Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 400 - 419)



  400. I am interested to explore what are you doing. Can I raise a question about the relationship between primary care and public health. I put this to Dr Veal, I know part of the area you cover, and I have always been very impressed by the work that you and your colleagues do on public health, however when I talk to some of the GPs in the part of my constituency that comes under your area they, certainly in the past, have not seemed to link-in in any real formal way to the public health structure. We had evidence from the NHS Confederation that Dr Stoate referred to, they said "Before the establishment of BCGs and PCTs primary care in the NHS had neither a structure to enable a more forward-looking approach to address wider community health needs nor the mechanism to influence strategic planning." That is certainly my experience in that part of my constituency. Have things changed with the recent moves in primary care? Do you see a much more important connection between your function and what is happening at primary care in areas like mine?
  (Dr Veal) I would hope so.

  401. What has changed, that you see, in practical terms?
  (Dr Veal) The primary care group or trust is looking very much more at its community needs. There is some disappointment, maybe they are coming in at larger levels than we thought they were going to do. That offers opportunities which could then link in very closely with community regeneration. If we can put those as coterminous then there is some real opportunities for us in the future. I think the access to the information systems for health needs within primary care we are starting to see movements towards systems that will, in a sense, collect all of the information for primary care. We have had a whole range of multiple systems and are not able to access the databases that primary care practitioners have. We have seen PCTs moving down that route, all of the GPs in the area will operate off the same system. We suddenly have a great deal more influence in terms of not being able to pull out that information and then to be being able to make recommendations back to the population and to be able to use figures that the population understands of GPs, health visitors. We can start to put together the community systems with the GP systems. I know this sounds like technological solutions, but it really does provide something where we have some real information. The absence of some of the use of general practice information in the past has been very, very poor quality and the ability to be able to use it. I think we can really motivate GPs to understand how they can influence their population in a much more real way than they could in the past.

  402. Do you see the evidence as realistic that was given by the Confederation in the previous session, where one of the witnesses made the point that it would not make sense for GPs to spend more time looking at the wider preventive aspects of their role than sitting dealing with dozens of patients. I would imagine it would be a difficult task to get GPs to move away from the pressure that they are under on a day-to-day basis towards the wider preventative issues because all the family doctors I talk to are under immense pressure due to the huge changes they are facing. Do you feel that is a realistic point that was made in the previous session?
  (Dr Veal) On an individual patient basis we have seen a huge change in general practice. When I was a general practitioner in the past, people came and presented problems, and I sorted their problems out and let them go on their way. If you go to a general practitioner's surgery now, your blood pressure will be checked, there is a whole range of preventative things, cervical screening, encouragement to go for breast screening, a range of things that general practitioners are getting involved in. There are also some opportunities in some of the more innovative practices to help with health promotion arrangements, to get involved in schools and community activities. There are also opportunities in relation to the way in which general practitioners are structuring their work. We are seeing a lot more use of nurses, counsellors, and a range of other people. General practitioners are freeing up some of their time to take on some of the issues. I have to say that a lot of that work has been preventative and a lot of that work has involved administration. I think, though, if I were honest that I would see more opportunities in terms of developing the public health function in looking particularly at joining up and utilising the health visitors and school nurses, being able to develop more health promotion roles, being able to work with community leaders and working through schools and a range of other areas than necessarily taking what is a relatively hard-pressed specialty at the present time and asking them to add on yet more additional pieces of work. But I would not want to stop them doing that individual preventative work and taking all the opportunities they have within their consultations to promote that public health agenda.

Mrs Gordon

  403. You talked about some of the measures that are now helping GPs to take on this wider role. I wondered if you had any thoughts on what measures would relieve the pressures and would give GPs more time to be proactive within the community?
  (Dr Veal) I still think there are issues around the independent contractor status. I would prefer to see general practitioners in the longer term become salaried, and to have a proper management structure in terms of general practice. I do not see why a good practice manager cannot run two or three practices. We should free a lot of the general practitioners' time up to work directly with patients or to take on some of those other issues. We have, in a sense, created a situation where they are spending quite a lot of their time on management issues and that is not necessarily where all their skills are best deployed at the present time if they are in short supply.


  404. Could I ask the two other groups of witnesses, from your experience in your localities, what the impact of moving to PCGs and PCTs has been in relation to the public health function?
  (Ms Griffiths) I will comment from our perspective. Very positive. We are fortunate in Surrey in having a typically very enlightened general practice community and primary care workforce. I must stress it is already quite well organised. It is a history of primary care in a relatively well-to-do area so it gives us a flying start. Three things have happened in the past couple of years which bode well for the future, and they pick up themes already commented on. They are all about primary care getting organised because that is what it is all about. One is about GPs with senior nurses, and the introduction, particularly under the personal medical services pilots of nurse practitioners and nurse consultants, and those sorts of roles are extremely important. They are developing more specialist roles. Those can be treatment and care roles but they are often roles that take them out into the wider community, so you are freeing GPs up from the day-to-day grind of the consultation process, several hundred patients a week, and giving them broader roles, and they are seizing these opportunities in many parts of West Surrey. That is the first thing that is happening. That is only possible because you have got an organisational structure in general practice and primary care for the first time. Secondly, because we are in a two-tier local government area, with seven boroughs in West Surrey alone and ten in Surrey as a whole, the PCGs are now taking the lead on the relationship with boroughs that you were talking about before. For the first time ever we have got primary care and general practice in boroughs working up jointly organised programmes in the areas you were talking about, which I will not repeat. That is a huge breakthrough. Our primary relationship with our boroughs is no longer with the health authority, we relate to the county down to the PCGs, and that will develop further as PCTs come through. The third area, as I say, is being able to get organised because you can set up implementation teams for different national level frameworks. You have got an EGP for each of them, an EGP in each practice for each of them and you begin to develop a structure and a way of working which would have been impossible without the managed system that primary care brings in. There is still a long way to go and all the characteristics that were previously described are still there. Over the next few years as we go into primary care trusts there is a huge potential for the synergy and integration between primary care and the broad public agenda based on these three things.
  (Mr Jarrold) Three quick things to add to what Jenny has said, and I very much agree with what Jenny has said. We believe it has been a very positive impact. The first reason is that we have seen PCGs very interested in working closely with public health and wanting public health time. We cannot provide all the time they want, but they are very keen to get public health specialists involved in their work and to look at the health needs of their local community in greater detail. Secondly, we have devolved health promotion services to primary care groups. We now have three services, each one serving two PCGs, and we have been delighted by their ownership of health promotion, and for the first time we are seeing them working very closely with primary care and that really is the key, and working closely with local schools and workplaces. So health promotion is the second benefit. And the third benefit we see coming with primary care trusts is this tremendous energy we believe will be released when you have got GPs, health visitors, district nurses, practice nurses, and health promotion workers all working in the same organisation, and we think that is great potential for the future.
  (Dr Woodhouse) The proof of the pudding for us has been to see the investments that PCGs have made in what are public health initiatives. Smoking is a particular example. We are seeing many other examples coming along, for example more practices offering welfare benefits advice in practice. That is an excellent development and now we have the capacity and time to reflect and develop these public health services, which is very encouraging.

  405. Can we turn to Manchester. You have set out your network in an interesting way to address some of the problems that we have discussed in the relationship between local government and health, and also the issue of the relationship between primary care and public health. Can you briefly describe how the network is operating and what the reasons were for you moving in this particular direction.
  (Dr Hoskins) Looking at the Manchester scene, for the time being Manchester Health Authority is co-terminus with our city council. We now have three primary care trusts in the city and there is public health support in each of those primary care trusts at this stage devolved/seconded from the health authority. We envisage in the not too distant future a bigger authority.

  406. You mean a bigger health authority in terms of numbers of staff?
  (Dr Hoskins) In terms of geography. So for us it is quite important that there is a public health function at the borough level. Just bringing on some of your questions earlier, I think it is important to straddle the two. I think it would be very important to have a public health function and accountability to the primary care trusts as well as to the borough, and that is something that we are trying to set up with the health unit, albeit at this stage, as somebody said, the devil is in the detail, but we are working through that detail for the time being. If you do think about the role of public health in its scrutiny function as well as its delivery of the public health function, there is a scrutiny function around the primary care trusts standing slightly outside and really looking at are how they are changing the inverse care that we all know is alive and well in primary care where the most affluent areas get the best services. I think that there is a great challenge for primary trusts—that we should not under-estimate; improving the quality of primary care. I think public health should be in there supporting that and working with the public health practitioners in PCTs, health visitors, and district nurses. Also health promotion in our city has been devolved to one PCT and they will continue to work on a city-wide level. There is also the scrutiny role looking with the local authority at what they are actually doing to improve health. I have been scrutinised by my city council on the health improvement programme and that is an interesting experience, but for me one of the important issues was how are they scrutinising themselves in the health and well-being role and not just scrutinising the Health Service on what it is doing. I think there are a lot of bridges to be built there and a lot of learning across both organisations as to how we work together. I favour that straddling, but I agree with some of the previous speakers, that it is really important that this role has authority, responsibility and resources.

  407. Do you feel in your current role that you are able to influence the direction that the local authority takes in areas of policy that directly impact on public health?
  (Dr Hoskins) Not at this stage.

  408. You think you will be able to?
  (Dr Hoskins) When we are positioned across the two I would hope we would have more of a role in the local authority.

  409. You have been scrutinised by the city council. Have you scrutinised the city council?
  (Dr Hoskins) At this stage I am based purely in the Health Service.

  410. Could you not do that in your previous role? This is the issue we are talking about. What ability do you have to influence the impact of local authority policies on health? My perception of the previous arrangements with the old MOH pre-1974 was that they very much had a role in doing that. I remember vividly where they were quite frequently taking to task the chief officers in charge of certain local authority committees for not, for example, addressing slum clearance issues within the housing remit. Have you not been able to do that or have you not seen that as your role specifically?
  (Dr Hoskins) In the way it is set up for the time being, I have not had any authority to do that. We have set up a joint Healthy City initiative which is now in its fourth year and I think that has started to break down the barriers and we have made sure the Healthy City co-ordinator in the first three years was based in the health authority and at the next stage they are based in the local authority, so working much more closely and influencing at that level. One of the reasons for the health units looking at bringing that health and well-being agenda higher up the local authority's agenda is that health is one of the corporate aims of the city council, but I think they would be the first to admit, given all the other issues they have had to deal with, it has not been as high up on their agenda as they would like it to be in the future.

  411. You said you have not got the authority to tackle council policies in certain areas. Do you feel you ought to have that authority in the way that certainly I recall the old system did? Do you feel you could impact more directly on the areas that you need to address if you had more authority within the role which you currently occupy?
  (Dr Hoskins) I think it would be important that, yes, we did have more authority, but I would then have to say that looking from where we have come if we are going to have more authority there has got to be much more joint learning together because I think we have focused on the NHS and we will have to refocus ourselves in some of those wider areas. There is an important development role.

  412. Dr Hoskins mentioned that you may in future have a larger DHA function. What is the logic of that in respect of what you are doing in public health? What is the reasoning behind that? What impact could that have on the arrangements that you are bringing together in Manchester?
  (Mr Goodwin) Our first priority is to influence the local authority a lot more, as Ann was saying, hence proposing establishing this joint health unit. I too, Chairman, just about remember the old MOH days when I was growing up in Salford, which is the city next door. What I do remember at that time was that Salford had the second highest rate of bronchitis in the world. I am not convinced that that model delivered that much. Now I have moved to Manchester, which in health terms is ten years behind the rest of England, so I have been hit by a double whammy, I wonder whether the arrangements we have now work. It is not so much about the structures, although they are a part of it; it is much more about the relationships that are established and it is much more about a lot of softer issues. Not just resources, as some of my colleagues have said, but things like the ability to influence and persuade and educate, as Ann has said, particularly the senior political leadership of local authorities. Historically, health authorities have dealt primarily with directors of social services. Maybe we have got our foot into the door of people like directors of education. That just is not good enough for the future if we are to improve health, particularly in places like Manchester. We have got to get the political leaders of the local authorities firmly on board, understanding the agenda and saying, "Yes, we are going to allow the director of public health to flow freely through the local authority organisation and scrutinise, be critical in a constructive way on the implementation of national government policies locally and on the development of local authority policies."

  413. Do you feel that is possible within the current restrictions on Dr Hoskins' role? You gave an example of Salford in the 1960s and 1970s. I know it reasonably well and it is not dissimilar in terms of background to parts of my own area. On the issue of chest complaints I certainly recall the MOH arguing very strongly on the smoke issue (I cannot remember the term they used to use) and directing towards using smokeless fuels. That was a major impact in public health in my area which the MOH played a part in. If we are to move more in that direction would Dr Hoskins in your neck of the woods need more empowerment in relation to her wider role to undertake what you are suggesting she should be able to do?
  (Mr Goodwin) The short answer is yes. Ann and her colleagues do well at the moment in influencing the local authority through things like the Healthy City initiative, through proposals like the Joint Health Unit which they have embraced with enthusiasm and we hope to get that off the ground properly in about three months' time. There is only so much they can do without more formal authority.

  414. Can I ask that question to the other witnesses who are here. What you are saying in terms of a recommendation is that we need to be looking at the actual function of a director of public health in relation to what they are required to do, the current statutory function. Is that an area where other witnesses would agree that we need as a Committee to make a recommendation in respect of that?
  (Dr Woodhouse) I would agree. I think the statutory public health function should extend to local government. I think there are practical issues there, but where this works well already because of local arrangements and relationships, it works very well indeed. I think if it were a statutory function then it would be very much welcomed by myself and my colleagues.
  (Dr Veal) I think it has got to have a very clearly defined role in terms of the local authority. I do not think the idea of wafting through the local authority and commenting on this or that is appropriate. There has to be ownership of the local authority by the director of the public health. I think that will take you back into the issue of training because I do not think you will find many directors of public health have had training in local authorities or local government. The opportunities for exchange have been relatively small. Manchester and Salford is probably one of those areas where there has been those forms of exchange. It is very important that you do not take somebody with just a health service background and put them in a local authority. We have not prepared our DPHs. We prepare our consultants reasonably well in terms of local authority training but we have not prepared our DPHs very well in terms of the roles they take on when they move up to DPH, and particularly their relationship with local authorities.
  (Dr Jessop) I would agree with the general sentiment. I would, however, add that I think the local authorities already do a terrific job to improve health in a whole range of areas. The air quality management programme is a local authority programme, the environmental health department, food hygiene, damp housing, they do not need us to tell them either what to do or how to do it. Another statistic we are terribly proud of in West Surrey is that not one West Surrey child died on the roads in 1999 according to official statistics. A whole year went past with no child killed on the roads. That is a terrific public health achievement but it is achieved entirely by the local authorities without anything on my part other than congratulations really.

John Austin

  415. I wanted to follow the Chairman's position as to how we might consider recommendations. In the Modernising Local Government agenda there is the role of the scrutiny committee within the local authority and there is clearly a responsibility for the local authority in terms of the new agenda for the NHS. Should there not be some guideline or guidance whereby the advice of the director of public health should routinely be made available to the scrutiny committee of the local authority, so that you have a duty to comment on the health impacts of local authority policy, whether they be in education, housing, or whatever?
  (Dr Jessop) I think that would be very helpful.
  (Mr Elson) I would agree entirely that guidance to indicate the importance of getting views from directors of public health would help to encourage those authorities which perhaps might not think of it as first order—although I would think most would.

  416. It might apply to pricing policies on their leisure centres, for example.
  (Mr Elson) Indeed, absolutely right, and to have free reign to do so. One of the things I find interesting in debates of this nature is we do get pulled towards a discussion about structure and about the authority and about the various legislative powers and responsibilities needed. The thing that strikes me is they already have the power and authority to speak out about local authority services. The law did not change. Where they were located changed but your recollections, Chairman, of the role of DPHs in being able to make statements, they still have legal powers to do that. I think it is a change in mind-set on both sides of the fence. Local government lost its interest in health as various functions were transferred out of health in the last half century. For too many of us within local government we see problems in terms of social regeneration issues without thinking of the health component of it. I think the changes are not just structural, although some of them may help, it is very much about looking at joint training, joint development across both sectors. It is about looking at driving the public health agenda through, joint leadership initiatives across the health and local sector, and making it a priority and not just rhetoric. Too much is rhetoric and not enough is building it into the main priorities of our agencies.

Mrs Gordon

  417. I was going to ask if there were tensions about statutory duties. I recently came across a case in my own constituency where something had to be done but who was responsible? Who would pay? It was batted backwards and forward for ages until there was a resolution to that problem. Although they were trying to work jointly there were statutory obligations about this and about how you could solve that and come to some resolution on that. Financial tensions; do you find the traditional view that local government is under-funded causes tensions with the health authority about joint ventures?
  (Ms Griffiths) Yes, there are definitely tensions. We are short of money and our local government colleagues are short of money as well for these sorts of areas. In Woking, one of the main towns in the area, we have got a Healthy Woking project, a miniature version of Healthy Manchester. It has been very striking that despite the utmost collaboration, at chief executive level in this particular case, how difficult it has been to get either agency to provide additional money for very well worked out projects. I think joint accountability is the key to this. Joint performance management processes, which were touched on in the earlier evidence, are key. We do not have those at the moment. We are hardly performance managed in our region on this agenda and certainly not performance managed in a joint way, so the whole public health agenda needs to become much more prominent really in NHS and local government accountability processes than it would be at the moment. That would be a very strong view that I have. I think there needs to be a lot more reciprocity in the relationship between health and local government. I very much buy into the need for scrutiny committees for democratic reasons, but the danger of that is that it becomes a one-way process and does something to alter the power relationships between health and local government in a way that is seen as one being dominant and the other subservient. I am very concerned about that because we will only make progress on the public health agenda if it is seen as an equal partnership. I think some duties do need to pass the other way, as we have all been saying, to get some reciprocity back into that. I do not think there is a solution to the structural issue and I am rather weary talking about structure. It is about relationships and checks and balances and processes. I would urge the Committee to think that through in its recommendations about what we could do to create a real joint accountability and a real joint performance management process and some checks and balances in the power relationships as well, because I think that could make a lot of difference on the ground.
  (Mr Jarrold) If I could just add to that. From the community's point of view, the most difficult divide (and I do not know if this was the one in the case you mentioned) is the one between health and social services, and people do find that very difficult because they have needs and they cannot understand why people are wrangling about who is going to meet them. There are three things about that. The first is that even under the present system it is very important that local authorities and health authorities have clear criteria for responsibility, for referral, and for levels of access to treatment, and where that exists most of those issues are resolved without the community becoming aware of those discussions and that is how it should be. Secondly, Health Act flexibilities are very important. We are moving, and so are many other places, use those flexibilities. For example, from 1st April last, all the learning disability services in Darlington are being run by the local authority and that will come in in Durham next year. That is very powerful for people with learning disabilities and their carers. Thirdly, although I share Jenny's weariness with structures, we do sense that care trusts offer an opportunity in the future and that you could see a situation where, for example, older people's services and primary health care services and learning disability services and community health services were all run by one organisation. We can see that possibility. So structure may offer in the medium term some hope but in the meantime there is a lot we can do by working properly together and using Health Act flexibilities.

Siobhain McDonagh

  418. I am not sure who I am directing this to but to the panel as a whole; how far will the proposed Local Strategic Partnerships help to provide focus and momentum to help to tackle health problems and inequalities?
  (Mr Elson) I will start off on that from the local government perspective. I think they are going to be incredibly important. They build on a tradition of joint working in our area which goes back more than ten years, but I think the impetus of Local Strategic Partnerships will help to create the umbrella organisation or forum that we need to achieve better integration of the planning processes. At the moment we are bedeviled by far too many planning processes. I am sure you will have heard in evidence to you that we have more than 40 statutory plans which local authorities have to produce and they are all driven by separate sets of guidance and separate government departments requiring separate presentational styles. There is a lot of work going on in the Cabinet Office to try and achieve greater rationalisation around that and then what we will be able to see is drug action strategies, children's plans, and health improvement plans beginning to fit into a more coherent whole. The Local Strategic Partnership is the way people like us may stay sane in a world where there are ever greater demands on our time to appear in different settings talking about different perspectives of the problems that are often very similar in nature. That is important. For me—and I think the LGA's evidence to you will have stressed the importance of local solutions rather than a national framework on structure—but for us I think the prospect ahead, which we would like to pursue with our partners, is using the local strategic partnership as a way out of the structure debate, out of the "who sits where" debate because I think there are functions in local strategic partnerships needs which need to be supported by a team of people with expertise, and public health is one of the key elements of that. Who pays them and what badge they wear is not necessarily the most important thing. The fact they work together towards core objectives tackling social exclusion problems, inequalities, and problems across the whole agenda is at the heart of that. I think LSPs, if it goes the right way, particularly because they are going to be fuelled by money and that always helps bring people together and motivate them, will help.
  (Mr Jarrold) I think Local Strategic Partnerships are absolutely fundamental, particularly when linked with this other question of community strategies, if you put those two together. If I could very briefly tell you about a meeting of our joint executive group this week. That group brings together PCG chief executives and district council representatives, social services and education at county level, and the health authority, and we all realise that what we have been trying to do so far is have organisations that primarily bring together social services and health and what we really need is member and officer bodies led by the local authorities that provide the focus for this huge range of initiatives, and that is under the heading really of community strategies, so a local authority lead for this great range of things, the health improvement programme, crime and disorder initiatives, the work of the drug action team, Sure Start, all of these things that make a vital contribution to the welfare of the community. We would certainly see community strategies, local strategic partnerships and local authority leadership as a key to this whole agenda.

John Austin

  419. Following on from Mr Elson's point, which seemed to be that local areas probably know their needs best, the Government is talking about collaboration and partnership and yet there is a whole series of pots of money and a bidding process and a competitive ethos whereby at the end of the day Whitehall decides who can spend money on what. Do you think this is the best approach to tackling neighbourhood problems? Does it also work against the mainstreaming of the services which you have said are so important?
  (Mr Elson) The way your question was phrased probably answers it. No, it does not make sense as the best way of doing things. By the time you have identified your way through different funding paths and bidding processes, the amount of energy that goes into bidding for resources is unnecessarily high at the cost of the outcome. Moving towards integrated financing of integrated service delivery is going to be far more attractive. Again, the local strategic partnership may provide the vehicle for that. We should aim for the same sort of approach on revenue which we are promised now in the local government sector held a single capital pot, with the different Secretaries of State merging their funding into a single stream and giving local flexibility to prioritise within that programme. I think that there is a strong need for movement in that direction. What my answer perhaps dodges is the issue of the geography because I think for many of us we recognise that the boundary debate will never ever be satisfactorily answered. It can go up and it can go down. There is a great benefit in focusing in on individual communities but also for a local authority like mine in the West Yorkshire context more and more we need to look at sub-regional issues and resource initiatives. To some extent at the regional but certainly at the sub-regional level, I think there is a planning vacuum at the present time across the whole of this sector. Local authorities are not working well together on public health across West Yorkshire. I do not think the regional offices have got the capacity to provide direction at that level. So it is down to informal networks and informal relationships perhaps rather than a formal network.
  (Dr Veal) I think the bidding processes distort local priorities very frequently. They also distort the aim of producing equity based on need. In other words, you will get some areas which have health action zones, and additional resources, and you will get other areas alongside which will have the same sorts of needs but will not actually get the same sort of input. Very often it also does not allow you to develop long-term policies because there is this issue about when you bid for things whether you are able to fund them coming out the other end of them. You should be making plans which are longer term plans in terms of direction. Yes, you can use the money for short-term change agendas but you have got to mainstream funding. There is no easy way of planning for things if you do not know whether you are or are not going to get something. You raise people's expectations. You create huge amounts of disappointment when the money does not come in or you create distortions when you have to find an additional sum of money to top up the schemes that you have originally put in for, and that takes it out of somebody else's pot.
  (Mr Goodwin) I agree with the last point. Somehow a way has to be found to move between the Government's approach of allocating money in this way and dealing with longer term local priorities. One example in Manchester which may be of interest to the Committee is a mental health partnership we have established. In essence, we have pooled resources, that is money and staff, for mental health services from both the health authority and the city council and we have established a joint responsibility for delivering what historically have been poor mental health services in Manchester, previously provided by five separate organisations which resulted in differential levels of service across a city that is no more than 20 miles from north to south. So pooling these resources into an organisation that is led by a city councillor, who is appointed by the health authority as the main body with a board, and is now responsible for delivering mental health services across the whole of the city, commissioned jointly by the health authority and city council, has allowed us to tack our way through the somewhat labyrinthine approach to funding and to relationships between the health authority and the local authority to deliver something which at the end of the day is certainly much more beneficial to patients and clients requiring mental health services.
  (Dr Hoskins) I wanted to pick up two slightly different issues. One is the issue of zone-itis. Any zone that you mentioned, Manchester has it. We have a health action zone, an education action zone, a New Deal for the Community, each for slightly different population levels, each in many ways working towards the same objective of improving the health and well-being of local populations, but each performance managed down a different tunnel of the central government. I think we must be performance managed but in a way where we cut across those boundaries, and we are looking at discrete areas within the council where you are measuring all those things in an holistic way. I must say another bug bear is around performance management. Every six months we get high level performance indicators and every six months my community is told how sick they are. If I look at my public health reports and go back 100 years ago and look, Manchester was sick 100 years ago. I think if we are going to develop performance management arrangements, let us set arrangements where we deliver for long-term targets, and performance manage us on the long term targets, not every six months. For things we can deliver within a shorter timescale performance manage us hard and fast. But please do not performance manage me every six months on something that is not likely to change for 10-20 years. Manchester will be at the bottom of that pile for another ten to 15 years, if I am lucky, if we ever improve that much. Because it is about reducing the gap. I think it is really important that we do it in a way that is sensible and reasonable and not demoralising to both staff and our own population who come up to me and say, "Are we really that sick in Manchester?" I think performance management is important but let us make sure we do it in way that is meaningful for all players.

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