House of Commons - Health

Select Committee on Health Second Report

PERFORMANCE MANAGEMENT

204. A consistent theme throughout the inquiry was the fact that public health was considered a low priority. Jane Naish of the RCN told us that:

"public health is not particularly mainstream in the NHS. It is not sexy, it is not high status, if you are pukka you do not go into public health."[271]

205. This is largely due to the performance management system in the NHS and local government. A particular problem is the fact that the targets set for the NHS are too often focused on short-term "must dos", such as reducing waiting lists.[272] The memorandum by Hillingdon HImP Partnership states that:

"NHS performance management gives scanty recognition to the wider determinants of health and excessive emphasis in the narrower aspects of health services like waiting times."[273]

The DoH has made some attempt to address this problem: one of its Public Service Agreement (PSA) targets is on improving health outcomes;[274] Saving Lives established local targets to reduce health inequalities; and the NHS Plan[275] proposed national health inequalities targets which have recently been published. We welcome these initiatives. However, we found much support for the further development of public health targets.[276] The Health Development Agency remarked that the White Paper did not contain any other measures for assessing whether or not the policies are working, and suggested that some of the ideas "could be translated into process indicators" to allow the "monitoring of risk factors, the development of the public health infrastructure or national and local partnerships, and trends in major public health-related policies, such as those on employment, social security, transport and the environment".[277]

206. The Secretary of State agreed that improving health outcomes was a critical aim of the DoH, but cautioned that:

"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."[278]

We accept that there is no benefit in encouraging an "us versus them" debate. However we consider that NHS resources, time and effort are being directed towards healthcare services issues, to the detriment of the wider improvement of the public's health. We recommend that new high level performance indicators are developed around public health.

207. The Local Government Act 1999 places a new duty of Best Value on local authorities. In meeting this duty local authorities are required to: challenge past patterns of service delivery; compare services using benchmarking and other measures; consult the public on priorities; and compete where appropriate for the provision of services. We think it is vital that health improvement is a key objective for local government. One way to achieve this would be to frame the best value indicators around improving health and well-being. Professor Parish of the HDA told us that they:

"have been working with the Improvement and Development Agency for Local Government to see how we can bring a public health perspective to their best value reviews so that when they undertake these reviews of local government, we bring public health to bear."[279]

We strongly support this approach. Local PSAs are also being piloted[280] and we urge that some of these are also based on public health.

208. Another problem we found was that the recent moves to improve and strengthen partnerships across agencies has not been reflected in NHS performance management arrangements. The NHS Confederation made the point that the present single-agency, or "silo", accountability approach:

"may unnecessarily require constituents of the partnership to put in effort to address the distinct requirements of their agency, thereby taking energy away from the core purposes of the partnerships projects."[281]

209. Encouraging progress has been made in respect of joint performance management across social care and health care but this needs to be broadened.[282] Mr David Panter, Chief Executive of Hillingdon PCT, said:

"It would be incredibly helpful¼to have consistency around the centrality of health in those performance management frameworks and targets¼All too often we find ourselves, at a local level, as different public sector organisations trying to work for the collective good, driven apart by the different demands in terms of performance management from central government ."[283]

210. In its evidence the DETR told us that its corporate aim was to improve everyone's quality of life and that this incorporated, through sustainable development, "improving the health of the population overall".[284] The evidence we have received indicates that this clear commitment has not filtered down to local and regional level as a key aim for regeneration or wider policies within local government. The Government has stressed the need for joined-up policy; we believe it should also have joined-up objectives and a common methodology. We recommend that the DETR and DoH develop a shared Public Service Agreement based on the need to narrow the health gap between socio-economic groups and between the most deprived areas and the rest of the country.[285]

211. A related issue concerns the performance management dimension of partnerships. Mr Neil Goodwin, Chief Executive, Manchester Health Authority reminded us that performance management "is not just about numbers and targets but about the system up the line having confidence in local management teams to do the job".[286] He felt this "softer element of performance management" was receiving insufficient attention. Yet it leads directly into training issues to ensure that public health and management teams generally have the skills in order for them to work together more effectively than is presently the case. Mr Goodwin considered these to be "new skills that we are having to learn because of the Government's new agenda around partnership and collaboration. The Government can legislate for partnership and collaboration but it cannot actually make it happen. That is down to local people, local relationships and having the right skills and the training to do it".[287]

HEALTH ACTION ZONES

212. Health Action Zones (HAZs) were announced by the then Secretary of State Frank Dobson on 31 March 1998 with the aim of targeting "areas where the health of local people could be improved by better integrated arrangements for treatment and care", and tackling "health inequalities" and modernising services through "local innovation". According to the DoH one of the objectives of HAZs was to involve local people in improving their health and give them "ownership" of the projects. Aimed at areas of "high need" the initial 11 zones have been supplemented by a second wave of 15 HAZs, though Ministers have ruled out creating a third wave. The HAZs are working to a seven year timetable.[288] Total funding of HAZs will rise this year from £87 million to £120 million, though some local projects face budget cuts "as the government directs cash at national priorities such as heart disease and cancer".[289] However budgetary limitations have not presented many of the early HAZs with problems: as the King's Fund notes "most HAZs have under spent their budgets spectacularly, because they have been unable to get enough "action" going fast enough to justify the release of funds".

213. We have already described above some of our reservations about the capacity of area- based strategies to deliver efficient and equitable health gains. Many of our concerns apply to the HAZs. On the issue of the appropriateness of the areas covered by HAZs, the Democratic Health Unit of the Local Government Information Unit referred to research conducted by Davey Smith and Gordon which suggests that "an area-based approach only partially deals with those with the greatest health need since most deprived areas of the type identified for HAZ status contain only a minority of poor households". This research also suggests that "it is not clear that the HAZ areas have been defined on the basis of greatest health need, since they are allocated on the basis of competitive bidding, the criteria of which do not appear to be exclusively related to need". An example cited is the Luton HAZ where the health needs of Asian women are particularly addressed, which is set against Birmingham, which has many more Asian women and no HAZ.[290] Conversely, residents on a deprived estate in an affluent area, Sutton, cited "employment" as a key factor determining their health, but would not be the beneficiaries of a HAZ. As the RCN pointed out, HAZs could actually generate geographical health inequalities between areas within and immediately outside the HAZ. The Medical Practitioners' Union noted that HAZs were being used for two different purposes: "as a mechanism for targeting deprivation and as the place for trying experimental approaches". They pointed out that "these are not identical and trying to do them together wastes the potential for innovation elsewhere whilst failing to target resources fairly. There are genuine feelings of unfairness in districts which have pockets of deprivation that are concealed by global indicators".[291]

214. On a more positive note, East London Health Authority, although disputing the utility of HAZs which supported multiple health authority and local boroughs, thought that those which were coterminous with one borough, such as Sandwell and Brent, were much more effective and enjoyed "the luxury of focused cross fertilisation".[292] Gateshead Metropolitan Council argued that the most important organizational achievement under the Tyne and Wear HAZ was the establishment of multi-agency local health partnerships in each of the local authority areas. They recorded that the creation of the HAZ had "fired tremendous enthusiasm to make a difference" and felt that the level of co-operation engendered by the HAZ had become "embedded".[293] They felt that it was too soon to rush to judgement on the effectiveness of the HAZ. Similarly the Royal Institute of Public Health and Hygiene and Society of Public Health, responding to rumours (which we ourselves have heard) that Ministers are reported to be "less keen" on HAZs since they are not yielding quick results, urged that a longer view should be taken. They noted the example of one HAZ where "some measurable improvement in population blood pressure has been achieved over two years" but pointed out that it would take several more years for that to feed through in terms of improvement in the incidence of stroke.[294]

215. We ourselves were struck by the energy and enthusiasm to be found on the different Health Action Zone projects we have visited in the course of this and previous inquiries. We also have been told that new partnerships have been brought about as a consequence of the HAZ and this will no doubt be beneficial in the formation of local area partnerships. We would have preferred to see a closer integration between the HAZ schemes and other regeneration initiatives - we were surprised to note the absence of correlation between Sports Action Zones and Health Action Zones. Aside from these observations, we do not think it appropriate to comment further on the value of the HAZs. The Government has commissioned a team from Glasgow University working under Dr Ken Judge to evaluate the HAZ scheme and they will report next year.

COMMUNICABLE DISEASE CONTROL

216. The control of communicable disease involves the surveillance of the population's health, the co-ordination of preventive strategies such as immunisation campaigns, and the management and containment of outbreaks of infectious diseases. The Government is, we gather, close to finalising a new communicable disease strategy.

217. The person ultimately responsible for the control of communicable disease at Regional and District level is the Director of Public Health. In the wake of Sir Donald Acheson's report of 1988, Public Health in England, however, a new medical consultant post, that of the Consultant in Communicable Disease Control (CCDC) was established, to improve the level of activity and expertise in the control of communicable disease. These CCDCs work with the DPH and other colleagues, for the health authority, and in effect manage and co-ordinate the surveillance and containment strategies for the area.

218. At regional level, the Public Health Laboratory Service (PHLS) provides an epidemiology service under a contract with the NHS Executive. The evidence from the PHLS makes clear that this important service is under strain, drawing attention to "the vital need for increased investment in training in general and in developing coordinated 'surge capacity' for dealing with infection incidents. Surge (or response) capacity cannot be maintained where staffing is reduced to the bare minimum through imposition of excessive efficiency savings. We cannot wait for incidents before deciding there is a need for preparedness".[295] We recommend that the Government assesses the capacity of the communicable disease control service, and in particular that of the PHLS, and takes the necessary steps to ensure 'surge capacity' is in place. We hope that these issues will be addressed by the Government in its forthcoming Communicable Disease Strategy. We would urge the Government to issue its new strategy as quickly as possible.

Consultant in Communicable Disease Control

219. The evidence we received from the DoH describes how each Health Authority's DPH takes responsibility for communicable disease control, and how the CCDCs, working for and with the DsPH, "also have responsibilities within the local authority and normally have responsibilities exercising statutory powers and duties in respect of the control of communicable diseases on behalf of the local authority".[296] This ambiguity glosses over the problem of exactly what constitutes the responsibilities of local authorities in regard to communicable disease control, and how the CCDC and DPH are able to influence and interact with the local authority. Gateshead Metropolitan Borough Council expressed the desire for "clear national guidance ... on the respective roles and responsibilities of the Director of Public Health and the Consultant in Communicable Disease Control. In particular this should cover the support they give to local government in carrying out their public health functions".[297] The Royal Institute of Public Health and Hygiene and Society of Public Health told us that despite carrying out a consultation exercise in 1989, the DoH had failed to follow up recommendations relating to the clarification of the statutory responsibilities of Communicable Disease Control, with the result that "we still have a situation where both health and local authorities have responsibilities and expectations placed upon them but no-one has a statutory duty to control communicable diseases".[298] Frustration has also been expressed at the relationship between Directors of Public Health and CCDCs, where lines of responsibility appear to be blurred. The Public Health Medicine Environment Group, the professional body representing and supporting CCDCs and other specialists in Public Health, called for a review of this relationship.[299] Even if their anxieties are misplaced they illustrate the feeling of confusion about where responsibility lies. We recommend that the DoH issues guidance to health and local authorities clarifying the roles of the DPH and the CCDC. This is another manifestation of the lack of clear leadership within public health.

Data Protection Law

220. The PHLS makes clear that "overly strict interpretations of new legislation relevant to patient confidentiality could potentially place patient health and even lives at risk from infection if they make proper surveillance and infection control impossible".[300] We recommend the Government revisits data protection legislation and takes action to ensure that proper health surveillance at a population level is not jeopardised.

271 Q492. Back

272 QQ366, 692. Back

273 Ev., p.227. Back

274 Public Services for the Future: Modernisation, Reform, Accountability, HM Treasury 1998 (Cm 4181) set out the DoH PSA Objective 1: Improving health outcomes for everyone. This was reflected in Objective A in The Government's Expenditure Plans 2000-2001 (Cm 4603), p.11. Back

275 The NHS Plan, para 13.4. Back

276 QQ 366, 417, 419, 421, 431, 492. Back

277 Ev., p.127. Back

278 Q704. Back

279 Q285. Back

280 Local PSAs were first announced in the July 2000 comprehensive spending review. Back