Examination of Witnesses (Questions 420
THURSDAY 7 DECEMBER 2000
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 sectorsall 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.
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
424. You have obviously got a good story to
(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.
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
(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 saidthese
are long-term targetsso 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 targetshow many
people you have treated, this sort of thingand 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 authoritiesI guess I would say this, wouldn't
Iis 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 rolethis is not a defensive pointfor 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
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.