Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Medical Practitioner's Union (PH 22)



  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

    3.3  Boundaries

    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

    4.4  Transport and Health

    4.5  Chemicals and Health

    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

    5.1  The Two Roles

    5.2  The Doctor to the Town (or County)

    5.3  Public Health Management in Health Authorities

6.   Inequalities

    6.1  General Statement

    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

    6.6  A Citizen's Income

7.   Multidisciplinary Public Health

    7.1  Introduction

    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


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.


1.1  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

    (a)  a health authority;

    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.


  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.


  1.5.1  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)
















    Isle of Wight*






    West Sussex















    *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 AuthoritiesNew Authorities Mini Authorities
Newcastle & N TyneNewcastle North Tyneside
Gateshead & S TynesideGateshead South Tyneside
North YorkshireNorth Yorkshire York
Redcar & Cleveland
South Humberside*North Lincolnshire
North East Lincolnshire
Calderdale & KirkleesKirklees Calderdale
County DurhamCounty Durham Darlington
Bury & RochdaleRochdale Bury
St Helens & Knowsley* St Helens
BerkshireBerkshire County Newbury
Special Health Authority Reading
Bracknell Forest
Windsor and Maidenhead
BuckinghamshireBuckinghamshire Milton Keynes
Cornwall & Isles of ScillyCornwall Isles of Scilly
Kensington, Chelsea & Westminster* Kensington & Chelsea
Richmond & Kingston* Richmond-upon-Thames
Barking & HaveringBarking Havering
Camden & IslingtonCamden Islington
East London & the CityNewham Hackney
Tower Hamlets
City of London
Merton, Sutton & WandsworthWandsworth Merton
ShropshireShropshire The Wrekin

  *Becomes an agency supporting a group of mini authorities.

  1.5.13  B2.   Boundary change only
Old AuthorityGains (e) or losses (r) New Authorities
Portsmouth & SE Hampshirer Portsmouth
Southampton & SW Hampshirer Southampton
North & Mid Hampshiree Hampshire
North & East Devone Devon
North Derbyshiree Derbyshire
South Derbyshirer Derby
North Nottinghamshiree Nottinghamshire
South Essexr Southend
North Essexe Essex
North Staffordshiree Staffordshire
South Cheshiree Cheshire

  1.5.14  B3.   Both boundary change and creation of minis
Old AuthorityGains (e) or losses (r) New AuthoritiesMini Authority
South & West Devonr PlymouthTorbay
North Cheshirer WarringtonHalton

  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 AuthorityNew Authorities Mini Authorities
West PennineOldham
Wigan & BoltonWigan
Salford & TraffordSalford
East Sussex, Brighton & HoveEast Sussex
Brighton & Hove
Brent & HarrowBrent
Enfield & HaringeyEnfield
Redbridge & Waltham ForestRedbridge
Waltham Forest
Bexley & GreenwichBexley
East YorkshireEast Riding of Yorkshire
AvonAvon County Special Health Authority
South Gloucestershire
Bath & NE Somerset N Somerset
Ealing, Hammersmith & Ealing
Lambeth, Lewisham & SouthwarkLambeth

  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 AuthorityNew Authority Mini Authority
East & North Hertfordshire
West Hertfordshire¹
East Surrey
West Surrey¹
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 AuthorityNew Authority Mini Authority
NW Lancashire
E Lancashire
S Lancashire


Morecambe Bay
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.



    Greater Manchester

    West Yorkshire

    South Yorkshire

    West Midlands

    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.


  2.1  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.


3.1  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

    (a)  absent;

    (b)  unattractive;

    (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.


4.1  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.


  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.


  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

    —  noise

    —  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

    —  overwork

    —  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.


  4.6.34  A healthy economy would:

    —  protect open space and create peace and beauty

    —  reduce motor vehicle exhaust emissions

    —  reduce unemployment

    —  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.


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.


  (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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