Examination of Witnesses (Questions 400
- 419)
THURSDAY 7 DECEMBER 2000
MR TONY
ELSON, DR
CHRIS VEAL,
MR KEN
JARROLD, DR
JOHN WOODHOUSE,
MS JENNY
GRIFFITHS, DR
EDMUND JESSOP,
MR NEIL
GOODWIN AND
DR ANN
HOSKINS
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.
Chairman
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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