THE NHS PLAN
41. The current Government seemed to give a high
priority to public health when it took office. The Acheson report
was commissioned within two months of the General Election. As
we have noted, this report presented a comprehensive and wide-ranging
critique of those measures which would do most to reduce health
inequalities. Following the Acheson Report, the Government released
Reducing Inequalities: an Action Report alongside Saving
Lives: Our Healthier Nation, which was then given to a Modernisation
Action Team to oversee implementation and incorporate the process
in the NHS Plan.
42. So a picture emerges of a government expending
a good deal of energy in the sphere of public health in the first
months of office. What is, to us, less clear is whether that energy
has been sustained and whether it has been channelled effectively.
In this regard, the NHS Plan is a key area. The Secretary of State
told us that the White Paper Saving Lives: Our Healthier Nation
shared "equal status" with the NHS Plan.[45]
Indeed, he felt that the Plan "broadly reflected the aspirations,
ambitions and some of the targets within Our Healthier Nation".[46]
Written evidence from the King's Fund analyses the public health
content of the Plan. The following public health initiatives are
reported:
- new national health inequalities targets "to
narrow the health gap in childhood and throughout life between
socio-economic groups and between the most deprived areas in the
rest of the country" to be developed in consultation with
stakeholder groups and experts
- a new health poverty index combining data about
health status, access to health services, opportunities for good
health
- a new funding formula making the reduction of
inequalities a key criterion of resource allocation
- new Personal Medical Services schemes for salaried
GPs and other NHS personnel by 2004 in disadvantaged communities
- by 2003 a free translation and interpretation
service via NHS Direct
- an extra £500 million for the SureStart
programme
- a new Children's Fund worth £450 million
- an enhanced smoking cessation programme with
nicotine replacement therapy available on prescription
- free fruit in schools for children aged up to
6 years old
- local strategic partnerships developed with the
help of the NHS with a view to integrating health action zones
with other action zones (education and employment)
- by 2002 single integrated public health groups
formed across NHS regional offices and government offices of the
regions. Accountable through the DPH to CEOs of health and government
at regional level
- by 2002 a new Healthy Communities Collaborative
to spread best practice, following the formula of the Cancer and
Primary Care collaborative
- by 2003 a new leadership programme for health
visitors and community nurses to develop their capacity to work
directly with local communities[47]
43. However, the King's Fund also voiced a number
of reservations about the Plan: they were "disappointed"
that it failed to announce further convergence between the HImP
and the Community Plan; they questioned whether the Plan would
impact favourably on the development of local partnerships; they
queried whether the mainstreaming of partnership working had sufficient
emphasis; they were concerned at the fact that the HDA is barely
mentioned in the Plan; and they noted that the Plan said nothing
about the need to develop effective links between England, Scotland,
Northern Ireland and Wales in the public health area.
44. Other witnesses also had misgivings. Professor
Sian Griffiths, DPH in Oxfordshire and Vice President of the Faculty
of Public Health Medicine, told us that she thought Saving
Lives was a very good strategy but risked being lost in the
"reformatting" of the NHS Plan. She felt that this posed
particular threats to proposals for increasing workforce capacity
and building up skills in the community at large, rather than
just among GPs.[48]
John Ransford of the Local Government Association said that the
chapter on public health should have featured much earlier in
the Plan (it is chapter 13 out of 16) and that this chapter should
have been "firmer".[49]
Jane Naish of the RCN praised the proposal for national health
inequalities targets and the commitment to a health poverty index,
but criticised the lack of a strategy on how public health could
be delivered in the field and the omission of the issue of water
fluoridation.[50]
For the BMA, Dr Peter Tiplady felt that "the root causes
of ill health" received little mention in the Plan, believing
that it represented a falling off in the early promise of the
Government's public health strategy.[51]
We note that both the Scottish and Welsh NHS Plans accord a
higher prominence to the health agenda, an approach that we welcome.
45. Professor Whitehead, was another who felt that
the "initial flush of enthusiasm" for public health
had perhaps "cooled off" over the last twelve months.
She cited the "muted consideration" of public health
in the NHS Plan as a sign of this.[52]
She praised the Plan for "the setting of the new overarching
resource allocation objective for the NHS: 'to contribute to a
reduction in avoidable health inequalities'" as "a world
first" adding that she knew "of no other national resource
allocation effort that has gone so far towards a focus on public
health". On the other hand she felt that the Plan contained
a number of flaws. First, although improving health and reducing
health inequalities had its own chapter, these themes did not
seem to pervade other areas of the plan - so chapter 14, for example,
which deals with clinical priorities remained silent on the social,
economic and environmental determinants of health. Second, in
general the targets and performance indicators in the Plan were
expressed as averages and did not give sufficient recognition
of the need to monitor the distribution of outcomes across different
social and ethnic population groups. Third, the Plan did not specify
the need for capacity building for public health efforts including
epidemiological expertise and skills in inter agency partnership
working, nor did it address the dangers of not maintaining a critical
mass of expertise in strategic agencies at local and national
level. Finally, no specific resources were earmarked for building
up the evidence base on the effectiveness of health promotion:
she felt that the HDA had been given a very small budget to investigate
a "potentially enormous field".
46. Further grounds for believing that the Government's
early enthusiasm for public health has been diverted comes in
the lengthy delay in the publication of the report commissioned
from Sir Kenneth Calman, the former Chief Medical Officer, into
public health capacity and the public health infrastructure. An
interim version of the report was published in 1998, so we asked
the Chief Medical Officer when the report would be completed and
published. Back in July 2000 he told us: "The report has
been completed and it is with Ministers".[53]
But when we asked the Secretary of State, at the end of January
2001, why it had not been published and when it would be, he replied:
"I hope we can publish it quickly. I hoped we
might have been able to publish it this week but for various obvious
events we have not. It is literally on the stocks and it has been
with Ministers and it will be published, I hope, within the next
few weeks. The major reason is that we had a change of Chief Medical
Officer and it was important that Liam Donaldson had an opportunity
to put input into it."[54]
This strikes us as a weak argument, since the CMO
himself told us that, so far as he was concerned, the report was
complete over six months earlier. We recommend publication
of Sir Kenneth Calman's report on the public health function without
delay.
47. We accept the Secretary of State's assurance
that the NHS Plan is of equal status to Saving Lives.
We particularly welcome the fact that the Plan includes a commitment
to health inequality targets. But we believe that a great opportunity
to give public health a real impetus has been lost by the lack
of emphasis on this area in the Plan. The whole notion of a Plan
is of a working agenda. So if it is the case that Saving Lives
has equal status with the Plan this should have been made explicit
in the Plan itself. Taken with the interminable delay in the publication
of the Calman report on the development of the public health function
we believe it adds credence to the notion that, for all the laudable
Government rhetoric about dragging public health from the ghetto,
in the race for resources it runs the risk of trailing well behind
fix and mend medical services.
EVIDENCE-BASED POLICY
48. The Government has placed great emphasis, over
the past three years, on evidence-based policy, particularly in
the health field. One of our witnesses, Professor Sally Macintyre
of the Social and Public Health Science Unit of the Medical Research
Council, argued that many of the problems in judging the effectiveness
of the interventions lay in the flawed methodology used to assess
their success:
"One of the reasons we have no idea is that
a lot of these interventions are not set up in a way that can
be fairly robustly examined. The temptation is to take the worst
places and give them everything. We do not know whether that is
a good thing or a bad thing, whether it would be better to spread
that around, we do not know whether harm is caused by having everything
going on at the same time. There is this obvious political desire
to take the worse places and give them something, but often that
is related to who is best at writing bids. I wonder whether some
of the ways we allocate things like health action zones, healthy
living centres, all these huge numbers of interventions, could
not be somewhat more systematic and let us evaluate their outcomes.
I have a slightly sceptical hypothesis that the time people spend
in partnership arrangements may well be a waste of time. They
may be better not doing things in partnership."[55]
49. Professor Macintyre went on to suggest randomised
control trials could be employed to assess the efficacy of particular
interventions: "You could take all the bad areas and give
half of them one initiative each and the other half lots and then
another group none and see what happens and then we shall know
and we shall also measure the harm".[56]
Professor Macintyre's own research suggested that interventions
which intuitively seemed likely to have positive public health
outcomes could in fact yield unforeseen problems. She cited the
example of a cycle safety education campaign in Australia which
seemed actually to have led to an increase in cycling accidents
amongst boys and children from poorer families.
50. We believe that there is merit in Professor
Macintyre's suggestion that area-based interventions should be
subject to far more rigorous analysis, although we are not convinced
that randomised controlled trials are necessarily practical. We
hope that this void can, at least in part, be filled by the work
of the Health Development Agency.
39
Cm 4386, p.viii. Back
40 Q528. Back
41 Ev.,
p.107. Back
42 Q141. Back
43 Ev.,
p.520. Back
44 Ev.,
p.521. Back
45 Q682. Back
46 Q681. Back
47 Ev.,
pp.473-74. Back
48 Q224. Back
49 Q360. Back
50 Q486. Back
51 Q485. Back
52 Ev.,
p.75. Back
53 Q85. Back
54 Q734. Back
55 Q169. Back
56 Ev.,
p.189; Q178. Back
