Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 420 - 437)




  420. So if we recommended public health league tables and performance-related pay for directors of public health, you would not be totally on board?
  (Dr Hoskins) Not particularly, but my performance related pay is not really that I am talking about. It is about how we are working to reduce that gap.
  (Ms Griffiths) I am very interested in that one! The point I was going to make is going back to the earmarking bidding and that question you asked which is actually a slightly dissonant one in the sense that in the harsh reality of the present situation where right across the health and social care agendas, in particular, we are in the business of bidding for pots of money or dealing with ear-marking of funding or various other mechanisms that are used to ensure we target funding in particular ways. In that harsh reality there is scope for reviewing the relative priority of public health as against other priorities. I probably feel distorted about this because I do not get zone money and I do not get healthy living centre money and it is very hard for us to find any additional resource for public health and health promotion at all. If the current system of heavily ear-marking or bidding for pots of money is going to exist, there is room for looking at the relative priorities. I would dearly love to have an additional dollop of money for health as well as well as for winter because I do not feel the priorities are right at the moment. We have only got very small amounts for teenage pregnancy, smoking, etcetera, to improve the health of our population

  421. I get the impression that the other witnesses broadly concur with what you have said.
  (Mr Jarrold) Could I just make one additional point. We need two things really, perhaps three. First of all, we need a robust formula for allocating resources on a population basis that takes adequate account of deprivation. The new DETR index is a very powerful way into that and I think it really is important to look at that. If we had resources allocated fairly on a population basis, with both health and local authorities taking account of deprivation, there would be no need for these endless bidding processes. Secondly, though, of course it is right for government to set out its expectations of how we use that money very clearly and, thirdly, to hold us to account. If they did those three things we could much more effectively deliver rather than spending a lot of time and energy on bidding processes which are not the most effective way of distributing resources. So we need population-based funding and clear policies.
  (Mr Elson) Could I add that we need strong performance management on indicators of health not just on indicators of sickness.

  422. I think the encouraging thing about this morning is that we are all struggling toward a holistic approach to people's health and also a holistic approach to how we deliver that because it is quite a complex issue. One of the things which is now recognised is that regeneration of communities plays a big part in tackling health inequalities and in closing this gap, but there seems to be not very good contact between health and regeneration sectors—all the agencies, the RDAs, DETR. On one particular project we looked at we had evidence that the regional development agency was notoriously slow and dragging their feet in handing over money and they had all the money from all the other agencies as part of this bidding process but the RDAs were almost reluctant to hand it over, it seemed. How do you see this relationship between the regeneration sector and the health sector and how do you feel it could be improved?
  (Dr Woodhouse) I think this reflects the discussion we had about the relationship between public health and local government. In my area I think we have worked our way into these processes to a degree, which is partly satisfactory. I think the impact of health on regeneration and regeneration on health is something that seems to have been forgotten in the past. We need to be more cognisant of the impact of good health and what good health can do for regeneration as part of that process. I do not think we should rely on what we have now, which is basically people like me having to work our way into those processes rather than having some input which I think we should have.
  (Mr Goodwin) I think it is difficult to generalise about the practice across the country. In Manchester it is pretty good, largely because the local authority takes the initiative and invites public health staff and other staff from the health authority to participate in regeneration initiatives, often by giving them formal places on regeneration boards and executive groups and so on. I would share the last view which is that I do not think it should be left to either the largesse of local authorities or health authorities to work their way in. I think it should be a little more formal than that in future.
  (Mr Elson) I am just wondering whether you may have been given the impression that it is different for local government and regeneration agencies because the pattern of trying to work out the relationships with RDAs is as big a problem for local authorities. We have been working with regeneration programmes for a number of years. In fairness, RDA's are very new creatures, and they are often channelling money from Europe or individual government departments and there is a lot of bureaucracy around that which causes difficulties. It is certainly a problem where the wheels need oiling. It is back to the issue about the bidding culture and also back to the resourcing issue. Because regeneration and regeneration funding initiatives are important to local government we devote a lot of staff time to it. We get teams working on initiatives on a full-time basis over many months to build up a bid. We are looking at the same faces in the health authority, people who are already overworked struggling to deal with the problems of the GP who is not doing something they should be or whatever. It is competing for time; it is competing for a scarce capacity. I would urge this small point on you as a recommendation on a side issue on regeneration. Regeneration is delivered usually through companies that are set up for the purpose and the current position is that health authorities cannot put their people on the company as directors, which is a nonsense. They sit there as observers but the rest of the people are there as full participants. It is simply an issue about NHS organisation that could be swept out of the way if there is a mind to do it.

John Austin

  423. Can I follow through the regeneration thing and talk about employment as well. Often on regeneration schemes health is one of the measures in terms of good outcomes, but it is almost as if it is a by-product of the regeneration scheme. What we do not see is many health-led regeneration initiatives. Do you think there is much greater capacity for that? The second point is we have acknowledged in terms of determinants of health that economic conditions are a key determinant and also whether you are employed or not employed. The NHS is one of the largest employers and yet in many areas the very people who need employment may not have the necessary skills to access those jobs. Do you think the NHS itself is doing enough to address those issues, particularly in the deprived areas?
  (Mr Jarrold) I would be very happy to say something about that.


  424. You have obviously got a good story to tell.
  (Mr Jarrold) I will try and tell you an honest story. If I could just say something about Easington. It is in the East Durham coalfield and is becoming known now as the setting of Billy Elliot, a very deprived community indeed. In the DETR concentrated index, it is the eighth most deprived community in England. There was an East Durham Task Force set up as in other coalfield areas but there was no health group. There was a group for employment, a group for housing, a group for transport, but no health group. There has been one for the last two years and we have seen real benefit from that. It is very important that health and local government make sure between them that whenever there is a major regeneration issue, as there is in Easington, there is a strong health stream alongside education, employment, transport, and all of the other things. I think that is very powerful and very important. Certainly I believe that one of the best things the Health Service does for the health of people in this country is to provide about one million reasonably paid jobs. They vary of course in how reasonably they are paid, but about a million jobs. That is extremely important. In many of our local authority areas, apart from the local authorities, the Health Service is the biggest employer, and that is a major contribution. I think we could do more to provide access to employment. One area that I am particularly interested in as Chairman of the Education and Training Consortium is the great potential for health care assistants who tend in the main to be people without formal qualifications who then move on to formal professional training. There is great power in that and it is something we are looking at closely. Health should lead aspects of regeneration and the Health Service could do more, particularly in deprived communities, to bring them initially into employment and then into professional roles, for which many of them do have the innate ability and intelligence.

  425. Do you think Easington is an exception in going down this road?
  (Mr Jarrold) I think Easington has been badly treated by the Health Service for most of the period of the Health Service. At long last we are beginning to get our act together. I am sure there are many other areas, including Manchester, that are ahead of us in that, but we are trying.

  426. The Government has talked about health audits of major health decisions. For example, Easington is not dissimilar to some of the areas I have represented in the past where we have had mines closed and the knock-on effect in engineering has meant thousands of jobs gone. Do you see in practical terms any sign of anything emerging from the Government that would bring about a health audit of that kind of decision in future? Any kind of inkling from Richmond House that perhaps you ought to be involved in looking at some of these wider issues?
  (Mr Jarrold) No, Chairman.

  427. Thank you!
  (Mr Elson) Could I come in on the same question because I think if you look to the source of regeneration funding it explains why health does not come through as a major theme. It comes into the regeneration pots that go out for bidding. What you end up doing is reinterpreting the goals and objectives that are set for the regeneration programme in ways which allow you to put health components in, so the health components you build into the programmes are because of the need to raise skill levels, and to increase employment opportunities, and you have to trace it through low level mental health problems through to employment opportunities in that process. A lot of the life that we lead on the interface between health and local government is reinterpreting the language of one agency or government department in a form that can be understand by the others. So you can set objectives that fit a local authority's agenda on education improvements or crime in ways that can also meet health objectives to show where the synergy lies.
  (Dr Veal) Local authorities have responsibility for well-being; health authorities have responsibility for health. I interpret them as the same but I think it would be very helpful if local authorities had the responsibility for health and that would flow through into your concept of bidding for money and resources that local authorities currently put into bidding for regeneration resources that come round.

John Austin

  428. Can I come back on the NHS's role as employer. When we did the mental health inquiry, we came across one mental health trust which had a positive action policy in terms of recruitment and employment of people who had experience of mental health problems. If not unique, it was quite an exception for a mental health trust to have a policy in relation to employing people with mental health problems.
  (Dr Veal) I can remember a period in the Health Service when a large number of employees in the Health Service had pronounced and obvious disabilities. The pressure of work and the need not to provide that social form of employment has changed dramatically the picture and pattern of the workforce. I am sure those of you who are as old as I am will remember that workforce as a very different workforce to the one we have got at the present time. If you are not fit, you are not healthy, unfortunately there are not as many opportunities as you would think or hope. We are all trying to change that but we have asked for more and more performance with less and less resources over quite a period of time which has squeezed the system significantly.

  429. Can I come back on that to Dr Hoskins' point about performance management. It seemed to me that Dr Hoskins was reading from the NHS Confederation's evidence to us, singing from the same hymn sheet about heavy-handed performance management and the fact that different departments, DETR, DHS, the regional offices, all have their own accountability approach which frustrates the local partnership working. Is that a view which is generally shared by all of you? How do we overcome that to ensure that we have accountability through performance management but which does not stifle the initiatives of local partnership working?
  (Mr Elson) It is a major problem. It is an increasing problem from my perspective. I think there is a confusion about trying to drive accountability up, with the increasingly bureaucratic performance management systems to which local authorities are exposed. I am perhaps in a stronger position than my colleagues to say that it does seem to me that the culture of the Department of Health does not help us in terms of achieving some of the objectives around public health.


  430. Could you be more specific?
  (Mr Elson) I think it is the urgent pushing out the important. I think it is a fact that you end up with the situation where very busy people who are trying to deliver an innovative, creative, ambitious programme have their time taken up on journeys down to London during train crises to see Ministers for briefings that last half an hour and trekking back and that gets in the way of doing the job.

  431. Do you agree with that?
  (Mr Jarrold) If I could take a slightly different approach, but one which I suspect Tony might agree with. The key to good performance management is differential performance management. We are promised in the NHS plan that is what we will get. In other words, there will be a genuine loose/tight approach. There needs to be intervention and a concentrated focus where there is really poor performance. Where there is really poor performance; I do not think anybody could reasonably object to that. But for the great majority of people who are either doing a reasonable job or better they should be left as much as possible to get on with the job at local level. The problem at the moment is everybody, whatever their level of performances tends to be treated in the same way with the same burden and that means that the performance management function is less effective because good performance management is about rapiers and not about blunderbusses. You need to focus on where there is poor performance, not scatter gun everyone in the system and tar them with the same brush however well or badly they are doing.
  (Dr Veal) There are some training issues as well in that in a bottom-up approach you need a workforce that has skills in terms of evaluation of its own clinical practice and you need to develop that work. We do not want a Health Service style or an approach which is "as Buggins did". We want general practitioners to be able to evaluate their performance and to be able to work from the bottom up to look at how they are benefiting their populations. People need skills and that is where we ought to be concentrating. I think that a lot of people at the present time feel weighed down with having to produce returns, numbers. We end up with huge sets of traffic lights. If there is red on something, then all attention is diverted to that particular area of the red light, and you stop all the other things that you were doing that was good. Particularly from a public health point of view, we really are getting pulled into the clinical problems of the waiting lists, winter planning, a whole range of things which are important but they stop you doing some of your longer-term agendas. You are not going to be able to performance manage them in the same way for the reasons that have already said—these are long-term targets—so what happens is the important is pushed out by the urgent and we end up having to deal with short-term agendas. We need a performance management culture that takes us long term not short term.

  432. Do you think some of the targets are wrong then and we have got too many ill-health targets—how many people you have treated, this sort of thing—and we have not got enough good health targets?
  (Dr Veal) Yes.

  433. Is not one of the problems that we as politicians inevitably think in the short term? How do we as politicians get over that because what we have to face up to possibly next May 4 is we have to be seen to deliver, and certainly the issue we discussed last week is for politicians to have a public health agenda ( which is something that is implied) you are talking ten or 20 years ahead, which for most of us as politicians is no good, speaking for myself anyway!
  (Dr Veal) It is even worse for those authorities in Scotland and Wales where they almost go through a continuous system of elections with different tiers of government.
  (Mr Goodwin) There is a slightly different perspective, Chairman. We accept that governments come and go, or indeed stay, and there will always be political priorities. That has never changed. I think, though, that although we do have to fill in a lot of returns and demonstrate we have met a number of bottom lines, there is a soft dimension to this, certainly in our experience in the North West, which is about the system up the line having confidence or not in the local management teams or the local chief executive or director of public health to tackle the issues or the indicators that are labelled "red". In Manchester year-on-year we get red indicators on health, but generally we do pretty well on the delivery of health services, we have a pretty efficient Health Service in Manchester but every six months we have to explain what is happening on health. What we feel is, yes, we have to fill in all these returns and so on, that is a given, but there is general confidence that what we are doing with local authorities—I guess I would say this, wouldn't I—is going to produce the results in the longer term. There is a softer element of performance management. It is not just about numbers and targets but about the system up the line having confidence in local management teams to do the job. That then leads into questions for public health, for management teams generally in health and local government about training in the skills in order for them to work together perhaps more effectively than some of them are doing at the moment. I think these are new skills that we are having to learn because of the Government's new agenda around partnership and collaboration. The government can legislate for partnership and collaboration but it cannot actually make it happen. That is down to local people, local relationships and having the right skills and the training to do it.

  434. Do any of my colleagues have any further questions? Are there any points anybody wants to raise?
  (Dr Jessop) Can I make one point very briefly. Can I plead the importance of public health data systems. We need to know whether we are winning or losing the public health battle. I think the latest confidentiality guideline of the General Medical Council will hamper our ability to know what is going on on cancer and substance misuse and probably a number of other registers as well. I think we need to consider statutory notification of things other than infectious disease. It would have to be confidential but I think it needs to be thought whether this would be statutory.

  Chairman: Would you follow up that point with a letter to the Committee which would give us a chance to look at it in more detail? That would be very helpful.

  John Austin: An Early Day Motion has been tabled by Dr Gibson on that very point.


  435. We are always on the ball here!
  (Mr Jarrold) I wonder if I might make one very brief point because I think the evidence from the NHS Confederation did not give a balanced picture on this. I think most of us feel that the NHS is moving towards three levels. There is the regional level which is not a distinct level of central government in that it does not exist in Wales or Scotland, it only exists in England because England is big. So you have a regional level and that is fine and it would be helpful if it were co-terminus with government regions, one or more. We have a very clear account from the NHS Confederation of the third level, which is the primary care trusts of the future linked to unitary authorities or district or borough councils in some combination. That is absolutely fine. What you did not get from the NHS Confederation is a clear understanding of the middle level, which Tony referred to, which is the sub-regional level. There is something real around Tyne & Wear, around Greater Manchester, around West Yorkshire, around Durham & Tees which is about clinical networks for specialist services but also about large groups of population living and working together. That sub-regional level is very important, I believe, to the future of health as well as health services. I do believe that there is a role—this is not a defensive point—for some sort of sub-regional organisation, and I also believe that it could play a crucial role in public health by providing a sufficiently large critical mass of public health specialists well supported and resourced.

  436. Thank you for a very helpful point.
  (Mr Elson) A very brief point, Chairman, reflecting back to the question you asked which is how do politicians cope with long-term agendas when there are short-term priorities too. The obvious answer, surely, is about putting a degree of funding protection around public health so it does not get squeezed out so there are resources available to drive it forward.

  437. We were more concerned because we went into an election with promises on waiting lists. Some of us who looked at the detail of health policy were not entirely happy with that, as I am sure you will appreciate, but it is very difficult to put in a public health agenda for doing such and such because using the achievement of public health is a long way down the line far beyond one Parliament.
  (Dr Veal) The Health Service is encouraged to invest in evidence-based policies and approaches. There is quite a good evidence base in relation to a lot of the clinical evidence but we really do need some pressure to divert an agenda to produce the evidence base in terms of community interventions and a range of public health measures.
  (Ms Griffiths) I just wanted to strengthen the point about public health resources which we have not really gone into this morning, but we touched earlier on the importance of public health support to primary care groups and primary care trusts and organisational questions around that, as you know, but I think it is very hard to be able to see one's way to sustaining and developing further the amount of community-based public health activity that we have all been talking about within the existing resource. I would make a plea for some expansion in capacity, and I am using the term "public health resource" in its broadest possible sense here. Some very welcome developments around the non-medical side of public health professional development are under way at the moment and I do not think without that we will be able to reap the benefits of what we were discussing an hour ago which is the growth in community-based primary care and related developments in community-based public health.
  (Dr Hoskins) I would like to pick up a point about evidence-based approaches. I suppose it is interesting to me that one of the good evidence-based approaches is Sure Start. What has interested me is that has come down through education, it has not come down health and maybe there is some scope for protecting some of the public health initiatives so that they do not go down the health budget because they get very tied up with health services and go down other budgets. It is of interest to me that Sure Start which is an evidence-based approach around young children which we know will have a good effect in the future, the funding has gone down the education funding route.

  Chairman: Can I thank you all for your participation. We have covered a very wide-ranging area and there may be areas that you feel you would like to have said more about. Please feel free to drop us a line. This inquiry will run until early in the new year so we have plenty of time. We appreciate the efforts that you have made today. Thank you very much.

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