Examination of witnesses (Questions 665
- 679)
WEDNESDAY 31 JANUARY 2001
RT HON
MR ALAN
MILBURN and YVETTE
COOPER
Chairman
665. Colleagues, can I welcome you to this session
of the Committee, which is the last oral evidence session of this
inquiry, and particularly welcome our witnesses, the Secretary
of State and the Minister for Public Health. We are very pleased
to see you. I know it has been a pretty tough week and we appreciate
the time you are giving to the Committee today. Can I ask you
briefly to introduce yourselves to the Committee?
(Mr Milburn) Yes, Alan Milburn, Secretary of State
for Health.
(Yvette Cooper) Yvette Cooper, Minister of Public
Health.
666. As you know, we have been holding this
inquiring for some months now. We have had the opportunity to
take evidence from a range of agencies, individuals, organisations
and also had a number of visits related to the inquiry, and I
think it is fair to say from my perspective that we have seen
a great deal of positive evidence of very clear progress in public
health, but one of the issues which it will not surprise you I
would like to raise with you, an area of some contention, concerns
the organisational structure of public health which we have currently.
We have had substantial evidence from a range of sources raising
questions about the current location of the public health function
within DHAs, indeed very serious questions have been raised about
the whole future of DHAs with the developments in primary care
and primary care trusts, et cetera. I would be interested in establishing,
first of all, what your views are as to the future location for
the direct function of public health at local level. Some of us
at the veteran stage of the Committee go back prior to 1974 and,
as you well know, recall a model that certainly I believe operated
more effectively in relating to elements of policy in local government
that were able to drive changes in policy forward in a way we
have not managed to do since it was detached from local government.
Can I begin by asking you about your thoughts on that general
area?
(Mr Milburn) I am tempted to say, Chairman, it was
before my time, but that would not get me off to a very good start.
667. But you have read about it.
(Mr Milburn) Yes, I have, and I have also thought
about it quite a lot, and I know you and other members of the
Committee have strong views about the issue. What is true and
what is common ground amongst all the participants in this debate
is that if we are going to improve public health, that is more
than the job of the National Health Service, point one. Point
two, much of our effort should be focused upon dealing with some
of the determinants of ill health. I think that is also common
ground, whether it is poverty, poor housing, environmental problems.
However, in the end it seems to me that public health in purpose
is about achieving certain health outcomes and although there
would be a myriad of views about where best to locate the co-ordination
function, because inevitably wherever you draw the boundaries
there will be a whole host of local organisations or indeed national
organisations which will have a bearing on the health of the public,
in the end somebody has to hold the ring. The question really
is, who best should do that, who is in the best position to do
that. It seems to me—and I have thought about this and I
have thought about the arguments you and others have made in relation
to local government—in the end since it is a health function
and a health purpose, probably that location is best done on a
local level in the Health Service. However, what is also clear
is that we cannot have what I have described in the past as the
ghettoisation of either health or, more particularly, the public
health function within the National Health Service, and there
are some real issues about how best we break public health out
of its ghetto.
668. Do you not accept that that ghetto arose
from the disposal of public health in 1974—
(Mr Milburn) No, I do not.
669. —and its detachment at that point
from local government? I was a councillor pre-1974, as I believe
was John Austin—a very young councillor, I hasten to add—and
recall very vividly the role of the Medical Officer of Health
who held to account in a very serious and important way the individual
committees of that local authority. I see at local level some
very worthy reports from our Directors of Public Health—I
have two local authorities in my area, as you are aware—some
excellent reports making some very positive proposals but it is
not attached to the driver of policy that those reports relate
to in any meaningful way. That worries me because prior to 1974
we saw the attachment of these recommendations to the ability
to deliver change on things like smokeless fuel and a range of
issues which the local authority could clearly concentrate on—slum
clearances and that kind of thing and I know we have moved on
from those days—but it was a very important relationship
with the Government function.
(Mr Milburn) You are right that there are a number
of drivers or a number of interventions which are necessary in
order to improve the health of their local communities, that is
absolutely true, and local government will have a very important
role in regard to its environmental health functions, its transport
functions, social services or education, and so does the National
Health Service. Whichever way you cut the cake, as I was saying,
there would be a need to better co-ordinate functions, and certainly
that was true of the pre-1974 situation. You say the Medical Officer
of Health played an important role but, for example, if they wanted
to influence rates of coronary heart disease or interventions
in coronary heart disease, then they had to make the leap over
the boundary into the National Health Service. That was just a
function of the way the Medical Officer of Health and the related
public health functions were organised. So I think that sometimes
this game of structural musical chairs which we are all interested
in inevitably, because we have to get the location right, becomes
a bit of an excuse for a lack of co-operation. I think reorganisation
becomes an excuse for lack of co-operation. What is true is that
we need to improve the means of co-operation, there is no doubt
about that, and on the ground, as you know, in many parts of the
country now there is much closer co-operation than there has ever
been, indeed there are statutory duties to co-operate for the
first time which we put through in the 1999 Health Act. That is
becoming evidenced I think now in the way that you see, for example,
in some areas—largely where there are coterminous health
authority and local authority boundaries—joint appointments
of Directors of Public Health. I do not have a problem with that,
I think it is a perfectly sensible thing to do but I think we
need to assess its impact. When you talk, as you did, about drivers
and leverage, there are some interesting international experiences
here too more at a national level than at a local level. In New
Zealand in the 1990s, as members of the Committee are aware, there
was a similar debate going on about the location of public health
policy-making at a national level. The then Government in New
Zealand decided to separate the public health functions, through
a Public Health Commission which was established in 1993, from
the Ministry of Health, particularly to try to beef up the public
health function because there was a feeling, as perhaps the Committee
is feeling, that public health was getting ghettoised. That seemed
a very sensible idea. It certainly gave a higher profile to public
health in New Zealand, but the consequence of doing so was that
the real life intervention impact in terms of public health was
actually diminished, and it was no surprise that in 1995 therefore
that Public Health Commission which had been established two years
earlier was abolished. It is very, very important in my view we
keep in mind that what we want to do is to drive public health
ever more into the mainstream of the National Health Service,
precisely so it has greater leverage as far as access to Health
Service resources are concerned.
Chairman: There is a division so I adjourn the
Committee for 15 minutes.
The Committee suspended from 4.09 pm to 4.23
pm for a division in the House.
Chairman
670. You were answering, Secretary of State,
the initial question. I believe, Minister, you were indicating
you were wanting to come in?
(Yvette Cooper) Only briefly to add, Chairman, that
if the argument is that we should have closer working around public
health in local government, that local government could play a
greater role in terms of public health and could have more public
health support, I think that is absolutely right and I think we
would agree with that, whether it is through joint appointments
which some areas are experimenting with, whether it is through
the local strategic partnerships or whether it is through closer
working around the community plan or health improvement plans.
But if the argument is we should take public health out of the
NHS, that I think would be a massive mistake. There is so much
potential for further work to be done in the NHS especially in
primary care around public health, I really strongly think we
need to keep that public health function in the NHS. Even on top
of all the work which is done on public health at the moment by
the NHS, there is so much more we could do, that we should be
building on, particularly in primary care.
671. One of the issues that the Committee have
been concerned with is the role of health visitors, and some of
us remember when they were employed within local authorities in
a much closer working relationship with local authority services
like housing and social services, and that is an area where we
picked up very strongly there were arguments we needed closer
collaboration. Picking up your point about the location and function
and looking at it locally but also nationally and again whether
public health is appropriately placed within the Department of
Health—and I know, Minister, you said the idea of taking
public health out of the Health Department would be a crazy and
retrograde step—we have had a fair bit of evidence which
suggests that the function you occupy ought to be much more wide-ranging
than it is currently and perhaps located, say, in the Cabinet
Office or within the Cabinet with a role ranging over other government
departments. Can you say a little about your views on that and
your experiences of working with other government departments
in the role you currently occupy?
(Yvette Cooper) I think it is extremely important
to have the public health ministerial post located in the Department
of Health, I suppose for several reasons. Firstly, in the end,
a lot of it is about improving health and promoting health, and
having access to the vast resources of the NHS, the Department
of Health and the Chief Medical Officer is incredibly important.
Secondly, whilst it is absolutely true that a lot of the work
does involve cross-governmental working, actually being located
in a department makes a huge difference. You will be aware where
we have done the Social Exclusion Unit reports, the Social Exclusion
Unit has tended to draw up the report and to drive a lot of the
first wave of co-ordination across government departments but
then the report has been passed on to a particular government
department to actually lead the implementation. It is because
ultimately you want a delivery route rather than simply a co-ordination
route, ultimately you need a government department backing up,
and given that the NHS is the biggest employer in the country,
it has huge resources when it comes to delivery. It is right that
has to be in partnership but I think it would be terribly wrong
and would be a huge retrograde step and a mistake to leave it
behind. I will just give you one brief example of where I think
cross-departmental working can be very effective, and that is
the Sure Start programme. I am responsible for Sure Start but
the Cabinet Minister responsible is David Blunkett in the DfEE
and the Sure Start Unit itself is located within the DfEE, and
that is quite a novel approach to working across government which
involves a very close partnership between different departments
and it is working very well, with my responsibilities both to
drive the programme and to chair the cross-ministerial group but
using resources located in different departments as well. So there
are different cross-departmental models you can look at but fundamentally
it would be a huge mistake to separate public health from the
big killers—cancer, heart disease. All the work we are doing
on prevention has to involve the NHS otherwise we will never make
the difference we need to.
672. When you are looking at any policy initiative,
how do you determine who might be involved in developing that
initiative? For example, we had the mental health initiative which
came out recently where, arguably, some of the key players within
different government departments have a role to play. You probably
know that we were prompted as a Committee by evidence we received
from the Yorkshire Post newspaper, which you will see as
a Yorkshire-based MP like myself, which has done a very important
campaign on sport and the way sport relates to health, and as
a consequence of their evidence and other evidence we determined
to have the Minister of Sport before the Committee. We had a very
useful session, I think, listening to what she had to say but
my concern, and the reason why I raise this point about the public
health location within government, is that she answered very honestly
when I asked specific questions about whether she had been involved
in certain initiatives, which I think she should have been involved
in, where on a number of developments the Government can claim
great credit at a local level which should relate to sport, and
she had no involvement whatsoever. How do you, not just with you
but in other areas where the Minister has a part to play, ensure
they are involved, because in that case clearly she was not and
in my view she should have been?
(Mr Milburn) I think there are always improvements
which can be made, of course there are, but the machinery for
cross-government working now in this Government—and certainly
that is the view of the people who have been around in previous
times—is immeasurably enhanced. I think the commitment to
joint working is a big commitment. On the public health front
you will remember when we published Our Healthier Nation
White Paper, of course it was my Department which was in the lead
but there were contributions from other relevant departments,
of course there were. Issues like sport obviously would relate
to DCMS. On one of the important Our Healthier Nation target
areas, the prevention of accidents, we worked closely with colleagues
in the DETR, DTI, DfEE, across the piece. The point about this
is that in a sense it is rather like a local co-ordination function,
wherever you locate it there is still going to have to be co-ordination,
and where there are co-ordination issues and where there are boundary
problems then inevitably you hit difficulties. But what I believe
absolutely fundamentally is that if you take the public health
function out of the Department of Health and if you put it in
a ministry like the Cabinet Office, what you remove is the Minister
of Public Health and all of the officials and all of the machinery
and indeed all of the financial leverage which goes with a location
in a big spending department. For example, this year I think the
Department of Health will be spending between £40 and £50
billion and it is one of our commitments that we want to see a
growing proportion of that resource spent on public health measures—defining
cancer, coronary heart disease and so on and so forth—by
contrast, I think the Cabinet Office has a budget of less than
£200 million. In the end, money talks because it provides
you with leverage to get things done. There is an argument about
whether or not we need to do more within the National Health Service
to better focus growing resources on prevention, on tackling inequalities,
on intervening sooner rather than later, and that is a perfectly
reasonable debate to be had and I think all of us sat around this
Committee table would think there is a lot more to do, of course
there is, but actually the chances of doing it, it seems to me,
are decreased and not increased if you strip out the public health
function from the mainstream Health Service delivery functions.
673. In simple terms, how do you avoid treating
policy issues in separate boxes? The best example I think we had
with the Sports Minister was when I raised the initiative of healthy
living centres, which I think is an excellent idea, and I see
a very clear connection between the role of sports clubs and healthy
living centres, but there had been no connection between your
Department on this issue and her Department. What I am trying
to say is, how can we ensure structurally that that happens, that,
to me, a fairly obvious connection at local level is made nationally
and locally in a way which is not being made at the moment?
(Mr Milburn) I think two things. First of all, there
is a big commitment to do this across the Government and Our
Healthier Nation is an expression of that but the truth is
it is early days. It is the first time we have had a Public Health
Minister, the first Public Health Minister was appointed in 1997,
and I think that was the right step to take and it allows us to
focus on these issues in a way perhaps politically which has not
always been possible in the past. It is a positive step in the
right direction but there is a big commitment across the piece
to improving the health of the nation. If you take the argument
to its logical conclusion I think you are left with some pretty
anomalous potential structural arrangements, because most of us
would agree that poverty has a bearing on ill health. That is
certainly the position in the Black Report, in the Acheson Report,
it is the position that many people in the medical and health
service field would agree on. The Government has a big commitment
to abolish child poverty, I think it will make a huge contribution
to improvements in public health and to narrowing health inequalities,
but the logic of the argument, with respect, is if we believe
that child poverty is going to be a major determinant of improved
health then why do we not take the public health function out
of the Department of Health altogether and put it in Her Majesty's
Treasury?
674. Something we could think about actually!
(Mr Milburn) I am not going to give you ideas, Chairman,
because I am slightly worried you will recommend that!
Dr Brand
675. Is it not already?
(Mr Milburn) You can say that, Dr Brand, I cannot
comment!
Mr Burns
676. We have a Department of Health that has
overall responsibility for improving and enhancing patient care
and the health of the nation, and it does seem odd to seek to
take out public health and give it to the Cabinet Office or the
Treasury, or whoever else, because it just becomes diffuse and
to my mind ridiculous. Can I ask the Parliamentary Under-Secretary
whether the structure of the Department of Health at the moment
means that she, as Parliamentary Under-Secretary, is answerable
solely to the Secretary of State, as certainly under the last
Government the Parliamentary Under-Secretary who was responsible
for mental health, children's issues, drug abuse, alcohol abuse,
et cetera, had no Minister of State above them, they were answerable
directly to the Secretary of State? Is your position answerable
solely to the Secretary of State, or do you have a Minister of
State above you and below the Secretary of State?
(Yvette Cooper) I answer directly to the Secretary
of State.
677. I am glad you said that because there is
a view held by some people that if you put public health, which
is considered to be a very important issue, at Parliamentary Under-Secretary
level you have down-graded or minimised the issue. The fact that
you, I suspect, and you can correct me if I am wrong, are unique
in that presumably other Parliamentary Under-Secretaries at the
Department of Health at the moment have a Minister of State above
them and under the Secretary of State, surely enhances rather
than down-grades the role of public health because without having
a Minister of State to go through you have direct access to the
Secretary of State, you are working simply with the Secretary
of State? So would you agree with me that in fact, presumably,
given your line of command and that you are answerable simply
to the Secretary of State so it is just the two of you within
that narrow ambit, the whole area of public health has not been
down-graded simply because it is at Parliamentary Under-Secretary
level?
(Mr Milburn) Let me answer because it is slightly
invidious for Yvette to answer questions about command structures
in the Department of Health. I know the argument, Mr Burns, that
because the previous Public Health Minister was at Minister of
State level and Yvette is not, somehow or other this represents
a down-grading. All I say to you is that nothing could be further
from the truth. Not only does Yvette answer to me personally but,
in addition to that, when Yvette came into the post one of the
things I wanted to do was better "mainstream" public
health within the Department, and that is why actually we changed
some of the functions around within the ministerial team, so that
she as Parliamentary Under-Secretary for Public Health has responsibility
for the two big areas of public policy where we need to make rapid
improvement in terms of mortality and morbidity rates—cancer
and coronary heart disease. That was not the way the Department
had previously been divvied up. I did that precisely, one, in
order to locate responsibility where it should be; two, to ensure
the focus was as much on prevention as treatment; but, thirdly,
to actually "mainstream" the public health function
within the Department of Health, because I do think there is a
tendency, if I may say so, with respect, within the public health
world, for public health professionals as narrowly defined to
believe that they are the only purveyors of public health. If
that is the case, if we actually believe that it is the 600 public
health consultants and 32 epidemiologists who are going to improve
the health of the nation, however good they are, frankly we can
all go away and give up now. The people who should be "mainstreaming"
and delivering public health are our 30,000 GPs, our 12,000 district
nurses, our 14,000 health visitors. They are in the best position
to do that and if they are going to do that then actually we have
to have a line of command, a line of delivery, all the way from
Richmond House down to Wakefield, Darlington and Chelmsford.
Mr Burns: Thank you.
Mr Hesford
678. In terms of this issue, Secretary of State,
in 1997-99 the Chancellor has made it clear for very good reasons
that spending was tight in those years in order to stabilise the
economy and get rid of the £28 billion deficit. Those in
the public health field will have recognised that between 1997
and 1999 public health had a Minister of State-level occupancy
at a time when the money was tight. At a time when others might
have felt money was coming on stream, the position was, in some
people's terms, down-graded just at the point in time when that
person might be expected to spend some money. Can you deal with
that point?
(Mr Milburn) I do not know who is making that point
but it is a ludicrous one. I would say that this Minister of Public
Health has more influence and more power within the Department
of Health than any previous minister who has occupied a previous
position, precisely because she is dealing with the mainstream
issues of cancer, coronary heart disease, improvements in public
health across the piece. Rather than being a retrograde step,
I think that is a huge step in the right direction of ensuring
that we target in a rather more consistent and effective way than
perhaps has been done in the past our efforts, the machinery of
the Department and, most importantly of all, the resources we
have available to us on those areas, those disease groups, those
parts of the country, those sections of the population, which
need most help.
679. In terms of raising the awareness of public
health, which I know the Minister is absolutely keen on and does
a very good job of, would it not send out the wrong message to
those areas that need support in their job—that very difficult
job of raising awareness of public health—to have what others
have described as a retrograde step in terms of the exact status
of the Minister of Health?
(Mr Milburn) If that were the case, it would indeed
be a retrograde step, but it is not.
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