Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 500 - 516)



  500. In your area but it is not true everywhere.
  (Dr Rylands) No.
  (Dr Tiplady) I would like to point out that certainly in my district we have local authority representation throughout the planning structure for health improvement programmes. We have a very important programme board which we set up for promoting good health because the local authorities, not the Health Service, were complaining that they did not think enough emphasis was being given to the promotion of good health. We now have a health board promoting good health and that will be chaired by the local authority person.

  501. If it is not happening in all areas and it is happening successfully in yours, do you think there is some need for guidance from the Department of Health?
  (Dr Rylands) There is a duty of partnership now and it may be that some people have managed to do it more quickly than others because of the historical relationship that already existed. I think some of the other initiatives that are around have expedited that. For instance, I know the health action zones which we have and which Peter has as well have brought local authorities and health authorities together to work on those plans. I think it is happening, albeit slowly.
  (Dr Tiplady) It is always a good plan to share examples of good practice.

Mrs Gordon

  502. Could I direct this question to the BMA—although the RCN may have a view on it. On our visit to various community-based public health projects in the South West of England we were told that GPs were often reluctant to become involved, indeed could not be dragged kicking and screaming to be involved. Can you suggest why this should be and what can be done in practical terms to increase their participation? They are at the front line and if they are divorced from the projects going on, that is sad.
  (Dr Tiplady) We both work very closely with GPs and primary care groups. My experience is that GPs are under enormous pressure to join in by coming to meetings and they often feel paralysed by meetings—"death by meetings" is the phrase. I think there is a certain truth in that. After all, a primary care job is about developing primary care, not assisting the health authority to carry out its functions. I think the answer is that we should expect and hope GPs that would be involved in the things they can contribute best to and there are other areas to which public health can make the best contribution. The answer is we should be working closely together. I do not think it is a question of money; it is time. GPs have a limited amount of time and there is an enormous number of meetings to which they are invited. I try to engage them in what I think are the important areas.
  (Mrs Naish) I think there are several fairly obvious issues as well though. One of them is that nurses and doctors are primarily educated to work with individuals. To get them to make that huge shift into population thinking would need quite a lot of investment in education, which is not currently going on. Secondly, there are some difficulties, as an ex-health visitor, when you are in the field. There are two things; one is what people expect of you. What they want you to do is work with the person in front of you at that moment. There is always the tension of how to balance this. I am not surprised that GPs do not get involved—and I know they are not on the whole involved in community schemes—because their workload is predicated on working with individuals and individual care.
  (Dr Rylands) It goes back to the point I made earlier about education and training and it is about enabling general practitioners and other professionals, who are more used to dealing with an individual case load, in a sense to take that population perspective and then see an opportunity, as was described, to change their career focus slightly or to engage in a wider range of activities. There are different ways of doing this. Some may say you can go off and become a public health practitioner (and a lot of my colleagues have had a general practice background) or you might take the opportunity to do a sabbatical or ensure there is some public health training within a vocational training scheme for general practitioners. The Master of Public Health I did was extremely multi-disciplinary. We had teachers, nurses, environmental health officers, occupational health practitioners, GPs, and specialist registrars. You gain so much from that environment that even if you go back to being a jobbing GP you take with you a completely different perspective that changes the focus of your work somewhat.

  503. Do you think that there should be much more emphasis on preventative health care in the training? We are an "Ill-Health" Service and GPs, quite rightly, see their role as dealing with sick people and making them better and the preventative health side has not had great emphasis.
  (Dr Rylands) I think the GMC has recognised that to some extent and the new medical curriculum has suggested that there should be much more emphasis on public health. That is not a medical speciality, but as a core underlying theme that makes medical students in particular think about why people have the lifestyles and life behaviours they have and what are the causes of ill-health. Much more of the medical training is about working with other disciplines as they go through their training programmes. In Liverpool, nurses and doctors and physiotherapists are doing their training together to a large extent and that can only be beneficial.
  (Ms Gough) Can I just make a comment while we are talking about training and education. I am very keen that if people want to go on to do a Masters in Public Health that they are given the opportunity to do so, but funding is quite an issue. In the role that I have begun working on and developing I have had to fight to get funding to do my Masters, which I hope to start in Birmingham in September. I could not get any funding from my region or my own local school of nursing and health authority and I have been funded by the Black Country Education and Training Consortium. This is an issue where we do not give opportunity and we do not encourage people. I am motivated, enthusiastic and I like to do innovative things, but if we are going to expect people to deliver a service like this we need to put our money where our mouth is and provide some funding. You do not have to resource community developments and training issues out of your own pocket all the time. I have already funded a degree out of my own pocket. I also fund some community development. Here you are in your two days a week public health role and there is no more money, no more resource, so when I have developed parenting packages and domestic management packages and taken young lone parents shopping to do budgeting and very basic things that will provide our next generation with a better quality of health, the money for that shopping round the local market is out of my own pocket. I do not have a problem with that but I should not have to do it. It is an issue. It is only a very small amount but I still should not have to do that.

  504. Do you feel that with any new money that has to go to the NHS, the emphasis should not be on this end of primary care but preventative health care?
  (Ms Gough) I think it is a very important part of training and I think it should be combined. You have got to have medical input alongside social care and I think it is important to try and combine it. As we heard earlier, if you choose to be a district nurse or a health visitor the career pathway is into management so you either become an assistant general manager or a general manager or, as is happening now, you can develop a career in public health if you want to do that. What we need is back-up training and funding to enable practitioners to go along that pathway and also matching salaries. The work that I do, especially working with things like New Deal for Communities, is very stressful and you need training and input. You look at the salaries of public health directors and they are on, say, £55,000 and I earn £25,000 for 34 years' experience, sometimes 15 hours a day three or four days a week and weekends because if you are working with communities they are out working themselves during the day, so if you want meetings with communities they are in the evenings or on Saturdays.
  (Mrs Naish) Just coming back to that question, what one needs to do is engage the public in some of these debates about public health because at the moment the public see the Health Service, as you know, as about delivering acute care. There are some real issues about how we engage the public in some of the debates on how we spend Health Service resource and engage them in spending on public health issues.


  505. Can I come back to the relationships with general practitioners. I was interested in the BMA witnesses saying that in their area that it was not a problem, it was not an issue and there was a relationship between the current health function and general practices. I would be interested to know how you created that relationship and also how you see the PCT development impacting on the on-going relationship.
  (Dr Rylands) If I can answer from my perspective. I cannot give you chapter and verse because the relationship already existed when I took up my post. There had been links between the Public Health Department and the localities, as they were then, across the Wirral.

  506. You heard my earlier question.
  (Dr Rylands) They certainly know who I am—

  507. I saw your expression.
  (Dr Rylands) I have a lead role for a couple of things across the district.—the GPs in my Primary Care Group, and, I would hope, the other practitioners within the Primary Care Team, although to a lesser extent. I wonder if I asked the health visitors whether they would know who I am, some of them would, GPs certainly do. It is historical. It has been about the Health Authority and the Department of Public Health being prepared to offer the time of an individual, it has been doctors and public health specialists, to the localities, the subsequent GP Commissioning Pilot that we became and then the PCG. It has been there and negotiated and is actually used. I am a cooperative board member, even though I have an official position in the Primary Care Group, and that is true for a number of our neighbouring districts, it is not unique to the Wirral. I am involved in clinical governance; in the health improvement programme; in specific clinical areas; in working with lay representatives in terms of community and public involvement. We have a public health facility which is part funded by the PCG and by the Health Authority, who works very closely with the primary care team, the local authority and the voluntary sector. It is about relationships and getting to know individuals. I think in health authorities where they kept their Public Health Department remote as an advisory service it will not be successful.

  508. You see a distinction between the approach of some health authorities in terms of public health, as something far more hands-on, traditional, even in advance of the current change?
  (Dr Rylands) In terms of developments around primary care trusts there has to be somebody with public health expertise. What has happened in our location is that they have seen that that needs to be somebody with additional training, not just somebody who might have walked past the Department of Public Health on occasions. I think that is quite important from a professional point of view but also from an expertise point of view.
  (Dr Tiplady) In my case I was a GP before public health so I have always put high priority on maintaining relationships with primary care teams. As the commissioning of primary care groups developed because we are so closely involved with them it was very easy to identify what they wanted from public health. For some time now we have had each primary care group, and they are all hoping to be PCTs next year, there are three of them, having a notional of one day a week from one of the consultants in the department and also the same amount from the Health Education Department. This fits well with what they do. It is about local needs assessment and promoting health, but also some of the jobs that they simply find it difficult to do because they do not feel properly trained or they simply do not have the right time to do it. Doctors are involved in looking at various treatments and assessing the effectiveness of treatment that the GPs are not sure about. It works well. We also have one doctor, the same doctor is notionally allocated to each of the four local authorities.

Mr Amess

  509. The BMA obviously places much importance on health impact assessments. In your evidence you said that the most important new process proposed was in the Green Paper, "Our Healthier Nation Health Impact Assessment". You said, "We believe that HIA might become as important to public health as the control trials have become to clinical medicine". You then go on to say, "Whenever any consultation paper from another Government department is commented on by the Department of Health or Local Authority Department of Public Health a health impact assessment is being performed which, although, may be a fairly superficial, qualitative assessment is often based on considerable experience". Can you expand on that a bit, please?
  (Dr Tiplady) The principal or the detail at the end?

  510. Both aspects. You think it is very important. We would like some information as to how you think this can all be delivered in practice.
  (Dr Tiplady) The evidence based clinical practice is now a fact of life. All clinicians are expected to have a lifelong commitment to evidence-based practice. Evidence is now accumulating and it enables authorities, whether it is local, regional or at national level to make assessments of the impact that that policy is going to have on the health of the community. It seems to us that this ought to be done as a matter of routine. When policies propose they are going to change the way services are managed or resourced we ought to know what is going to happen to the health of the community. The real excitement, of course, of health impact assessment is when it extends beyond the margins of traditional medical approaches, like how effective tablets or pre-hospital thrombolysis is going to be. One of the very first examples which was published was the health impact of Manchester Airport.
  (Dr Rylands) Liverpool University is at the forefront of that. We have had several pilot studies done in our local community, it is not just about health impact on policies but also on new developments. There is a new astronomy development happening—which is a big thing in Birkenhead—in conjunction with one of the local academic institutions, and a health impact assessment is being done on that. As Peter says it looks at not only medical issues but it concentrates on things like what is the impact of increased traffic flows, what is the benefit of having increased employment in that area and the resources that will follow, a new tourist and academic development. That is something that public health practitioners have developed a lot of skills in and worked with the local community to make sure their voice is heard in looking at what the effect of such developments will be.


  511. I was thinking, Dr Tiplady, you could have an interesting challenge if it was proposed to close Sellafield, an assessment to cover that issue.
  (Dr Tiplady) That happens all of the time. We do know what that would involve. It could be closed but it would never disappear.

  Chairman: You said that.

Mr Amess

  512. I just want to pursue this a bit more. It does all sound wonderful in theory and if this all worked we might as well pack up and go home, it would solve all of the problems. Yours is an organisation which has plenty to say for itself. Do you not think there is a slight tendency to go through the motions, tick a box, yes we have done HIA? Do you really see that?
  (Dr Tiplady) I hope not. I think the BMA, not just the BMA but public health practitioners in general, are deeply committed to the idea of measuring the impact of policies and medical practice so you can see what is going to happen. We have national objectives, like reducing the levels of coronary heart disease, mortality and improving levels of mental health and health improvement programmes, and others come up with often very complex proposals to achieve this. What is missing is the assessment of how effective that is going to be in achieving the objectives before the resources are changed to invest in it. We have had for far too long in the Health Service considerable investment made in services that have not shown their worth.

  513. I heard your opening statement, the way that it has panned out. This is not something that the BMA is going to lose interest in, you are going to monitor what is happening and we will have pronouncements on this.
  (Dr Tiplady) Not pronouncements.
  (Mrs Naish) One of the most obvious candidates for the health impact assessment, which should include inequality, is local authority policies. The local authority makes decisions all the time on things like transport and where you site roads and speed limits, that has an effect on the accident rate and that can actually increase inequalities in childhood accidents. That is the most obvious candidate for health impact assessment, the local authority policies.
  (Dr Rylands) If I can give you an example, we have a large hospital that has severe car parking problems—

  514. Join the club.
  (Dr Rylands)—there is actually going to be a health impact assessment on how what parking issue might be addressed. One of the options will be to start charging, because we are one of the few hospitals that does not charge, and immediately hackles start to rise. There are two sides, and many more, to every argument, and a health impact assessment might start to tease some of those out. That is being done in conjunction with the local authority as part of a big transport plan.

  Mr Amess: Could you privately send me your conclusions? You can charge but you will still have an absolute problem with it all.

Mrs Gordon

  515. One of things that kept cropping up is how many initiatives there are and how many different schemes there are, Health Action Zones, HiMP, Community Plans, Sure Start, and there are so many different streams of funding, which are sometimes hard to pull together. Is there one thing that you can suggest as a way to simplify the whole system?
  (Dr Tiplady) There is a model developing, the National Treatment Agency, for drug misuse, where the objective is that all of the sources of funding would be identified for it for a county and the commissioning of those services would be done through the Drug Action Team, which is a county-wide organisation. Drug action teams have been variable in their effectiveness. I think I belong to a good one. We have been complimented on good partnership work. That is a model for the future, where all of the funding sources are to be identified and then the commissioning is to be done through a single multi-professional, multi-agency, top level, highest commitment organisation. Our Drug Action Team has chief officers of all of the organisations in Cumbria, including the two health authorities.
  (Dr Rylands) I would support that. It is more than we are trying to develop. We have a health and social care partnership, which is multi-agency and multi-disciplinary and there are a number of subgroups that are looking at priority areas. For instance, the implementation of the MFS, Mental Health, heart disease, et cetera and the health authority and the local authority are working together to try and identify the resources and asking those groups to think about how services should be commissioned and the implementation of the various initiatives. To go back to the question you mentioned earlier about prevention, that will enable a multi-disciplinary group to say, "Hang on, we are not going to spend it all on more tertiary cardiac services, we are going to look at exercise and life-style as well. It does mean that you identify that part at an early stage and not 10 months into the year.
  (Ms Gough) We have a system in Wolverhampton which is very similar to the one Alison has just explained. Even when we move into PCTs, which we are not in yet but we will move into fairly shortly, they are the movers of the health economy, so that as PCTs and PCGs we can respond to local need with that pot of money and develop those services where they are needed.


  516. Any points which anybody wants to add? If not, thank you once again for your written evidence and for coming along today. We are very grateful, it has been a very useful session. As this is the last session of the Committee before Christmas, I wish everyone the compliments of the season.
  (Dr Tiplady) And from us too. Thank you very much.

previous page contents

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

© Parliamentary copyright 2001
Prepared 1 February 2001