Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 484 - 499)




  484. Can I welcome you to this second part of the session and thank our witnesses for their attendance and written evidence. Could I ask you each to briefly introduce yourself to the Committee.
  (Mrs Naish) I am Jane Naish and I am policy adviser at the RCN. I am also an ex-health visitor.
  (Ms Gough) I am Jenny Gough. I am a public health development nurse for the South East Primary Care Group in Wolverhampton and I have been a health visitor since 1974 so I remember working in a Local Authority, but I am wearing well!

  (Dr Rylands) I am Alison Rylands. I am a Consultant in Public Health at Wirral Health Authority and a I am co-opted board member of Bebington West Wirral PCG.
  (Dr Tiplady) I am Peter Tiplady, Director of Public Health in North Cumbria and I am old enough to remember the golden age you to which refer. I started my career in public health working as an assistant to the last Medical Officer of Health for Carlisle.

  485. Thank you very much. The last witness, Dr Crowley, made some critical comments about the NHS Plan; you probably heard her a moment or two ago. Your written evidence, I understand, was submitted to this inquiry before the National Health Plan was published. I wonder whether in view of that that you feel beyond Chapter 13, which relates to health improvement, that the plan does not offer a great deal on public health. This is an issue that has been raised by other witnesses. Do you share that concern?
  (Dr Tiplady) I share some of it. I think this Government started with such an exciting development with the Green Paper on Public Health and the White Paper, a Healthier Nation, which had a powerful and major public health agenda. We were all delighted to see that. For the first time there was the emergence of a strategy for health at a national level which recognised the root causes of ill health. I think it would be fair to say we have not seen that promise materialised in the national plan. There are clear resonances of it but the root causes of ill-health do not figure so much. Public health is not mentioned very often. I think the most frequent mention of it is as titles of witnesses rather than as topics within the paper. A structure has been developed which I think is a very positive thing, but I share some of the concern that the early promise has not been maintained.

  486. Does the RCN have a view?
  (Mrs Naish) There are some very exciting things in the NHS Plan. For one thing, there is the setting of national inequality targets, which I think most of the organisations that have been here have been badgering for. There is also the construction of a health poverty index, and that is very important in terms of public health. We were quite surprised that the paper ducked the issue of water fluoridation. That is very important in terms of health inequalities. But it also ducked—and the Green Paper did so too—the actual process of how you deliver public health in the field. It remains at a strategic or overview level. There is nothing in there about one of the two key issues about how public health departments relate to practice including, importantly, primary care which you have heard a lot about that this morning and there is a whole range of issues within that. Also, quite frankly, at local level most people just do not work together. Housing departments do not necessarily know social services let alone the health visitors. Jenny has got lots of examples. If you want to get a real change in practice you have to get people locally to work together, rather than just at strategic levels.
  (Ms Gough) I think the new NHS Plan gives us lots of opportunities to work on those links and to work on those partnerships. A little bit of background; as I say, I have been a health visitor since 1974 and in 1996 I was given an opportunity—that wonderful word—to develop a public health role in Wolverhampton alongside a traditional three-day health visiting caseload. I was given this job, which nobody else seemed to have done before, to develop and what struck me as a worker and health visitor along the way is this lack of information, lack of co-ordination about exactly what people that are working on the ground do or do not know. Hopefully, I have been instrumental along the way in developing and being a resource and being a link for my colleagues. That is not just as health visitors; that is district nurses, practice nurses, GP practices and across local authorities and voluntary organisations. I have not heard them mentioned this morning but they are a very important part of that integrated team. The result of work that I did on the ground developing a public health role opened the door for me. The Director of Public Health found out what I was doing on the ground and I have been seconded to the Public Health Department for the last 18 months working alongside the Director of Public Health both at a strategic and clinical level. I have been able to widen those links across all boundaries. This is quite a new development. It has not been a lateral curve; it has been straight up to the ceiling, but to get colleagues and to get communities together is certainly a way forward for better working.

  487. Can we explore a point that was discussed in the last session which is about how we address this joint working. It is very gratifying to see that people can remember the structure before 1974. I worked in that structure within local government pre-1974. It worked well and I would put to you the point I raised with the previous group of witnesses that there is a lack of clarity about the future role of DPHs and we are all raising questions about where that function will be in five years' time. Is there not the opportunity to look quite radically at recreating the networks we had pre-1974? I worked as somebody involved with child protection on a day-to-day basis in the same room as health visitors. It was at the time of the Maria Colwell inquiry so we were involved with the problems we had with child protection. We had the networks there that were based on being in the same agency. We had housing managers within the same agency which made it much easier for the kind of example Siobhain gave about notes from health visitors. They could directly influence the process of allocation. Should we not been exploring the positives of that previous system in going back to your point about the role of public health directors?
  (Dr Rylands) There is an assumption that that does not happen already when, to my view, it does. The experience that Jenny has just described is similar to the experience we have had in the Wirral, for instance, but it has gone the other way round and the Department of Health has identified health visitors and decided to further develop their role in ensuring that they understood what went on at a health authority strategic level, and to work closely with them in their links with the community, but bringing in the local authority colleagues as well. I do not think you have to necessarily be in the same building. That does not necessarily mean you are going to work together. Partnerships are about relationships and you develop those as you work together. I think that is happening, often through the auspices of public health being the catalyst for change to some extent.

  488. You are a consultant in public health. Can I put to you a concern that I have got about the new public health departments that arrived post-Acheson. I think what has been in existence post-74 has been more concerned with public health science than practice. I am interested in the role of the director of public health propounded in the Acheson report: "to develop and evaluate a policy on prevention in health promotion and on litigation". There is no mention of implementation in there. You could come back to me and say that you do that, but what I see in various parts of the country is all sorts of brilliant reports produced annually, very important reports, making some very important recommendations, but the person who is responsible for that report is not in a position—as the old MOH was in my experience—to get up at a council committee and bang some heads together about why people were not driving forward the policy changes that were needed.
  (Dr Rylands) I think some of that will change with the NHS Plan with the whole idea of scrutiny committees and changes in accountability arrangements, but I think implementation has become more and more a function of public health. The implementation of the NSF, by and large, has landed on public health consultants' and specialists's desks and they are very much responsible, but working very very closely with their clinical and managerial colleagues and not just in the Health Service but with local authorities as well. In the NSF for heart disease, for instance, we have an enormous linkage with our local authority in terms of leisure, education and housing to try and ensure we do something about heart disease. So I think implementation is there as part of our function.

  489. Sticking with you, Dr Rylands, on the issue of the domination of the medical model, which has been thrown at us time and time again from a range of witnesses including medical witnesses. How do you react to that? How do you see that holding back the process of change which we all think is needed?
  (Dr Rylands) That is an absolutely crucial role for public health practitioners, be they medically qualified or not, because it is those individuals who can shift from the medical to the social model. With all due respect to my colleagues in general practice, they have been trained in the medical model and unless we do something about further changes to the medical curricula or we ensure that their vocational training includes more of a focus on public health, it will still need to be public health practitioners and that includes health visitors and district nurses—who understand the social determinants of public health almost more than anybody because they are there on the ground with those individuals.

  490. Going back to the point made by Dr Archard about his partners not believing he was doing proper work when he was away doing public health, you see that being addressed in the longer term with training?
  (Dr Rylands) Yes.
  (Dr Tiplady) I feel very clear about the future role of health authorities—they are public health organisations, and I see an even stronger role for a public health population-based approach to the community. I have spent most of my professional life trying to retain the networks that we used to have in the old days and I put a lot of time into doing that. They are very strong and we have maintained links with housing managers, with social services departments, with social workers, with occupational health departments in the trust, and these are all very positive features that we have struggled to maintain over time. I see this as a core function of a health authority in the future in delivering a public health agenda, but the key to it is that it is a multi-disciplinary agenda involving a whole range of professionals, not just doctors and a medical model, and it should embrace all of them.

Mrs Gordon

  491. I think it is true to say that governments are notoriously bad at taking a long-term view, given our electoral system and given the need to produce short-term results is a great imperative, although I hope we are trying to change that. In the RCN memorandum you called for the introduction of performance management indicators for public health. Do you think these would be viable given the length of time that interventions take to take effect? If you do, can you give some examples of public health performance management targets which you feel would be appropriate and effective.
  (Mrs Naish) I think the reason the RCN put that in its evidence was because we think they would be a useful lever. One of the key things, which I have not heard previous witnesses today say, is that public health is not particularly mainstream in the NHS. It is not sexy, it is not high status, if you are pukka you do not go into public health. I think one of the issues is getting an organisational corporate hold on public health because it is very marginalised in the work of trusts, PCGs, still at the moment, and indeed in health authorities to a large extent. So using performance indicators as a lever is very important. The sorts of things that we had in mind could be around the process, whether it was about community involvement, or it could be about achieving local targets and the implementation of that. It is basically to get some kind of commensurate pressure on chief executives, dare I say this, to other issues they have such as waiting lists. They have got this other heap of things around waiting lists and so on.

  492. You feel that would make a real difference?
  (Mrs Naish) That would be just one of the things that would change the culture.
  (Dr Tiplady) I think there are public health initiatives that do bring results in the short term. It is a mistake to think that everything is on such a huge horizon that we never get there so we start mucking about with very wishy-washy performance indicators and forget the targets. There are two that I would bring to your attention. One is the fluoridation of the water supply where benefits are seen very quickly in dental health and certainly fluoridation results would be seen within the term of one Parliament! Secondly, in Russia the decrease in life expectancy that took place after the dissolution of Russia was rapid, suggesting that environmental causes were very significant in determining life expectancy. What we all know in public health is that there is a very dramatic demonstration of how health can change so rapidly, so we do expect that environmental changes brought about through partnership issues like health action zones and education action zones will improve health as quickly as it fell in Russia, so again short-term objectives may be seen.
  (Dr Rylands) Can I make a point to shift the perception a little bit in terms of the role of public health with trusts, particularly acute trusts. There are a number in the country that have consultants in public health medicine and specialists in public health in post. My local acute trust is one of those. That not only facilitates reasonable discussion between the health authority and the trust because we talk the same language, but also ensures that the public health message is on the agenda of trust chief executives. It is not only about epidemiological analysis and being able to interpret statistical information, it is about ensuring that population perspectives in the health promotions are starting to be shared with the clinical consultants and nursing staff across that trust. I think it goes back to the point that was made earlier today about health being there at every level right down to the individual and up to a national perspective.
  (Ms Gough) I would be very keen to see public health incorporated in a mainstream service. In Wolverhampton we have got a director of public health joint appointment with the local authority and health authority and that has moved things forward tremendously because we are forging really good links with our local authority and voluntary organisation colleagues. Looking at the short term, I agree that you could provide short-term successes. For example, I have been setting up breakfast clubs within schools. I kept calling them "quick kills" when I meant "quick wins" before I was corrected. They are quick wins and they do show benefits. They are having a great effect on the children in Wolverhampton schools. I have concerns about short-term contracts for professionals trying to deliver the public health agenda. In my own instance I was given contracts on a six monthly renewable basis. It takes six months to get a community's confidence and trust. They would not recognise me today because I am normally out there in my jeans and my Doc Martins or something. I had to fight every six months because I am so committed to public health, so enthusiastic and passionate about it, and at my last six month contract I staged a sit-in in the general manager's office with my sandwiches and my tin of Pepsi I had asked for my contract to be renewed time and time again. I had written, phoned and had no response and was I was determined because the role I had developed was so important to those communities and to myself because the links we had formed were too valuable to lose. I think it is really important that we do have some performance indicators and we do incorporate public health into the mainstream. Yes, let us look at things that we can get there in the short term as well.

  493. You are a trust?
  (Ms Gough) We are a health care trust, yes, we are.
  (Dr Tiplady) I did give some thought to what indicators could be used. This is not by any means a comprehensive list but I have got a few ideas like monitoring the health status of the community. That is a simple public health task. Is it done and how good is it? Does it identify hazards to health in the local community? What plans have been set up to protect the public from those hazards? How effective has the public health department been in mobilising and energising partnerships? Does it provide a competent workforce to address these issues? What research does it do into innovations in public health and how does it evaluate the effectiveness of its own actions? I used to be on the Kerner (?) Committee for statistics all those years ago and my main contribution was developing performance indicators for hospital chaplains, but it was withheld from the file!

John Austin

  494. Could I pose the question that I put earlier as to why a director of public health has to be medically qualified. Is it necessary?
  (Dr Tiplady) At the moment it is a legal requirement.

  495. I know it is a requirement.
  (Dr Tiplady) Public health is a multi-disciplinary speciality and the issue about people other than doctors becoming directors or specialists is that they should have a proper training programme which delivers the skills they need to practise public health and when that is done I think that specialists will be on an equal footing with doctors and eventually I am sure they will be competing for the post of director.

  496. Do you think there could be a potential at the present time for splitting the post of director of public health into two posts, one which deals with the medical responsibility roles of a medical director of public health and the other more managerial, epidemiological, social?
  (Dr Tiplady) I think that may have the danger of fossilising the medical model. We are all convinced that is not right way; the social model is the best model.
  (Dr Rylands) The mixture that makes up a public health medic is a good one, just as the nursing input plus background and further training adds to the mix, and I do not think you should try and separate them. I think the two together are what makes the role effective, as it would be if a general practitioner had done some public health work or an environmental health officer had worked on the management of public health. I think it always goes well together.

  497. Earlier on Ms Gough said that in her case the director was a joint appointment of the health and local authority. The RCN are, very clearly, powerful advocates of that policy. Is there any evidence that you have to show that this has worked or been effective? What impacts have there been which would not have been achieved if it had been a health appointment only?
  (Ms Gough) I think our director is more aware of looking at the social model of health as well as the medical model of health. I am now in the public health department because he was aware of what was going on within local communities. He comes out to local nurse meetings and to health visitor staff meetings. He is also on regeneration and partnership boards so he is going into our local civic centre where our housing associations and housing local authorities are based. The fact he does not just set himself apart in the public health department, that he comes out and sees what goes on in other authorities and in other departments has made an amazing difference to the way Wolverhampton is now structured and working, particularly in partnerships, bringing people in at a local level and he goes out to local communities as well not just to inform staff but to inform consultants. We have a consultant in public health now in each PCG area, so if there are concerns by the PCGs' chief executives, staff, health visitors, district nurses, GPs, they do have a named person with whom they can liaise on community development. I have to say that our assistant director of public health is not a doctor and he was an Assistant Director of Strategy before taking up his post.
  (Dr Rylands) You do not need to have a joint appointment to be able to do all of those things. I think my director of public health would be very upset if I did not say that she comes out of her department and sits on all the regeneration, Objective 1, health action zone groups, etcetera, etcetera.
  (Dr Tiplady) I think what would be helpful is movement in both directions because one of the statements in the White Paper was that they would anticipate that directors of public health (or presumably on their nominees) would be invited to local authority council meetings. In my experience health authorities have taken up that challenge quite rapidly and usually invite representatives from the county council and occasionally the districts to attend health authority meetings. I do not think that is happening in the other direction and I think that would be very positive.

  498. I am grateful for that because the Chairman mentioned earlier going back to pre-1974 and the old MOH. I can recall when the MOH published his report, other chief officers would be quaking in their boots, particularly the housing manager as he was then, to hear what the doctor was going to say about the council's housing policy. To what extent is the annual director's report less powerful than the old MOH one? I think Dr Tiplady has already answered that question by saying that one way he has become more powerful is he is going along to council meetings. Do you think that report can be made a much more powerful document?
  (Dr Rylands) Again using the local context, one of the reasons they are not quaking in their boots when the DPH report comes out is that they helped to write it and, although the director of public health is the editor and it is their report, it is much more about the health of our local population and that includes all those wider determinants as well as how well the trust is performing, for instance. We try not to get too bogged down on what our SMRs are and we try to expand on the community development that has gone on and the links that have been made with other agencies.
  (Dr Tiplady) A public health report now can discuss and make recommendations across a much broader area than we could in pre-1974 days where it tended to be about the services provided by the local authority.

  499. Does that raise the issue of HiMPs being separate from the community plan and whether they should be brought together?
  (Dr Rylands) We are bringing them together.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 1 February 2001