Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 680 - 699)



  680. Do you accept that there could be a feeling abroad that that is what it looks like?
  (Mr Milburn) I have no doubt that for various reasons people within particular parts of the National Health Service or particular parts even of the Department of Health may feel that is the case, but believe you me it is not.

  681. It is just that quite a number of witnesses we have heard, and no doubt you have seen the transcripts, have made this point time and time again and it is something the Committee will have to deal with.
  (Mr Milburn) Yes, I can understand that, but one of the pleasures of my job is that I get a broad over-view of all the issues which come before the Department of Health and I am acutely aware of protectionism in many, many parts of the field. It is very, very important that we keep these things in balance. It is very hard for people to argue, when we are investing in the way that we are in improvements in coronary heart disease and cancer and focusing resources as much on prevention and treatment in the way that we are, making, I think, some pretty major—or about to make—improvements as far as the diet of the population is concerned, when we are empowering primary care to get a population focus as well as just a focus on individual lists of patients, that somehow or other public health has been down-graded within the Department of Health. Far from it. What is very, very important for people in the public health field to realise is that the two major policy statements we have had over the course of the last couple of years—Our Healthier Nation and the NHS Plan—together form the basis, if you like, of a health plan for the country, and they are of equal status. Indeed the NHS Plan broadly reflected the aspirations, ambitions and some of the targets within Our Healthier Nation but then it went further and suggested, for example, we are going to roll out more screening programmes, a greater emphasis on prevention and, most important of all, for the first time in this country and I think for the first time in any developed country that I know of, we are going to set a national inequalities target precisely to ensure the whole of the National Health Service, not just one part of it, is focused upon these very, very important public health issues.


  682. Minister, this is a debate about your pay rise, do you wish to comment?
  (Yvette Cooper) I am really touched that people are so concerned about my status and my pay. I just think this is such a trivial argument. What is the title of the minister in charge of public health, is it a Minister of State or is it a Parliamentary Under-Secretary? I do not think most people in the country know the difference between a Parliamentary Under-Secretary and a Minister of State, and I do not think most people care. In the end, the test is what we are delivering. What are we delivering on public health? The test of what we are delivering I think is showing huge improvements. If the test is money, there are extra resources going into public health, into prevention, into smoking cessation services, into fruit in schools, whatever your test, in terms of the extra boost to public health we have seen, building on the work which was done under the previous Minister, and the extra work we have shown in the NHS Plan, on health inequalities and on tackling some of the key causes of cancer and heart disease, is really significant, and that is really in the end what people will judge our public health commitment on.

Mr Burns

  683. Secretary of State, can I try and help you?
  (Mr Milburn) Oh dear!

  684. As your Parliamentary Under-Secretary has said, it is trivial, and it is in one way but it is important in another because of misapprehensions which abound in the health area. Can you categorically confirm that my view is right—
  (Mr Milburn) You are making me very nervous!

  685. I am trying to be helpful, keep cool! If you have an area which the Government of the day has prioritised as an important area where you want action and achievement, if you have a Parliamentary Under-Secretary rather than a Minister of State with no Minister of State above her, where the Parliamentary Under-Secretary is directly answerable to the Secretary of State and they are working in tandem, it is totally irrelevant whether the person is a Parliamentary Under-Secretary or a Minister of State, providing the commitment is there and the objectives are vigorously pursued by that Government, and that the whole argument is actually time-wasting and fallacious?
  (Mr Milburn) I think that is broadly right and frankly I think people would be bemused—there will be some people who are not bemused and who find this all incredibly interesting and revealing—the vast majority of people working in the National Health Service, working in local government, working in any arena which has any bearing on public health, let alone the public, would find this whole debate a rather bizarre one.

  Chairman: I have just had a note passed to me asking me which position Mr Burns had in the Department of Health.

  Mr Burns: I did not have a Minister of State over me either!

Mr Austin

  686. I think you have both made a very cogent and convincing argument for the location of the public health function departmentally in the Department of Health, but can I ask you whether you feel the Minister for Public Health within the DoH can really affect the main determinants of health—housing, employment, poverty, et cetera?
  (Yvette Cooper) The biggest determinant of public health I think is poverty. The most important thing we will do over the next 20 years is achieve our target to abolish child poverty. In the end, a lot of that is within the power of the Treasury but it is not all within the power of the Treasury because it is also about providing opportunities for young people from the very start, which is why Sure Start is part of our programme to tackle child poverty. But it is absolutely true that all of the determinants are widespread across all the different departments and we will only do this if we have all the departments working together. But we cannot just say that the NHS should play no role in that, the NHS should play a huge role in it both nationally and locally.
  (Mr Milburn) Let me add to that very briefly. When Sir Donald Acheson produced his report for us in 1998, he came up I think with 39 recommendations, something like that, three of which pertained particularly to the Department of Health, the rest pertained to the wider governmental agenda, and that is right because we all know from our own constituents that poor people tend to be iller and certainly they tend to die sooner than people who are rather more affluent, so there is a broad cross-Government agenda here. Sometimes though I think that people in the National Health Service, faced with this point about the determinants of ill health being so big and so deep-rooted, throw up their hands in horror and almost adopt a counsel of despair that nothing can be done until you abolish poverty, until you ensure nobody lives in a damp house, until you ensure that every person is eating five pieces of fruit and vegetables a day. All of those things need to happen but actually it is very, very important that the NHS better focuses on what it can do to contribute to improvements in public health. Of course, some of those will be very deep-seated issues and will take time to deliver, but some will not. Providing the will is there and the commitment is there and the resources are there, actually we can begin to make a difference quite quickly. I think a good example of that, frankly, is when we decided, when Frank Dobson decided, to invest very, very early in the meningitis C vaccine. As I said in the debate in the House the other day, being the first in the field is always a risky place to be, because when you are out in front it can all go horribly wrong. It did not go horribly wrong, despite some of the adverse comments at the time in the newspapers about the dangers of the vaccine and so on. We invested quite a lot of money in it, we concluded a deals promptly with the companies concerned, in order to ensure that people in this country were the first people in the world to get access to a vaccination programme which has already saved lives. I want to see more of that happening and to do that we have got to have a proper focus and a co-ordinated focus through the Minister, and through her line to me, on public health in a way that has not always happened in the past. That is why I believe that the arrangements that we have—and they are not perfect arrangements and they will never be perfect arrangements—are the best arrangements that we are going to get.

  687. Can I take you back to the original question that the chair put. Let us say that you have convinced us of the departmental responsibility of location for the public health function but in terms of the local delivery of public health, several government departments relate to local government, including your own, and you are responsible for social services, child protection, all of those areas of delivery by the local authority. The DfEE is involved with the local authority, the DTI, a whole range of public departments. Since I am a dinosaur with the chair and remember the 1970s, all of that comprehensive range of functions is delivered by local authorities. You mentioned anti-poverty and local authorities are key players in developing anti-poverty strategies. Does that not therefore suggest that wherever the departmental responsibility for public health lies, and particularly now local authorities also will be given the scrutiny role of health services, that public health should be located at local authority level?
  (Mr Milburn) No, I do not believe that for the reasons we discussed earlier in answer to the Chairman's questions. What I do believe is that the local authorities have a very, very important co-ordinating role at a local level and indeed we as a Government have given them certain statutory obligations to promote the well-being of their local communities and personally what I want to see is much better co-ordination at a local level. As Yvette was suggesting, I think the local strategic partnerships that are beginning to roll out across country will provide a very, very important vehicle for the Health Service, for local government and, indeed, for the contribution of the voluntary sector and the private sector to make a big contribution to improvements in the well-being of the local community and specifically the health of the local community. That begs some important questions about how best we are going to co-ordinate public health functions as widely defined at a local level. Some parts of the country, Somerset and Wolverhampton are two for example, do have joint appointments of directors of public health between the local authority and health authority. That is a welcome development. I think we should assess it but if it makes sense we would want to see more of it. There are issues about the future of health action zones and employment action zones, and so on and so forth. For my part, as far as this is concerned, I am completely unterritorial about this. If in some parts of the country we are great closer collaboration, as we are for instance in the Chairman's constituency in Wakefield, of the health action zones and some of the other partnerships and that makes sense, then we should encourage it. I do not have a problem with that at all. I think it makes absolute sense to do it.

  688. I am not wanting to challenge your territorial integrity or sovereignty—
  (Mr Milburn) You are welcome to.

  689. What you are saying is that the director of public health is a key figure in terms of the local authority for fulfilling its public health role?
  (Mr Milburn) Yes, I think that is right. All I would say about that is that in terms of the role of the director of public health we want to be a bit careful about being overly prescriptive about this. In some parts of the country, particularly where there are coterminous local authority and health authority boundaries, it is fairly simple, frankly, to have a joint director of public health. In my part of the world that does not happen to be the case. There is a unitary authority in Darlington and there is a huge County Durham and Darlington Health Authority so there is not the coterminousity issue. What we have to ensure, regardless of the organisational structure that is put in place, is that the director of public health has a close and growing relationship with the local authority precisely because of its wider statutory duties but also because of the wider contribution it can make to public health improvement.

  Chairman: Before we move off this important area, you mentioned health action zones in my area—and I have taken a close interest in it as the constituency MP—and what strikes me about that and a number of other initiatives I have looked at is so much of the work and operation of these action zones is recreating relationships that I saw in existence in practical terms pre-1974. We were in Scotland looking at a scheme in Glasgow and my colleagues who were there will bear witness to the fact that there was a health visitor—

  Siobhain McDonagh: As old as him!

  Chairman: Who was as old as me who had worked pre-1974 and was looking at this brilliant new scheme that they had got in this particular part of Glasgow, the Gorbals area, and she said—and my colleagues will bear out that this is correct—it was basically back to what she did pre-1974 restructuring. It is not simply abstract debates in this place about where we place the function, it is about people at grass roots level having sensible structures that enable them to work together. The worry I have got is all the good work we are doing on these initiatives is simply recreating the relationships that I saw in existence pre-1974 at a local level. It will certainly not come as a surprise to the Minister. If you want to come back on that one, fine, otherwise I will move to Marion. Marion?

Mrs Roe

  690. Secretary of State, can I first of all apologise to you and the Minister that I shall not be able to stay for the full session and therefore the questions I am going to put to you will be disjointed groupings, if I can put it that way. First of all, it is claimed that one way to influence the wider determinants of our health is through health impact assessments. Could you suggest any ways for their effectiveness to be scrutinised?
  (Mr Milburn) I think that is true. I think that health impact assessments have potentially an important role to play in determining whether policies, not just in the Department of Health but in the DfEE or the Treasury, across government and indeed local government and other organisations whether they contribute to improvements in health, one, and, two, contribute to the wider governmental agenda which is not just to get improvements of health overall for the population but is also to bring about improvements for health in the poorest people at a faster rate than the average. I think there is a potential role. We are looking quite carefully at health impact assessments. There are various tools and frameworks around, within government and outside. Potentially they have an important role to play, but they only will have an important role to play, in my own view, because they provide a methodology and that is all. In the end what we have got to do across government and within the Department is get the commitment and the focus and the resources on improvements in public health, and health impact assessments potentially are an end to that means.

  691. What would be your view on a Health Audit Committee on similar lines to the Environmental Audit Committee?
  (Mr Milburn) It is the first time I have heard that suggestion made but in many ways I guess that is the role of this Committee and certainly if you have had witnesses from DCMS and from other departments that seems to me to be a perfectly sensible and reasonable thing to do, if we all accept that it is not just what Yvette and I do, it is not just what the GP does, but it is what the local employer does and the local charity and the local council and, of course, individuals themselves that will have an impact upon the health of the nation.
  (Yvette Cooper) There has been a lot of work going on on developing health impact assessment methodologies and how you would assess them. One of the things we are interested in is whether the Health Development Agency could play a role in standardising or evaluating health impact assessments and how effective they are. That is one of the things that we are looking at at the moment.

  692. Thank you very much indeed. Can I put it to you, Secretary of State, that there are serious concerns that local health improvement programmes are losing significance to a multitude of national priorities which are passed down increasingly from a centralist health agenda, as a consequence of which the public health needs of local populations are being ignored in favour of the rush to meet national targets. Secretary of State, could you reassure us that local community specific health agendas will not be squeezed out at the expense of what your own Permanent Secretary and also the NHS Chief Executive Nigel Crisp terms as the "must dos".
  (Mr Milburn) It is very, very important that local services, whether they are health services or local government services, whether that be education or transport functions, are sensitive to the particular needs of the local community. I guess your constituency and mine may be quite different constituencies and I guess the communities are pretty different too and they will have different needs and it is therefore important that local services are attuned to those needs because otherwise they do not enjoy public confidence and, frankly, they do not reach the people they need to reach. However, sometimes when this sort of question is asked I do think the people rather want to have their cake and eat it because they also want to see a proper and strong focus upon some of the big determinants of public health, about whether people are getting a decent diet, about whether people are getting access to cancer screening services, about whether people are getting access to heart operations, and so on and so forth, in a way that brings about improvements in health. You know as well as I do that unfortunately one of the things that most characterises the NHS is the fact that there are such enormous variations both in performance and access to those services and that is why we have got to get the balance right, which is what we are seeking to do, between establishing very clear national standards and, if you like, a very clear national framework of what must be done. What must be done is to invest in cancer services and heart services, on the prevention side, the screening side, as well as the treatment side, not just in some parts of the country but in every part of the country. That is what must happen, but then of course it is for the local service to determine how best to deliver that national framework. What we cannot have is, frankly, sometimes the lottery of services that we have seen in the past. Let me finish on the health improvement programme because I think it is extremely important. For me it is a very, very important co-ordinating device to try to ensure that the national priorities are translated sensitively into local priorities, that if there are specific developments that need to take place in local services that are required by the local community they are reflected in the health improvement programme, one, but, two, that the health improvement programme, if you like, should become a focus, just for the local health service (whether that be the trusts, PCTs or the health authorities) but also for local government input or for employer side input or for voluntary sector side input. For the first time at a very local level what you have is an agreed local health plan. That is what the health improvement programme should be about. If people think that is not happening I would be interested to know why.

  693. Could I take you a little bit further down the path on access and talk about inequalities of access to medicines. I wonder if you could comment on the National Institute for Clinical Excellence's ability to in the words of your own Minister of State for Health, Mr John Hutton "mark the end of an era of postcode prescribing in the treatment of Alzheimer's" when in fact Wiltshire Health Authority states it cannot afford to provide the very Alzheimer's drugs recently recommended by that body?
  (Mr Milburn) With respect, I do not think that is Wiltshire Health Authority's position.

  694. That is what I would understood but I would be very pleased to hear you correct it.
  (Mr Milburn) I try not to believe everything that I read in the newspapers because otherwise, frankly, I would not get up in the morning—and I quite like getting up in the morning. I saw that in one of the papers and I think it was one doctor of the health authority but that is not the health authority's position, as I understand it. I am very happy to send you a note on that.

  695. I would be grateful.
  (Mr Milburn) There is a broader point. We set up the in National Institute of Clinical Excellence—and I know it was a controversial thing to do but I think it was the right thing to do—precisely in the face of the lottery in care and prescribing regimes that you describe. Under the old order it was up to the individual GP practice and the individual health authority, too, to decide which drugs and treatments were available to which patients and inevitably in that situation you ended up with the rather absurd, and I think unfair, proposition whereby different people with very similar conditions sometimes living in neighbouring streets were getting different access to the same health treatments. That cannot be right and certainly does not fit with the principles and values and philosophy of the National Health Service, and that is why we have an Institute that can produce clear guidance and authoritative guidance to the National Health Service. From our position as Ministers we have made it absolutely clear that it is very, very important that when NICE produces its authoritative guidance that that should be taken full account of by each and every health authority in the land and there should be not opt-outs of taking full account of each and every piece of NICE guidance. As far as Alzheimer's is concerned, as you are aware, the National Institute recently produced authoritative guidance on Aricept and two other drugs largely found in their favour. I think that has been broadly welcomed. It will help ensure that these cost-effective and clinically effective drugs are available to more people.

  696. Thank you very much. If you could send me a note on whether that is accurate or not I would be very grateful.
  (Mr Milburn) I will send you a note on Wiltshire.

Mrs Gordon

  697. The Committee visited Cuba last year and I think we were all impressed by how they do so much with so little and how good their health outcomes are given that their health budget is only one per cent of ours. I think this is partly due to the fact that their national health service started some ten years after ours but they went off in a completely different direction. Ours is basically a sick health service in that most of our resources go into the acute sector whereas they went down the road of trying to stop people becoming ill simply because they have not got the resources to provide for the acute services. We found going round that this idea of public health, health promotion, is deeply entrenched in their culture. Everybody that we have come across in the organisations we have met has given this Government credit for taking up the public health agenda and trying to widen it and run with it, but it is this cultural thing which is not engrained, I do not think, in the same way in our culture. I would be interested to know if you feel we can achieve this cultural shift and how we can improve the health structures that we have to bring that about given the pressure on GPs, the health visitors who will deliver that service.
  (Mr Milburn) I think the points that you make are very, very important ones and I think it is something we have got to get engrained first of all within the culture of the National Health Service to realise it is not just a service to treat sick people, although of course that is hugely important, but it is also a service that can do much more to prevent sickness in the first place. I hope that we are beginning to shift the balance in the way that, for example, we are developing more prevention and more screening programmes over the course of the next few years. I am hopeful that we will have more screening programmes for everything from chlamydia to colon/rectal cancer when we have got an appropriate test available for people. We have made commitments similarly that when we can get to a position where there is an effective and safe test for prostate cancer then we would want to roll that out. We have got to do something more than that as well. We have got to get into the business more actively not just of primary prevention but secondary prevention. Here I think primary care, as Yvette was suggesting earlier, has a hugely important role to play. I think you are beginning to see some of this now beginning to happen on the ground. Traditionally the view has been that the GPs' function is effectively to act as gate-keeper into the Service, to wait for patients to come through the door and then to deal with them, and that produces a lot pressure on GPs and other staff too. There is another very, very important role, it seems to me, and that is the role of getting into some of these areas of secondary prevention. For example, when I visited Bradford several months ago I was very, very impressed to see the work that they were doing in relation to diabetes, and they have got a large Asian population, a high prevalence of coronary heart disease and diabetes. They are now establishing registers of people who are at most risk of those two diseases and they are actively intervening at an early stage. In Northumberland the health action zone is doing something very, very similar, setting up a register of people who are vulnerable to or have had heart disease and GPs and people working in primary care are doing everything that they can to get cholesterol levels down. Their estimates of what they will be able to achieve within the next five years—not just in the long and distant future but in the immediate future—are very, very impressive. They are saying they expect to save between 150 and 200 lives alone in that one county precisely because they are getting into that very active interventional business. That is where the National Health Service, it seems to me, has to go. We have to see a lot more of that. As I think I have said at this Committee before, it has got to get into the provision of more information to people. I do think it is important on public health that we recognise that the Service has got a big part to play, but in the end individuals have got a big part to play. Somebody with heart disease or who is prone to heart disease might need an operation, they might need a drug, but they will almost certainly need a balanced diet and regular exercise and in end that becomes their responsibility and we in the National Health Service have got a lot more to do to help people through that.

  698. Some of the organisations, the community projects that we saw bottom-up coming from the community, although in some of them the GPs were very involved in others they found it almost impossible to get the GP involved. They have had trouble doing that, partly because the GP felt overwhelmed already by the workload. Back to Cuba, the family doctor there deals with something like 800 people whereas obviously our lists are 1,000 or almost 2,000 for a GP. Are there any practical measures that the Government can take to lift some of that workload?
  (Mr Milburn) I think there are several things. First of all, you have got to expand the workforce. The truth is that we need more GPs, we need more doctors, we need more nurses, we need more scientists and technicians working in the National Health Service and we will get there in the medium term. I think we have got fairly ambitious plans to expand the number of doctors working in the Service and certainly the NHS Plan says they want to see an extra 2,000 GPs working in the National Health Service over the next three or four years. That should be a minimum. If we can go faster we should go faster. The more the merrier, as far as I am concerned, because we need more family doctors. That is the first thing. The second thing is to recognise that there has to be a better division of labour within primary care. A lot of people do not need to be seen immediately by the GP but can be seen by the nurse. That is happening in a lot of GP practices already and it should be happening in more; I hope that it will. Thirdly, I think we have got to change the terms of this debate actually because in many, many ways intervening later rather than intervening sooner increases workload rather than diminishes it. If you have people presenting with more acute problems precisely because the NHS, local services, primary care services have not been able to establish the registers of those at risk, it is more of a problem. I know all that is easy to say and it is not so easy when you are sitting at a GP's desk having to see lots and lots of patients, but that is the big shift we have got to bring about and that is about, if you like, changing the culture of the Service so that it recognises that this whole focus now on prevention is at the top of the agenda rather than way down the agenda.
  (Yvette Cooper) There are some amazing things going on already in the NHS. I think the Committee has been to the Beacon Project in Cornwall, Hazel Stutely's project with health visitors working in the local community, working with the tenants' and residents' associations, making a huge difference not simply on levels of breast-feeding but also teenage conceptions, levels of crime, a huge impact that people working in the National Health Service can have working in the community as well. There are other examples. There are examples of the NHS and primary care working with housing organisations to make sure that the people who are prioritised for central heating or insulation are families of children with asthma or families with young children and so there are all those kinds of examples. There is work going on around teenage pregnancy. There are GPs and primary care teams playing a huge role now in starting to work to prevent teenage pregnancies, mainly working with local schools. It is that point that I think would reinforce our previous point. It is because there is so much starting to happen and really starting to spread throughout the NHS, whether it is smoking cessation, whether it is working on teenage pregnancy, whether it is work on housing, whatever it might be, that now would be the worst possible time to take public health out of the NHS at exactly the time we could be driving more and more public health work and prevention through the NHS and getting the NHS, particularly in primary care to play a much greater role in prevention than it ever did, than it ever did before 1974, than it ever has done ever in its history.

John Austin

  699. Can I come in on the point made about the Beacon Project. All of us were greatly impressed by the work Hazel Stutely and others have done there but up and down the country in the projects we have been to one of the key players has been the health visitor, as you recognise, and also the role of school nurses as well. I know that the Government has done a great deal to redress the rundown in recruitment and training of nurses but in the specialist area of health visiting, in our previous inquiry on the staffing requirements of the NHS, one of the most alarming statistics we saw was in the reports that came from the CPH, BMA and others about the likely age range and the retirement and drop-out rate of health visitors. Are you confident that within the general desire to get more nurses into the specialist areas like health visiting that the training is being expanded sufficiently, and what are the implications for the training of health visitors, not just the quantity but the content in terms of the new public health agenda?
  (Yvette Cooper) The expansion in the size of the nursing population working for the NHS is something that has to happen in terms of the community-based nurses as well. There is a lot of work that has been going on to develop leadership functions and training through the Health Visitors' and School Nurses' Development Programme, trying to improve the training and support for health visitors and school nurses across the country. I think we should not under-estimate quite how vital they are. School nurses were absolutely vital to delivering the Meningitis C vaccine. We would never have got the entire under 18 population of this country offered the Meningitis C vaccine in the space of around 15 months if it had not been for the role of school nurses. We just could not do it. We do very much see the commitment in terms of expanding nurses as one which applies to community-based and district nurses as well.

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