicit substances, and by promoting a sense of safety.


  3.5  Voluntary sector organisations contribute to securing and improving health through a wide variety of means. These include offering practical services to vulnerable people, being advocates for those not well placed to stand up for themselves, and educators in relation to particular issues eg meningitis and child cruelty.


  4.1  PCGs and PCTs are a welcome innovation in relation to promoting public health. We have seen PCGs become the focus for much practical public health action. PCGs/PCTs are particularly well placed to take such action as they are in a position where they can use local knowledge of their communities to indentify specific needs and commit resources to address those needs.

  4.2  PCGs/PCTs are well placed to develop and maintain important local partnerships, particularly with local government and it is important that boundaries are co-terminus. Only social services are formally represented on PCG Boards. It is vital that PCGs/PCTs develop joint working with other local government functions.

  4.3  In County Durham and Darlington we have placed specialist health promotion services within our PCGs. Three services have been established, each serving two PCGs. This is working well and creating real engagement between health promotion, primary care and local government.

  4.4  The development of PCTs should bring new opportunities for developing the public health agenda. Managing and delivering community services as well as undertaking PCG functions should add a new dimension to their public health role. Ensuring that the public health member of each PCT Executive Board is appropriately able and qualified will be particularly important.


Role within Health Authorities

  5.1  The DPH is one of the three statutory Executive Board members that are required of health authorities. Their function is to report on the state of the health of their local population, advise the health authority on public health matters, and provide medical advice to the health authority. In addition, DsPH share corporate responsibility for the actions of the authority, and are normally responsible for health authority-based public health functions, including communicable disease control and screening programmes.

  5.2  Most health authority departments of public health also support the planning and commissioning of services by the health authority and PCG/PCTs. Often other aspets of health service development or delivery, for example, NHS quality improvement, are supported by members of the health authority public health team.

  5.3  We have strengthened our public health function by the appointment of an additional consultant, nurse, public health analyst, librarian and information assistant. It is important that the public function is well resourced. Public Health Directors have a wide range of responsibilities, including medical issues within the NHS. They need appropriate support to enable them to undertake the full range of their duties.

Role in Relation to Other Local Organisations

  5.4  We are fortunate in County Durham and Darlington in that we enjoy good relationships with local councils and other local statutory bodies. Local councils recognise and welcome reports on the health of the population. There are many examples of good joint working.

  5.5  DsPH and NHS-based and so do not have a direct responsibility for adivising or supporting local government with their key public health responsibilities. It has been suggested that DsPH would be better placed in local authorities, hower this would simply perpetuate the present difficulties, but in reverse. Many DsPH would welcome formal joint responsibility to both a health authority and the related local authorities. It has been suggested that DsPH would be well placed to be formal advisors to cabinets of local authorities.


Role of Health Authorities


  6.1  Health services can contribute to directly addressing poverty through facilitating access to welfare advice and other key non-NHS services. The NHS can make access to such services non-stigmatising. A particularly good example are the schemes in County Durham and Darlington where people can gain access to welfare advice at some GP surgeries.

  6.2  The importance of the NHS as a major employer should not be overlooked. In many of the poorest communities it is second only to local authorities in providing jobs.


  6.3  Tobacco consumption is highest amongst the least well off. This leads to a double disbenefit as these are the individuals who are likely to have the least good experience of health even without smoking. The new systematic approach to tobacco control and smoking cessation within the NHS is based on evidence of effectiveness and is likely to be successful.


  6.4  The single greatest contribution that the NHS can make to addressing the inequalities arising from social exclusion is to ensure that services are accessible to everyone regardless of geography, language, age etc. It is particularly important to provide accessible and acceptable primary care services but specialist services, particularly mental health services, are also very important. People with access to good services feel less excluded.

  6.5  It is essential that NHS resources are equitably distributed both within health authorities (to PCGs/PCTs) and between health authorities. The proposed index of health deprivation is very welcome.


  6.6  Pregnancy early in life often leads to exclusion. The NHS leads the efforts to reduce the number of young people becoming pregnant. The key partners in this endeavour are the education service and young people themselves. The NHS can provide better and more accessible services for young people but education services have a vital role in providing young people with the knowledge, skills and attitudes to avoid pregnancy.


  6.7  The impact of crime and disorder on health is considerable and disproportionately affects the least well off. Areas where the NHS is able to influence these factors include substance misuse and illicit drug and alcohol misuse which have a profound affect both on those who abuse these substances and on those around them. However, the NHS is still not able to provide adequate prevention and treatment services. This is partly due to competing financial priorities and partly due to the availability of skilled staff. The new resources made available in the comprehensive spending review are very welcome.


  6.8  There are a wide range of areas where NHS services complement education services including the needs of children with educational difficulties. Not only are such children more likely to come from poorer families but if their needs are not met they are more likely to become excluded from society. NHS services such as school nursing, specialist health promotion, occupational and speech therapy are all important in supporting schools.


  6.9  For many people in need, the organisational division between the NHS and social services seems bizarre and unhelpful. If the needs of vulnerable people, which includes carers, are to be properly met then the closest possible working relationships are required. Often close working is undermined by organisational, budgetary or charging policy constraints.


  1.  Addressing public health issues, especially the underlying causes of inequality and deprivation, is complex and often slow. It is important to be realistic about what can be achieved.

  2.  Reductions in poverty and unemployment would have a profound impact on the health of our people.

  3.  Real joint working between health authorities and local government is vital. Many Directors of Public Health would welcome joint responsibility to health and local authorities.

  4.  Primary Care Groups and Primary Care Trusts have a vital role to play in addressing these challenges. Health promotion services should be placed within PCGs/PCTs.

Factors Affecting Health

Social and Economic
Access to Services
Social exclusion
Air quality
Water quality
Social environment
Physical activity
Sexual behaviour
Social Services

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Prepared 26 January 2001