Select Committee on Health Appendices to the Minutes of Evidence

APPENDIX 12 (CONTINUED)

Memorandum by Medical Practitioner's Union (PH 22)

4.7  EARTH SHELTERED BUILDING

What is an earth sheltered building?

  4.7.1  An earth sheltered building is a building which is partially buried in earth. In its perfect form the roof and walls are hidden beneath earth and only the windows and doors are visible.

  4.7.2  Partial forms are possible, for example conventional buildings with roof gardens or buildings that are covered by earth on only certain aspects. An earth sheltered building can either be built into an existing earth mound, or can be built in the normal way then buried.

Is this just a silly idea?

  4.7.3  No. Earth sheltered buildings are common in America and Australia. Roof gardens are required by planning regulations in parts of Germany. There are some buildings with roof gardens already in England and one earth sheltered housing estate.

What are the benefits?

  4.7.4  1.  Reduced Visual intrusion

            2.  Brings a green aspect to built up areas

            3.  Double use of space—roofs can be used for gardens or open spaces

            4.  Potential for increased housing density due to the double use of space

            5.  Energy efficiency

Are the technical features fully understood?

  4.7.5  Yes

So why isn't it widespread?

  4.7.6  1.  Inertia

            2.  Doubts about public attitudes

            3.  Construction firms and architects reluctant to learn new skills

            4.  People haven't heard of it

            5.  When they do hear of it, it is so alien to our current experiences that they think it is a joke

            6.  Association with the Teletubbies

What are its planning benefits?

  4.7.7  1.  Can preserve any open space that it is decided to permit building on

            2.  Can bring back open space when new areas are developed

            3.  Allows combination of requirements for high housing density with high levels of public open space

What are its public health benefits?

  4.7.8  Open space provides exercise opportunities and raises the human spirit.

What can be required?

  4.7.9  We can reasonably require earth sheltering in any area where we permit the release of open space for development.

  4.7.10  We can reasonably require earth sheltering on any development that is large enough to provide a self contained area of useful open space.

  4.7.11  Roof gardens and earth sheltered perimeters in new industrial parks would create large areas of public open space and introduce the surrounding area to the concept of earth sheltering and change attitudes towards the relationship of buildings to greenspace.

4.8  A NEW PUBLIC HEALTH ACT

  4.8.1  In 1997, we submitted to the incoming Government a draft Public Health Act. At the time, a number of public health organisations were suggesting that the 150th anniversary of the first such act, the Public Health Act 1848, would be a good opportunity for a modern version. We felt it would be eminently appropriate for a Government which was establishing the first Minister for Public Health to adopt that approach by passing a Public Health act in 1998, within its first Parliamentary session. We suggested the Act should address:

(i)  structures for public health;

(ii)  specific measures that promote public health; and

(iii)  manifesto commitments that could be seen as health improving.

  The third of these points has clearly been overtaken by events as they have been embodied in separate individual pieces of legislation. The first two points remain valid even though the opportunity for symbolism in the date has been lost.

  4.6.2  There could be one long Act or a shorter Act every session, like the Finance Act. An advantage of the latter is that it would foster an inter-departmental approach as departments would start to see this as an additional way to get legislative time for things they want to do and they can demonstrate would improve health. It would provide a compelling reason to take the Minister for Public Health seriously.

  4.8.3  Recognising the links between public health and the environment it could be called

—  the Public Health Act

—  the Public Health & Environmental Protection Act

—  the Health & Environments Act

Public Health Structures

  4.8.4  On the public health duties of health authorities and local authorities it could:

(i)  create a duty on health authorities to promote the health of local communities, to define local communities which suffer social or environmental deprivation and to draw up, in conjunction with the local authority, plans for addressing those problems;

(ii)  extend s113 of the Local Government Act (empowering local authorities to delegate local authority officer functions to NHS staff) so that it also applies to family health services contractors and their staff (The Health Act Partnership process is a mechanism for this, but there may be occasions where this simpler power is more appropriate);

(iii)  for the avoidance of doubt confer a power on health authorities and Trusts to delegate officer functions to local authority staff, family health services contractors or staff of FHS contractors (this is a reciprocal of s113. There is a question as to whether it is necessary or whether health authorities or Trusts can do it anyway, since s113 was intended to overcome some specific restrictions on local authorities. However, some auditors have argued that in the absence of a reciprocal provision to s113, this can't be done. The Health Act partnership process is a mechanism for this but there might be instances where this power would be simpler).

(iv)  empower the Secretary of State to delegate to a local authority any power that he could delegate to a health authority (our original proposal also suggested that this power to delegate should be delegable but the Health Act Partnership process obviates that need);

(Note points (ii) to (iv) would also be of value for health care purposes as well as public health);

(v)  empower the Secretary of State to constitute a public health office as a corporation sole and to delegate to it any power that he could delegate to a health authority;

(vi)  require him to use that power so as to establish as a corporation sole a Borough Medical Officer or County Medical Officer for the area of each county council, unitary borough, metropolitan borough or London borough;

(vii)  provide that any power delegated to a local authority or a corporation sole under these provisions will be subject to the same accountabilities and flows of funds as if it had been delegated to a health authority;

(viii)  provide for the Borough and County Medical Officers to have a right to appoint a nominee to the Board of each NHS body established within their area (acting jointly where a body covers more than one such area);

(ix)  establish for Borough and County Medical Officers a right of access to local authority committees and executive bodies; and

(x)  extend the powers conferred by S4 of the Health & Medicines Act (trading powers of health authorities), so that they may be exercised not only (as at present) for the raising of money for the NHS but also for the improvement of health.

  4.8.5  The Act should give a special status for public health measures in terms of the Deregulation Act by:

(i)  excluding health and safety, public health and environmental protection from the Deregulation Act; and

(ii)  provide that existing deregulation provisions within these areas will cease to have effect 12 months after the passage of the Act unless renewed by the Minister for Public Health, the Health & Safety Commission or the Environment Agency (as appropriate).

  4.8.6  To entrench the position of public health in planning law the Act should:

(i)    provide that the public health is a material consideration for planning law purposes;

(ii)   provide that costs may not be awarded against a local authority in favour of a commercial body on a planning appeal insofar as it applies to decisions reasonably taken in good faith upon the advice of the Borough Medical Officer or County Medical Officer for the protection of the public health (which should be explicitly stated, for the avoidance of doubt, as including, the reduction of road traffic, the reduction of pollution, the promotion of social networks or the protection of open space);

(iii)  power for Borough and County Medical Officers to object to planning applications, to require preparation and consideration of health impact assessments, to enter into s106 agreements as to terms on which their objections will be withdrawn, and to appeal against a grant of a planning application to which they had objected;

(iv)  restrictions upon the power of planning inspectors or the Secretary of State to overturn local decisions to refuse planning applications on the grounds of protection of open space, reduction of road traffic, or prevention of pollution of residential areas. Only unreasonable decisions, or decisions which can be shown to have been primarily taken on other grounds should be open to reversal on appeal. The same should apply to calling in and granting an application to which a local authority objects;

(v)  power to attach conditions for the improvement of the nutrition of the population to planning approvals for the use of premises for the sale of food;

(vi)  power on local authorities to require public roof gardens on appropriate buildings in areas of open space deficiency (our original proposals also suggested a power to require public open space in new developments but the High Court has since ruled that they do have such power);

(vii)  duty on local authorities to achieve by the year 2010 a specified number of trees per hectare across their area and power for them to require tree planting as a condition of planning consent if they have not yet achieved their target.

  4.8.7  To institutionalise responsibilities for health improvement policies the Act should:

(i)  require each Government Department (including departments in devolved Executives) to lay before the appropriate Parliament or Assembly each year a report of its health improvement policies and the comments thereon of the appropriate Chief Medical Officer;

(ii)  provide for 20 per cent of the revenue support grant to a local authority to be paid via the Minister for Public Health and to be dependent on satisfactory participation in health improvement programmes. There should be provision that in exercising this function the Minister should take account of advice from the Borough or County Medical Officer; and

(iii)  provide that any money withheld under this clause shall be paid to the local Borough or County Medical Officer and ringfenced for health promotion or public health expenditure within the local authority area in question.

  4.8.8  To establish freedom of information in the public health field:

(i)  there should be a clause defining the duty of public health practitioners to engage in public health advocacy.

(ii)  there should be protection of freedom of speech of health workers (non- statutory provisions have been introduced by this government but we still think they should be statutory) and a duty on Borough and County Medical Officers to promote public debate on health matters;

(iii)  there should be freedom of information provisions on public health information applicable to both the public and the private sector;

(iv)  it should be a serious criminal offence to suppress information about the existence of a serious public health hazard;

(v)  there should be curtailment of the right of commercial bodies to use libel laws to suppress debate on the health implications of their businesses;

(vi)  there should be protections for the independence of the Chief Medical Officers; and

(vii)  there should be immunity for health authorities, environmental health authorities and the HSE against libel actions for health warnings issued in good faith.

  4.8.9  To update environmental health legislation the Act should include:

(i)     a review of communicable disease legislation;

(ii)   a review of the law on nuisances;

(iii)  a review of the law on drinking water including;

—  control of land contamination that may pollute water supplies

—  a timescale for eradication of lead pipes

—  power for the Drinking Water Inspectorate to act on the balance of probabilities

(iv)  a review of the law relating to air quality; and

(v)   a declaration that environmental health services are part of the NHS and provision to include them within certain NHS systems.

  4.8.10  To improve the statutory definition of public health professions the Act should:

(i)    place on a formal statutory footing the duty on the GMC to maintain a specialist register for public health medicine;

(ii)  place a requirement on the UKCC to maintain a specialist register of public health nurses and also to provide a route of entrance to the health visiting profession (and thus the specialist register) for community development professionals;

(iii)  require the GMC, UKCC and Council for Professions Supplementary to Medicine also to maintain a register of clinical epidemiologists, practitioners who are qualified to practise public health to the extent that this is ancillary to another speciality;

(iv)  place a requirement on the Council for Professions Supplementary to Medicine to register health promotion advisers, public health scientists, human ecologists, public health nutritionists, health economists and environmental health officers;

(v)  define a "public health professional" as a person named in any of these registers;

(vi)  confer a power on the GMC to grant an exceptional licence, based on personal skills and qualities, to a registered member of a health profession (registered either in this country or overseas) to exercise the functions of a medical practitioner within a defined specific sphere of practice, and (without prejudice to the generality of that power) a specific duty on the GMC to use that power for the following purposes;

—  facilitate the integration into employment of refugee doctors;

—  simplify the training of persons requiring dual medical and dental qualifications for practice as maxillofacial surgeons

—  make provisions for physiotherapists, occupational therapists and speech therapists to render themselves eligible for entry to the medical speciality of rehabilitation

—  make provisions for persons already qualified in other public health professions to render themselves eligible for entry to the medical speciality of public health medicine

  (The power conferred and the uses proposed for it are wider than just public health, because we feel it is important that public health is not the only area where this power is exercised and for convenience in making some other useful minor provisions at the same time); and

(vii)  provide that from a specified date, and with protection for existing incumbents and their deputies (both in their present post and to move) the Chief Executive of a health authority should be a public health professional and the Director of Finance should be a health economist in the light of the central importance of the training and skills of these groups to the task in hand.

  4.8.11  The Act should confer powers on the Secretary of State, either directly or through a health authority or public health corporation sole, to exercise any power conferred by any public health legislation upon any body, if he is satisfied that that body is failing to exercise it adequately, and to recharge the costs.

  4.8.12  The Act should empower a Borough Medical Officer or County Medical Officer to serve upon a local authority any notice which the local authority is empowered under public health legislation to serve but is unable or unwilling to serve upon itself. There should be a duty upon a local authority to make its inspectorates available to the Medical Officer for the purposes of this power. (This overcomes the restrictions in the Cardiff case where a local authority environmental health department was held not to be empowered to serve an unfit housing notice on the council's housing department because the authority can't serve enforcement notices on itself).

Measures to Improve Health

  4.8.13  The Act should make provision for green taxes including:

(i)  environmental levies;

(ii)  more effective Road Traffic Act charging procedures for health authorities;

(iii)  similar new provisions for industrial accidents;

(iv)  road traffic generation levies on large site operators;

(v)  a carbon tax.

  4.8.14  To improve health at work the Act should include:

(i)  new corporate manslaughter provisions;

(ii)  increased penalties for health and safety offences;

(iii)  a clause providing that a local authority, the Environment Agency and the HSE may, by agreement, exercise each other's powers, thus giving greater flexibility in boundary areas or dually inspected premises like food factories;

(iv)  power for a police authority and the HSE jointly to establish a Serious Criminal Negligence & Environmental Offences Squad, whose members would have the combined powers of a factory inspector, a pollution inspector, an environmental health officer and a police constable;

(v)  a duty upon an employer to secure at each workplace an adequate occupational health service, either by providing a service licensed by the local health authority, or by providing a national service licensed by the HSE, or by subscribing to a service commissioned by the local health authority or by subscribing to a national service licensed by the HSE. There should also be a duty upon the HSE and health authorities to secure the involvement of the workforce and the local community in the management of any service they license or commission. Employers whose services are licensed by the HSE should still reach agreement with the local health authority to ensure compatibility with local arrangements;

(vi)  perhaps a clause relaxing the restrictions on industrial action (eg secondary action, picketing) where the dispute does not affect pay and is about health and safety or other issues of relevance to public health; and

(vii)  "family friendly" employment.

  4.8.15  To improve transport safety the Act should include:

(i)  a 20mph universal speed limit on minor roads;

(ii)  new drink driving provisions similar to those in France where there is provision for a fine and penalty points (but not imprisonment or mandatory disqualification) for driving with blood alcohol levels of more than 50 but less than 80 mg/100mls;

(iii)  powers to establish Home Zones;

(iv)  legislation requiring Chief Constables to achieve specified standards of speed limit observance and allowing them to precept on fines revenue from speed limit enforcement;

(v)  a duty on the Strategic Rail Authority to secure a more extensive and comprehensive rail network, and on County Councils, the Mayor of London and Passenger Transport Executives to secure a comprehensive bus network, so that people have the genuine option of a safer form of transport;

(vi)  duty on the Railways Inspectorate to exercise its powers with regard to the principle that transport safety is damaged if the access to railway services is diminished by inflexible or bureaucratic regulation which diminishes the scope for rail expansion; and

(vii)  establishment of a Road Safety Inspectorate closely linked to the Railways Inspectorate and with a duty to raise the standards of road safety closer to those on the railways through improvements in road and vehicle design and traffic regulation.

  4.8.16  The Act should require the fluoridation of water supplies.

  4.8.17  To promote walking and cycling the Act should:

(i)  place a duty on the Highways Agency to establish and maintain a national cycling network;

(ii)  place a duty on local authorities to establish and maintain safe local cycle networks;

(iii)  place a duty on franchised rail operators to carry bicycles;

(iv)  establish, as a Special Health Authority, a Walking Authority with a duty to ensure protection and maintenance of the rights of way network, to ensure the creation of adequate networks of recreational footpaths, to ensure adequate use of the powers relating to access agreements and the right to roam, to ensure pedestrian safety, and to ensure the creation in urban areas of aesthetically attractive pedestrian networks. The authority should have default powers to assume the responsibilities of local authorities which are failing to achieve adequate standards, and to precept to recover the costs of exercising these default powers;

(v)  provide that compensation for Creation Orders should be limited to interference with the use of the land and not to any general reduction in value. The basis for this should be that responsible landowners cooperate with the creation of path networks;

(vi)  provide that no compensation should be payable for a Creation Order where the landowner has unreasonably refused to negotiate in good faith with a local authority seeking to establish important concessionary access;

(vii)  place a duty on the Highways Agency to provide a safe crossing where a right of way crosses a road with more than a 30 mph speed limit;

(viii)  establish, as a Special Health Authority, a National Cycling Authority with a duty to ensure adequate local cycle networks connecting to the national cycle network (with default powers similar to those of the National Walking Authority) and with powers to issue advice concerning cycling to the Highways Agency and Strategic Rail Authority; and

(ix)  abolish the power to close public footpaths permanently for reasons of the prevention of crime but to replace it with a power to close footpaths (or to dedicate them subject to this proviso) during certain hours.

  4.8.18  To address the problems of homelessness and of travellers the Act should:

(i)  place a duty on local authorities to provide, or secure the provision of, an adequate supply of affordable housing; and

(ii)  establish a Nomadic Citizens Council, elected by gypsies, travellers and other persons of nomadic lifestyle, established with the status and powers of a unitary local authority with the responsibility to make appropriate provisions for persons of nomadic lifestyle.

  4.8.19  The Act should make provision for better nutritional food labelling.

  4.8.20  To address the problems of fuel poverty the Act should:

(i)  prohibit disconnection; and

(ii)  place a duty on a fuel supplier to provide heating to houses on affordable terms. Where a house is hard to heat it may discharge this duty either by offering improvement loans to rectify the situation or by putting a ceiling on the bills.

  4.8.21  The Act should improve the mechanisms for control of chemicals.

  4.8.22  To prevent the loss of efficacy of antibiotics due to clinical and agricultural overuse the Act should provide for the Chief Medical Officer to specify the purposes for which each antibiotic may be used and it should be a criminal offence to use it for any other purpose.

  4.8.23  To address the health problems of unemployment the Act should:

(i)  establish a levy on businesses which employ less than their share of the workforce (defined as turnover of the business divided by the GDP and multiplied by the national workforce expressed as whole time equivalents) amounting to the national minimum wage for a 40 hour week multiplied by the shortfall. The proceeds of that levy should be paid to public authorities for the creation of socially useful work (the degree to which such work is temporary or permanent to be a matter of local judgement based on the local labour market). There should be a right to be offered such work if genuinely unable to find work on the open market; and

(ii)  provide that the refusal of or resignation from unsafe or health damaging work does not constitute intentional unemployment or evidence of failure to seek work.

  4.8.24  The Act should make the following provisions relating to public health in Europe:

(i)  a duty on British representatives at the Council of Ministers to pay due regard to public health; and

(ii)  a duty on the Foreign Secretary to lay before Parliament from time to time (as events overtake the most current statement) a statement of the public health policies which the United Kingdom will press the European Union to adopt.

5.  THE ROLE OF THE DIRECTOR OF PUBLIC HEALTH

5.1  The Two Roles

  5.1.1  The Director of Public Health fulfils two roles and their requirements are coming increasingly to conflict.

  5.1.2  For a century and a half this country has had a group of doctors who analyse the health of communities and act as advocates for health improvement. This role needs to be filled by a doctor because of the trust the public places upon a medical opinion, because of the medical culture of independence and because of the specific skills and training, including knowledge of disease processes and treatments. In a century and a half it has led to the eradication of water borne diseases of cholera and typhoid, dramatic improvements in child and maternal health, the eradication by vaccination of smallpox, diptheria and polio, the clearance of the slums, and the cleaning of the air. This rate of achievement has not been maintained since it was absorbed into the cloying defensive corporate managerialism of the post 1974 NHS.

  5.1.3  The other role is as the health authority's public health manager. This role, not specifically medical, requires approaches and attitudes which might well be incompatible with successful advocacy.

  5.1.4  There are many Directors of Public Health who are exceptionally able at one or other of these roles. There are very few who are good at both. The temperaments required may perhaps be incompatible. More importantly the attempt to encapsulate the two roles in one individual is bound to lead to compromises at some point in both roles.

5.2  The Doctor to the Town (or County)

  5.2.1  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.

  5.2.2  It is important that this function should be independent and professionally honest with moral courage. These are not qualities currently valued in British public administration.

  5.2.3  In this context we view as sinister the current proposals to widen the professional base from which Directors of Public Health can be recruited. We are not saying that only doctors can be independent, professionally honest and have moral courage. We do, however, say that it will be easier to eradicate these qualities if the range of people from whom appointments may be made is broader and includes professional groups without a strong professional tradition of independence and without the degree of professional power and public respect necessary to afford protection.

  5.2.4  We develop our ideas about multidisciplinary public health in section 7 of this evidence. We do not seek to defend medical hegemony but rather to allow the traditions of each of the public health professions to develop properly. Once the professional function of analysis and advocacy has been removed from the role of Director of Public Health (and only then) that important managerial function that remains would appropriately be open to multidisciplinary tenure. Doctors would be required in the team but not necessarily in the lead.

  5.2.5  The office of County and Borough Medical Officer should be part of the NHS but it should not be part of any NHS body, since it needs to have access to all agencies. Joint appointments are a possible mechanism but to emphasise its independence and to allow statutory functions to be conferred upon it directly we suggest it should be established as a corporation sole.

  5.2.6  The status of a corporation sole should not mean that complex infrastructures need to be created. A small office at regional level should be able to cope on an agency basis with the corporate administration of the public health corporations sole in the region (such as accounts, convening Advisory Appointments Committees to fill vacancies, contractual matters for the Borough and County Medical Officers etc).

  5.2.7  Nor should it mean that individuals should work in professional isolation. There is no reason why the doctors in question should not work from NHS or local government premises, draw upon NHS and local government administrative systems, and work within a Dept. of Public Health Medicine shared with colleagues working for health authorities and Trusts, thus providing professional interaction and shared statistical, information, library and scientific support.

  5.2.8  It should be possible for these public health corporations sole to become part of Health Act partnerships.

  5.2.9  The Borough and County Medical Officers should be entitled to be represented on the Board of all NHS bodies and of all Health Act partnerships. They should also have a right of audience at local authority committees and executive bodies.

  5.2.10  The Attorney General should establish mechanisms for supporting Borough or County Medical Officers who wish to bring legal proceedings for the protection of health, and they should be acknowledged as entitled to seek judicial review of decisions if they feel this would benefit health.

  5.2.11  Section 4 of the Health & Medicines Act (the trading power of health authorities) should be extended to these new corporations sole and should also be extended to allow trading for the purposes of promoting health rather than just for the purposes of raising money for the NHS. This would allow Borough and County Medical Officers to enter into public/private partnerships.

  5.2.12  A new Public Health Act should confer a variety of powers on Borough and County Medical Officers. We drew up a draft bill for the incoming Government in 1997 and are sad that it was not adopted. We have updated it at section 4.8 above.

  5.2.13  As an example of the kind of power we are referring to we suggested that when there is a public health objection to a planning application a local authority which refuses the application should be protected from the risk of costs in the even of an appeal. We also suggested that Directors of Public Health (and now, our suggested Borough and County Medical Officers) should have a third party right of appeal against planning application approvals, a right that could also be conferred upon other bodies which represent key social values, such as the Environment Agency or the Countryside Commission. There may also be a case for conferring this right of appeal upon Parish Councils and equivalent community representative bodies.

  5.2.14  Whatever formal statutory powers are conferred and whatever services are placed within the new corporation sole, the right of audit and report is fundamental. Until well into this century the Medical Officers of Health operated with this power alone, and they did so highly effectively. NHS bodies and local authorities should have a duty to consider reports by the Borough or County Medical Officer, including the Annual Public Health Report.

  5.2.15  The independence of this report would be re-emphasised by our proposal for status as a corporation sole. If this is not adopted other ways to assert the independence of such reports need to be found as this is often not understood.

  5.2.16  As well as conventional reports the increasing discussion of health impact assessment is also relevant here.

Health Impact Assessment

  5.2.17  A health impact assessment is carried out whenever a public health professional systematically recognises the health implications of a proposal and offers advice.

  5.2.18  Techniques for carrying out set piece health impact assessments are being developed such as the Liverpool Checklist of matters to consider, the London Quantification Framework for recognising how they might be quantified and the Manchester Airport Grid for surveying how useful quantification might be. The Transport & Health Study Group has recently issued guidance on health impact assessment of a transport policy. The University of Liverpool is building up expertise in health impact assessment of policies.

  5.2.19  Such set piece assessments will always be the minority of health impact assessments. Resources in public health and the timescales of decision makers will always ensure that most health impact assessments are broad brush and are expressed in a letter of comment.

  5.2.20  The underlying duty of public health professionals to make such comments and the professional body of knowledge that underpins them needs to be appreciated. They can be seen simply as a letter of opinion or, because they operate in a different conceptual framework from the one the decision maker is used to, they may simply fail to register. For example Directors of Public Health in the North West of England took considerable trouble to develop comments on the draft regional planning guidance addressing the public health implications of the proposals but were not invited to be participants in the public examination.

  5.2.21  Highways engineers and estates professionals are renowned for the belief that their own system of professional knowledge is a substitute for intelligent thought and that any other way of viewing a problem is wrong. They particularly resent any suggestion that they have any duty to take account of strategic goals of any kind and will usually argue that coordinated social policy is illegal.

  5.2.22  Training of decision makers in the health implications of their work is essential both for them to see the need for public health advice and to value it when they receive it.

  5.2.23  As a long stop structures should be put in place for informing DPHs (at present) and (in future) Borough and County Medical Officers of decisions they may wish to comment on. But the field is vast and the mail of DPHs already submerges the important beneath the merely urgent, and both beneath civil service requirements for Ministerial information.

  5.2.24  For example the public health department in Sandwell, a leading edge department, did not realise until after the closing date for comments that a planning application would increase gambling opportunities in an area where they were convinced this would be damaging to health. They were unaware of the application and the planners were unaware of the public health issue.

  5.2.25  Timescales for rapid resolution of planning decisions, set in the name of efficiency, preclude any sensible formal health impact assessment.

  5.2.26  A commitment to health impact assessment must be more than a belief that public health professionals, if asked, will do a calculation that will make a report look nice.

  5.2.27  What is needed is a belief that all decision makers have a duty to improve health and that public health professionals are there to help with this.

  5.2.28  It will be important for Borough and County Medical Officers to devote time and energy to enthusing a wide range of local authority staff with the health implications of their work and their place in the health improvement process.

5.3  Public Health Management in Health Authorities

  5.3.1  It seems likely that health authorities will merge into large remote bureaucratic entities, allegedly strategic but in fact composed of reformed hackers sitting in front of large computers monitoring services they do not understand for populations they have never met. This process was set in motion by NHS managers under the previous Conservative government and has continued under the present government with a sustained dynamic but changed rhetoric.

  5.3.2  We do not believe that the system which destroyed the economy of the Soviet Union will improve the NHS. For the record we must emphasise that we made this same criticism in these same words under the previous government.

  5.3.3  Centralised target driven top down planning does not work for two reasons

—  the mathematics of chaos theory has demonstrated that some systems are too complex to plan and the interactions simply cannot be accounted for but become random events;

—  organisational theory has shown that the more performance is monitored the less likely people are to exceed the minimum required and the more closely activity is targetted the more neglect affects the things that have not been targeted.

  5.3.4  A more sensible approach would be one which sought to work with the enthusiasm and commitment of staff whilst developing accountability to consumers and communities. This should take place within the context of the public health body of knowledge and the guidance this offers to evidence based organisation and strategies.

  5.3.5  The current government has not departed anything like as much as it should have done from the over managed systems introduced by the Conservatives but it has at least put in place the system of clinical governance, tried to monitor care rather than meaningless indicators of volume, and launched visionary programmes of staff development (albeit that its spin doctors then undermined them by presenting them as punitive so as to appear tough).

  5.3.6  It is important that the assessment of need for health services should be rooted in an understanding of health care and should not become a technical statistical issue. We continue to believe that this will be achieved best in a democratised NHS.

  5.3.7  Public health practitioners need to have a key role in health authorities and Trusts. It is the public health approach which is most likely to accentuate the positive features of managed clinical pathways and needs based plans, use indicators as information instead of being dominated by them, and resist the distorting effect of inappropriate targets. All too often this potential is unrecognised and hence untapped.

  5.3.8  Public health doctors have a broad vision of health and a full range of epidemiological skills combined with a professional background shared with other doctors. This makes them particularly well placed to win the support of clinicians for strategic change.

  5.3.9  The skills of public health nurses, rooted in work with families and communities, could be of immense value in ensuring that the wishes of consumers are not overlooked.

  5.3.10  There is a need for a career structure for public health scientists who may perhaps be able to tame the monster of NHS information systems.

  5.3.11  Health promotion specialists have skills in programme management which could be valuable in the introduction of service frameworks.

  5.3.12  Environmental health officers have an approach to public health which is rooted in legislation and enforcement. It is unfortunate that the relevance of these skills to NHS commissioning has been generally overlooked.

  5.3.13  The approach of health economists, with their emphasis on resource optimisation, could almost certainly make a greater contribution to the planning of NHS commissioning budgets than the traditional public accountancy approaches which are more suited to provider budgets.

  5.3.14  It is unfortunate that these public health skills, with their capacity to shape the strategic direction of health services, have been generally neglected in favour of skills of operational management, bureaucratic administration and conventional public accountancy which have much to offer large provider organisations but are of little relevance to strategic authorities.

  5.3.15  We suggest that the Chief Executives of health authorities should in future be drawn from the ranks of public health professionals.

  5.3.16  In 1998 the then Chief Medical Officer, in his report on strengthening the public health function, said "the present resource of specialist public health expertise is already very stretched and there is a need for more dedicated staff from a number of disciplines to deliver the current agenda."

  5.3.17  The scarcity of public health skills will affect the capacity of authorities to address the agenda in the way that we advocate. A workforce plan is called for.

6.  INEQUALITIES

  6.1.1  We welcome very much the current renewed interest in inequalities in health. The Government is to be congratulated on this approach.

  6.1.2  Inequalities in health will not be reduced until the poor cease to be differentially exposed to the determinants of ill health.

  6.1.3  It is not enough simply to address inequalities in access to health care, although that is important. We must also, indeed primarily, address the more fundamental causes.

  6.1.4  About a third of inequality in health is work related. We must therefore address the issue of health at work if we are to address inequality.

  6.1.5  Given the powerful association between social networks and health the stress and powerlessness of social exclusion must also be addressed. We believe that community development is important.

  6.1.6  The material issues of poverty and the environments in which poor people live provide the rest of the problems.

6.2  The Public Health Case for relief of poverty

  6.2.1  It is well established that poverty is the greatest single cause of death. Whenever death rates are correlated with indices of deprivation, whether in small area analysis, in large area analysis, in time series or in the comparison of different social groups, the correlation relentlessly identifies deprived and oppressed groups.

  6.2.2  At the time of the Black Report 70,000 deaths occurred each year in the UK under the age of 65 which would not occur if the health of the whole population were the same as that of the professional and managerial classes. By the publication of "The Health Divide" the figure had increased to 85,000. It may well have increased further since.

  6.2.3  Furthermore both these figures are diluted by the imprecisions introduced by inadequacies in current taxonomies of social class. Occupation is not the most precise indicator of social class and if better indicators were used, perhaps based on housing type and area of residence, it is likely that wider differences would be found.

  6.2.4  From the work of Fox & Adelstein, who compared variances between industries with variances within industries, it can be shown that between a quarter and a third of these deaths are occupational in cause. This does not only demonstrate the need for stricter regulation of occupational hazards, important though that. It also shows the need to think more broadly of working conditions in terms of their security, psychological impact, and general pleasantness. Regulation is not enough

—  -it is also necessary to alter the balance of power in the labour market. Low paid workers especially must be better able to demand dignified treatment and acceptable conditions of work.

  6.2.5  Unemployment is also a major cause of ill health. The ill health of poor quality work and the ill health of unemployment are not alternatives. Poor working conditions and insecurity of employment are correlated so these two forms of health damage have a strong tendency to fall successively on the same people. There are people who enjoy high levels of job security in good quality well paid work, people who alternate between unemployment and poor quality low paid work and people whose experiences of job security, pay and work quality are, in various ways, intermediate between these two groups.

  6.2.6  Low levels of disposable income impact adversely on health in a number of ways. Healthy diets are more expensive than conventional diets if they use simple substitutions of low fat, low sugar, high fibre versions of conventional diets. Cheap healthy diets do exist but are distinctly unusual, demanding much greater lifestyle change to adopt them. Exercise is easier in rural environments or in leafy suburbs than in inner city environments and is also easier for those who can afford access to leisure facilities.

  6.2.7  Transport is an important factor in health inequality. Car owners find it easier to access a wide range of health promoting facilities. Access to the countryside by public transport is increasingly difficult. The price differential between healthy and unhealthy food is lower at out of town hypermarkets than at shops accessible without cars. The planning of health facilities increasingly assumes a mobility which only car owners actually possess.

  6.2.8  The poor are more likely to own old cheap furniture and equipment which may well be less safe. They are less able to afford safety equipment such as stair guards and smoke alarms.

  6.2.9  As well as these direct material factors there is the stress of exclusion from lifestyles regularly presented as the norm. Also stressful is the powerlessness which goes with lack of choice, lack of respect from those in power and the dependency creating models on which the welfare state is organised.

International comparisons

  6.2.10  Correlations have been established between the degree of equality of income in a nation and its health in relation to its GDP. Countries with high levels of equality enjoy better health then other countries with the same level of economic success.

  6.2.11  There has been incomplete investigation of this correlation and a wide range of possible explanations can be advanced as possibilities, including the following:

—  equality of income may occur in the same countries as social policies which promote health;

—  there may be a greater health benefit from money spent on the relief of poverty than the marginal benefits from the same amount of money made available to the rich;

—  inequality may itself create ill health through the stress of relative poverty and failure to achieve the norm for the given society;

—  the social cohesion produced by equality may be health beneficial;

—  societies which tolerate inequality may do so only because of inadequate social cohesion (itself health damaging);

—  at least one of the drives for higher income is a drive to establish a relative position so inequality of income may itself be economically inefficient. It leads to the expenditure of excessive sums of money on positional goods marking social positions that could equally be marked at less expense;

—  current measures of GDP, which do not, for example, count the value of economic growth deliberately foregone for social good, may underestimate the wealth of the kind of society which opts for more equal incomes;

—  in societies with greater equality a greater proportion of the society's entrepreneurial skills may be devoted to socially beneficial activity rather than the mere enrichment of the entrepreneur.

6.3  Community development

  6.3.1  Community development is an antipoverty intervention which aims to empower communities to work together to address their own problems.

  6.3.2  It benefits health by

—  enhancing social networks, itself a measure that improves health (indeed associations of total mortality with social networks are as strong as with social class)

—  increasing the power of communities to do useful things together and improve their situation.

  6.3.3  Since the early initiatives in Parkside and in Nottingham community development projects in the NHS have been tried widely but often briefly. The evidence from the Royal College of Nursing draws attention to the way they have often been closed down before having a real opportunity to achieve long term effects.

  6.3.4  Some longer lasting projects such as those in Salford and Oldham have affected a small area in which it is difficult to attribute effects specifically to the intervention because of the small number random variation.

  6.3.5  Northern Ireland and Stockport are the two places where NHS community development has been pursued for the greatest length of time across relatively large numbers of small areas.

  6.3.6  In Northern Ireland community development has for many years been a central feature of health strategy. The interventions have had significant effects on the communities where they have operated. There is some concern however that they have worked within, rather than challenged, communal divisions.

  6.3.7  In Stockport community development was introduced in two tranches in 1991 and 1995 to the borough's most deprived wards. SMRs began to decline in the first tranche wards taken as a whole after about three years whilst no decline took place in affluent wards and in deprived wards where no community development project was introduced. This means that whilst the health of the borough as a whole was improving only in line with England as a whole the wards where community development had operated were improving faster and health inequalities were therefore being reduced. Overall excess deaths were approximately halved. A downward movement in the SMRs where community development had been introduced four years later was noted four years after it was noted in the first tranche wards. A ward where community development interventions were reduced part way through the process for a number of reasons, including the introduction of a large regeneration initiative, initially improved in line with the other community development wards but after withdrawal returned to its previous status.

  6.3.8  Although the time relationships here are suggestive it is important to bear in mind that the relationship between wards and communities is imprecise, the data is crude, there is considerable scope for small number variation and the comparison was not randomised.

  6.,3.9  We believe the case is however made out for large scale randomised trials.

  6.3.10  Community development projects have often come to grief because of the failure of local politicians or health managers to prepare for the prospects of conflict with a more empowered community. There must be clarity that an empowered community is the objective and that the workers prime goal is its creation. Where conflict arises the worker must be able to take the side of the community.

  6.3.11  We believe public health nurses are well equipped to carry out community development.

6.4  Other measures to address the health effects of poverty

  6.4.1  Food co-operatives can help overcome the high cost of healthy food in local shops.

  6.4.2  Free bus services funded by the NHS can take people from deprived areas to swimming pools and leisure facilities.

  6.4.3  Parks can help overcome the difficulties of local distance from the countryside.

  6.4.4  Community art can affect the drabness of deprived environments and help raise the human spirit.

  6.4.5  The Peckham Health Centre between the wars undoubtedly had a deep impact on the lives of those who participated in it and it is to be hoped that healthy living centres will have a similar effect.

  6.4.6  Regeneration initiatives can address the underlying economic and environmental problems of deprived areas.

  6.4.7  Targeted recruitment can help mobilise the skills present in many poor areas and reduce unemployment. For example the Manchester Airport Second Runway Health Impact Assessment noted that economic growth was one of the main health benefits of the development and so part of the mitigation package was to ensure that jobs were locally advertised within inner city Greater Manchester.

  6.4.8  LETS schemes can help mobilise local skills and counter lack of local resources. Problems are sometimes created by the treatment of such schemes for tax and social security purposes. We have suggested that transactions on LETS schemes be disregarded for tax and social security purposes but instead LETS schemes as a whole be taxed in their own currency for the benefit of local public agencies, thus creating a useful source of voluntary work.

  6.4.9  Credit unions can help conserve resources in local areas.

  6.4.10  Energy efficiency measures in homes can directly address both the problem of cold and the cost of fuel bills.

  6.4.11  Disability is a cause of poverty and measures to reduce discrimination against disabled people can address this and also reduce care costs for the NHS.

  6.4.12  Ultimately the solution to the health problems of poverty is the elimination of poverty. We therefore develop in a later section of this evidence the case for a citizens' income.

6.5  Workplace Public Health

  6.5.1  A significant part of inequality in health arises at work so improved working environments (both physical and social) will help address health inequalities.

  6.5.2  We believe there should be an occupational health service,

—  funded by employers;

—  jointly managed by employers, unions and local communities;

—  commissioned by health authorities;

—  provided either by employers or by large industry wide arrangements (perhaps set up by the HSE) or by PCTs or NHS Trusts for group services to small workplaces;

—  licensed by the HSE for nationally organised services or by health authorities for local ones;

—  open to inspection by CHI;

—  providing a full range of workplace emergency care, health promotion/information, safety professionals, biological monitoring, employment rehabilitation and social audit;

—  complying with a National Service Framework.

The Contribution of Work Related Ill Health to Inequalities

  6.5.3  The work of Fox & Adelstein has demonstrated that about a third of the social class variation in ill health is caused by work.

  6.5.4  This is much more than can be accounted for by known occupational illnesses or hazards.

  6.5.5  The reason for this is that

—  many occupational hazards are unknown;

—  it is especially difficult to recognise occupational causes of common diseases;

—  the psychological hazards of work are rarely fully recognised or accounted for.

  6.5.6  Psychological hazards of work that can cause stress and hence physical and mental ill health include;

—  excessive working hours;

—  working under pressure to deadlines;

—  unsatisfactory work situations, ranging from poor physical conditions to bullying to lack of recognition and boring work, which the individual sees no way to improve or escape from;

—  lack of control over the work;

—  responsibilities which the individual is not trained, resourced and empowered to carry;

—  the Damocles situation where fear, whether physical as in dangerous work, or social, as in failing enterprises carrying redundancy risks, continuously hangs over somebody without a chance to influence it;

—  low status damaging self esteem;

—  frequent life changes such as job changes or relocation;

—  conflicts with other aspects of life.

  6.5.7  Trends to longer hours and labour flexibility increase a number of these.

  Organising Occupational Health Services

  6.5.8  Problems in organisation of public health at the workplace include:

—  separation of responsibility for health at work from health in the general community;

—  the lack of any coherent form of organisation of occupational health services;

—  attitudes of deregulation;

—  lack of teaching about work hazards in the education of health professionals even though all health professionals encounter their consequences;

  6.5.9  The debate that was prominent in the 1940s, 50s, 60s and early 70s of whether occupational health should be part of the NHS has died down following the redefinition of the NHS in 1974. However there are serious problems in the current system of unregulated private provision.

  6.5.10  Britain and Ireland are the only countries in Europe where there is no public control of occupational health services to ensure they pursue the health of the workforce as their prime goal and maintain a comprehensive service. To counter this we believe:

—  occupational health services should be commissioned by the NHS;

—  there should be a National Service Framework for occupational health services;

—  CHI should enforce this;

—  Occupational health services should be jointly managed by employers, trade unions, and the local communities upon whose environment the enterprise impacts rather than, as at present, by employers alone.

  6.5.11  When the coverage of occupational health was last assessed only a third of the workforce had access to a comprehensive service providing a full range of workplace emergency care, health promotion/information, safety professionals, biological monitoring, and employment rehabilitation. Social audit of the enterprise, which should also be a function of occupational health services, was not included in the study but its inclusion would undoubtedly have reduced the proportion even further. About a third of the workforce had access to no service at all. This study was two decades ago but our impression is that in those two decades things have got worse not better due to changing employer attitudes and a trend to smaller workplaces.

  6.5.12  We believe there should be a statutory duty for employers to finance an occupational health service either by providing it themselves and satisfying the commissioning authority that it meets the needs or by paying the commissioning authority to commission it for them.

  6.5.13  Only a small proportion of workplaces (albeit employing a significant proportion of the workforce) are large enough to support a comprehensive service of their own. Most will need to associate with other workplaces either vertically (where workplaces across the country unite in a service provided for a multisite company or industry) or horizontally (where local workplaces combine together eg a service for all the shops in a shopping centre). Both options should be available to employers. The Health & Safety Executive should sponsor vertical integration, providing it where this meets the needs of an industry best or alternatively licensing it for the guidance of commissioners, although commissioning should still be local in order to ensure the service fits into local patterns of health promotion, emergency care etc. Health authorities, NHS Trusts and PCTs have roles in stimulating, and even supplying, horizontal integration.

  6.5.14  Ever since Ernest Bevin fought successfully to keep occupational health out of the NHS on its creation the NHS has felt this is an area that lies beyond its remit whilst those areas of government responsible have seen it as a distraction from their main goals.

  6.5.15  One way or another this must be overcome.

  6.5.16  We welcome NHS+ as a cautious step in the right direction but much more courage by Government, including a willingness to regulate and to join up thinking across departments, will be needed to make a real impression on the problem.

  6.5.17  We believe our proposal for the NHS to be the commissioner of occupational health services but not the funder and not necessarily the provider is a sensible middle way.

6.6  CITIZEN'S INCOME

The Cost of Abolishing Poverty in 1991

  6.6.1  In 1993, based on 1991 data published in "The Justice Gap" we calculated the cost of increasing the income of each household to two thirds of the national average, a measure which would abolish poverty by any definition accepted by any substantial body of reasonable opinion.

  6.6.2  The calculation was as follows:

Household type	Adjusted household income (+/-£33)	Number of persons in such households	Average shorfall of adjusted income per household below national average	Correction factor back to cash per adult person	Weekly total income shortfall below national average
2 adults	£150	1.6 million	£16	0.5	£12.8 million
1 adult	£150	1.6 million	£16	0.6	£15.4 million
1 adult + children	£150	0.7 million	£16	0.85	£9.5 million
2 adults + children	£150	2.6 million	£16	0.375	£15.6 million
2 adults	£116	1.6 million	£50	0.5	£40 million
1 adult	£116	1.8 million	£50	0.6	£54 million
1 adult + children	£116	0.8 million	£50	0.85	£34 million
2 adults + children	£116	2.4 million	£50	0.375	£45 million
2 adults	£83	1.0 million	£83	0.5	£41.5 million
1 adult	£83	1.2 million	£83	0.6	£59.8 million
1 adult + children	£83	0.6 million	£83	0.85	£42.3 million
2 adults + children	£83	1.2 million	£83	0.375	£37.3 million
2 adults	£50	0.2 million	£116	0.5	£11.6 million
1 adult	£50	0.2 million	£116	0.6	£13.9 million
2 adults + children	£50	0.8 million	£116	0.375	£34.8 million
2 adults + children	£16	0.4 million	£150	0.375	£22.5 million
1 adult	£16	0.1 million	£150	0.6	£9 million
TOTAL		18.8 million			£499 million

  6.6.3  In 1991 to achieve an income of of national average income, adjusted for household size in the manner described in "The Justice Gap", would benefit 18.8 million people and cost £499 million a week, or £25.9 billion a year.

  6.6.4  The adjustment to household size which would pay two people living alone 20 per cent more than two people living together, although based on valid cost of living data justified in "The Justice Gap" can be philosophically criticised as subsidising a voluntary life choice and practically as requiring a draconian conhabitation rule to enforce. Without this adjustment the cost would fall to £23.1 billion.

  6.6.5  Since the money would be given to the poor it would therefore be likely to be spent rather than saved. The Government would raise £4 billion in VAT when the money was first spent, reducing the net cost to £19 billion.

  6.6.6  £19,000,000,000 a year in 1991 was a lot of money. It was, for example about two thirds as much as the benefits conferred on the richest 20 per cent of the population by tax changes during the Thatcher years.

  It was indeed slightly greater than the amount by which tax was increased in the full year effects of Kenneth Clarke's November 1993 budget.

  6.6.7  It was therefore a large figure but a figure of the order in which Governments can deal, if the priority be sufficiently great. The package necessary to fund this measure would not be beyond the means of a Chancellor of the Exchequer in a government that was determined to make the abolition of poverty its main contribution to history.

  6.6.8  A Government willing to raise in extra taxation sums similar to the full year effect of the November 1993 budget would have needed only to trim £500 million from each of six lower priority programmes in order to have been able to afford this change.

  6.6.9  Indeed even this combination of tax increases and expenditure cuts may not be necessary as there would be scope for reductions in public expenditure programmes that are made necessary by poverty.

The cost of abolishing poverty today

  6.6.10  Inflation since 1991 will have altered all the intermediate figures in the above calculation and proportionately altered the end result.

  6.6.11  On the other hand the substantial fall in unemployment and the introduction of the national minimum wage will have reduced the size of the problem.

  6.6.12  It would be nice to repeat the calculation but the basic information has not been produced since.

  6.6.13  We suspect however that it may not be greatly different when the two effects set out at paras 6.6.10 and 6.6.11 are netted off.

The idea of a citizen's income

  6.6.14  We believe that the simplest way to abolish poverty is to give everybody who is willing to contribute meaningfully to society (or is exempt from doing so by virtue of age or sickness) a citizen's income of two thirds of the national average income adjusted for the number of children so as to pay more to parents and less to those without children using the household income adjustments used in "The Justice Gap".

  6.6.15  The costs of this system are:

(a)  the costs of abolishing poverty, which we have calculated above;

(b)  the costs of paying the money to people who do not need it and then clawing it back in taxes. This is a purely circular transaction which in reality costs neither the state nor the individual anything. The mechanism for achieving it, however, need to be thought about. It cannot, for example, be achieved through general taxation without creating very high rates of marginal taxation. We return to this practical issue later in this evidence;

(c)  the costs of incomplete clawback resulting both from restrictions on the proportions of earnings that it is possible to claw back from low earners and the payment of citizen's income to low earning members of high earning families.

The costs of incomplete clawback

  6.6.16  For the cost not to exceed the shortfalls of income below the baseline:

—  people whose income was previously below the level of the new citizen's income would have to experience a clawback of the whole of their previous income;

—  people whose income was previously above that level would have to experience a clawback of the whole of the citizen's income they receive. To the extent that this is not feasible the cost would be greater than that calculated in the above section.

  6.6.17  Income derives mainly from four sources:

(i)  welfare benefits and other state support to income;

(ii)  earnings;

(iii)  investment, savings and private pensions;

(iv)  internal transfers within households.

  6.6.18  Upon the introduction of a citizen's income other welfare benefits would be replaced by it and income previously derived from such benefits would therefore clearly be effectively clawed back.

  6.6.19  Problems arise with the other forms of income.

  6.6.20  Any form of income support faces the problems of "earnings rules". It is unacceptable to leave a person with no gain from income that they earn. However allowing them to keep other income increases the cost of the benefit by increasing both the number of people eligible and the amount that each receives.

  6.6.21  From the chart in "The Justice Gap" it is possible to estimate the total income earned by people below the level proposed for citizen's income and to estimate the cost of restricting claw back to particular percentages of those earnings.

  6.6.22  Claw back from income is also subject to losses due to tax evasion and tax avoidance but a system of citizen's income is simpler than other forms of welfare benefit and probably no more open to fraud or manipulation.

  6.6.23  The further area in which clawback will not be 100 per cent effective arises from the citizen's income paid to non earning members of households in which earnings are on average above the baseline. It is possible from the chart to count the total number of such people.

  6.6.24  We calculated from the figures in "The Justice Gap" that in 1991 the cost of incomplete claw back from having only an 80 per cent earnings rule (more generous than current welfare benefits) and not having a cohabitation rule would approximately double the cost of introducing a citizen's income to a total of £39bn.

  6.6.25  Only dual high income households without children would fail to benefit from the incomplete claw back. Most people would be left no worse off by tax measures to cover it, and the exception is a group well able to afford to contribute.

  6.6.26  The greater security that people would enjoy with a citizen's income would reduce the need for them to make provision for their own old age or sickness and it would be appropriate therefore to abolish the tax relief on pension contributions.

  6.6.27  In 1991 that measure coupled with abolition of mortgage interest tax relief would have covered the cost of incomplete claw back.

  6.6.28  Clearly the situation has changed since and would need to be reassessed. It is important to bear in mind however that whatever tax changes are necessary to cover this cost they are, for the population as a whole, circular and for individuals they represent a redistribution from dual high income families to low income families and average income families with children.

The Philosophical Case for Citizen's Income

  6.6.29  We have asserted above that the ideal method for the abolition of poverty is a citizen's income—that is to say an income paid as of right to every citizen, whether or not they are considered to need help from the state. The sums paid to those who do not require help would be recovered through the tax system—this recovery is usually called "claw back", and this is the term we have used in this paper. For reasons which we will discuss later we believe full payment should be dependent on a meaningful contribution to society or exemption therefrom on the grounds of sickness or age.

  6.6.30  Having discussed the cost of such a system we now address the philosophical basis for it.

  6.6.31  Philosophically citizen's income can be justified from right wing, traditional left wing, market socialist or centrist standpoints. It is in fact one of the few social policy approaches which can be so justified.

  6.6.32  From a traditional socialist standpoint the underlying concept is "to each according to his needs". In the field of personal consumption it is difficult to plan to meet the needs of the individual through a social agency. It is simpler to allow individuals to judge their own needs within the resources available. Therefore alongside those fundamental services and commodities whose provision needs to be arranged by the state there are other services and commodities which can legitimately be left to a circumscribed form of market. As planner the state must determine the extent of each individual's influence on that market. A citizen's income represents the resources made available to the individual for that purpose. In a truly communist society, as described by Marx, this would be the only income the individual would have and it would vary only with variation in need.

  6.6.33  From a free market standpoint the underlying concept is different. The problem is a conflict between the requirements of the market in labour and the idea of the market as the hidden hand for meeting the needs of people. A free labour market requires that the cost of employing somebody should be the same as the marginal value of their labour, however high or low that should be. Allowing that to determine their consumption power is attractive as a way of making the market entirely a closed system. However it is unattractive if the market is to be presented as a way of meeting human needs. There is no reason why the needs of human beings should relate to the market value of their labour. The idea that they should has the embarrassing effect that some people will starve in order that the market be undistorted. It is relatively simple to overcome this by acknowledging that people's consumer input into the market is different from other inputs in that it represents one of the purposes of the market, rather than simply an intermediate transaction. People's income can therefore be varied so that it is a transformed function of their market income rather than their market income alone. The transformation must be one that is based only on value judgements about the extent of legitimate variation in consumer power, and not on anything else. The transformed income is thus a function of human need and the market value of the individual's labour (and investment rewards etc). If the transformation involves only these functions the market has not been distorted.

  6.6.34  Thus far a right wing market theorist and a market socialist would agree (except for the most rabidly fanatical right wingers) but at this point they would diverge. A market socialist would argue that since the ideal is "to each according to his needs" the variation in income to be permitted should be the minimum variation consistent with the effective operation of the labour market. A right wing market theorist would argue that since the ideal is a completely self contained market the degree of redistribution permitted should be the minimum consistent with the majority of citizens feeling comfortable that fundamentally uncivilised states of existence were not being created. Either, however, would see a citizen's income as the simple way of achieving the transformation and the one to be preferred because it confines the state to its legitimate role as redistributor and creates no distortion beyond that.

  6.6.35  From centrist social policy standpoints the philosophical argument is different yet again. The relief of poverty is taken for granted as a goal. The welfare state is seen to have as one of its main problems the fact that it is disempowering. Citizen's income is a form of relief of poverty which empowers its recipient and confers no power on agents of the state.

The practical arguments

  6.6.36  A citizen's income is the easiest form of welfare benefit to administer. It requires no process of assessment, since assessment is replaced by claw back which operates through the ordinary tax system. For persons in employment payment can be made through the employer and reclaimed by the employer as a set off against PAYE, VAT and NI payments. For persons in voluntary work or education in an organisation which has a payroll system the organisation can administer payments to them through that system as if they were employees. It is only necessary therefore to set up a separate payment system for people who are not in such a situation. These would mainly be people who would be in receipt of benefit anyway and the flat rate payment would make the system easier to administer.

  6.6.37  The automatic universal payment without stigma is much more effective than other benefit systems in ensuring complete uptake.

  6.6.38  The system has positive economic effects which are discussed in a later section.

  6.6.39  It is sometimes argued that a citizen's income will make it possible for employers to offer low wages. However the main reason that we dislike low wage employment is that it leaves people living in poverty. If an adequate income has been provided otherwise low wages can be seen as a benefit—making the worker less dependent on his/her job and making job creation cheaper.

Achievement of Claw Back

  6.6.40  Clawback could be achieved by income tax, by national insurance contributions or by wage adjustments recouped through taxation of industry.

  6.6.41  To achieve it through taxation personal allowances would be abolished (the citizen's income having replaced them) and a lower band of income would be introduced equal to the citizen's income less the cash value of the personal allowance plus X%, X being the "earnings rule" figure (the proportion of low incomes not clawed back). We suggest X should be at least 20 per cent. This band would be taxed at (100-X) %.

  6.6.42  It would be blatantly unfair to tax the lowest band of income at a penal rate and then reduce it for higher bands, but this would only embody the current impact of benefit withdrawals, so that it would simply make an existing unfairness explicit—indeed if X were 20 per cent it would significantly ameliorate it. In rendering it explicit and starting the process of amelioration it may well pave the way for further gradual future resolution of this injustice.

  6.6.43  To achieve it through national insurance contributions the contribution would be applied to all forms of income and increased by whichever is the lesser of a flat rate equal to the citizen's income or (100-X) % of actual income where X is the "earnings rule" figure.

  6.6.44  This would be the simplest and least visible of the options. If citizen's income for employed people were paid through employers, this option would, for people whose salary exceeds the citizen's income, appear simply as a book keeping transaction. Identical sums would be credited to their pay slip as citizen's income and deducted as a national insurance surcharge.

  6.6.45  On the other hand precisely because it would be so invisible to the majority of the population it might well fail to capture hearts and minds effectively.

  6.6.46  To recoup it through wage adjustments there would be a once and for all statutory adjustment reducing all wages by whichever is the lessor of a flat rate equal to the citizen's income or

(100-X) % of actual income where X is the "earnings rule" figure. Taxation of industry would be increased to recoup for the Exchequer the money which industry saves by this adjustment. Anomalies in the labour market created by the adjustment would subsequently be resolved over a period of time by collective bargaining.

  6.6.47  This, coupled with abolition of the benefits that a citizen's income replaces, would achieve claw back from people who either have a single job as their sole income, or who are dependent entirely on benefit, or who have a single job with a wage exceeding the citizen's income.

  6.6.48  It would not achieve full claw back from those with pure investment incomes, self employed people, or people with investment incomes and a wage less than the citizen's income.

  6.6.49  It may achieve excessive claw back for those with more than one job or those who derive their income partly from a wage and partly from an abolished benefit.

  6.6.50  Special provisions would need to be made for these anomalies.

  6.6.51  This would be the most complex of the methods, the most visible, and the most sensitive.

  6.6.52  It would, however, have the following advantages:

(a)  by rendering explicit the very low sums which low paid people retain from their wages it might well stimulate action on low pay;

(b)  by overtly introducing wage reductions and ensuring that the money is recouped for the Exchequer it would prevent employers covertly shifting costs to the Exchequer;

(c)  by rendering available a large sum of money to be withdrawn from industry by taxation it would open the way for a new system of taxation to be introduced, for example one based on social and environmental audit;

(d)  if the taxation of industry were divorced from numbers of people employed capital intensive industries would have to make their full contribution to sustaining the standard of living of the population, and this would benefit labour intensive industries;

(e)  by reducing the cost of labour to the employer it would stimulate job creation;

(f)  the reduction in the cost of labour would reduce the cost of public services. Public services would be treated as part of industry and the money saved recouped by budgetary reductions in lieu of taxation. Without in any way affecting real levels of public spending this would diminish substantially the headline proportion of GDP spent on public services. However capital intensive industries are to bear a greater part of the burden of supporting the population and labour intensive industries are to benefit correspondingly. The public services would fall in this category and would therefore retain some of the windfall savings as an increase in real budgets. Hence real budgets would rise and headline proportion of GDP spent on public services would fall;

(g)  by involving everybody in the process of introducing the new system it would make very clear that change had occurred;

(h)  because this system would alter the way that employers and employees perceive wage rates, and because its reversal would be as complex as its introduction, it would be much more difficult to reverse;

(i)  once people had adjusted to the once and for all wage reduction this system would not entail high rates of visible deductions from income. It would entail high rates of taxation of industry but this would be matched by low labour costs. It would also entail sharp contrasts between British and overseas wage rates but these would be made up for by the citizen's income.

  6.6.53  It would be possible to combine these methods, each being applied only to the extent necessary to achieve a proportion of the claw back.

  6.6.54  For example if it were thought to be unreasonable to tax the lowest band of income at more than 40 per cent, or to increase national insurance contributions by more than five percentage points, the proportionate contribution of taxation and national insurance as claw backs could be limited accordingly and wage adjustments/industrial taxation used to make up the difference.

  6.6.55  Whilst this would combine at least part of the benefits of each method and dilute their disadvantages it would also be unnecessarily complex, and would, at least partially, dilute the benefits of each as well as the disadvantages.

The Economic Effects of a Citizen's Income

  6.6.56  The introduction of citizen's income is not simply a social policy—it is a significant package of economic adjustment.

(i)  The system itself is a redistribution of income to the poor.

(ii)  It also represents substantially increased security which may diminish people's need to save.

(iii)  Greater security is likely to alter people's attitude to work. People would have more freedom to choose to make their contribution to society through voluntary work or creative activities rather than through paid work.

(iv)  This in turn will shift the balance of the labour market in low paid work. If the loss of such work represented a much smaller fall in the standard of living of the individuals involved—a loss of the jam rather than of the butter and half the bread—it would be less likely that people would accept dangerous or unpleasant working conditions or work systems which lack dignity.

  6.6.57  The above changes are implicit in the system of citizen's income however it is organised. There are five further economic effects which might or might not occur dependent upon the claw back methods used.

(v)  If the opportunity is taken to adopt a claw back rate for low income significantly less than that in current welfare benefit earnings rules the poverty trap is eliminated and an incentive to work created.

(vi)  If the opportunity is taken, as part of the process of funding the citizen's income, to abolish certain tax reliefs which are generally acknowledged to be distorting a simpler tax system is created.

(vii)  If the citizen's income to homemakers without paid work is paid directly and recovered from general taxation, rather than clawed back in any specific way, there is a shift in the balance of economic power within the families affected comparable to that of a "Wages for Housework" policy.

(viii)  If the opportunity is taken to shift labour costs from wages to taxation and then to divorce that taxation from numbers of people employed there is also a fall in the marginal cost of labour. This would benefit labour intensive industries at the expense of capital intensive industries.

(ix)  If the new system of industrial taxation necessary for the above point is a system which embodies social audit it will benefit socially responsible industries at the expense of socially irresponsible industries.

  6.6.58  In considering the economic effects of a citizen's income it is therefore necessary to consider;—

(a)  the economic effects of redistribution of income to the poor;

(b)  the impact on the incentive to work;

(c)  the creation of incentives to "socially useful" rather than "wealth producing" activity;

(d)  the effect on the competitiveness of British industry;

(e)  the effect on the pattern of investment.

  6.6.59  Conventional views would hold that;—

(a)  the redistribution of income to the poor would be damaging to incentives;

(b)  the reduction in the impact of non employment would produce a disincentive to work and an increase in parasitism;

(c)  a shift of labour from the production of goods to socially useful activity would produce a burden on the wealth creating sector which ultimately would diminish the power of society to pursue social goals, thereby more than eliminating the apparent social gains from socially useful work;

(d)  Britain cannot afford a system which imposes on its employers burdens that its competitors do not impose;

(e)  any shift in the pattern of investment produced by this package of economic adjustments would be a market distortion and therefore of net disbenefit.

  6.6.60  We believe that these conventional views are in each respect wrong.

  6.6.61  We believe that the relief of poverty and the promotion of greater economic security can be an engine of economic growth by increasing consumer spending. Consumer confidence will be increased and the needs of the poor will be expressed as demand instead of lacking expression on the market.

  6.6.62  This is an unashamedly Keynesian position. Keynesian policies were based on the belief that in a state of recession the injection of money into the economy would produce growth rather than inflation. The money would correct an artificial shortage of demand and thereby stimulate the economy to produce the wealth necessary to back the money that had been injected. This belief has been widely abandoned because of its failure in the 1970s. Implicit in Keynesian theory was the idea that the money injected would be spent on meeting the real needs of real people. Indeed the mechanism by which Keynesianism successfully worked for over a quarter of a century was to pay people to undertake programmes of public works, or other programmes of social value, thereby both meeting a social need and also turning into demand the needs which those people were unable to express as consumers whilst unemployed. Keynesian theory assumed that money injected into the economy would be spent. And when it was given to the poor this was a fair assumption. Unfortunately this assumption was not made explicit and the idea began to develop that any method of injecting money into the economy would have the same impact. Reducing taxes on the rich, or spending money on subsidies to produce things that nobody wanted were thought to be just as valid a way of injecting money. All that was necessary was an unbalanced budget, and since the poor had ceased to be a high political priority these other methods were, on the whole, preferred. It is hardly surprising that money given to the rich will be more likely to be saved than spent. This simple common sense statement is only rendered inexplicable when it is turned into the language of economists and called a "shift in the savings ratio", which sounds like something weird and unpredictable, and can therefore be presented as some mystical flaw in the Keynesian idea. Since "unpredictable shifts in the savings ratio" is the explanation given for the failure of Keynesianism in the 1970s we would advance the proposition that money given to the poor will be spent not saved, and that it has always been true that giving more money to those who cannot afford to express their needs as demand will lead to increased demand. This is why Keynesianism worked for a quarter of a century and it was not Keynesianism that failed in the 1970s but some silly caricature of it.

  6.6.63  It should also be borne in mind that greater security of income will also lead to a greater consumer confidence. There are many people who can today afford to buy things that they need but do not do so for fear that they may lose the jobs and need the money as savings. Greater security will strengthen their willingness to spend.

  6.6.64  One of the objections to a citizen's income is that it will diminish the incentive to work if people can live an acceptable lifestyle without doing so. This principle is as old as the Speenhamland system. It has been the cause of a great deal of gratuitous cruelty in British social policy over many years from the harshness of the workhouse in the 19th century to the inhuman administration of the income support system today.

  6.6.65  The contrary proposition is that on the whole people will choose to work because work gives rise to social status, to the structuring of time and to social interaction and because people have a strong need to be of value to society. Entrepreneurs and professionals continuing their work long after they have earned enough to retire, voluntary workers, people working for pay barely higher than the dole, and women who choose to work even though the bulk of their income is spent on childcare are all sources of data for the concept that people will choose to work. Little data has been advanced to support the proposition that people are inherently lazy, and the examples of such laziness are usually isolated examples of individuals who are deeply alienated from society, often for reasons that are not difficult to understand.

  6.6.66  A citizen's income would have little impact upon the incentives to work of those whose incomes are high since it would form only a small part of their income. And for those whose incomes are low the elimination of the poverty trap would in fact be an increase in work incentives.

  6.6.67  In any case it would be desirable to build into the concept of a citizen's income a system which created an incentive to engage in a meaningful contribution to society through making part of the income dependent on such a contribution. Voluntary work and formal education could be incorporated by treating them as employment at zero wages. Housework could be incorporated by allowing excess hours worked by one member of a household to be transferred to other members of the household and by making allowance for carers and parents. It would be necessary to work out some system for incorporating informal education and creative activity. Unemployed people could qualify for the full payment by engaging in voluntary work or education. People who are sick or above retirement age would be exempt from the obligation to contribute to society and would receive the full payment automatically.

  6.6.68  The differential between the level of citizen's income payable as of right and that payable only to those engaged in a meaningful contribution to society could be adjusted until the proportion of the population electing for the lower payment achieved a fixed figure—perhaps 5 per cent, perhaps 1 per cent—or until the differential was completely eliminated without this figure being exceeded. If we are right in our belief that people would normally choose to contribute to society the differential would become small or non existent. If we are wrong this system would automatically accommodate for that situation.

  6.6.69  If voluntary work became an acceptable way to contribute to society and was linked to an acceptable citizen's income it is likely that it would increase. To the extent that it substitutes for unemployment this would be an extremely positive step both for the individuals concerned and for society as a whole which would benefit from their work. To the extent that it substitutes for paid employment there might arise the question of whether this deprives industry of needed workers.

  6.6.70  Goods and services produced by industry are not the only source of well being and the benefits produced for us all from the increased voluntary work would need to be weighed in the balance against any lost production.

  6.6.71  But in any case the amount of such lost production is probably exaggerated.

  6.6.72  The fact that individuals have the choice of voluntary work rather than employment would alter the nature of managerial relationships at the lower end of the labour market. No longer would workers be compelled to accept undignified, dangerous or unpleasant work for fear of losing the source of their basic standard of living.

  6.6.73  Managers would need to change their approach—attracting workers by paying attention to their needs and creating pleasant and inspiring working conditions.

  6.6.74  For too long British management has been featherbedded by outdated concepts of managerial authority and by an attitude that sees safety and quality as unnecessary costs. This attitude represents a subsidy—a subsidy paid with our environments, and with the health of workers. Like all subsidies it drives out better quality investment.

  6.6.75  The shift in attitudes towards investing in people, in safety and in quality go hand in hand. They will be overwhelmingly beneficial to British industry and the shoddy unsafe back street sweat shops that go out of business will not be missed.

  6.6.76  It is important to appreciate that the so called burdens of tax and labour costs upon industry in fact represent the mechanism by which society draws the benefits of wealth creation in terms of social improvement and individual living standards. It is therefore rather irrational to increase wealth creation by diminishing the enjoyment of that wealth.

  6.6.77  Even ignoring that point, however, we challenge the idea that the package of changes produced by a citizen's income would in any way diminish the overall competitiveness of British industry.

  6.6.78  The competitive position of British industry is not determined by any particular single burden but by the total of the burdens upon it. The total tax and labour costs imposed upon the whole of British industry will alter under our proposals only by the £19 billion necessary to abolish poverty and even that only to the extent that this burden is imposed upon industry rather than achieved by redistribution of wealth, and even then only to the extent that we are wrong in our belief that it will be offset by Keynesian growth.

  6.6.79  It is true that some of the models we have discussed would increase the burden on some industries. But if the burden as a whole is unchanged this means that other industries would benefit.

  6.6.80  It might even be argued that if the distribution of burdens in this country differs from that in other countries there will be more companies in other countries which experience an incentive to relocate to Britain than there would be companies in this country experiencing an incentive to relocate out.

  6.6.81  A system which:

—  lowered wages and hence the marginal cost of labour;

—  correspondingly increased the burden of taxes on industry so that the overall tax and labour cost burden was unchanged;

—  distributed the extra tax burden according to social audit;

—  would benefit socially undamaging labour intensive industries such as personal services, public works or craft industries;

—  adversely affect socially damaging capital intensive industries such as highly automated polluting industries (nuclear power for example);

—  have mixed effects on labour intensive socially damaging industries, such as smokestack industries. Lower wages would benefit them, social audit would harm them, but there would be a pressure to realise the benefits by eliminating the source of the social charges. Improved environmental and social impacts would replace redundancies as the main way to reduce costs and gain competitive advantage;

—  have a neutral effect on capital intensive socially undamaging industries such as electronics.

  6.6.82  We see no reason to suppose that this shift in the balance of economic activity would adversely affect the standard of living of the British people—certainly any effects would be marginal.

  6.6.83  Whatever marginal impacts there might be on the standard of living there would be overwhelming positive effects on the quality of life.

7.  MULTIDISCIPLINARY PUBLIC HEALTH

7.1  Introduction

  7.1.1  There is much discussion at present of multidisciplinary public health.

  7.1.2  Public health is practised at several levels. Firstly there are those whose work improves health but who do not need to perceive the broader public health picture or even to recognise it. This group ranges from binmen to firefighters to health professionals. Secondly there are those who carry out a specific health improving function, and need to know how it fits into the broader picture, but who do not need to concern themselves with matters outside their own function. Teachers including health education in their materials, those who operate a screening programme, or exercise promotion staff would fit into this category. Thirdly there are those who concern themselves with the totality of a particular health problem and fourthly there are those whose job is to maintain the operation of the entire public health system. The third and fourth groups are appropriately called public health professionals.

  7.1.3  There are a number of different groups of public health professionals and the relationship between them and the way they work together needs to be addressed.

  7.1.4  This is often presented as bringing all the public health professions together into a single new profession.

  7.1.5  Often however discussion excludes some key professions, such as public health nursing and environmental health, and seems to do little to preserve the traditions of any of the professions or to recognise their different perspectives.

  7.1.6  We believe that multidisciplinary public health should mean a family of professions, each with its role and proud of its traditions. It should not mean mashing the different professions together into a soup tasting of the lowest common denominator. As outlined in section 5.3 each of the professions has distinctive traditions, strengths and contributions. There are examples of the functioning of public health as a multidisciplinary family in some leading edge public health departments.

  7.1.7  In this section of our evidence we:

—  restate our commitment to multidisciplinary public health

—  summarise the traditions of the different public health professions

—  argue that each of these traditions is important and that attempting to merge them in a single professional group is unlikely to enhance them

—  suggest that there are better ways to improve the career prospects of non medical public health professionals

—  outline our belief in a family of public health professions

—  suggest that it would be sensible to establish mechanisms for transfer between these professions

7.2  Our Commitment to Multidisciplinary Public Health

  7.2.1  The MPU has a long tradition of support for team working between the different health professionals. We are the only medical organisation to be part of a wider trade union representing a range of health professions. We have long advocated simpler interchange between health professions including the power of exceptional licence included in our proposed Public Health Act.

  7.2.2  As long ago as 1980, long before it was fashionable, we advocated improved career structures for non medical public health professionals.

  7.2.3  We remain firmly committed to the belief that a range of professions have key roles in the public health endeavour.

7.3  The Traditions of the Public Health Professions

Public Health Medicine

  7.3.1  Research by the BMA has shown that the majority of public health doctors perceive themselves as change agents and entrepreneurs for health and chafe at the restrictions of NHS bureaucracy.

  7.3.2  Other research has shown that local authorities value the decisive and authoritative nature of advice from public health doctors.

  7.3.3  Doctors remain one of the most trusted of professions in opinion polls even after a somewhat unfortunate period. One of the reasons for this is that doctors have a strong tradition of independence and honest advice.

  7.3.4  Public health doctors are able to discuss health service issues with other doctors from the basis of a shared professional background.

  7.3.5  The medical profession is at times an assertive and single minded body of people. Outsiders might even call it unreasonable. George Bernard Shaw pointed out that reasonable people accommodate to the world and unreasonable people expect it to accommodate to them, so all change is brought about by unreasonable people. Single minded assertiveness is needed in public health at any time. The very existence of public health medicine has been under attack for 150 years (as our early quote from "The Times" about Dr. Snow points out) and it will be under attack for a further 150 years because it speaks for a social value that many would wish to ignore.

  7.3.6  We believe that public health doctors are, by virtue of their professional standing, training and traditions, equipped to:

—  be the advocates for public health in those settings where it is important that the individual be trusted as a doctor rather than as a public official and should have a background of honest assertiveness

—  be the advocates for public health within the medical profession

—  be uniquely qualified to carry out needs assessment as individuals since they bring with them an understanding of disease and medical practice. Professions without this background need to work in teams where the clinical background is supplied by others.

—  be well placed as an honest broker between primary and secondary care clinicians in implementing the clinical modernisation which is at the core of the NHS Plan.

Public Health Nursing

  7.3.7  Health visitors originated in the local authority health departments as lady sanitary inspectors. There was for some time in the early years of the century a debate as to whether they should be nurses or simply specialist sanitary inspectors, a debate which nursing won.

  7.3.8  For many years health visitors practised as public health practitioners working within the setting of the home. They came to have an understanding of the place of families and communities both as sufferers from ill health and as potential agents for tackling it.

  7.3.9  In the 1980s and early 1990s health visitors were increasingly forced to conform to concepts of nursing which underplayed their public health traditions and saw them in many ways as some kind of specialist children's nurse.

  7.3.10  Despite this their representative organisation, the Health Visitors' Association (now Community Practitioners' & Health Visitors' Association) continued to be a mainstay of the public health movement and student health visitors continued to be taught public health skills. A number of experiments in the 1990s demonstrated that these skills could still be used in fields like community development or neighbourhood public health.

  7.3.11  This understanding of public health at the grass roots is the key contribution that public health nursing brings today to public health.

  7.3.12  Their standing in the primary care team and in the nursing profession is also an important contribution.

Health Promotion Specialists

  7.3.13  Health education was a relatively low status activity in the pre 1974 system and one of the few benefits of the 1974 reorganisation was that the NHS established Health Education Departments which developed into Health Promotion Departments.

  7.3.14  The original professional skill of this professional group lay in marketing and in lifestyle modification and they still carry the greatest expertise in this aspect of the public health body of knowledge.

  7.3.15  Ultimately however Health Promotion Departments grew beyond the original role in health education and came to be the focus for the organisation of health promotion programmes.

  7.3.16  This skill in programme management neatly complements the predominantly visionary and entrepreneurial skills of the public health doctors and the practical grass roots professional skills of the public health nurses.

Environmental Health Officers

  7.3.17  We have discussed the history of environmental health in section 3.5 of this evidence.

  7.3.18  In that section we pointed out that environmental health officers bring a perspective to public health based on the technical assessment of hazards and the use of enforcement of legislation to control them.

Public Health Scientists

  7.3.19  The academic discipline of social and preventive medicine was one of the founding disciplines of public health medicine. It brought with it to public health a world renowned standing for British epidemiology and British medical sociology. This has contributed to the academic rigour and analytical skills of public health medicine.

  7.3.20  Social and preventive medicine was a multidisciplinary speciality comprising public health doctors, other academic disciplines and clinical specialists who carried out epidemiological research. Only the first group were found a place in the new medical speciality.

  7.3.21  As a result a significant academic tradition has been left separated from the scope for practical application and separated from a significant group of its practitioners.

  7.3.22  The Faculty of Public Health Medicine is now belatedly bridging the gap.

Clinical Epidemiology

  7.3.23  Clinical specialists carrying out epidemiological work were another group affected by the way the 1974 reorganisation tore apart a British academic success story.

  7.3.24  The tradition of all doctors concerning themselves with public health issues is a valuable distinctive feature of British medicine. It needs to be built upon.

  7.3.25  There is also scope for clinical epidemiology in other health care professions.

  7.3.26  Settings should be established in which clinicians who have been trained in certain public health skills can apply that knowledge within fields directly relating to their own clinical area.

  Cardiologists who contribute to control of heart disease or dieticians who contribute to food policy would be examples. (In the case of dietetics there is also a need to involve nutritionists as well as dieticians).

Health Economists

  7.3.27  A great deal of work has been done in academic departments on resource optimisation in health services but it has had virtually no systematic application within the NHS.

Human Ecologists

  7.3.28  In recent years local authorities have developed structures for addressing environmental initiatives such as Agenda 21 or sustainability. These initiatives are central to public health. A new professional group is emerging with considerable skills in these areas. This group moves beyond the technical enforcement oriented perspective of environmental health and is more visionary, long term and policy-oriented. Although a variety of names have been used we call this group "human ecologists".

7.4  Why Creating a Single Public Health Profession Will Not Work

  7.4.1  No one person is capable of fully grasping the full range of perspectives that the above traditions draw together. If we try to create a single public health profession there is a danger that all these rich traditions will be impoverished.

  7.4.2  More likely some will dominate and some will lose out.

  7.4.3  There is some uncertainty as to whether the Government has entrusted the creation of a single public health profession to the Faculty of Public Health Medicine or to the Health Development Agency. Each can point to clear statements entrusting it with the role.

  7.4.4  The HDA, entrusted with a task of developing the public health workforce, is approaching the task through a process of skills audit and vocational development which we believe has a bias that could ultimately base public health practice on the principles of health programme management. This could disempower other perspectives and seriously damage independent professional advocacy.

  7.4.5  The Faculty of Public Health Medicine, entrusted with developing standards for public health specialists, is approaching the task through a process of professional development which we fear could ultimately base public health practice upon the underlying principles of public health medicine. Ultimately therefore it could peripheralise other perspectives, in which case it would reinforce medical hegemony by allowing a few non doctors to join the group.

  7.4.6  It would be a disaster if either of these projects were to have the effects that we fear.

  7.4.7  It would be even more of a disaster if the fall out of them coming into conflict, as they inevitably will, were to embitter relationships between traditions which should complement each other.

  7.4.8  We note the concern of the Royal College of Nursing that public health nurses are being excluded from this process. They are indeed. In fact they are being generally ignored, or referred to as support workers.

  7.4.9  We resent this. These are valued colleagues of ours, whose perspective is as important as ours and who are needed to complement us.

  7.4.10  We regret however that the RCN has chosen to enter the fray by advocating that public health be reshaped along a grass roots perspective. We wish that instead of entering the fight they had thrown a bucket of water over it.

  7.4.11  Environmental health officers are also being ignored.

  7.4.12  We believe that the attempt to create a single public health profession should be abandoned forthwith and we should concentrate rather on glorying in the diversity of the different and complementary traditions.

7.5  The Career Structure for Non Medical Public Health Professionals

  7.5.1  An important factor in the drive to demedicalise public health is the poor career structure for non medical public health professionals.

  7.5.2  This needs to be addressed but there are simpler and better ways which do not involve destroying old traditions in the process.

  7.5.3  We believe that for most public health doctors the natural pinnacle of their career will be the role of County Medical Officer or Borough Medical Officer which we have described in our main evidence as taking over the professional functions of a Director of Public Health.

  7.5.4  We believe that for most public health nurses, environmental health officers and health promotion specialists their ambition would be to head their profession within the new Health Act partnerships that we envisage PCTs and local authorities forming. These form valuable and important roles heading up key perspectives of the public health endeavour.

  7.5.5  Beyond these uniprofessional posts, custodians of a key part of the public health heritage, the post of Director of Public Health of a health authority could, once its specifically professional medical functions had been transferred to the County and Borough Medical Officers, be a multidisciplinary post needing doctors in the team but not necessarily in the lead. And all public health professionals could legitimately aspire to be Chief Executive of a health authority.

  7.5.6  The post of Professor of Public Health is appropriately open to medical and non medical public health scientists alike and so should be the senior research and health analysis posts in the regional and health authority tiers of the NHS which we believe to be the natural leadership roles for public health scientists. Networks need to link these leadership roles with people working on research and analysis at local level. A clear career path can be created using the clinical scientist grading structure, the most senior points on which are generally acknowledged as consultant equivalent.

  7.5.7  This is a much more effective way to overcome the career structure problems that have led to the demand for a new profession.

7.6  A Family of Public Health Professions

  7.6.1  There are two models of multidisciplinary public health. The model in which all the professional groups are mashed together into a liquefied traditionless mass we call the public health soup model. Our model is the model of a family of public health professions, respecting each other's complementary skills and glorying in each other's histories, successes and traditions.

  7.6.2  We share this model with the BMA, but we may differ from the BMA when we say that this family should not have a head profession, but that the different professions are complementary.

7.7  Transfer Between Professions

  7.7.1  Although the priority at the moment is to restore the traditions of each professional group, we have always argued that there should be flexibility in interprofessional relationships and there should be scope to transfer between the different health professions, with appropriate additional training but with recognition for the knowledge and skills already acquired. This should apply in all health professional areas, including public health.

  7.7.2  Elsewhere in this evidence we have argued for the GMC to have a power of exceptional licence for individuals who are able to practice appropriately in a specific field of medicine, and we have argued for the UKCC to reopen the non nursing route of entry to health visiting. This would ensure that public health professionals wishing to retrain in public health medicine or public health nursing need not return to the very start of medical and nursing careers. We envisage similar arrangements elsewhere—for example, rehabilitation, so this should become an exceptional but not abnormal route into professional practice.

  7.7.3  If proper career structures are established in all the public health professions we believe that interprofessional transfer will be highly exceptional.

  7.7.4  It is worrying that non medical public health professionals prefer to seek access to the work of public health doctors than to develop their own complementary and equally important and challenging roles. This is understandable given the different career structures. However there is no other rationale for it and it should be seen as the consequence of a failure to develop other professions rather than as an aspiration that has value in its own right. The solution is a proper career structure in all areas of public health practice.

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Prepared 28 March 2001