Examination of Witnesses (Questions 388
THURSDAY 7 DECEMBER 2000
388. Can I welcome you to this part of our session
this morning and thank our witnesses for being willing to come
along. I am sorry there are rather a lot of you all crammed onto
the one table. You are people of great expertise and we felt we
could not miss out the opportunity to meet you as part of this
inquiry. Can I make an apology that the Committee is rather thin
on numbers. We have a debate about to start in the chamber on
the health aspects of the Queen's speech and a number of our colleagues
are hoping to speak on that. One or two more may disappear, but
it is no disrespect to yourselves. You are left with the quality.
Can I begin by basically asking you, broadly, about your own definitions?
Can you introduce yourselves to the Committee very briefly?
(Dr Hoskins) I am Dr Ann Hoskins, DPH,
Manchester Health Authority.
(Mr Goodwin) I am Neil Goodwin, Chief Executive, Manchester
(Dr Jessop) I am Dr Edmund Jessop, Director of Public
Health, West Surrey Health Authority.
(Ms Griffiths) Jenny Griffiths, Chief Executive, West
Surrey Health Authority.
(Dr Woodhouse) I am Dr John Woodhouse, Director of
Public Health, County Durham and Darlington NHS Health Authority.
(Mr Jarrold) I am Ken Jarrold, Chief Executive, County
Durham and Darlington NHS Health Authority.
(Dr Veal) I am Dr Chris Veal, Director of Public Health,
Calderdale and Kirklees NHS Health Authority.
(Mr Elson) Tony Elson, Chief Executive, Kirklees Metropolitan
389. Basically you are here really, in a sense,
to look at the practicalities of the issues we talked about in
the first session, because you all have direct hands-on experience
of attempting to wrestle with the structures and deal with issues
we are concerned about in this inquiry. What I would welcome from
one or two of you as a starter is your own definition of public
health in the context of what we discussed in the first session.
How do you feel we should define public health, looking at it
as an issue that does, indeed, involve far more than simply the
(Dr Hoskins) I think if we are looking at health,
for me it is looking at how we generate health and well-being.
I think it is very important that we do not just look at the medical
model but we look at the social and economic model as well. It
has been shown that just looking at the health model is not going
to improve the health of our local population. Speaking for Manchester,
who is at the top of the hit parade as the worst health statistic,
I speak from the heart on this one.
390. We will come back to you on what you have
(Ms Griffiths) I would define it very similarly, as
you would not be surprised, as all of those activitieswe
can talk about what they are in a momentthat contribute
to the health of the population. That needs to take in the social
and economic determinants of health and how we support communities
to enable them to become as healthy as possible, as well as the
precise programmes that we deliver or organise, which we will
talk about in moment, I am sure. I agree with the very broad definition.
Even in affluent Surrey we have deprived areas, they are in the
top 20 per cent nationally and yet have the same issues, albeit
more focused, in smaller pockets that our colleagues in Manchester
391. Just out of interest, which areas of West
Surrey do you cover, what are the towns we would recognise?
(Ms Griffiths) The biggest is Guildford, Woking is
the other largest town. We go into outer South-West London, to
Spelthorne and the Hounslow area, and at the other end we go right
down to the Sussex border. It is a very varied area.
(Mr Jarrold) The definition of health I try and keep
in my mind is that health is the strength to be fully human. If
you then look at all of the factors which affect health, which
are set out in our evidence and elsewhere, you immediately see
that you do have to think about not just the health service but
local government, the full statutory and voluntary sector and
the community themselves. You do need the broadest possible definition
because only by taking that stance you can have any chance of
improving health itself.
(Mr Elson) I would identify with everything that has
been said so far. I think that it is a very broadly-based, socially
defined term, which I would not distinguish from well-being and
from the whole concept of regeneration. I think for me the whole
strength of the public health agenda is about trying to create
the self-confidence and self-value in people that makes them feel
they are fully part of our community, and should give them the
power to care about their own lives and promote their own health.
392. From the debates that we had in the first
part of the session you were aware that we explored the placement
of the director of public health, we explored the role of local
government. What are your thoughts on who should take that leadership
role at a local level on public health? I was not totally convinced
I got an answer on this question as to why the uncertainty about
the future of the health authority could not simply shift the
wider public health function to local government, putting it back
to what we had pre-1974, which some of us were happy with, were
we not, Mr Austin? Doctor Veal, why should you be within Kirklees
Council? What is the problem, have you actually undertaken your
function within an environment where, surely, you would have more
influence on the direct policy impact on public health in the
area you cover.
(Dr Veal) I am quite happy to be within Kirklees Council
or another local authority. What is important is that we rely
very much at the present time as the Director of Public Health
on our influence. We do not have too much control over resources,
so wherever I am placed I want to have some greater influence
on the disposition of resources. I work in the Health Service
at the present time and I find it difficult to understand what
proportion of the Health Service expenditure is actually expended
on health and what proportion is expended in terms of Health Services.
I deliver some of my public health function because I also deliver
for my authority a lot of the other issues that have to do with
clinicians; that have to do with doctors who are performing badly;
the service reviews of acute hospital services; the ability to
act as the medical figurehead for the authority from that point
of view. I have to do my public health function as a part of that
overall goal. I think wherever I go and whatever my role is the
important thing is that I am given the authority and the position
to be able to address the public health agenda. If it is going
to be local authorities, fine, but do not just dump me on a local
authority without any support mechanisms.
393. You would have no objection to moving over,
would the other directors feel the same way, that their function
would be better placed within a local government setting?
(Dr Jessop) I feel quite strongly that I would prefer
to remain within the National Health Service for three quite distinct
reasons. The first is the point that has already been alluded
to, to do the job properly you do need resources, so you can be
an effective advocate, but you can get a lot further if you do
394. Why would you not have, necessarily, the
appropriate resources to do your work in local government?
(Dr Jessop) As the director of public health for a
health authority you essentially have command influence over the
entire resources of the National Health Service, which are enormously
greater, I suspect, than anything than the local authorities could
bring to bear because, and my second reason, it is slightly artificial
to distinguish between medical health and wider health. If you
think about how you bring about improvements in the mental health
of the population you need health service staff as well as tackling
the wider determinants of health. It produces a much more effective
programme if you can integrate those two.
395. You talk about the resources, surely the
resources of the NHS are geared at ill people. The kind of resources
you are talking about in the public health domain are largely,
so far as they are in the public sector, with the local authorities,
the sports centres, the leisure centres, the community centres,
housing. These are the resources that are key, are they not, to
(Dr Jessop) Absolutely. That is half of the story.
With respect, you underestimate the commitment, of primary care
teams to public health, to smoking cessation, to improving diet,
to tackling teenage pregnancy, and a whole range of other programmes.
396. Some of those are done through schools,
youth service and, harking back to our previous existence, things
like health visiting within the local authorities.
(Dr Jessop) They were. My belief is that these programmes
are developed and delivered more effectively by teams that are
fully integrated, with colleagues, who deliver the more specialist
(Dr Woodhouse) My view is that we should remain in
the Health Service. I reinforce the views of Dr Jessop. Many services
are fed through the Health Service. I also fear the effects of
such a change, because you will remember the post-74 the Public
Health Movement went to the doldrums, and I would be afraid that
that would happen again.
397. It was sidelined, that is why it went to
the doldrums. It was removed from the reality of the services
that impact upon the local community. We have ended up with people
who write brilliant reports but they just do not seem to have
an impact on the service delivery they really ought to impact
on. The old MOH, in my experience as a very young councillor,
used to make people jump on some of the committees that I sat
on with the reports, they were very objective and hard hitting.
(Dr Woodhouse) What I would say to you is the director
of public health needs access to the NHS and local government.
The reality that possibly needs to be remedied here is to have
more direct and legislative access to local government. Many of
us have this. It happens through developing those relationships,
which is time-consuming, and depends very much on personalities.
398. Taking the last question I put to the previous
group of witnesses, if we were starting from scratch what would
we do, would we start from the basis of having an integrated health
and local government structure, even taking account of the point
Dr Jessop made about his resources? If we had a service under
one umbrella, whether it be health or local government, these
services are under one organisation, how can that impact on the
role you could play in relation to public health at local level?
(Dr Woodhouse) It is very hard to speculate what you
might have in the future if you started from scratch. If you started
from scratch I would have a completely different structure.
399. Imagine we had one structure. Say, with
the demise of health authorities we could move the remaining health
authority function into local government, it would not be that
dissimilar to what we had in pre-1974, if we had that kind of
structure, you would be based in local government, what impact
would that have on what you were able to do, assuming we take
account of the resources in question that Dr Jessop quite rightly
pointed to, how would that improve what you are able to do now
in your role as director?
(Dr Woodhouse) The fear I would have is that it would
distance me from the other health agencies.
(Mr Jarrold) There are two separate issues running
here, one is the wider question of the role of health authorities.
Health authorities do a lot of things which are not to do with
public healthI assume you do not want to concentrate on
those issues this morning, you want to concentrate on the public
health issue. If we take the public health issue I think it is
perfectly possible to envisage a situation in which public health
could function, either under a local government structure or a
health structure. What I think is very important is that we develop
joint accountability for public health, wherever it lies. You
will know that in the NHS plan the regional directors of public
health are to be jointly accountable to the regional director
of the NHS regional office and the director of the government
office. I think that is a very clear indication of the way we
are going. I think there would be a strong argument for directors
of public health to be jointly accountable to health authorities
and local authorities. I think joint accountability may be the
key. We then have to ask ourselves, what are the arguments for
placing public health within local authorities or health. I personally
think there are strong arguments for placing public health within
health, one of them is the question of influence over health resources,
which is extremely important, and one is the question of scale.
It is not possible, really, to imagine a director of public health
at every single local authority in the country in the terms of
the numbers, the scale of resources and in terms of back-up it
is very difficult to imagine that happening. One of the arguments
is, I think, is that the new organisations that will merge from
health authorities will be on a big enough scale with their local
government partners at appropriate levels to develop a strong
public health function with the resources and specialisation that
it needs. If you are operating with very small populations it
is simply not going to be possible to resource and staff independent
public health functions.