Examination of witnesses (Questions 680
- 699)
WEDNESDAY 31 JANUARY 2001
RT HON
MR ALAN
MILBURN and YVETTE
COOPER
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 majoror
about to makeimprovements 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 yearsOur Healthier Nation and the NHS
Plantogether 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.
Chairman
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 bemusedthere will be some people
who are not bemused and who find this all incredibly interesting
and revealingthe 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 healthhousing,
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 haveand they are
not perfect arrangements and they will never be perfect arrangementsare
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 areaand I
have taken a close interest in it as the constituency MPand
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 saidand my colleagues will bear out that this is
correctit 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 morningand 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 Excellenceand I know
it was a controversial thing to do but I think it was the right
thing to doprecisely 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 yearsnot just in the long and distant future
but in the immediate futureare 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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