Memorandum of Evidence
1.1 There are many definitions of health,
For the purpose of this memorandum we shall use the following
Health is the strength to be fully
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.
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.
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.
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
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
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
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.
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.
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
4. ROLE OF
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
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
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.
5. ROLE OF
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
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
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
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
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