APPENDIX 12
Memorandum by Medical Practitioner's Union
(PH 22)
CONTENTS
EXECUTIVE SUMMARY
About ourselves
Some Important Quotations
Our Key Themes
Your Key Themes
1. The Interoperation of Health Action Zones,
Employment Action Zones, Healthy Living Centres, Education Action
Zones, Health Improvement Programmes and Community Strategies
1.1 HAZs etc etc etc etc etc etc etc etc
etc
1.2 HImPs and Community Strategies
1.3 Strengthening Links Between Local Government
and the NHS
1.4 Boundaries and Coterminosity
1.5 The BMA Proposals for Coterminosity
2. The Role of the Health Development Agency
3. The role of PCGs and PCTs
3.1 Community Development
3.2 Resident and Registered Populations
3.4 Neighbourhood Health Committees
3.5 The Link between Primary Care and Environmental
Health
3.6 School Health Services
4. The role of the Minister for Public Health
4.1 Policies Affecting the Determinants of
Health
4.2 The Minister for Public Health
4.3 Public Health in Downing Street
4.6 Promoting Healthy Economics
4.7 Earth Sheltered Building
4.8 A New Public Health Act
5. The role of the director of Public Health
5.2 The Doctor to the Town (or County)
5.3 Public Health Management in Health Authorities
6. Inequalities
6.2 The Public Health Case for Relief of
Poverty
6.3 Community Development
6.4 Other Measures to Address the Health
Effects of Poverty
6.5 Workplace Public Health
7. Multidisciplinary Public Health
7.2 Our Commitment to Multidisciplinary Public
Health
7.3 The Traditions of the Public Health Professions
7.4 Why Creating a Single Public Health Profession
Will Not Work
7.5 The Career Structure for Non-Medical
Public Health Professionals
7.6 A Family of Public Health Professions
7.7 Transfer Between Professions
EXECUTIVE SUMMARY
About Ourselves
The MPU is the medical organisation committed
to the Labour Movement, patients' movement, environmental movement
and other similar movements of the people. We combine this commitment
to the grass roots with a membership which can draw upon the expertise
of members at the heart of the medical establishment and at the
cutting edge of our profession's development. We have a longstanding
interest in public health, workplace health, NHS democracy, quality
of working life, family friendly policies, the removal of poverty,
patients' rights, political impacts upon health and the ways that
economic structures damage health.
Some Important Quotations
"The health of the people is the first concern
of Government"—Disraeli
"The health of the people is the concern
of the people themselves"—Lenin
"It is often said that the health of the
people has improved naturally with economic development. But each
of the changes in living and working conditions that brought about
those improvements had to be fought for and was bitterly opposed
by the very economic system whose advocates later claimed that
it was a natural advance. Capitalism proudly displays the medals
won in the battles it has lost"—Nye Bevan
"We would rather have the cholera than the
hectoring of Dr. Snow"—19th century editorial in "The
Times"
Our Key Themes
The first major theme of our evidence is that
public health is not just about disease management programmes.
It is fundamentally about the political action needed to create
healthy environments and the potential for healthy lifestyles.
We review a number of these political issues both in section 4
(the Minister for Public Health) and section 6 (Inequalities)
of the evidence.
Our evidence is structured around the committee's
key themes not our own but this theme of ours enters into all
the themes you raise.
— it points to a need for the HImP
and the Community Strategy to be linked more closely;
— it raises questions about the idea
that the Health Development Agency can have just a technical role;
— it leads us to suggest that the role
of the Minister for Public Health should be more powerful, more
political and more interdepartmental, and should entail control
of some cross departmental legislative time;
— it leads us to call for separation
of the managerial and advocacy functions of the DPH with a major
reassertion of the latter in the creation of new functions of
Borough and County Medical Officers that we suggest should be
constituted as corporations sole;
— it leads us to point out that addressing
inequalities is not just about improving health care—it
is also about addressing the political determinants of inequality
in health and addressing the problems of health at work and of
poverty.
The second major theme is the way the NHS is
currently being managed in a centrally directed hierarchical way.
The system which destroyed the economy of the Soviet Union will
not improve the NHS. The NHS has been run like Gosplan for some
years now and the present Government has improved things slightly.
But they need to change them fundamentally to carry through reforms
which depend on revitalisation of morale and changing practice.
Because this Government is doing more and investing more the defective
management structures will be even more damaging. This theme of
ours again crosses all your themes
— In discussing the HImP we point out
how the central direction of resources leads to little scope for
local innovation or preventive initiatives even in a resource
rich environment.
— It is important that the Health Development
Agency should not just be a disease management process body.
— We call for local democracy in PCTs.
— We seek to free the Minister for
Public Health from a role in fronting disease management processes
within the DOH.
— With the professional roles of the
DPH moved to our new proposed Borough and County Medical Officers
the managerial role could then be developed as a post that is
not specifically medical and that could lead a new approach to
change in the NHS. We suggest what that new approach might be
and how the skills of the different public health professions
could contribute. We suggest that the Chief Executives of health
authorities should be public health professionals because the
skills and training of public health would drive this new model.
— We point out that improving the health
of local communities must include community development processes
that work with people rather than doing things to them.
The third major theme of our evidence is the
nature of multidisciplinary public health. In section 7 of our
evidence we call for a family of professions, strengthening the
traditions of each, rather than the current project of merging
to an amorphous mass. We prefer this model not only because it
preserves the traditions of our own profession, which we are proud
of, but also because the other professions should have a similar
pride. We strongly support enhanced career structures for non-medical
public health professionals. These enhanced structures should
exist because of the importance of those other professions. It
should not be necessary for them to pretend to be doctors in order
to avail themselves of them.
Fourthly we emphasise the importance of adopting
models of organisation for public health which are not just an
afterthought of health care structures but consider the importance
of public health in its own right. Reorganisation is not just
an organisational and political game, although it is often played
as if it were. It also affects the way people see themselves and
the power and resources they are able to command. We give a number
of examples of how the 1974 reorganisation created problems which
are still not resolved.
Your key themes
Responding to your own key themes our comments
are:-
1. There is too much confusion about multiple
initiatives and too much time spent on bidding and completing
monitoring returns. HImPs are valuable but need closer links with
Community Strategies if they are to address the real determinants
of health. This means they must be drawn up by bodies coterminous
with local authorities and with enough local discretion to introduce
innovation and preventive initiatives.
2. We look forward to understanding the
role of the Health Development Agency. We have long advocated
a central public health body but it should also have incorporated
PHLS, the HSE and the Environment Agency and had links to a Royal
Commission or Select Committee. It must not become a technical
body focussed on disease control programmes.
3. Community development is an important
role for public health nurses within a PCT. PCTs should promote
the health of their resident population, commission services for
their registered population, carry out health protection and emergency
provision for all those within their boundaries and promote workplace
health for all those employed within their boundaries. PCTs should
be coterminous with district councils and should establish a Health
Act partnership so that public health nursing, health promotion
and environmental health can be managed together. They should
have a structure with local democratic roots.
4. The policies which influence the determinants
of health reach deep into the heart of government. We believe
that the Minister for Public Health should be equal in status
to the Chief Secretary to the Treasury with an acknowledged interdepartmental
role in a department whose remit crosses the whole of Government
and therefore able to deal with Cabinet Ministers as an equal
and, indeed, to be regularly in attendance at Cabinet. It is particularly
unfortunate that at the very heart of Government public health
is equated with disease control programmes rather than being recognised
as a social value.
5. We believe that the populations of each
of the 150 top tier local authorities in England—each county,
each unitary authority, each metropolitan Borough and each London
borough should have a Borough Medical Officer or County Medical
Officer to take on the role of analysis and advocacy in direct
historical lineage with the former Medical Officers of Health.
This office should be part of the NHS, established as a corporation
sole. A new Public Health Act should be enacted conferring a number
of powers to allow this office to function as an active participant
in the local community. The right of audit and report is fundamental.
In future the Chief Executives of health authorities should be
drawn from public health professionals. NHS management should
use a public health approach.
6. Health inequalities will be reduced when
deprived groups cease to suffer high levels of exposure to determinants
of ill health. Community development, social inclusion, improved
working environments (physical and social) and reducing poverty
will address health inequalities.
1. THE INTEROPERATION
OF HEALTH
ACTION ZONES,
EMPLOYMENT ACTION
ZONES, HEALTHY
LIVING CENTRES,
EDUCATION ACTION
ZONES, HEALTH
IMPROVEMENT PROGRAMMES
AND COMMUNITY
STRATEGIES
1.1 HAZs etc etc etc etc etc etc etc etc etc
etc
1.1.1 The multiplicity of initiatives is
confusing. The dramatic multiplication of processes for bidding,
reporting and monitoring targets seems likely to replace meetings
as the main alternatives to real productive work.
1.1.2 At best the processes for bidding
and reporting distort local priorities (without having sufficient
coherence necessarily to serve national ones). At worst unsuccessful
bidding processes can lead to disillusionment and can significantly
damage relationships with clinicians and other agencies who began
as enthusiastic and committed partners. Bidding processes regularly
undermine the addressing of inequalities.
1.1.3 Health Action Zones are being used
for two different purposes—as a mechanism for targeting
deprivation and as the place for trying experimental approaches.
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 are innovative but not deprived or which have
pockets of deprivation that are concealed by global indicators.
Health Action Zones are not so structured as to be the organisations
best placed to evaluate new interventions.
1.2 HImPs and Community Strategies
1.2.1 Health improvement programmes are
a valuable new tool for partnership.
1.2.2 Just as health authorities vary in
the priority they give to public health so they vary in the extent
to which their HImP addresses issues beyond the NHS.
1.2.3 A HImP which genuinely addressed the
determinants of health would inevitably overlap considerably with
the Community Strategy.
1.2.4 Some districts plan to address this
by having a common section to the HImP and Community Strategy,
others by cross referencing them, others by publishing them together.
Some districts, unfortunately, do not seem to have noticed the
problem.
1.3 Strengthening Links Between Local Government
and the NHS
1.3.1 Four very important steps towards
strengthening NHS/local government links have been taken by the
present Government:-
— involving local authorities as partners
in Health Improvement Programmes;
— creating Health Act Partnerships;
— clarifying the powers of NHS bodies
to spend money on local authority functions that improve health;
— extending the scrutiny remit of local
authorities to include the NHS;
1.3.2 Unfortunately
— the emphasis in the National Plan
on treatment services has led to many HImPs having a treatment
oriented focus;
— most of the discussion of Health
Act Partnerships has taken place in the context of social services;
— the strong central direction, towards
treatment services, of the new money fed into the NHS has meant
that even in the current resource rich environment there is virtually
no money available for local priorities, innovation or preventive
programmes not formalised in National Service Frameworks;
— scrutiny committees within the local
authority have powers to call in decisions and to take to full
Council proposals for changes in the policy framework and budget.
Without those powers scrutiny is toothless.
1.3.3 These obstacles need to be overcome.
1.3.4 We welcome as a step in the right
direction the trend to make Director of Public Health appointments
joint appointments between the NHS and local government even though
we ourselves argue later in this evidence for a more radical approach.
If our own proposal for corporations sole with statutory powers
were not adopted we would wish to see joint appointments of this
kind made universal.
1.3.5 Coterminosity between some level of
NHS structure (whether it be the health authority, the PCT or
the local health economy) and the local authority is essential
for such joint appointments to work and for HImPs to fit together
properly with Community Strategy.
1.3.6 It will also be necessary for the
level of structure which is coterminous, whatever it may be, to
be the level on which is placed the responsibility for coordinating
the local health economy and producing the HImP. Health authorities
can discharge performance management and broad strategic functions
without coterminosity and might even benefit from a larger population
size. But they cannot fulfil the functions set out in Leadership
for Health at anything but a coterminous level of population.
1.4 Boundaries and Coterminosity
1.4.1 Organisations work better together
if they are serving the same population.
1.4.2 Health professions and local authorities
have consistently argued for coterminosity. Only NHS managers
and civil servants have queried the need for it.
1.4.3 However managers and civil servants
have failed to deliver effective joint working on any other basis
1.4.4 Research undertaken by the BMA has
shown that there are more joint projects on public health in areas
with coterminous boundaries than in areas without.
1.4.5 Coterminosity used to be taken to
mean that for every top tier local authority there should be a
matching health authority.
1.4.6 Changes in NHS structure make it possible
to be more flexible.
1.4.7 We argue now that for every top tier
local authority there should be either
or (b) a Primary Care Trust;
or (c) a local health economy (ie a group
of partners producing their own Health Improvement Programme)
with a defined HImP structure and local lead agency;
or (d) a health authority which only serves
as the HImP lead agency for that one local authority even though
it also supervises delegated functions of Primary Care Trusts
or local health economies in other areas (eg a county health authority
which works directly with the county council but also contains
within its boundaries a number of unitary authorities in which
it delegates to Primary Care Trusts the task of producing HImPs).
1.4.8 We also argue now that second tier
local authorities can also have coterminous health structures
based on primary care trusts or health act partnerships
Top Tier Local Authorities
1.4.9 In 1997 the BMA produced and placed
in the public domain a document showing how easy it would be to
produce universal coterminosity. We reproduce it, with full acknowledgement,
as section 1.5 of this evidence, unamended except for numbering
its paragraphs consecutively with this evidence for ease of reference.
1.4.10 In that document the BMA was trying
to achieve 1:1 coterminosity of health authorities and top tier
local authorities. With the greater flexibility of the new arrangements
it will be easier still, especially in the areas where the BMA
in 1997 suggested mini-authorities or federal structures.
Second Tier Local Authorities
1.4.11 The creation of PCTs was an opportunity
to establish coterminosity also at the second tier level of local
government.
1.4.12 NHS guidance suggested that Primary
Care Groups should be coterminous with social services divisions.
1.4.13 Unfortunately it also laid down other
criteria which in some cases distracted from this objective.
1.4.14 Where county councils based their
social services divisions on district council boundaries, and
the NHS followed those boundaries, coterminosity at second tier
level would have been achieved.
1.4.15 The NHS did not universally follow
social services divisions boundaries.
1.4.16 Incredibly county councils do not
universally base their division boundaries on districts.
1.4.17 We believe that each county should
have a single geography for PCT, division and district boundaries.
Regions
1.4.18 The decision in the National Plan
that Regional public health departments should serve regional
development agencies and government offices as well as regional
NHS offices was welcome.
1.4.19 In the south of England a single
set of regional boundaries has been put in place to facilitate
this.
1.4.20 In the north of England it hasn't.
This defies belief.
1.5 THE
BMA PROPOSALS FOR
COTERMINOSITY
1.5.1 This section reproduces, unamended,
Section 6 and Appendix 4 of the Evidence submitted by the British
Medical Association to the Chief Medical Offier's Enquiry into
Public Health Infrastructure. Apart from renumbering we have made
no amendment. We fully acknowledge the BMA as the author of this
material.
1.5.2 Unless health authorities can be made
coterminous with local authorities they cannot properly exercise
the public health function. All the health professions believe
coterminosity to be vital, as do those managers who are most fully
committed to the public health function. However, there are problems
in achieving coterminosity, including the need for strategic overviews,
the small size of many local authorities and the fact that the
location of the smaller authorities often makes it difficult to
include them in a health authority boundary without disrupting
the coterminosity of their neighbours; many counties, for example,
would be "currant bun" shaped with the county totally
surrounding some small unitary authorities isolated from each
other.
1.5.3 We believe that with care and innovation
these problems can be overcome. The following pattern for example,
would achieve most of the objectives:
— 103 DHAs coterminous with those unitary
or top tier local authorities that exceed 200,000 population;
although only 60 per cent of local authorities, these would cover
85 per cent of the population.
— The 33 DHAs which would be coterminous
with county councils to play a lead role for all DHAs in their
county on strategic issues such as tertiary care.
— The creation of 10 special health
authorities to play this role in counties without county councils.
— The DHA functions in those 47 areas
covered by unitary local authorities smaller than 200,000 population
to be vested in innovative local network arrangements which the
local authority and the county health authority would be jointly
responsible for establishing and which, apart from a DPH, would
not include a conventional infrastructure but would draw on the
infrastructure of the local authority, county health authority,
neighbouring authorities, trusts and locality commissioners.
— A locality commissioning unit to
be established coterminous with each of the second tier local
authorities.
1.5.4 After the production of the NHS White
Paper the BMA made the following modifying comments:-
1.5.5 NB: Although this was agreed BMA evidence
at the time, the situation has now moved on with the creation
of primary care groups and it is possible that, when we have had
a chance fully to discuss it, we may replace our advocacy of "mini
authorities" with a proposal for the public health function
in those areas to be located in Primary Care Trusts.
1.5.6 The following material was included
in the Appendix.
1.5.7 Attached is a list of the reorganisations
that would take place if the proposals (in the above) were to
be implemented in full in all areas. It is an illustrative list
and should not be taken as advocating any specific local reorganisation—we
assume that any national model would be open to modification in
the light of experience and local opinions. We also assume that
change would be organic over a period of time as vacancies and
opportunities arose.
1.5.8 These proposals would be substantially
less disruptive for most authorities than a merger process.
1.5.9 Thirty-six authorities would require
no change; a further 35 authorities would not require any change
in their core corporate structure but would need to create mini-authorities
or to undergo a boundary change or to undergo a change of status
(becoming a support agency for a group of minis or a county special
authority). A further 15 authorities would need to demerge, but
we would expect these authorities to retain common support departments,
and there is even an argument for retaining a common Chief Executive
so this could be quite non-disruptive. This means that there would
be a total of 86 authorities for which the restructuring could
be handled with relatively little disruption for existing corporate
structures and only 14 for which it would pose a more substantial
problem.
1.5.10 A. Authorities requiring no change
(36)
*Less than 200,000 population but suggest we
retain them for geographical reasons rather than convert them
into minis.
1.5.11 B. Authorities requiring only boundary
change or creation of mini authorities (35)
Thirty-five existing authorities create 28 new
authorities, 1 new County Special Health Authority, 6 agencies
supporting a group of mini authorities, and 39 mini authorities.
1.5.12 B1. No boundary change (apart
from creation of minis) (20)
| Old Authorities | New Authorities
| Mini Authorities |
| Newcastle & N Tyne | Newcastle
| North Tyneside |
| Gateshead & S Tyneside | Gateshead
| South Tyneside |
| North Yorkshire | North Yorkshire
| York |
| Tees* | | Hartlepool
|
| | Redcar & Cleveland
|
| | Stockport-on-Tees
|
| | Middlesbrough
|
| South Humberside* | | North Lincolnshire
|
| | North East Lincolnshire
|
| Calderdale & Kirklees | Kirklees
| Calderdale |
| County Durham | County Durham
| Darlington |
| Bury & Rochdale | Rochdale
| Bury |
| St Helens & Knowsley* |
| St Helens |
| | Knowlsey
|
| Berkshire | Berkshire County
| Newbury |
| Special Health Authority
| Reading |
| | Wokingham
|
| | Bracknell Forest
|
| | Windsor and Maidenhead
|
| | Slough
|
| Buckinghamshire | Buckinghamshire
| Milton Keynes |
| Cornwall & Isles of Scilly | Cornwall
| Isles of Scilly |
| Dorset | Dorset | Bournemouth
|
| | Poole
|
| Kensington, Chelsea & Westminster* |
| Kensington & Chelsea
Westminster
|
| Richmond & Kingston* |
| Richmond-upon-Thames |
| | Kingston-upon-Thames
|
| Barking & Havering | Barking
| Havering |
| Camden & Islington | Camden
| Islington |
| East London & the City | Newham
| Hackney |
| | Tower Hamlets
|
| | City of London
|
| Merton, Sutton & Wandsworth | Wandsworth
| Merton |
| | Sutton
|
| Shropshire | Shropshire |
The Wrekin |
| | |
*Becomes an agency supporting a group of mini authorities.
1.5.13 B2. Boundary change only
| Old Authority | Gains (e) or losses (r)
| New Authorities |
| Portsmouth & SE Hampshire | r
| Portsmouth |
| Southampton & SW Hampshire | r
| Southampton |
| North & Mid Hampshire | e
| Hampshire |
| North & East Devon | e
| Devon |
| North Derbyshire | e
| Derbyshire |
| South Derbyshire | r
| Derby |
| Nottingham | r | Nottingham
|
| North Nottinghamshire | e
| Nottinghamshire |
| South Essex | r |
Southend |
| North Essex | e
| Essex |
| North Staffordshire | e
| Staffordshire |
| South Cheshire | e
| Cheshire |
| | |
1.5.14 B3. Both boundary change and creation
of minis
| Old Authority | Gains (e) or losses (r)
| New Authorities | Mini Authority
|
| South & West Devon | r |
Plymouth | Torbay
|
| North Cheshire | r |
Warrington | Halton |
| | |
|
1.5.15 C. Authorities requiring demerger (15)
Fifteen existing authorities create 32 new authorities, one
County Special Health Authority and three mini authorities.
| Old Authority | New Authorities
| Mini Authorities |
| West Pennine | Oldham |
|
| Tameside |
|
| Wigan & Bolton | Wigan |
|
| Bolton |
|
| Salford & Trafford | Salford
| |
| Trafford |
|
| Bedfordshire | Bedfordshire
| |
| Luton |
|
| Wiltshire | Wiltshire |
|
| Swindon |
|
| East Sussex, Brighton & Hove | East Sussex
| |
| Brighton & Hove |
|
| Brent & Harrow | Brent |
|
| Harrow |
|
| Enfield & Haringey | Enfield
| |
| Haringey |
|
| Redbridge & Waltham Forest | Redbridge
| |
| Waltham Forest |
|
| Bexley & Greenwich | Bexley
| |
| Greenwich |
|
| East Yorkshire | East Riding of Yorkshire
| |
| Hull | |
| Avon | Avon County Special Health Authority
| |
| South Gloucestershire |
|
| Bath & NE Somerset |
N Somerset |
| Leicestershire | Leicestershire
| |
| Leicester | Rutland
|
| Ealing, Hammersmith & | Ealing
| |
| Hounslow | Hounslow | Hammersmith
|
| Lambeth, Lewisham & Southwark | Lambeth
| |
| Lewisham |
|
| Southwark |
|
| | |
1.5.16 D. Authorities requiring simple merger
with one other authority (with or without creation of mini-authorities)
(9)
Nine existing authorities (plus two other authorities which
are included in group E because they suffer division at the merger)
merge into six new authorities with two mini authorities.
| Old Authority | New Authority
| Mini Authority |
East & North Hertfordshire
West Hertfordshire¹
| Hertfordshire | |
East Surrey
West Surrey¹
|
Surrey | |
East Kent Towns
West Kent¹ | Kent
| Medway |
| North Cumbria* | Cumbria |
|
| Cambridge & Huntingdon* | Cambridgeshire
| |
| East Norfolk* | Norfolk |
Peterborough |
| | |
*Merge with part of a neighbouring authority.
1.5.17 E. Authorities merging with more than
one other authority (6)
3.5 Authorities merge into one with two minis. One other
authority is divided and merged with two neighbouring authorities.
| Old Authority | New Authority
| Mini Authority |
| NW Lancashire | |
|
E Lancashire
S Lancashire |
Lancashire
|
Blackburn |
| Morecambe Bay | |
|
| | Bolton
|
| North West Anglia$ | | Peterborough
|
| | |
$Area divided. Meges with Cambridge and Huntingdon to create
Cambridgeshire and with East Norfolk to create Norfolk.
Also merges with North Cumbria—area divided.
1.5.18 F. New county authorities to be set up.
Whatever it is decided to establish in Greater London.
(Avon and Berkshire are set up in List B and List C)
1.5.10 It should be noted that the above BMA analysis
was based on the health authority structure of the time and there
have been some changes since, but not such as to detract from
the thrust of the analysis.
2. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
2.1 The MPU has long argued for a central public health
agency.
2.2 We have always advocated that it should be a major
body, addressing all the determinants of health, and incorporating
bodies like the Health & Safety Executive, PHLS and the Environment
Agency.
2.3 It is not yet clear how a body which is narrower
in focus will be more than the Health Education Authority was.
The former Health Education Council was policy-oriented and critical
of Government and was neutered by its conversion into the HEA.
At the moment the HDA just looks like the HEA, possibly unneutered
again.
2.4 It is important that the HDA should have the freedom
and duty to promote public debate on the political determinants
of health. Recognising the constitutional implications of such
a role being exercised by a public agency accountable to Ministers,
the MPU has in the past argued that the national public health
agency should have amongst its functions the duty to act as the
secretariat to a permanent cross departmental Parliamentary Select
Committee on Public Health. The BMA has more recently made a similar
suggestion, but suggesting a standing Royal Commission rather
than a Select Committee.
2.5 It would be unfortunate if the current style of NHS
organisation led the HDA to believe that it would fare better
if it confined itself to facilitating the management of disease
control programmes rather than promoting professional independence
and addressing the determinants of health.
3. THE ROLE
OF PCGS
AND PCTS
3.1 Community development
3.1.1 We welcome the increasing emphasis on community
development, believe that public health nurses are well placed
to lead community development in the health field and believe
that this is a key role for a PCT.
3.1.2 We develop this point in our section on inequalities.
3.2 Resident and registered populations
3.2.1 We are pleased that PCGs and PCTs have a resident
and not just a registered population. You cannot traffic calm
a practice population or fluoridate its water.
3.2.2 There is a degree of lack of clarity about the
responsibilities of PCGs, PCTs and health authorities to their
resident populations as opposed to their registered populations.
We support the BMA view that they should promote the health of
their resident population and commission services for their registered
population. We are sorry that the Government was too confused
to endorse this.
3.2.3 There may also be other relevant populations. We
believe that PCGs, PCTs and health authorities should be responsible
for workplace health in the population employed within their boundaries
and should be responsible for health protection and emergency
provision for all those present within their boundaries.
3.3 Boundaries
3.3.1 We would have liked to see PCTs established coterminously
with district councils and to see a Health Unit established as
a Health Act partnership with responsibility for public health
nursing, health promotion and environmental health.
3.3.2 Considering that some county councils do not even
have coterminosity between their divisions and district councils
it is easy to see why the achievement of this vision on a universal
basis would not have been easy. Some counties now have three different
geographies—one division into district councils, one into
county council divisions and one into PCTs.
3.3.3 We think people need their heads banging together.
3.4 Neighbourhood Health Committees
3.4.1 In 1982, we proposed, in conjunction with Sheffield
City Labour Party, that neighbourhood health committees should
be established with boundaries corresponding to the catchment
areas of each health centre, elected by local people to manage
the primary care services—both community health services
and family health services. We proposed that one half of the membership
of each health authority (at that time health authorities were
large bodies containing representatives of various interests)
should be appointed by the neighbourhood committees and that money
should flow through the NHS by being paid to neighbourhood health
committees. Health authorities (which at that time were provider
organisations) would secure funding for secondary and tertiary
functions by a precept on neighbourhood health committees which
would be voted upon only by the neighbourhood representatives
on the authority. In the same way health authorities would pool
resources to fund the regional and supraregional services. We
proposed that part of the membership of neighbourhood health committees
would be based on representatives elected by the people of the
neighbourhood, part on representatives elected by the local primary
care professionals, and part on health professionals elected by
the people. In this way the majority could have professional expertise
and the majority could be democratically elected by the people.
3.4.2 This was the first proposal for a primary care
based commissioning structure in the NHS. Indeed it was the first
proposal for a commissioning structure.
3.4.3 We gave evidence on this, both written and oral,
to your committee in 1989, and submitted supplementary evidence
commissioned by your committee in the course of the oral hearing.
3.4.4 In their responsibilities and funding mechanisms
Primary Care Trusts are very similar to what we advocated in 1982.
They are somewhat larger than we advocated (which we think is
right after the experience of fundholding), their relationship
to the health authority is somewhat different and our 1982 fund
pooling proposals have been replaced by more sophisticated structures.
But with one important exception, the democratic structure, they
are the same concept.
3.4.5 Clearly our views in 1982 were far-sighted. Indeed
they were more than far-sighted—they were influential. The
development of our original ideas into the concept of locality
commissioning was undertaken by us, by members of ours inspired
by our ideas into establishing local initiatives and by others
who were in turn inspired by those initiatives. We were the organisation
which persuaded both the Labour Party and the BMA to support locality
commissioning. The combination of those local initiatives with
BMA and Labour Party support created the consensus which the new
Government was able to implement.
3.4.6 Whilst most of the changes to our original idea
are genuine and welcome developments of it, there is one remaining
difference between what we advocated and what is in place. We
intended the neighbourhood health committees to have a local democratic
structure.
3.4.7 The case for local grass roots democracy that we
argued before your committee in 1989 has not changed. It had not
changed then from the days when it was argued for before we even
existed (either as an organisation or as individuals) in the creation
of National Health Insurance in 1911, or when our organisation
and the Socialist Medical Association and many others argued for
it in 1948 at the time of creation of the NHS, or when Community
Health Councils were created as a sap to those who unsuccessfully
argued for it in 1974. It is not a case that we have any unique
qualification or expertise for making. We just believe in it.
3.5 The Link Between Primary Care and Environmental Health
3.5.1 In paragraph 3.3.1 we suggested that PCTs and local
authorities should combine their grass roots public health functions—public
health nursing, health promotion and environmental health—in
a Health Act Partnership.
3.5.2 To justify that proposal, we need to examine the
link between environmental health and primary care.
3.5.3 From 1948 to 1974, the NHS was so defined that
it included environmental health. It met the expectations of its
founders that it would promote improved health—it cleared
the slums, eradicated polio, and cleaned the air. The parts of
Bevan's NHS which did this are no longer regarded as part of the
NHS. The significance of this 1974 redefinition needs to be understood
if we are to appreciate the true ambitions of the founders of
the NHS. The gap the 1974 reorganisation opened up between local
government and the NHS needs to be diminished (a point discussed
above in section 1 of this evidence). And environmental health
should no longer be a forgotten backwater of the Town Hall.
3.5.4 Sanitary Inspectors, later called Health Inspectors,
later called Environmental Health Officers were developed in local
authorities from the end of the 19th century onwards.
3.5.5 Their main role has always been the enforcement of public
health legislation, although they have also had other roles such
as health education.
3.5.6 During the 20th century up until 1974, they mainly
existed within local government units called Health Departments
under the leadership of Medical Officers of Health alongside health
visitors (who were originally called "lady sanitary inspectors"
and were seen as doing in the home what other sanitary inspectors
did in the world outside the home). These departments also managed
local government run health services, including community health
services (and some hospitals up until the nationalisation of the
hospitals in 1948).
3.5.7 The National Health Service as established by Bevan
was a tripartite service, the three parts being the newly nationalised
hospitals (managed by Hospital Management Committees), the family
health services established in 1911 for parts of the population
but made universal by the NHS (managed by Executive Councils),
and the community health services and preventive services (managed
by Health Departments of local authorities).
3.5.8 In 1974, the Health Departments were split up.
Public health doctors and the community health services were transferred
to the newly established health authorities which replaced Hospital
Management Committees and Executive Councils. The environmental
health services remained part of local government and now ceased
to be regarded as part of the NHS, as it was now no longer thought
to be possible to be both part of local government and part of
the NHS at the same time.
3.5.9 The 1974 reorganisation is often said to have been
an integration of the NHS. In fact, the health authorities were
required to keep separate structures (Family Practitioner Committees)
for the services previously run by the Executive Councils and
to devolve provision of hospitals and community health services
to districts, so there would still be three organisations—the
FPC, the health district, and the local authority—running
what Bevan had called the NHS. True integration, even of what
was still called the NHS, did not happen until the mid 1990s with
the merger of health authorities and FHSAs, and integration of
what Bevan called the NHS did not even begin to happen until the
creation of Health Act Partnerships by the present Government.
3.5.10 The main reorganisation in 1974 was not an integration
but a change of organisational alignments in which:
— community health services were seen as part of
the hospital;
— district nurses were separated from social workers
and home helps;
— health visitors were separated from environmental
health and treated as a special kind of district nurse;
— public health was aligned to management rather
than to front line services; and
— enforcement of public health legislation (and
therefore, by implication, the legislation itself) was seen as
separate from health strategies.
Every one of these realignments was not only wrong but silly.
The entire reorganisation was a disaster and the non-sensical
alignments it created has been an unnecessary complexity and the
direct cause of the repeated reorganisations which have disrupted
the NHS continuously since. Only now is the framework in place
to reverse this foolishness.
3.5.11 More important than the organisational realignments
was the change in concept in which the NHS was redefined as including
only medical and nursing services.
3.5.12 Bevan believed that the NHS would implement major
improvements in health. In its first quarter century it did not
disappoint him. What was then called the NHS eliminated polio
and diptheria, took the smoke out of the air and cleared the slums.
The services that did this are no longer regarded as part of the
NHS. What we now call the NHS is not capable of addressing the
fundamental determinants of health in this way. Believing that
the NHS has always been what we now call by that name people often
criticise Bevan for believing that health care services could
do more than they actually could and say that the NHS has never
pursued prevention vigorously. Both statements are wrong. They
ignore what Bevan meant by the term and what the service achieved
in the years that it was so defined.
3.5.12 Since separation from the NHS environmental health
services have languished. Neither the environmental health department
nor the public health services of the NHS have commanded the authority
the MOH once commanded to influence local government policy generally.
Environmental health has not been a high status service. It has
rarely been the subject of much debate and has been seen as a
technical system. Indeed many local authorities have grouped it
with other technical services or with other systems which also
inspect things (like consumer protection).
3.5.13 It is not surprising that in consequence important
services like food safety and air quality have been allowed to
decline in effectiveness. Reorganisation and redefinition are
not just political and academic games, even though they are often
played as if they were. Ultimately they do affect how front line
staff see themselves and how much power and resources they can
command.
3.5.14 We believe the pre 1974 definition of the NHS
needs to be restored.
3.5.15 At one level this need be no more than a declaratory
clause stating that the environmental health services are now
again to be regarded as part of the NHS, without any necessary
organisational implications. Services run by the local authority
were seen as part of the NHS from 1948 to 1974. They could be
so again. This alone would have value in terms of their status.
3.5.16 There could additionally be steps to bring environmental
health within certain NHS systems that would cement the link eg
workforce planning, the performance assessment framework or the
new patient advocacy and liaison services. Local authorities could
be required to organise their scrutiny committees so that their
environmental health services were scrutinised by the same committee
that scrutinises the NHS. Such measures would be simple, would
have some practical benefit, and would be symbolically important.
3.5.17 At a third level the role of environmental health
officers as public health professionals with an enforcement oriented
perspective could also be recognised within the NHS and wider
use made of these skills.
3.5.18 At a fourth level environmental health could be
drawn into the funding and commissioning streams of the NHS by
directing the environmental health element of the revenue support
grant to local authorities not via the revenue support grant mechanism
but by the NHS commissioning system.
3.5.19 At a fifth level we believe that the various front
line grass roots preventive services—health visiting, health
promotion, school health and environmental health—should
be drawn together into Health Act Partnerships established by
local authorities and Primary Care Trusts.
3.5.20 These measures could be pursued in relation to
environmental health alone, as part of a public health strategy,
or in parallel with similar measures for social services, as part
of a general reconfiguration. We are worried that at present the
reintegration process is running faster for social services than
for environmental health and that this would again sideline public
health.
3.5.21 We believe environmental health can be revitalised
by:
— re-emphasising its role as part of the public
health endeavour;
— passing a new Public Health Act so that enforcement
of legislation again became a central part of the public health
armamentarium;
— emphasising environments within public health
strategies;
— monitoring through accountability agreements the
success of health authorities in developing effective partnerships
in this area;
— linking environmental health with the health improvement
efforts of Primary Care Trusts;
— ensuring that local authorities could no longer
neglect this area and view it as an unimportant area ripe for
cuts.
3.5.22 As an example of what this could mean on the ground
we attach, courtesy of Stockport MBC, a review undertaken by Charlotte
Nicholls, an environmental health officer seconded for the purpose
to the health authority's public health department, exploring
the scope for links between environmental health and the rest
of the public health endeavour. We understand from the Secretary
to your Committee that this document will be placed in the Library
of the House.
3.5.23 The report identifies a number of areas where
working together would bring added benefits. For example it points
out that health visitors often identify hazards that they are
unable to deal with but that environmental health could address.
It points out the value of coordinating accident prevention strategies
with the work of those who actually deal with issues of safety.
3.5.24 The report recommends that eight of the Borough
Council's environmental health officers (two from each of its
four specialist teams) should be attached to the eight local primary
health groups which are projected as part of the substructure
of the Primary Care Trust. It also identifies feasible ways of
combining the genericism implicit in such attachments with continued
specialist expertise by relationships within the team of seconded
officers and between those officers and the specialist team from
which they come.
3.5.25 Implementation of the report is now under discussion
between the local authority, health authority and prospective
PCT.
3.5.26 This occurs in the context of a district which
has:
— a coterminous MBC, health authority and prospective
PCT;
— a record of innovative links between the local
authority and health authority;
— a strong primary care based public health nursing
structure;
— a declared intention to organise its PCT with
sub units coterminous with the Area Committees of the MBC.
3.5.27 We see this as an example of good practice that
forms the basis of our proposal for creating Health Act Partnerships
to bring together these functions
3.5.28 We will undoubtedly be accused of wishing to re-establish
the old Health Departments and the old MOH. This is not however
the case,
— The Partnerships that we propose would be based
on preventive services—the future of community health services
generally lies with primary care and social services in the general
structure of Care Trusts.
— We do not propose to reintroduce the subordination
of these professional groups to public health doctors—the
Partnerships should have their own management team comprising
a Director of Health Promotion, a Director of Public Health Nursing
and a Director of Environmental Health. In areas of single tier
local government these posts would be of equal status to the Borough
Medical Officer we advocate in section five of the evidence and
would operate in parallel structures not subordinate structures.
— In areas of two tier local government the population
level would also be different with the County Medical Officer
operating at the upper tier of population but the operational
Partnerships operating at the second tier.
3.5.29 Far from subordinating public health nursing,
health promotion and environmental health to public health medicine
we believe this structure would open up career opportunities.
3.6 School Health Services
3.6.1 Within the Primary Care Trusts and as part of the
preventive partnerships we suggest above there should be a fundamental
revitalisation of the school health service, based on the concept
of a healthy school.
3.6.2 In the late 1980s and early 1990s the school health
service in most parts of the country was substantially cut back.
This was extremely short sighted as schools clearly have a key
role in the promotion of health and need a health input.
3.6.3 A healthy school should address health on the curriculum,
making a reality of its place as a cross cutting theme. For example
a mathematics problem asking students to calculate how much the
state saves in pensions from smokers dying early is not only an
effective exercise in mathematics but also a contributor to antismoking
campaigns.
3.6.4 A healthy school should look at its role in addressing
lifestyle issues. Does it encourage positive images of healthy
lifestyles or does it make them seem boring and negative. For
example are healthy options at school meals
(c ) appetising—Rochdale Education Committee in
the early 1990s carried out a consumer survey to find out what
foods children liked and then provided the healthy foods they
liked best.
3.6.5 A healthy school should empower its students to
grow into citizens with self esteem and sensitivity to others
who will control their own lives but contribute to the community.
3.6.6 A healthy school counters stereotypes about disability
and old age.
3.6.7 A healthy school offers good sex education and
has thought out policies for dealing with teenage pregnancy, which
recognises realities instead of pretending that problems will
go away if you don't talk about them.
3.6.8 School nurses can play a key role in all these
strategies but the school must recognise that this is part of
their role.
4. THE ROLE
OF THE
MINISTER FOR
PUBLIC HEALTH
4.1 Policies affecting the determinants of health
4.1.1 It is regrettable that there is no public health
professional on any of the new transport bodies, despite the then
Minister for Public Health, Tessa Jowell, having asked that there
should be and there being a specialist public health body for
transport, the Transport & Health Study Group, which put forward
nominations. If you wish to develop this point you might wish
to take evidence from the Transport & Health Study Group.
We support their key themes of:
— reducing use of the car;
— promoting walking and cycling, recognising the
significance of safe cycle routes and aesthetically attractive
pedestrian networks;
— promoting slower speeds and especially 20mph limits
in residential areas;
— ensuring a rail core for the public transport
system in the light of European evidence that a high quality urban
rail system increases willingness to move from cars to public
transport (including, interestingly, higher bus usage than in
bus only systems);
— dedicated committed expansionary management of
the fringe railway (wayside stations, branch lines, rural lines)
reversing the false assumptions of the Beeching era;
— a more vigorous approach to road safety and a
less hysterical approach to rail safety;
We develop this point in section 4.4.
4.1.2 The goal of economic policy continues to be economic
growth despite the fact that international comparisons suggest
that once a country passes the standard of living of Portugal
its health is determined more by the structure of its economy
than by the level of GDP. In section 4.6 we summarise the state
of knowledge on this issue and suggest implications. You may also
wish to take evidence from MEDACT.
4.1.3 We welcome Government moves to improve the quality
of working life. Work causes over 30,000 deaths a year of which
only a small number are attributable to specific identified industrial
diseases. Work should be meaningful, pleasant, hazard free and
part of a full and varied life. Although professionals and managers
expect this, manual workers would regard it as an unrealistic
dream. We discuss this in section 6—inequality at work is
a major element of inequalities in health.
4.1.4 Poverty kills people. We agree with the BMA that
a basic decent income for all is a prerequisite for health. We
have argued for the elimination of poverty by the introduction
of a citizen's income guaranteeing any person who is willing to
contribute to society an income of at least two thirds of the
national average. We develop this theme in section 6 of this evidence.
We believe it is affordable and are sorry that the proposal is
seen as unrealistic.
4.1.5 On an international scale 20,000,000 people have
been killed by Third World debt. When the history of the 20th
century is written as the history of genocide it will be noted
that this genocide, performed only to save bankers from embarrassment,
exceeded that of Hitler and Stalin combined. We are proud Britain
has taken steps under this Government to pursue this issue. We
hope that you will take evidence from MEDACT.
4.1.6 Systems for control of chemicals need to shorten
the period, currently an average of 60 years, between the first
scientific suspicion of a health hazard and its legislative control.
The precautionary principle needs to be more readily applied.
We discuss this point below in section 4.5 of this evidence.
4.1.7 We welcome the moves to address social inclusion.
This does not seem to have been seen as a public health issue
or as linked to community development. We discuss these in section
6.
4.1.8 Pleasant green living environments contribute to
health. We are sorry that the debate about the Green Belt has
shied away from radical solutions such as earth sheltered buildings.
We develop this point in section 4.7.
4.1.9 Four decades after the Clean Air Act we again have
a problem of air quality.
4.2 The Minister for Public Health
4.2.1 We would be interested to know what proportion
of the time of the Minister for Public Health has been spent on
the nine key public health issues described in the preceding nine
paragraphs.
4.2.2 We have observed that the commitment to public
health has declined since the Ministerial post was downgraded
from Minister of State to Parliamentary Secretary. We do not believe
that this was the fault of the Minister herself, nor do we doubt
that she amply deserves the status that her job requires.
4.2.3 We believe that the Minister for Public Health
should be equal in status to the Chief Secretary to the Treasury
with an acknowledged interdepartmental role in a department whose
remit crosses the whole of Government and therefore able to deal
with Cabinet Ministers as an equal and, indeed, to be regularly
in attendance at Cabinet.
4.3 Public Health in Downing Street
4.3.1 There are a number of areas where it is unfortunate
that the Prime Minister has allowed his staff to copy his faults
without adequately impressing upon them his vision.
4.3.2 Downing Street's attitude to public health shows
signs of this problem.
4.3.3 It is particularly unfortunate that at the very
heart of Government public health has come to be equated with
disease control programmes rather than being recognised as a social
value.
4.4 Transport and Health
4.4.1 Transport is one field of political policy around
which a considerable amount of public health work has been done.
4.4.2 There is a specialist public health organisation
in the field, the Transport & Health Study Group, which has
existed since 1988.
4.4.3 More recently the Faculty of Public Health Medicine
has set up a Transport & Health Group of its own members.
The Faculty's group is composed entirely of public health doctors
and scientists but the free standing group also includes transport
professionals.
4.4.4 The BMA Board of Science has also done work in
the field.
4.4.5 There have been several attempts to review the
field of public health knowledge on transport. The Transport &
Health Study Group's publication "Health on the Move"
was the first comprehensive attempt. This was built upon and developed
in the BMA document "Road Transport and Health".
4.4.6 Over 90 of England's 100 health authorities have
appointed a designated transport and health lead.
4.4.7 The Transport & Health Study Group has prepared
guidance on how to conduct a health impact assessment in the transport
field and a number of such assessments are in progress.
4.4.8 it might have been thought that this volume of
work would have been welcomed and drawn upon by Government.
4.4.9 Neither the current nor the previous Minister for
Public Health have met any of the three groups working in the
field.
4.4.10 Although the Department of Health has a transport
and health contact, this is at a junior level within the department
and without any associated work programme or resources.
4.4.11 The Department of Health has turned down a request
to provide funding of around £20,000 a year to support the
network of health authority contacts
4.4.12 The previous Minister for Public Health did write
to the DETR asking that there should be public health representation
on the new transport bodies and drawing attention to the nominations
by the Transport & Health Study Group. However, the appointments
made did not include any public health representation. It is unclear
whether the rejection of the Minister's request occurred within
DETR or elsewhere.
4.4.13 The Transport & Health Study Group has, however,
now managed to establish regular meetings with both the Commission
for Integrated Transport and the Strategic Rail Authority. In
each case the meetings take place two or three times a year with
one designated contact person.
4.4.14 The DETR has established an internal coordinated
system for dealing with health aspects of its transport policies.
THSG has been supplied with lists of the members of this system
and has found them receptive to ideas and contacts.
4.4.15 The HDA has also proved receptive and helpful
and has published guidance on local work for health and local
authority professionals.
4.4.16 It seems therefore that in terms of coordinating
public health advice on transport
— the NHS in the form of health authorities and
the HDA has reacted positively;
— the DETR has demonstrated a clear commitment to
working with health as a social value;
— the professions have also responded well;
— the DOH has served as little but a block, not
even channelling the work of the NHS and of public health professionals;
— those responsible for public appointments have
ignored the clear public health contribution available in the
field; and
— the new public bodies have attempted to make up
for this through liaison arrangements.
4.4.17 This highlights our doubts about the capacity
of the DOH to support the Minister for Public Health, our doubts
about the capacity of the system to spread visions across Government
and our belief that interdepartmental structures need to be strengthened.
4.4.18 A clear message emerges from surveys of public
attitudes that people accept the need to move away from reliance
on the car but do not believe they can do this without better
public transport systems. We do not understand why the political
system can see that only as a procar message. We do not understand
why the Government finds it necessary to apologise for and hide
its investment in public transport—doing so, indeed, so
effectively that the public does not think it is happening.
4.4.19 Driving at no more than 20 mph in side streets
would save most child pedestrian road accident deaths. Few places
are more than a mile from a main road so few journeys are more
than two miles on side roads. The difference between travelling
two miles at 20mph or at 40 mph is three minutes. We are killing
our children for the sake of three minutes on our journeys. We
wish Ministers would say that instead of being afraid of being
laughed at. We welcome the measures taken to make it easier for
local authorities to introduce 20 mph zones but there is still
a low key incrementalist approach to what should be a moral imperative.
4.4.20 The research by Appleyard & Lintell which
documented much stronger patterns of neighbourship in lightly
trafficked as opposed to heavily trafficked streets has important
connotations for the role of traffic in the decline of community
spirit. This is rarely acknowledged. The role of traffic-induced
declining neighbourship has not been discussed in crime prevention:-
strategies. Closing streets to through motor traffic would strengthen
community spirit but, ironically, footpaths are often closed instead.
4.4.21 The Government has done a great deal to promote
walking and cycling but it would have been nice if the Walking
Strategy had been published early and prominently instead of it
being made so obvious that political advisers thought it might
not be the right modern image.
4.4.22 It is probable that more people have died as a
result of rail safety hysteria driving them onto the roads than
have been killed in train crashes. The present discrepancy between
attitudes to road and rail safety kills people. It kills them
by doing insufficient for road safety. It kills them by damaging
the development of the rail system and thus leading to a greater
proportion of journeys being made on a fundamentally unsafe road
system.
4.4.23 More people are killed on the roads each year
than have been killed on the railways in their entire existence.
In the week of the worst rail crash in the last ten years more
people died on the road than on the railways. More people die
on the roads each month than died in the worst ever rail crash
(Quintinshill in 1916). A decade ago the safety of the railways
was universally acclaimed as one of the great achievements of
transport safety. Since then the number of deaths has declined
further and yet there is deep concern about safety.
4.4.24 If the state of the railways after Hatfield justified
the measures that were taken there can be no justification for
the roads to be allowed to continue without equally urgent and
fundamental attention to their safety.
4.4.25 It is, however, worrying that both the Ladbroke
Grove and Hatfield accidents resulted from delay in carrying out
core safety functions (rail replacement, a signal sighting review
following a near miss SPAD). Unfortunately, this could be the
consequence not of neglect of safety but of the opposite—overburdensome
and overbureaucratic safety systems. Perhaps the person who should
have convened the signal sighting committee at Ladbroke Grove
was too busy writing a safety case about how to prevent passengers
falling off platforms.
4.4.26 We believe in railways. We believe in them because
they are the safest method of transport. We believe in them because
they are the form of transport which has the greatest potential
to attract people out of their cars. We believe in them because
European studies have shown that people are most likely to use
public transport rather than cars where the public transport system
is rail-based (including greater use of buses in such systems
than in bus only systems).
4.4.24 We welcome the new commitment to rail growth.
However, if road transport is to grow more slowly than the growth
of demand rail transport must grow much more quickly to pick up
the difference. However, high current projections may seem in
comparison to past decline they still fall short of what is required
to dent car use and protect air quality.
4.4.25 We agree with much that Sir Alistair Morton has
said. But on one point we disagree. He has said that the SRA has
no intention to try and reverse the Beeching Report. On the contrary,
this is exactly what is needed. We see no reason why a country
of 60,000,000 people who are very mobile should need a less intensive
rail system than was built for a population of 5,000,000 people
most of whom stayed for most of the time in their own villages.
Nor do we see why the creation of such a system should be merely
a long-term goal when 20,000 miles of railway were built between
1850 and 1855.
4.5 Chemicals and Health
4.5.1 Systems for control of chemicals need to shorten
the period, currently an average of 60 years, between the first
scientific suspicion of a health hazard and its legislative control.
The precautionary principle needs to be more readily applied.
4.5.2 The figure of 60 years was derived from a study
which looked back from recently introduced legislative controls
to see how long previously the first scientific suspicion arose.
The study is now two decades old but if anything things have probably
got worse.
4.5.3 Key problems include:
— reluctance to take early poor quality findings
seriously and invest in scientific research. Typically those who
first describe a hazard will be berated for scaremongering for
many years before properly funded scientific work occurs;
— reluctance to act off the precautionary principle;
the search for the levels of proof that will amount to scientific
certainty can add a number of years to the problem;
— belief that there is scientific controversy when
there is only a difference about values. A group of scientists
could be engaged in bitter debate about whether a chemical should
be banned because one group has a predisposition to protect the
public whereas the other group is reluctant to disrupt economic
progress without proof. They could all agree that evidence is
suggestive but not conclusive, that a student who claimed it was
conclusive should be failed for lack of intellectual rigour, and
that if anybody spilled the stuff the room would empty in ten
seconds. If this consensus were appreciated politicians could
deal with the underlying balancing of interests but it isn't—the
debate is all that is perceived;
— politicians, especially senior ones, have a naive
"Gee Whizz" approach to anything that looks like technology;
— issues that are in fact political have been entrusted
to technical bodies in which employers can obstruct agreement;
— civil servants are terrified of taking initiatives
in this area; and
— there is a powerful deregulatory value system.
4.5.4 If tomorrow somebody comes across a piece of scientific
evidence that suggests that a chemical we are using is dangerous,
people who are just starting work at 16 might continue using it
for the whole of their working lives, even if they delay retirement
into their 70s. Unless this is regarded as acceptable something
has to be done.
4.5.5 The way forward is to address the above obstacles;
— to invest much more quickly in scientific research
to explore initial evidence instead of rejecting it out of hand
as inadequate—all scientific advances start with inadequate
evidence;
— to act more readily off the precautionary principle;
— to create a better understanding of scientific
philosophy, seeing it as being as much a part of the politician's
stock in trade as history or economics, and therefore better understanding
the nature of scientific debate and its underlying values;
— to have a more balanced view about technology;
— to ensure that politicians do not duck decisions
in this area and do not use technical agencies to escape responsibility;
— to believe that health protection is a prime role
of the state not something to apologise for; and
— to believe that a subsidy paid in human lives
or environments is every bit as undesirable as one paid in money.
4.6 Promoting Healthy Economics
4.6.1 The 1997 Annual Delegate Conference of MSF adopted
the following resolution proposed by the MPU.
"Conference believes that for too long arguments about
job losses have been allowed to stand in the way of principled
decisions about economic activities and ties that are dubious
in terms of public health, environmental matters or moral and
humanitarian national and international issues. This Conference
sees no reason to believe that moral, humane, environmentally
sensitive and health promoting patterns of investment will produce
fewer jobs than current patterns and that arguments to the contrary
should always be countered by proposals for diversification, transitional
relief and green accounting".
The MPU was subsequently asked to prepare support material
for this resolution and delegated the task to Dr Stephen Watkins
and Dr Brian Gibbons, AM. This evidence substantially reproduces
that paper with the omission of some purely internal items.
4.6.2 This paper falls into two parts.
4.6.3 Firstly, it reviews the scientific evidence on
the relationship between economic activity and health. Apart from
the international sections, this part of the paper is largely
based on a chapter of the 1996 Annual Public Health Report for
Stockport and some of the figures used may therefore no longer
be the most recent.
4.6.4 Secondly, it considers the implications of this
for political action, both nationally and locally, collective
bargaining and investment policy.
ECONOMIC GROWTH
4.6.5 On the whole economic growth is good for health.
Over time populations have become healthier as they have become
wealthier. And on international comparisons wealthier countries
enjoy better health.
4.6.6 Up to a certain level of wealth this is a very
major determinant of the health of a population. However, above
that level economic growth is much less powerful a factor in determining
health. The threshold appears to be about a PPR of 40 (ie 40 per
cent of the GDP per capita of the United States, adjusted for
differences in purchasing power of different countries). The UK
national economy, like all the economies of the western world,
is well past that threshold, so it is important to worry not just
about achieving economic growth but about what type of economic
growth is achieved.
4.6.7 The currently used measure of economic success
is the gross domestic product per capita. This is the total income
of all the people and organisations in a country divided by its
population. Wherever money changes hands this contributes to the
GDP.
4.6.8 As a measure of economic success GDP per capita
can be subject to several criticisms:-
— it only measures economic activity for which somebody
pays. Many contributions to society do not figure. For example,
salaried decision makers are a contribution to GDP but a group
of people making their own decisions in a voluntary organisation
are not. If somebody works full-time and pays for childcare then
their income and the payment for childcare are counted in GDP,
whereas if somebody works part-time and looks after their own
children no account is taken of the childcare, and the contribution
their income makes to GDP is reduced;
— it counts in GDP economic activity which simply
cleans up the damage caused by other economic activity. For example,
if an aeroplane crashes the work of the rescue services, the health
care given to the survivors, the life insurance payments and funeral
expenses of those killed, and the cost of the replacement aeroplane
that will need to be purchased would all be counted in GDP. An
aeroplane crash would appear as a major economic stimulus; and
— it does not account for the using up of non-renewable
resources or for the load placed on ecosystems which have a limited
capacity.
4.6.9 It may be that these defects in the way we account
for economic growth contribute to the discrepancy between measures
of economic well-being and measures of health in advanced economies.
4.6.10 The United Nations Human Development Report has
developed a simple indicator of human development based on income,
literacy, and life expectancy.
4.6.11 The United Kingdom is ranked tenth in the world
on this measure with a score of 0.919.
4.6.12 This compares with:
a best score of 0.932 (Canada)
a median score of 0.670 (Botswana)
a worst score of 0.191 (Guinea)
a worst score in the European Union of 0.874 (Greece)
a worst score in Europe of 0.714 (Albania)
a worst score for a G7 country of 0.891 (Italy)
a worst score for an "old Commonwealth Dominion of 0.907
(New Zealand)
4.6.13 Countries performing better than the UK include
Canada (0.932), Switzerland (0.931),
Japan (0.929), Sweden (0.928), France (0.927), Australia (0.926),
USA (0.925), and the Netherlands (0.923).
4.6.14 It is interesting that the UK performs tenth on
this index but only eighteenth on conventional economic indices
so it outperforms a number of countries which are often seen as
doing better than us economically such as Germany (0.918), Italy
(0.891) and Hong Kong (0.875).
4.6.15 A more sophisticated attempt to improve on GDP
as a measure of economic success is the development of the Genuine
Progress Indicator which deducts from GDP the activity which merely
repairs damage caused by other activities and also makes deductions
for the use of non-renewable resources and the load placed on
ecosystems.
4.6.16 The only country for which GPI has yet been calculated
is the United States and there is a fascinating situation in which,
until 1970, GDP and GPI grew together, but over the last two and
a half decades GDP has grown and GPI has fallen. This period of
disparity started with the decade during which Keynesian policies
began to fail, and then accelerated (with both an increasing rate
of growth of GDP and an increasing rate of fall of GPI) after
they were abandoned. This disparity between economic growth and
general well-being was last observed in the nineteenth century,
when recessions improved health, and is markedly different to
the situation for most of this century.
4.6.17 The GPI is now being calculated for other countries
and it will be fascinating to see if a similar picture emerges
for the UK. It would certainly fit in with the way in which people's
perceptions of the quality of their lives do not accord with economic
indicators.
FACTORS MODERATING
THE ECONOMIC
GROWTH/HEALTH
RELATIONSHIP
4.6.18 What then are the factors which assist an economy
in turning economic growth into personal well-being and hence
into health?
4.6.19 The following properties of an economy have been
shown to be associated with improved public health:
— low levels of unemployment;
— slow steady economic growth as opposed to rapid
growth or growth punctuated by recessions or crises;
— low levels of military spending;
— high levels of health spending and welfare spending;
— greater equality in income distribution;
— low levels of motor vehicle exhaust emissions;
— low levels of pressure for urbanisation; and
— low levels of geographical migration.
4.6.20 It is necessary to attach certain reservations
to this list:
— interest in this subject has been particularly
strong amongst people who favour social intervention in the economy.
They are more likely to have researched it and to have tested
the hypotheses that interest them. Therefore, although the research
itself is unbiased, the selection of subjects to research has
had an ideological slant;
— relationships may not be causal. For example,
the negative association between military spending and health
could be because military spending damages health, or because
military spending diverts resources from things that would benefit
health, or because countries which choose military spending have
some political attitude which damages health in another way (impact
of authoritarian attitudes on social relationships, for example)
or because military spending is higher in countries that have
a lot of enemies and hence feel insecure and stressed, or because
a particular cultural group of nations have high levels of military
spending and also have poor health due to entirely unrelated cultural
or genetic factors. This point is particularly important when
considering unemployment rates in econometric studies, since it
is almost impossible to separate unemployment rates as a measure
of unemployment from unemployment rates as an indicator of recession;
and
— the research base from which these conclusions
have been drawn is limited, since this is not a field in which
a great deal of research funds have been invested.
4.6.21 If these reservations are set to one side and
the above conclusions accepted, it will be seen that the British
economy performs badly on most of them, although some improvement
has occurred under the present Government.
Production Factors
4.6.22 Work is good for health—it provides social
interaction, a meaning to life, a personal identity, an income,
and time structuring. But work causes between a quarter and a
third of the social class variation in health, so nationally in
excess of 20,000 deaths a year result from people's work.
4.6.23 Factors which make work unhealthy are:-
— chemical and physical hazards
— lack of attention to safety
— unpleasant working conditions
— carrying responsibilities for which people
are not trained or which they do not have the resources or power
to carry out
— working under pressure to deadlines
— underwork or insufficiently challenging work
— work which is not meaningful or satisfying
— lack of control over one's own work
— inflexibility towards conflict with other roles,
especially family roles
4.6.24 To the extent that these factors can be minimised
the generally beneficial health effect of work will have its greatest
opportunity to contribute to the health of the population. The
process of production also affect the health of the communities
in which economic activity is located, through the impact of chemical
and physical pollution, noise, aesthetic factors and traffic.
They may benefit the health of the community through investment
in the local economy.
4.6.25 Processes of production can also affect the health
of the communities in which their workers live (which may or may
not be the same as the community in which the process itself is
located) through their contribution to its income, and through
the impact on its social structure of the stresses they create,
the respect they show for family and community roles, and the
extent to which they disturb stable communities by requiring geographical
mobility.
Consumption Factors
4.6.26 Patterns of consumption have well documented impacts
on health. There has been much consideration of individual risk
factors, individual products and individual diseases. The debate
can however be broadened from consideration of individual products.
Money spent on one product is not spent on another product. Thus,
although there are no health consequences to gambling as such,
compulsive gambling can damage the health of an individual whilst
the money which the National Lottery extracts from poor communities
may well have been better used if kept in that community. Similarly,
estimates of the impact of the decline of the tobacco trade on,
say, corner shops, are grossly exaggerated because the money not
spent on tobacco will be spent on something else. Patterns of
consumption can be influenced by pricing policy—tobacco
tax is a classic example. They could theoretically be influenced
by controls on levels of production.
4.6.27 There is a growing trend for consumers to avoid
products which cause environmental damage in their production—refusing
to use unnecessary packaging or purchasing environmentally friendly
washing up liquids are examples. This trend should be encouraged
as it will, through market forces, create a healthier pattern
to the economy.
Distribution Factors
4.6.28 Over the last two or three decades there have
been important changes in the way goods are delivered from the
producer to the consumer.
4.6.29 These include:
— globalisation of the economy so that goods
are likely to be carried greater distances;
— a shift from rail to road in the carriage of
freight;
— a shift to more centralised distribution points
with the corner shop being challenged by the supermarket and now
the supermarket being challenged by the hypermarket;
— concentration of retail markets in the hand
of large retail companies;
— decline of delivery systems so that the consumer
has to bring their own goods home; and
— a shift to pre-packaging in popular quantities,
making it more difficult to buy small amounts of things.
4.6.30 These changes may have reduced costs and increased
choice. But they have also increased traffic, made it necessary
for people to make longer shopping trips, adversely affected people
who are housebound, and adversely affected people without cars.
4.6.31 There is a balance to strike, but the change has
probably already gone too far and needs to shift back somewhat.
International Considerations
4.6.32 When attention turns away from the economics of
the developed world towards those of the poorer nations a number
of considerations arise:
— millions of people are dying because of Third
World debt, and yet the entire debts of the Third World would
be paid off in less than 5 years by making a levy of 0.001 per
cent on world foreign exchange transactions. When the history
of the twentieth century is written as that of a century of genocide,
Third World debt will stand ahead of the genocides of Hitler and
Stalin, killing more people than both combined;
— Children are dying for the lack of medical
treatment that cost a few pence;
— The US patent office is issuing US companies
with patents over the traditional processes of nations like India;
— Western companies practise lower health and
safety standards in the poorer countries then they do in their
home countries;
— Repressive regimes are often supported in the
belief that they will protect Western economic interests;
— The concept of global free trade is often used
to dis-empower poor countries in their dealings with major companies.
Indeed it is not only poor countries that are affected by this.
Multinationals feel able to dictate even to Western governments
by threatening to move investment.
4.6.33 There is an urgent need to develop a wider understanding
of the processes of globalisation.
Conclusion
4.6.34 A healthy economy would:
— protect open space and create peace and beauty
— reduce motor vehicle exhaust emissions
— grow slowly and steadily rather than fitfully
— provide security, relieve poverty, and avoid
pressures for geographical mobility
— avoid chemical and physical hazards and noise
and prevent accidents
— provide pleasant working conditions
— train people for the responsibilities they
carry and avoid giving people responsibility without resources
and power
— avoid underwork, overwork, or working under
pressure to deadlines
— provide work that is meaningful and satisfying,
under the control of the worker, and flexible enough to accommodate
other roles
— avoid the disruption of communities
— empower consumers to act to promote health
and protect environments
— empower people to do not just to demand
— develop fair trading relationships with poor
nations.
ACTION REQUIRED
Protecting Jobs or Protecting People? The Case for Diversification.
4.6.35 Where job losses threaten they can be addressed
by protecting the jobs or by protecting the people and communities
dependent on those jobs. Traditionally, the trade union movement
has taken the first of these approaches. It is explicit in this
resolution that sometimes the correct approach is to protect people
and communities rather than jobs per se.
4.6.36 MSF does, for example, have a clear duty to protect
tobacco workers and defence workers, and communities dependent
on the tobacco or defence industries, from any run down in these
industries.
4.6.37 But tobacco is a health damaging industry and
high levels of defence spending are associated with levels of
health lower than an economy could otherwise sustain. Defence
industry investment is relatively inefficient—in pounds
per job terms—at producing jobs and research has shown that
when smoking declines the alternative ways people spend the money
they save create more jobs than are lost in the tobacco industry.
4.6.38 This suggests that there is every reason for the
union in these industries to focus on the protection of its current
members and the communities they live in, rather than to concern
itself with the protection of the jobs for the future.
4.6.39 There would be other instances, where an industry
contributes positively to health or is highly efficient in turning
investment into jobs, where it would be appropriate to protect
jobs per se, not just people.
4.6.40 Diversification is often advanced as the solution
to this quandary, but diversification can mean different things.
4.6.41 Diversification of plant workforce and capital
can occur when the staff and equipment of an enterprise are redirected
into healthier activities. This has been most widely examined
in relation to the position of the defence industry. ("Swords
into ploughshares") and MSF, through TASS, is heir to one
of the more well-known examples—the Lucas Aerospace Shop
Stewards Plan. Such schemes protect jobs, people and communities,
but will not be possible in all cases. The technology of the defence
industry is quite capable of re-use in other fields—this
is not true of all industries.
4.6.42 At the other extreme the process of diversification
currently being pursued by the tobacco industry creates real problems
for the union. The industry is diversifying its capital by buying
other businesses, but doing nothing to feed this investment back
into communities dependent on it or into jobs for its own workers.
This does nothing to defend people in communities and represent
the abandonment of a workforce by companies who have recognised
a sinking ship and chosen to emulate the rat.
4.6.43 In the case of tobacco it is accompanied by cynical
attempts to manipulate workers into defending the industry at
the same time that management deserts it. The union's position
should be that the deliberate running down of an industry, as
a matter of public policy, should be accompanied by planning to
protect the people and communities affected.
4.6.44 In between these two extremes of beneficial and
harmful diversification it is possible to encourage situations
where, although plants are closed and jobs are lost, investment
is directed towards regenerating the communities affected, and
placement strategies are operated to place the workers affected
into new jobs.
4.6.45 Such policies are uncommon because a political
philosophy of non-intervention combines with a managerial attitude
that companies have no responsibility for the workforce they have
shed. These philosophies need to change before good practices
become more widespread. One possibility would be to charge companies
for the social costs of redundancy, thus ensuring that redundancy
programmes would only be financially effective if accompanied
by placement programmes.
Green Taxes
4.6.46 Green taxes seek to bring the social costs of
economic activity onto the balance sheet through taxation. They
benefit healthy economics in two ways:
— by discouraging unhealthy activities; and
— by raising revenue which can substitute for
other taxes, thus reducing taxation on healthy economic activity.
4.6.47 Of course, the more successful they are at the
former, the less revenue they raise for the latter.
4.6.48 As with so much else the Government is committed
to green taxes but is very cautious. So far, they have been applied
only in the field of pollution, and discussion for further development
is mainly in the field of transport. They could potentially be
used across the whole field of social policy.
4.6.49 It would be helpful to develop imaginative proposals
for this more widespread use.
Local Economies
4.6.50 As part of local regeneration strategies a health
impact assessment of the local economy can be carried out. In
carrying out such an assessment of the Stockport economy the Director
of Public Health, Dr Stephen Watkins, recognised the health significance
of open space and of traffic, and also the scope for local businesses
to contribute to the development of local communities. The following
recommendations were addressed to the Stockport Partnership for
Urban Regeneration.
— SPUR should examine with developers the scope
for an urban development which seeks to solve the conflict between
constraints on open land and the value of open space by adopting
an innovative aesthetic approach to design and landscaping;
— SPUR should examine with employers ways to
enhance the quality of work in Stockport;
— SPUR should examine contributions that a wide
range of partners can make to reducing traffic;
— SPUR should develop a clear strategy for promoting
an attractive town centre, easily visited by public transport,
and with the benefit of a delivery service, as a practical alternative
to out of town centres;
— SPUR should examine in more detail the contribution
to the local economy of community businesses and a possible LETS
scheme;
— SPUR should examine whether a system can be
developed whereby the business sector contribute to the Stockport
Health Promise through the new business agreement system and its
other relationships with SPUR;
— SPUR should recognise the health significance
of the overall pattern of the economy; and
— SPUR should examine the kind of support that
can be given to communities which develop the initiative and skills
to address their own problems.
4.6.51 Clearly these are specific to the local Stockport
situation but it would be valuable if other Directors of Public
Health (or in future Borough or County Medical Officers) were
to develop appropriate local recommendations.
4.6.52 To do this properly more departments will need
resources like the innovative range of facilities for monitoring
and researching the local economy that have been established by
the Public Health Department in Sandwell.
Forging Links
4.6.53 From 1979 until the mid 1990s, the public health
community maintained an Unemployment, Economics and Health Study
Group, convened initially by Alex Scott Samuels then by Steve
Watkins then by John Middleton, all of them MPU members. This
group has fallen into quiescence; largely because of lack of administration
resources and difficulties in attracting people from the political
and economic worlds, so that it became a case of public health
practitioners talking only to each other. It would be valuable
for steps to be taken to revive this group as a focus for discussions
of these issues.
4.6.54 SUGGESTED PROGRAMME
OF WORK
(i) To develop a clearer understanding:
(a) of when it is appropriate to protect jobs, and when
it is preferable to concentrate on protecting people and communities;
and
(b) of how to defend people and communities, including
the impact of different mechanism for diversification of plant,
workforce and capital.
(ii) To develop a clearer understanding of the importance
of quality work rather than just work, and to ensure that people
understand this difference.
(iii) To ensure that politicians and workers are aware
of the public health evidence on patterns of economic activity,
of the fact that the UK has passed that point in economic development
when levels of economic growth are more important than its quality,
and of the serious concern that economic indices now misrepresent
well-being.
(iv) To press for a policy that encourages companies
to take responsibility for the placement of redundant employees,
perhaps by recharging companies for social security benefits paid
to redundant employees, and other social costs, for a period of,
say, three years, so that placement of redundant employees becomes
essential to the financial effectiveness of the redundancy programme.
(v) To develop a wide ranging set of proposals for green
taxes that not only address overt pollution but also consider
the whole social and health consequences of economic activity.
(vi) To protect the impact of such taxes on the economy,
including the scope for using the revenue from such taxes to reduce
taxes on industry generally thereby promoting healthy growth to
offset the impact of constraints on unhealthy growth.
(vii) To produce guidelines for Directors of Public Health
on making recommendations about local economic regenerations.
(viii) To explore the scope for reviving the Unemployment,
Economics and Health Study Group and making it a more effective
link between the worlds of economic policy, business and public
health.
(ix) To develop mechanisms for the social audit of industry
through
(a) occupational health services
(b) reporting requirements
(c ) some form of external audit
(x) To explore the scope for the acceptance of formal
social objectives, externally enforceable, to be a substitute
for traditional regulations.
(xi) To develop within Public Health departments the
capacity to research the impact of local economic structures upon
health.
(xii) To ensure that there is greater understanding of
public health issues within the Treasury, including the appointment
of a new Deputy Chief Medical Officer working on this agenda within
the Treasury.
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