Select Committee on Health Second Report


The Health Committee has agreed to the following Report:—


1. The Government has made the development of public health a key plank of its health policy. It appointed a minister for public health, commissioned a report into health inequalities[8] and has established a number of initiatives aimed at dealing with the health of the public. Rather than look in detail at the different aspects of poor health (such as coronary heart disease, stroke, or cancer) we wanted to examine how these policies were working, and in particular how they worked together.

2. Our terms of reference were as follows:

"The Committee will examine the co-ordination between central government, local government, health authorities and PCGs/PCTs in promoting and delivering public health.

In particular the Committee will examine the organizational arrangements and will address:

  • the inter-operation of Health Action Zones, Employment Action Zones, Healthy Living Centres, Education Action Zones, Health Improvement Programmes and Community Plans
  • the role of the Health Development Agency
  • the role of PCGs and PCTs
  • the role and status of the Minister for Public Health
  • the role of the Director of Public Health
  • the extent to which current public health policy is reducing health inequalities."

The Committee will also study alternative models of public health provision.

3. Between July 2000 and January 2001, we took oral evidence from Department of Health officials, Sir Donald Acheson, Sir Michael Marmot, Professor Margaret Whitehead, Professor Jennie Popay, Professor Sally Macintyre, Professor Richard Wilkinson, the Association of Directors of Public Health Medicine, the Faculty of Public Health, the UK Public Health Association, the Health Development Agency, the Local Government Association, the NHS Confederation, Calderdale and Kirklees NHS Health Authority, County Durham and Darlington NHS Health Authority, West Surrey Health Authority, Manchester Health Authority, the Royal College of General Practitioners, the NHS Alliance, the Community Practitioners and Health Visitors Association (CPHVA), the British Medical Association (BMA), the Royal College of Nursing (RCN), Hillingdon Health Authority, London Borough of Hillingdon, Healthy Hillingdon, Sandwell Authority, Walsall West Health Action Zone, Poole Hayes Community Association, Walsall, Blackliners, Ms Teresa Edmans, Redbridge and Waltham Forest Health Authority, Dr Faduma Hussein, the British Heart Foundation, Sport England, Kate Hoey, MP, Minister for Sport, Mr Harry Reeves, Sport and Recreation Division, Department of Culture, Media and Sport, Ms Yvette Cooper, MP, Parliamentary Under-Secretary of State, Minister for Public Health, and the Rt Hon Alan Milburn, MP, Secretary of State, Department of Health.

4. We also received around 100 written memoranda which were invaluable in our discussions. We are grateful to all those who have submitted written or oral evidence.

5. In October 2000 we undertook a visit to Cuba as part of our inquiry. We chose to visit Cuba since it achieves excellent health outcomes despite the fact that its resources are very limited. In Cuba we met the Commission of Health of the National Assembly, Abelardo Ramirex, Deputy Minister of the Ministry of Public Health and the President of Provincial Assembly, Pinar del Rio. We also visited the Latino-American School of Medical Sciences, the Pediatric Cardio-Centre "William Soler", the Maternal Home "Leonor Pérez", the Senen Casas Rehabilitation Centre for Disabled Children, the Geriatric Centro, the Carlos J Finlay Institute, the Santa Maria del Rosario Health Project, La Castellana special school, the Liberty City school centre, and various clinics in Pinar del Rio and Havana.

6. We also undertook a number of visits throughout the United Kingdom. We visited the East London & The City Health Authority, Bromley by Bow Healthy Living Centre, the Plymouth Health Action Zone, South and West Devon Health Authority, the Beacon Project, Falmouth, the St Sidwell's Healthy Living Centre, Exeter, the Starting Well Project, Greater Glasgow Health Board, the Health Promotion Policy Unit, Department of Public Health, University of Glasgow, the Centre for Social Marketing, Strathclyde University, the Eastern Health and Social Services Board, Belfast, the Chief Medical Officer (Northern Ireland), the Northern Ireland Assembly Health Committee, the North and West Belfast Health Action Zone and community leaders and health workers assembled at Corpus Christi College.

7. We are extremely grateful to all those who facilitated these visits which we feel made a crucial contribution to our inquiry.

8. We should also like to record our gratitude to our Specialist Advisers, Anna Coote of the King's Fund, Professor David Hunter, of the University of Durham Business School, Professor Michael Kelly of the School of Social Sciences at the University of Greenwich and Professor Harry Burns, Director of Public Health at the Greater Glasgow Health Board.

9. In our report we have explored the definition of public health, the factors affecting health and what can be done to improve the health of the public at every level - from the individual up to central government. In a series of annexes, we have analysed specific major public health issues relating to tobacco, violence, mental health and fluoridation.


10. "Public health", according to the Proprietary Association of Great Britain, is not a term understood by the majority of the public. They felt that the first task of the Minister for Public Health should be to define it.[9] But as Dr Peter Donnelly of the Association of Directors of Public Health suggested: "one of the difficulties with the term 'public health' is that it means different things to different people ... [it] can span everything from a medical specialty to a specialty which is an awful lot broader than medicine ... to almost a philosophy".[10] "Public health" can be variously defined so as to cover trends of disease in a population, the provision of preventive and health improving care, or a range of health-impacting factors including or excluding the NHS. The Nuffield Trust even went so far as to argue that the very phrase "public health" was "restrictive" and inhibited the broader agenda of "the health of the public", the quality of life lived rather than the absence of illness: in their view, a culture shift was needed away from "public health" and towards "the health of the people".[11]

11. The Acheson Committee on Public Health in England, which reported in 1988, at their first meeting defined public health as:

"The science and art of preventing disease, prolonging life and promoting health through organised efforts of society."[12]

They adopted this description to move away from previous narrow definitions of public health which associated it with "sanitary hygiene and epidemic disease control". The tension between an emphasis on the prevention of specific diseases through medical interventions such as screening, immunisation or disease cure and control (the so-called medical model) or on a more holistic view which gives precedence to the wider determinants of health (factors such as employment, social class, education - the social model) goes to the heart of the debate. It has implications for the role of the Director of Public Health, which - at least theoretically - straddles the two functions of physician for a community and health authority expert on the wider determinants of health. It even impacts on the location of the public health function itself, with some parties asserting that the very placement of the public health function in health authorities and the Department of Health implicitly favours the medical model of care.

12. In a key note speech delivered as the annual LSE health lecture on 8 March 2000, the Secretary of State for Health himself drew attention to the problems in defining public health and the implications of those problems:

"The time has come to take public health out of the ghetto. For too long the overarching label 'public health' has served to bundle together functions and occupations in a way that actually marginalises them from the NHS and other health partners ... Public health understood as the epidemiological analysis of the patterns and causes of population health and ill-health gets confused with 'public health' understood as population-level health promotion, which in turn gets confused with 'public health' understood as health professionals trained in medicine."

The danger of this train of argument, according to the Secretary of State, was that it played into the hands of those seeking to equate public health with the medical model of public health:

"By a series of definitional sleights of hand the argument runs that the health of the population should be mainly improved by population-level health promotion and prevention which in turn is best delivered - or at least overseen and managed - by medical consultants in public health."

He denounced such a chain of reasoning as "lazy thinking and occupational protectionism".[13]

13. One of the things we set out to establish in this report was the extent to which the Department of Health's actions substantiated the rhetoric of that speech; whether the measures the Government is taking will indeed take public health 'out of the ghetto'. When taking evidence in our inquiry into the Regulation of Private and other Independent Healthcare we were told that the then Secretary for State regarded his responsibility as being solely to the NHS. We felt there that he had an overall responsibility for the health of the nation, including patients in the independent sector. We would maintain that argument in this inquiry.


14. The Public Health Green Paper Reducing Health Inequalities: An Action Report analysed the factors affecting health, dividing these into five categories:

Fixed:          Genes, Sex, Ageing

Social and Economic:   Poverty, Employment, Social Exclusion

Environment:     Air Quality, Housing, Water Quality, Social Environment

Lifestyle:         Diet, Physical Activity, Smoking, Alcohol, Sexual Behaviour, Drugs

Access to Services:   Education, NHS, Social Services, Transport, Leisure

15. Any number of similar models can and have been constructed and we received a great deal of evidence which pointed to the fact that health was determined by a wide range of factors.[14]

16. What these analyses make clear - and this was reinforced time and again in evidence to us - is that the health of the population in the UK is not predominately determined by curative services

within the NHS. The Chartered Institute of Environmental Health affirmed that "mass vaccination programmes, the engineering works of the mid 19th century and the creation of social and welfare structures that addressed the needs of the poor" underlay the greatest strides in public health in the modern era. Moving away from a purely historical perspective, the Health Development Agency suggested to us: "It has been estimated that over 70 per cent of what determines a people's health lies outside the domain of health services and in their demographic, social, economic and environmental conditions".[15] With so many factors at play, and with so many different organizations and individuals involved, it is not surprising that the RCN should conclude: "it is important to recognize that in some senses, public health is everybody's business".[16]

17. The Chartered Institute of Public Health suggested that the model of public health within the NHS was not sustainable since "action was starved of resources by the insatiable 'treat and cure' model of care within the UK".[17] Dr Donnelly made explicit this gap in health service priorities when he told us: "When you [the Director of Public Health] go to the annual review you do not get beaten up because your statistics on smoking and your statistics on the consumption of food are bad; you get beaten up over waiting lists and issues such as that."[18] (We discuss this further at paragraph 204). But the Secretary of State for Health dismissed suggestions that the NHS prioritised treat and cure services over more general public health. He told us that the ingrained culture of the NHS needed to change so that people realized it was not merely a "service to treat sick people". He felt that, as well as increasing the amount of primary prevention by means of, for example, increasing the amount of screening "for everything from chlamydia to colon/rectal cancer" he also wanted to increase the amount of "secondary prevention". Here he cited work which had impressed him in Bradford, where a register had been constructed of those in the Asian population deemed to be especially at risk of coronary heart disease and diabetes, and in the Northumberland Health Action Zone which was establishing a register of people who were vulnerable to heart disease and tasking those in primary care to do "everything they can to get cholesterol levels down".[19]

18. Whilst such initiatives seem to us commendable we are still not convinced that the mind set of the NHS - let alone the limitations on its capacity and resources - allow it to get as far beyond the medical model as the Secretary of State would seem to imply. Even when talking of the need to take public health out of the ghetto, or in describing the benefits of secondary prevention, he seemed always drawn to medical interventions, to discussion of the provision of defibrillators or additional screening. The RCN felt that the very culture of the NHS was not conducive to it dealing effectively with public health. Its core business was perceived both by those working within it and the public at large to be "the care or cure of individuals who are ill". They noted that Department of Health circulars prioritised issues such as waiting lists (which has come to represent, quite mistakenly in our view, the litmus test of an effective health service) but failed to prioritise public health issues such as "the involvement of local communities in health promotion".[20]

19. We believe far more impetus must be given to public health policies in the UK. At present public health seems to be largely locked into the medical community - the occupational protectionists described by the Secretary of State. Yet ironically public health medicine is seen as a marginal discipline within that community. We witnessed a radically different model of health care in Cuba. The Chartered Institute of Environmental Health in their memorandum suggested "in Western civilisations, economic success ... has enabled society to regard health as something which deteriorates but which can be restored by medical intervention". In Cuba, resources for health care are scant. So the expensive "cure and mend" medical model cannot be sustained. Even so, Cuba manages to achieve rates of mortality and morbidity which are close to those of First World Countries spending vastly more on health care. Life expectancy is currently 76 years at birth, and we were frequently told that Cuba was "a Third World Country whose inhabitants die from First World Diseases". On our visit to Cuba we saw a number of different factors which underlie the success of the Cuban health care system.

20. In Cuba, there is a strong emphasis on disease prevention. Budgetary limitations and trade barriers make it difficult for Cuba to import drugs. The health care professionals we spoke to in Cuba observed no divide between proactive, disease prevention policies and disease management. There is a commitment to the practice of medicine in a community. Following alterations in the medical curriculum in the 1980s the great majority of Cuban medical graduates complete at least three years in General Practice, and are encouraged to analyse social and psychological factors in diagnosis, as well as physiological ones. Partly as a consequence of scarce resources and the wide dispersal of the population, primary and secondary care are much more closely integrated. Each neighbourhood has a consultario (waiting room plus examination room) staffed by a doctor and a nurse. Since the building is provided by the Government and doubles as living quarters there is a great incentive for the health care staff to remain in one site, in the heart of their community and access to them is straightforward

21. Every patient is obliged to attend their consultario at least twice a year. We were told that babies were examined daily during the first six months of life. Extremely high levels of immunisation were recorded. In the absence of expensive imported pharmaceutical products, considerable emphasis is placed on herbal and other alternative remedies. Every 10 to 15 family practices are supported by a polyclinic staffed by specialists in areas such as paediatrics, gynaecology and psychiatry. The presence of the polyclinics limits the numbers of patients referred to hospital and generally allows for treatment to take place close to the patient's home. Patients are heavily involved in decision making at every level. Cuban society also places great emphasis on the role of exercise. The Cuban Health Ministry and Health Committee are also responsible for sport (see below, paragraph 200).

22. There are clearly huge disparities between the UK and Cuban social systems. The Cuban system has elements of compulsion that would not be accepted in the UK. The prevalence of Cuban doctors allows a doctor patient ratio of 1:175 (compared with 1:600 in the UK). We believe that there are lessons to be learned from the Cuban model for public health in the UK and we note that the Department of Health has itself financed an ongoing study of the Cuban healthcare system.[21] The Cuban primary care system is extremely responsive to the needs of its community; patients are far more directly involved in their own health and well being; moreover prevention is prioritised over cure.

8  Independent Inquiry into Inequalities in Health, Report of the Committee chaired by Sir Donald Acheson, London TSO 1998. Back

9   Ev., p.329. Back

10   Q215. Back

11   Ev., p.459. Back

12   Public Health in England: The Report of the Committee of Inquiry into the Future Development of the Public Health Function, Cm 289, 1988. Back

13   For the text of the speech see Back

14   See, for example, Ev., p.19. Back

15   Ev., p.124.  Back

16   Ev., p.212. Back

17   Ev., p.388. Back

18   Q223. Back

19   Q697. Back

20   Ev., p.213. Back

21   Ev., pp.51-54. Back

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