Examination of witnesses (Questions 700
- 719)
WEDNESDAY 31 JANUARY 2001
RT HON
MR ALAN
MILBURN and YVETTE
COOPER
700. Can I come on to the general initiatives
that the Government has undertaken. No-one welcomes more than
I do the very high priority that your Department gave at very
early stages to public health. The commissioning of the Acheson
Report very shortly after the Election, the creation of the post
of Minister of Health are initiatives that all of us around this
Committee would very much welcome. Indeed, when Professor Acheson
came here he commented on the very positive steps which the Government
had taken in the light of his report. We have got the policy initiatives
of health action zones, health improvement programmes that have
been mentioned earlier. But now we have the new NHS Plan. Has
the new NHS Plan eclipsed those initiatives in any way and placed
new priorities on the National Health Service?
(Mr Milburn) I do not think it has. I think the sovereign
role of public health and the job of tackling health inequalities
and the bigger focus on prevention is very much at the heart of
the Plan and what we have now got to do—in the end writing
plans is easy and devising policy is easy, delivering it is sometimes
more difficult. What we have got to do is make sure that the Government's
intentions to improve public health and tackle health inequality
are embedded within the Health Service at every level and there
too we have tried to change the institutions in such a way that
they will deliver what we all want to see delivered—improvements
in public health and the health of poorer people, getting better
health opportunities. So, for example, as you are aware, for the
first time now we are measuring and indeed rewarding the performance
of local health services, recording not just how well they do
on waiting times and the traditional acute sector agenda but how
well they do, too, in improving health outcomes, ensuring there
is fair access to services (the point that was raised earlier)
and the performance assessment framework that we have includes
these two vital measures about health outcomes and fair access.
I think it is fair to say that as a consequence of doing that
not only does it hold the local health service to account against
our broad objectives but it provides some very positive incentives
for the local health service in every part of the country to take
seriously precisely these two issues, how you ensure fair access,
for example screening services where we know that although in
this country we have done incredibly well in screening services,
cervical cancer and so on and so forth nonetheless it is true
that poorer women tend to use those services less than others
and there are big differences according to ethnic minority background
too. If we are going to make the big improvements that we want
to see in cancer survival rates and we want to save the number
of lives that we do and people suffering from and dying from cancer,
then we have got to get into these difficult areas and make sure
that there is genuinely fair access. One of the ways you do that
within the National Health Service is to measure the performance
of every local service and to hold people to account against the
objectives that we have set. It is not just a question of writing
a plan or embedding prevention in a plan, it is also saying to
the service this has got to happen and these are the ways that
you have got to account for it happening.
Chairman: Have we politicians not got some responsibility
to broaden out the debate to include in the political mainstream
issues of public health in a way that certainly was not case from
our point of view at the last General Election where our pledge
related to one issue on health which was waiting lists. You can
ask anybody in the Health Service if you want to evaluate how
effective the Health Service is there are a number of measurements
and that is not one that I would have in mind. Looking at how
we broaden out the debate in ways you are describing and looking
at targets way beyond the immediate waiting list initiatives,
etcetera, are you optimistic that in the next Election we might
have a somewhat more mature debate on health—
Mr Amess: No chance.
John Austin: No chance if you are involved.
Mr Amess: I am replying to all the rubbish we
have to listen to.
Chairman
701. Do you understand the point I am making?
I think we have a responsibility to get the debate widened to
include the very important areas you are talking about. In a sense,
certainly at the last Election, I do not think that my Party did
that in a meaningful way.
(Mr Milburn) I think your Party, my Party, our Party—
Mr Burns
702. Different wings.
(Mr Milburn) There are no different wings in the Labour
Party, unlike others I could mention! I think our Party and our
Manifesto did have a focus on issues like cancer and heart disease
and so on and so forth.
Chairman
703. But key issues—
(Mr Milburn) Let me finish the point. I think it is
very, very important that there is a proper and mature debate
about these issues and, of course, improvements in health and
improvements in health services are not just about improving waiting
times for hospital treatment but improvements in waiting times
for hospital treatment have an enormous bearing on the health
of the population because, as we all know, people are waiting
too long for heart operations. That is a fact of life. Thankfully
because for the first time the Government has had the courage
to earmark funding for coronary heart disease in a way that perhaps
should have happened in the past, I am confident that we will
get those waiting times down. We will grow the number of staff,
we will invest in the treatments, and we will invest in the secondary
prevention too. So there is not a contradiction I do not think—
704. I am not saying there is a contradiction.
(Mr Milburn) Nor do I think there is a conflict. If
the argument becomes treatment versus prevention, that is the
wrong debate. It is about how we ensure that the Health Service
is both focused on treatment and prevention. Coronary heart disease
is a good example, if I may say so, because when we pushed our
coronary heart disease National Service Framework, our blueprint
for tackling the appalling incidence of heart disease we have
in our country, which incidentally is more concentrated in deprived
parts of the country than others, the focus was as much on prevention
as it was on treatment. That is the first time we have done that,
sadly, where policy has been rounded enough and, in your word,
"mature" enough to recognise that if you are going to
bring about big improvements in public health let alone tackle
these appalling health inequalities you have got to do the two
things at the same time rather than assuming that inevitably it
either/or. It is not either prevention or treatment; it has got
to be both prevention and treatment.
Mr Hesford
705. Can I pick up on something Mr Austin was
dealing with a few moments ago. One of the strongest statements
you made today was your support for the health improvement programmes.
I personally welcome that. There is evidence that within local
authorities, health authorities, PCGs/PCTs, the priority of HImPs
is slipping down the agenda. You also said in terms of public
health delivery that you are not territorial—partnership
working, all that sort of thing. In terms of tangible benefits
could you say something about the suggestion which we have heard
quite a lot of merging the HImP programme with community plans?
(Mr Milburn) I think in some parts of the country
already what you are seeing is the health improvement programme
where the health authority is in the lead (because somebody has
got to be in the lead) and the community plan where the local
authority is in the lead and because many of the contributors
are the self same contributors—local government, the Health
Service, the private sector, the voluntary sector and so on and
so forth—in some parts of the country already there are
shared objectives and common values that underpin the community
plan and the health improvement programme. That seems to me to
be a perfectly sensible thing to do. I do not have a problem with
that. One of my own objectives for local government is to cut
down on the number of plans that they have to prepare. We impose
all sorts of bizarre statutory obligations on local government
to prepare plans until they are blue in the face. In the end I
am not interested in plans, I am interested in delivery. I would
rather have people working in local government on delivering services
rather than writing plans about delivering services. I know one
is easier than the other, but actually we pay people to deliver
rather than simply to plan. We have to see a reduction in the
number of plans that we ask for in central government, we have
some responsibilities in that regard. If we can see a closer relationship
between health improvement programmes and community plans that
seems to me to be a perfectly reasonable thing to do. What we
should do is assess in those areas, I think, again, in I think
in Wakefield, the community plan process and the health improvement
programme process do have some share objectives and common values
and so on and so forth. We should assess what gains are made for
precisely that level of cooperation. If we think that that is
beneficial then surely we should learn a lesson from it.
Mr Amess
706. I certainly applaud the role of nurses
in schools. I have to say to our minister for the Department of
Health we have a desperate shortage of school nurses in Essex,
and if there is anything that can be done to help I would be grateful.
This is a subject that people laugh about but that for parents
it is a big problem, that is the problem of head lice, which one
of your colleagues has raised before. It is the sort of thing
we do not like to talk about. There clearly is a very real and
serious problem. It does appear that all the products which are
available at the moment do not seem to be working. They are very
expensive. There are new sprays and all sorts of things coming
on to the market. Unless every child is done—because with
the little ones their heads get together—it will go on and
on and on. As a constituency Member of Parliament I keep getting
letters about this, does the Government have any strategy to try
and do something about this problem?
(Yvette Cooper) It is something that I certainly answer
quite a few letters from MPs on, including correspondence from
constituents. There is an approach that is taken, that is supported
locally, through the whole schools approach. You are right, the
difficulty is finding it and catching it and supporting the whole
school. What I can certainly do is send the Committee the details
of that. It is something where we have cross working between the
Department of Health and the DfEE on that. It obviously something
where the whole school becomes involved, it is not simply an issue
for the school nurses. On the issue of the school nurses, it is
true that there are pressures and it is something that we are
very aware of and it is something that applies to a lot of sectors.
Certainly our commitment right across the NHS and right across
the nursing staff is that we want to see expansion, although we
do recognise that that is not always as easy as our intention
might be.
707. Thank you for sending us the document.
I would like to persuade our local authority do something about
it. They will probably say, "Where would the money come from".
What is the Government's position at the moment concerning the
MMR vaccine?
(Yvette Cooper) There have been a lot of concerns
raised about the MMR vaccine. We take the approach that whenever
there are any concerns raised about any medicine or any vaccine
we always refer it to the expert committees that advise the Government
on these issues, particularly the Committee on the Safety of Medicines
also the Joint Committee on Vaccination and Immunisation and we
seek the advice of the Chief Medical Officer. That is what we
have done on this issue. We have referred all of the research,
all of the publications, all of the claims that have been made
by Dr Wakefield, all of the claims that have been reported in
the papers to those expert bodies for them to examine them in
great detail and examine them thoroughly. Their advice to us has
been that there is no evidence of a link between the MMR vaccination
with autism. Secondly, MMR remains the safest way to immunise
children against what are quite deadly diseases. We think it is
important on an issue like this to follow the advice of the experts
and to make that advice available to the public. We should not
be in a position of hiding information from the public. All of
the information that we have been given from the CSM, from the
expert committees and from the Chief Medical Officer on this subject
we have made public and we need to continue to do so.
708. I know on 8th January you answered a question
about the TB programme. Do we have an update as to when the schools
can expect to have this vaccination programme resumed?
(Yvette Cooper) We do hope to be able to make an announcement
on that shortly. You will be aware that the vaccination programme
has already resumed in London. We are also very conscious of the
need to make sure that children do not reach the point of leaving
school without a catch-up programme reaching them in time. We
are very conscious of that. We have held discussions with companies
all over the world to try and make sure we can get a secure supply
of the BCG vaccination. There were problems with the sole supplier
that persisted over some time that lead to the suspension of the
programme. There is certainly a lot of work going on that and
we do hope to be able to make an announcement.
709. When can we expect the sexual health strategy
from the Government?
(Mr Milburn) Hopefully within the next couple of months.
710. Do you have any concerns about the way
the morning after pill will be administered?
(Yvette Cooper) Are you referring to the morning after
pill available in pharmacists?
711. Yes.
(Yvette Cooper) This is something which has gone through
the proper procedures, through the Committee on the Safety of
Medicines and the Medical Control Agency. The company applied
for a licence to use this to be able to deliver this product in
pharmacies for over 16s. All of the expert committees who assessed
it said this was a very safe product and this was something that
could be give in pharmacies. The Royal Pharmaceutical Society
has provided very detailed support and guidance for pharmacists
to ensure that it is done in the proper context, the right kind
of questions are asked and the right kind of advice is given.
My view is that this is an extremely positive move, it is about
giving women more access and choice to a product that all of the
experts say is safe. It could also make a big difference in terms
of bringing down the number of abortions and unwanted pregnancies,
which are highest amongst women in their 20s.
712. Two final questions, you and I have been
in correspondence about palpation. For the record, could you say
why your expert group, I am not challenging it, decided that palpation
should stop in terms of breast screening?
(Yvette Cooper) Perhaps I should write to you or the
Committee with the detail on that.
713. I would be grateful for that. I understand
that you will be visiting the Lupus Centre later this month, which
I am very pleased about, because we know this effects women between
20 and 40. The Secretary of State spoke earlier about why in the
discussion and knowledge it is quite clear that the number of
general practitioners do not—I know we have two on the Committee—seem
to know about sticky blood, and all of that. Is there something
that the Government might do if they are persuaded that this is
a problem that we should address?
(Yvette Cooper) We will certainly always look at any
new area or any particular condition where there might be improvements
that could be made. We have to take an evidence-based approach.
We have to look at what works, what is properly evaluated and
what will make a difference. Our approach right across the NHS
is as new techniques become available, as new technologies become
available we will also find areas that need research. We always
need to take all of those seriously.
Mr Amess: They do not get any money at all to
help with their research.
Dr Brand: Can I pick up one of the relevant
questions that David Amess asked?
Chairman: I thought they were all very relevant.
Dr Brand
714. The issue of sexual health, when the Government
reduced the public health targets, which were set in Health for
the Nation, two to four main targets that we got in Saving Lives
and Our Healthier Nation, I was given an undertaking by the Secretary
of State's predecessor that we would not lose sight of the other
targets. Although targets would be local for some of the other
issue, like sexual health, they would be collated in some form
so that we could see whether as a nation we were actually delivering
the agenda that needs to be delivered. Sexual health is a very
good example of that, teenage pregnancy, etc. I have asked this
question annually for the last three years and I have been told
that it will emerge from the system eventually. Can the Secretary
of State or the Minister tell me when it will be available?
(Yvette Cooper) What specifically are you asking for?
715. The previous targets that existed are no
longer national targets they are now local targets.
(Mr Milburn) You mean Health of the Nation targets.
716. When will we be able to see how we are
getting on as a nation in reducing the issues like genitalia infections,
teenage pregnancies, etc?
(Yvette Cooper) Most of the figures you are talking
about, like sexually transmitted infections are in the public
domain. The Public Health Laboratory Service publishes a lot of
information about communicable disease. There is a lot of information
in the public domain already. We have a commitment to demonstrating
progress against the targets we have set on sexual health. You
are right, one of key areas there is teenage pregnancies, where
we have set quite clear targets over the next ten years on teenage
pregnancies. We are also looking at publishing a technical supplement
to the work that went you on through our Healthier Nation but
also which is updated in the NHS plan that might also provide
more of the kind of information you are talking about. I think
our approach with a lot of these things is the information is
out in the public domain.
717. I am not denying there is not a lot of
information. What I think is difficult is to get the information
in a form that you can track what is happening. Where we had 27
targets before we could follow what was happening to them, I was
given assurance by the previous secretary of state that there
would be some way of seeing how we were getting on. That would
be helpful.
(Mr Milburn) Can I take that away. I am sorry I do
not have an answer for you today. I will take it away gladly.
718. While we are on targets and priorities,
it is a bit alarming to hear from some of our witnesses that during
regional reviews directors of public health would not necessarily
be invited to take part in a review. Health authorities, on the
whole, were questioned about the acute delivery of services, waiting
lists, and that sort of thing but the public health targets, if
they existed, were never discussed. Have we got the right mechanism
of delivering the public health agenda you talked about so eloquently
this afternoon?
(Mr Milburn) I hope we have. It is very, very important.
This is one of the changes that we have to achieve. If you like,
we have to take public health out of its ghetto within the National
Health Service. It not just a function and it is not just a responsibility
that belongs to one part of the Service or to one group of professionals.
It is a responsibility for the whole service, particularly in
primary care it is the responsibility of all professionals. We
have to, as I was indicating earlier in answers, have a means
of imbedding it within the Service. My guess is you share this
view, it is reflected in your question, that for too long these
public health issues have somehow been second order rather than
at the top of the agenda. The way that we have sought to do that
is precisely by making health outcomes and fair access to services
as important as the patient's experience in a hospital in determining
how well their local health service is doing and, therefore, being
able to hold a local health service to account. As you are aware,
in future being better able to reward good performance across
a whole range of quite complex health service responsibilities
according to performance of the individual health service, not
just on the waiting time issue, but on health outcomes and health
improvement too. Within a managed service that is the way it seems
to me that you stand a better chance of locating responsibility
for improvements in public health within the mainstream of the
NHS, rather than simply having it parked to one side, which I
think has been the position in the past. That is quite a big change.
I do not pretend that it will be easy. I think there is not a
chief executive in the country that does not realise that there
are certain important priorities for the NHS. Certain priorities,
in Mr Hesford's phrase, are "must dos". In the future
"must dos" will not just be about what happens in hospitals,
they will also be about what happens in primary care, what happens
to improve preventive screening services and what happens to bring
about what we are all in the business of, which is improving health.
Dr Brand: You are still talking about the medical
model of public health rather than the broader model of public
health—
Chairman: This is coming from a doctor!
Dr Brand
719. —which is something that saddens
me actually. We have been talking about screening, prevention
and some very good things have been done, I am not denying that,
but that really is improving things very significantly for a relatively
small number of people at risk. The broader population benefits
from the broader issues of the environment, housing, nutrition,
which have been touched on, but they are not actually delivered
through the Health Service.
(Mr Milburn) Hold on. With respect, and nor could
they ever be. Unless you want to have a rather Stalinist approach
to government—I know that is my reputation, Dr Brand, but
as you know I am much more amenable and flexible than he ever
was.
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