Examination of witnesses (Questions 540
- 547)
THURSDAY 11 JANUARY 2001
MS SHIRLEY
GOODWIN, MR
GRAEME BETTS,
MR TERRY
KELLY, MS
VALERIE LITTLE,
MR JOHN
GOALBY and MR
JOHN PARKES
Siobhain McDonagh
540. I am sorry about this, but it relates to
some of the points Ms Little made earlier on in relation to community
involvement. Can you describe some of the mechanisms by which
you engage the communities you serve to help themselves to better
health? We heard about the Bangladeshi women and the Pakistani
groups and the facilitators that you set up. What makes that work
well? Do local people have the skills to want to contribute to
rather detailed and specialised planning processes?
(Ms Little) I will hand over to my colleagues in the
health action zone because, in Walsall in the past, it has been
a politically controversial set of neighbourhood committees that
have been elected. It is not total coverage of the borough but
it is the most deprived areas of the borough. They are elected
on the basis of one per 100 households and you will find a select
committee on public administration chair looked at this in relation
to certain aspects of its work around a year or 18 months ago.
But interestingly, that was funded by SRB before health action
zones were ever thought of. Then the health action zone came on
board and we were able to use some of that community governance
work to provide us with a bedrock to engage local communities
in the health action zone planning. I am going to ask my two colleagues
to perhaps give you a bit more detail on that.
(Mr Goalby) The framework which Walsall set up for
local community involvement in the health action zone was very
important. The fact is that there were four local steering groups
and Hillingdon have just talked about "the local". It
is very important to establish local partnerships with local communities.
The capacity of the community to carry on the work is developed
by an ongoing mechanism of training. People are always learning
and getting the chance to take forward their own skills which
go back into the community. That is as brief an answer as I can
make it.
(Mr Parkes) We found in Walsall that, for example,
if you were to look at our chair inside West HAZ, and if you had
done a skills audit on that woman 12 months ago and done one now,
you would find that her personal development has gone off the
Richter scale. We are constantly looking at ways of trying to
improve people's management committee skills. As Val says, there
is a uniqueness about Walsall with these neighbourhood committees.
Because there is this community governance model, it has created
a bedrock for future things. It has been really useful. One of
the things from a steering group point of view is that I am always
of the opinion that if you have large numbers when you start and
then you have large numbers regularly attending meetings, you
must be doing something properly.
(Ms Goodwin) Can I answer briefly? In Hillingdon,
community development and capacity building is one of the six
priorities in the health improvement programme and we have always
fundamentally wanted to make it clear that for us, if we are going
to reduce the inequalities that exist even in a place like Hillingdon,
we have to do it through building capacity into communities, into
ordinary people. To a certain extent therefore we have captured
this requirement for community involvement, particularly for things
like best value and local authorities, to actually say we are
going to use that rubric to build capacity in those people themselves.
Because, what is in it for them? We are constantly consulting
them. We have got to involve them. We have got to tick the box
that we consulted them on this hospital change or that best value
indicator. But what was in it for them? So we have got a commitment
across the partnership once again. But one way of developing our
community consultation strategies and processes, fundamentally
always in their summary is what is in it for that community, that
neighbourhood, that group. We are running courses to give people
some of the committee management skills you have talked about.
We have already got some peer educators who, through becoming
peer educators can then move on perhaps to other things and become
community leaders and become active members economically, intellectually
and politically in their own communities. So we see community
development and community involvement as really part of a much
bigger package which is about building capacity into local people
individually and collectively. Every project we are involved in
through the Sure Start, SRB, our Glebe Community Cafe, have all
got elements of capacity building and community development. I
might say that our voluntary sector council is a very important
partner to that and they brought European social funding in to
build capacity into the voluntary sector locally. So it is all
of a piece hopefully.
(Ms Little) And you have got to give people some power.
You have got to give them some decision-making power so the SRB
in Walsall, the neighbourhood committees have made decisions about
the spend. Similarly, an element of the HAZ programme funding
has gone straight to the steering committees for spending along
the priorities along the lines that they want. So people have
got to have some say in something substantial as well as giving
something themselves.
(Mr Kelly) That is an important point. I think often
health services and local authorities start from, "We want
to involve the community to enable them to agree with our agenda".
That is a bad start from a community's agenda. As an example,
the Community Cafe on the Glebe Estate, whilst there has been
a spark of that idea and the resourcing came from the local authority
and the voluntary sector organisation initially, so it is not
in true terms a community development project because it was still
our agenda, we have been able to take a step back and say, "OK,
this is our idea. Let us work with the community to identify what
they actually want to do with this space". So we provided
them with the resources, the expertise and the support to develop
that cafe. The aim is that within three years they will actually
take over it and manage it. So we need to build capacity and leave
them with the mechanisms to do that.
(Mr Goalby) Can I just quickly mention the public
health worker in Walsall.
541. That leads into the next question. Are
community facilitators and public health workers the key to delivering
public health to communities and what exactly do they do?
(Mr Goalby) Firstly, I would say yes they are because
I am public health.
542. What do you do?
(Mr Goalby) My basic role is to act as the interface
between the health services and the community. I am very much
an advocate of the community to make sure that the process is
not highjacked by the services so the local authority and the
health authority are not imposing their agenda on the local community;
that it is the local community who are shaping the agenda of the
local authority and health authority.
543. But they pay your wages. Are they not suspicious
of you?
(Mr Parkes) I think John took some time—I would
not say some time but certainly from the early days of HAZ—from
our point of view, from the steering group, it took us some time
to trust John. There was this notion that here we are, we have
another professional coming along and imposing his ideas. I think
John's background in terms of being a community development worker
in his previous lives has helped the process enormously. I think
it is a very difficult role that he has. He has almost acted as
a catalyst for community activity and that has been really instrumental
in what has happened certainly in the West HAZ in Walsall.
(Mr Goalby) I get told off by the local authority,
the health authority and the community.
(Mr Kelly) The community facilitators that we have
been working with are essentially catalysts for the delivery of
public health and health education and health improvements as
opposed to the deliverers themselves. We see their role as advocates,
as facilitators, as supporters, as health educators; people bringing
communities together; people bringing services together with communities.
They contribute to the needs assessment and identification agenda
and an important role is their education role with services to
increase the understanding and awareness of services, of the needs
of the community. It is important for services to actually change
their work in order to respond to the community effectively. So
there are two sorts of sides to that coin.
(Ms Goodwin) You asked if they were key workers. There
are lots of different people who could describe themselves as
key workers. But perhaps I can go back to the question that Dr
Stoate put at the beginning, how do you know that what you are
doing is altering the coronary heart disease rate in a given area?
I would simply say that the things that cause coronary heart disease
are multiple—diet, physical activity, smoking, level of
self-esteem and control over your life, social class poverty.
Those are all the things that lead to some of the conditions that
we are trying to intervene in. So the interventions that we apply
to them have to be also multiple. They have to work at lots of
different levels. And community facilitators and public health
workers are the people who intervene at all those different levels
right down at the coal face. People like me in the grey suits,
we are intervening in those determinants at the strategic level
but if those people were not there to work flexibly and not just
on health services but across the wide range of determinants,
we are not going to see any permanent change or sustainable change
in the future.
544. I am not sure what to do about the next
question. This is about the health improvement programmes. We
talked a bit about what you thought and how they were a benefit
and a catalyst for joint working, certainly in Hillingdon. First
to Ms Little. Can you describe for us the successes and difficulties
of the Sandwell health improvement process and tell us why you
think it has been given an award? Later, when I will definitely
not be here, to Hillingdon, can you describe for us the implications
of calling your health improvement programme, "The Hillingdon
Plan for Health, Well-being and Quality of Life"—snappy
title? How easy has it been to embed the idea of public health
and health improvement as a broad social problem rather than as
a reaction to disease? Is it possible to create a sense of ownership
of the health improvement programme in the local population or
is it a document for the authorities only? And does it matter?
To Hillingdon again, can you see any reason why the health improvement
programme and community plan should not be merged along the lines
of yours? I apologise for having to leave.
(Ms Little) The successes have been the broad base,
the process in particular and I mean, why it got an award, perhaps
you had best ask the award givers. But I think it was around the
process and the engagement. We kicked off with a very large community
conference and engaged—we had two parallel pieces of work,
both with professionals and organisations and agencies and then
also with community groups in the voluntary sector. We ran those
things in parallel and then brought them together. It was quite
an exercise and I have to tell you that the amount of material
that was generated in July 1998, the issues that needed addressing,
the ideas for addressing them, we are still working through. It
was a very rich affair. We did a lot of preparation for it. We
had satellite meetings out and about with local communities. So
the process has been a big success. We have set some outcome targets.
We monitor them. What we found more difficult, as I said before,
is linking the specific interventions to specific outcomes. But
we do have a very clear set of outcome targets which we reported
on at the end of the first year and will continue to report on.
We link those into obviously the HAZ outcome targets that we had
to set and into the community plan in Sandwell. So the community
plan has about 10 high-level indicators of which about two or
three are related to the health area. You will see in our outcome
targets that we are quite clear that literacy and employment are
two key areas for health improvement and unless we can make progress
on that in the Sandwell borough, we will not improve health. So
that has been a success. Individual projects have been successful.
I think the housing work will prove its benefit substantially
and as I said before we have a longer-term programme on the data
on that. A particular success that is highlighted in here is the
stream of work that we have called "Work Well"—because
everything is "well" in Sandwell, you see; it is our
little logo. But that is the occupational health programme. It
is HAZ funding but we have also got it as part of the mainstream
health improvement programme and I think that has worked very
well. We have got occupational health into primary care now. We
said we would do it and we have done it. So all our contractor
staff have access to the occupational health service and we are
now on the other stream of working, working with small and medium
enterprises in the borough, focusing particularly—you may
be interested in this Mrs Gordon—on back pain. That was
seen to be the key. We have had a bit of national recognition
for it from the Health & Safety Executive but I think the
occupational health stream is one that I would highlight as a
particular success. We are short of time I will not go through
everything. Were those all the points raised?
(Ms Goodwin) We titled the document as we did because
it was a good process and a good document. I do not think HimPs
are always a document for the public. We did a bit of work on
whether people knew what a health improvement programme was. They
did not. Do a bit of work on if they know what a particular project
is and what is in it, and you get a different answer.
The reason for calling it "The Hillingdon
Plan for Health, Well-being and Quality of Life" was a deliberate
attempt early on in the partnership to respond precisely to the
point about the HimP and public health being much wider than just
about health services or the NHS. So we thought "Health"
is capturing the HimP; "Well-being" captures the community
planning well-being stuff that will be coming through local government
legislation, and "Quality of Life" was actually specifically
around community safety, local agenda 21. So we tried to wrap
up the major statutory plans in one document, anticipating a time
when HimPs would become part of the over-arching community plan.
That answers the last question Ms McDonagh put to us as well.
How easy was it to embed the idea of public health and health
improvement as a wider social issue? It was not easy but we found
using a simple back-of-an-envelope statement of what we thought
was the task of the HimP, which was to address the underlying
determinants, and we in fact used the old Public Health Alliance
charter which has 12 points in it. That is, enable you to have
enough income, proper homes, access to education, a healthy environment,
transport that is sustainable and so forth. We just used that
again and again and again. We found that because that did not
belong to the NHS, it did not belong to local government, everybody
could look at that and say, "Oh yes, that is us. We can understand
that". It helped education, for example—Terry tells
me—to identify how they would be assisted to deliver their
targets if they were working within that context as well. So,
about ownership of the local population? To be frank, I do not
think there is much and I think there is a point at which we have
to decide whether this kind of document is something which we
really fully and honestly can expect people to give up their time
to become engaged with when, at the end of the day, to some extent
it is something which is done to keep the people upstairs happy
and to perform a functional purpose for our strategic partnership
working. Those are the two key functions. We do produce a leaflet
and poster each year in community languages and send it round
the system. But to be frank, I think we have held back from trying
to do massive community conferences and lots and lots of meetings.
We do not think that for most ordinary people a strategic planning
document has got enough meaning to justify them giving up their
time. We would rather, and they tell us they would rather when
we have asked them this, work in projects and consultations which
are more linked to some of the client group services and some
of the projects rather than to a strategic planning document.
The last question: is there any reason why the HimP and the community
plan should not become one? Absolutely none! That is the agenda
we are working to in Hillingdon.
Mr Austin
545. Can I briefly put a question to Hillingdon
as well? We had evidence earlier on from Mr Panter who is the
chief executive of the Hillingdon PCT, but he was here wearing
another hat. He told us about the efforts to bring together the
communicable diseases function with the local environmental health
functions using the appropriate parts of the Act. But you have
decided to locate the health promotion service in the council
rather than in the NHS. The Chairman would have asked this question
if he had been here. Why did you decide to do that? What have
been the benefits and have there been any problems as a result?
(Ms Goodwin) Going back to the point Mr Panter made
about public health, that is still an issue under discussion.
We are looking at a number of ways in which Section 31 of the
Health Act might enable us to achieve closer joint working, make
better use of what is often a very small resource for a small
organisation but which, if pooled together, could become a significant
one. Of course, we have Heathrow in our patch which is why port
health and communicable disease becomes quite an issue. We have
not got to the point yet where we are even talking actively about
some kind of public health function but I believe in time we will
see something in which environment and health work closely in
that respect. Perhaps I can hand you over to Terry, who is the
product of the decision to locate health promotion in the council.
He can perhaps answer the question better than I can.
(Mr Kelly) The "why" was a fundamental belief
and commitment to addressing the big determinant of health, a
recognition that health promotion is wider than health education.
It is not about being health police. It is about influencing health
and public policy; influencing public policy to explicitly put
health within there. One of the things we have done as part of
that is to get a chapter on health and transport explicitly within
the interim transport plan for this year and recognise that we
need to develop that as part of the overall transport strategy
that we are developing over this coming 12 months. So it was a
recognition that if we are going to influence public policy the
best place to do that would be within the local authority. Certainly
as somebody who has worked on health promotion for some years,
I have worked closely with local authority colleagues throughout
that time. It is a hugely different activity or hugely more beneficial
to actually deal inside an organisation rather than working alongside.
It offers so many more opportunities for access, for communication,
for recognition, for relevance. Sot it has been hugely beneficial
in enabling us to get health on the agenda of a number of people
within the local authority with an opportunity to frame and shape
policy. In terms of disadvantages, it is very easy to be seen
as the health person so that anything that has got a health label
that comes through the local authority sometimes tends to end
up on my desk, whether it is to do with health promotion, health
services or whatever. But I think the biggest disadvantage is
to do with the sheer effort that has to be put in in order to
keep contact, mainly the contact with two major organisations.
(Mr Betts) Can I just pick that up because I think
in a sense we are still at the stage of transition here. It was
a really good step to see it within the local authority but with
the new powers that we have got under the Act, I think we will
begin to see different models delivering health and social care
services in the sense that where it becomes located is not really
the issue. What is important is the model that is being used.
It will draw on health; it will draw on local government. That
is the issue rather than is it here or is it there? I envisage
in Hillingdon over the next few years there will not be—it
will probably be a care trust or something like that. That in
itself is not important because there will be other organisations
which are different from the social services departments we have
now and so on and so forth. So really it is more important to
think about the models and how we develop those rather than where
the location is and so on.
(Ms Little) I would like to say that Director of Health
and Regeneration I regard as a public health post. It will provide
unique opportunities and I intend to take them.
Mrs Gordon
546. I was just going to ask how does your new
post differ from when you were Director of Public Health and what
agendas will it give you?
(Ms Little) The new post, as I say, had a previous
incumbent who is now currently the chief executive of the Metropolitan
Borough Council and is therefore very supportive of the whole
public health agenda. It will enable me to see the public health
dimension into economic development, the planning department and
the regeneration division. So those are the three areas. And I
think things like transport. I also have a remit in the post to
develop the public health and health aspects of housing in conjunction
with the relevant corporate director. I do not have the housing
remit. The corporate director for housing has that.
Mr Burns
547. I was wondering whether Hillingdon could
give us some details of their plans to create a single public
health resource centre for West London.
(Ms Goodwin) I do not think I can really, other than
to say what I said a few minutes ago, which is that we are at
an early stage in discussing across the partnership what the potential
might be for a Section 31 or some other arrangement to have a
common public health resource within our locality or more widely
given that there is a difference in our figures and those of the
health authorities. The areas of London-wide structures, processes,
public health observatory; there are lots of issues and it is
too early to say other than there is a strong commitment to doing
something jointly; to make better use of the resources themselves.
It is fair to say that we have not gone beyond that but it is
a fundamental commitment and understanding of the best way to
work.
Mr Austin: I thank you for coming and giving
evidence this morning. If anybody has further questions, we may
want to write to you for further information.
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