APPENDIX 13
Supplementary memorandum by United Kingdom
Public Health Association (PH 23A)
1. INTRODUCTION
1.1 As an independent UK-wide voluntary
association working for improved health and well being through
developing and promoting policies which provide the conditions
for a healthy life for all and support sustainable development,
the UKPHA welcomes the opportunity to amplify on points made in
our Outline Submission last July, particularly in relation to
certain aspects of the NHS Plan, which was not available at that
time. We have organised our evidence in line with the Committee's
terms of reference but start by offering the following definition
of public health:
1.2 Public health describes the health circumstances
of a society and the most effective means of protecting and improving
it. Public health encompasses the science, art and politics of
preventing illness and disease and promoting health and well-being.
It addresses the root causes of illness and disease, including
the interacting social, environmental, biological and psychological
dimensions, as well as the provision of effective health services.
Public health addresses inequalities, injustices and denials of
human rights which frequently explain large variations in health
locally, nationally, and globally. Effective public health works
through partnerships that cut across disciplinary, professional
and organisational boundaries and seeks to eliminate avoidable
distinctions. It relies upon evidence, judgement and skills and
promotes the participation of the populations who are themselves
the subject of policy and action.
2. CO -ORDINATION
BETWEEN CENTRAL
GOVERNMENT, LOCAL
GOVERNMENT, HEALTH
AUTHORITIES AND
PCG/TS IN
PROMOTING AND
DELIVERING PUBLIC
HEALTH
2.1 We welcome acknowledgement in the NHS
Plan of local authorities' new powers to improve the social, environmental
and economic well being of their communities, and we call for
the modernisation agenda to recognise the need for more coherence
in related policy initiatives. The Government's public health
strategy White Paper Saving Lives: Our Healthier Nation
is a broad-based health plan for England. It should now be brought
on to the modernisation agenda, and fully integrated with other
plans including community plans, health improvement programmes
(HIMPs) and local strategic partnership as well as the NHS Plan
itself and the national and local implementation plans being developed.
We believe that this will engender greater clarity about priorities
and funding for health improvement and for reducing inequalities
at national, regional and local levels.
2.2 Our members around the country tell
us of the large amounts of effort invested and resourcefulness
exercised by organisations and individuals attempting to join
up the plethora of national initiatives and plans at local level.
The extent of and pace at which local planning is becoming more
integrated between local government and NHS varies greatly across
the country but in general appears to be happening in most areas.
It could move further and faster if there were greater collaboration
at regional and national levels, within and between government
offices and departments, for example, through routine issuing
of draft and substantive guidance concerned with local planning
to both local authorities and NHS bodies, and cross-referencing
within guidance of key local plans. We would also like to encourage
such initiatives as joint performance review at regional level,
the issuing of joint regional planning guidance and secondment
schemes.
2.3 We consider, furthermore, that the NHS
Plan may betray the misplaced belief that setting up new structures
and initiatives, together with a raft of monitoring, audit and
inspection arrangements to assess performance, will ensure that
change will occur. We assert that, while this might yield the
semblance of change, it is arguable whether real, sustainable
change will result. We would rather see existing structures and
processes being made to work, rather than yet more new initiatives
and structures.
Public health is cross-sectoral
2.4 We believe that public health is an
approach, rather than a particular set of processes, and one in
which a variety of agencies and individuals play a role. Important
work has been undertaken to define these roles, including the
long overdue Chief Medical Officer's report on the public health
function, but we consider that much of this seems to focus on
the NHS. While we agree that the NHS clearly has a very significant
part to play, there is also a key role for local authorities and
one which is far wider than social care. The public health contribution
of local authority services such as anti-poverty strategies, regeneration,
leisure, housing, environment and community education is in our
view too often ignored or undervalued, something which its inclusion
in Best Value or performance management processes could alleviate.
Preventative structures and policies
2.5 Saving Lives: Our Healthier Nation contains
a number of important proposals for a strengthening public health
including partnership across government, individuals and communities
to co-ordinate and unify public health action. In our view, this
promise remains to be fulfilled and should be given high priority.
We continue to support this three-way partnership and regret that
the importance of this approach was also not mentioned in the
NHS Plan and linked to its various proposals, including for example,
the Healthy Communities Collaborative, about which we look forward
to learning more. While concerned that the NHS Plan focuses mainly
on individual lifestyle factors at the cost of interventions at
population level, we support the preventive role that individual
practitioners such as pharmacists can play through providing informal
health information and promoting effective lifestyle interventions
for the population as a whole, as well as those affected by inequalities.
2.6 We would also not wish to overlook,
in a public health and preventative approach, the place of the
individual as user of the full range of local authority, NHS,
voluntary and private services. We assert the importance of cross
sectoral collaboration and inclusive service design as ways of
reducing inequalities, particularly for those having difficulty
accessing services.
2.7 Without an effective cross-sector infrastructure,
public health and prevention strategies will remain largely ad
hoc, piecemeal and marginal to health care. We believe that a
highly credible set of cross-sector institutional arrangements
is required to achieve this, working from an understanding of
the root causes of health not of disease, evidence-based and able
to operate effectively across organisational boundaries to promote
changes which capture the imagination of the ultimate beneficiaries.
2.8 The long-term benefits of a variety
of preventative policy options must be properly modelled, based
on current knowledge and assessed in the context of other potential
health benefits. If, as seems likely, current patterns of public
and private health care expenditure predict an impact upon health
that can only be justified in the interests of expedient short-termism,
then this should become a matter for political resolution. At
present the prevention agenda is mostly obscured by other more
immediate concerns, but once public gains can be set against current
losses in a rational and well-informed debate, we believe that
the issues, and the case for prevention, become clearer.
Workforce issues
2.9 Effective public health work clearly
requires a dedicated and knowledgeable workforce ancillary to
nobody and not dominated by any one discipline or setting. Such
a workforce must be drawn from a variety of disciplines, function
in a variety of sectors and settings, and work participatively
with the communities it serves. At present, the public health
workforce which, in our view consists of a wide range of practitioners
across the local authority, voluntary and health sectors, is divided
and disparate with many of its key practitioners cut off from
each other.
2.10 We have been greatly encouraged, therefore,
by the proposals in Saving Lives: Our Healthier Nation for
enabling people from a wide range of professional backgrounds
to be trained and accredited, enabling effective leadership in
public health based entirely on public health competence. These
proposals are being taken forward by work at the Faculty of Public
Health Medicine and in the Tripartite Agreement with the Multidisciplinary
Public Health Forum and Royal Institute for Public Health and
Hygiene, and by Healthworks UK.
2.11 However, we have concerns that some
of the momentum may have been lost, the delay in publication of
the Chief Medical Officer's report not helping in this important
area. In particular, we are concerned that the necessary legislation
to enable comparability among public health specialists, whether
or not qualified in medicine, is not yet contemplated. Similarly,
little progress has been made in relation to how training will
be funded or on accreditation procedures. We were disappointed
that the NHS Plan made no mention of these developments or needs
when it is clear that plausible increments in effective public
health could be responsible for much more health gain than any
plausible increments in health care.
3. THE INTER-OPERATION
OF HEALTH
ACTION ZONES,
EMPLOYMENT ACTION
ZONES, HEALTHY
LIVING CENTRES,
EDUCATION ACTION
ZONES, HEALTH
IMPROVEMENT PROGRAMMES
AND COMMUNITY
PLANS
3.1 We consider that central guidance must
make links between community plans and HIMPs explicit, and ensure
that, at the very least, they join up. There are currently expectations
of two local over-arching strategic plans for health, well-being
and quality of life: one free-standing and led by health, and
the other part of a much wider strategic agenda, within which
health is one element, led by local government. While the Health
Act 1999 requires other partners including local authorities to
participate in the preparation and review of HIMPs, there is no
reciprocal obligation for the NHS to participate in community
planning in the Local Government Act 2000. This seems surprising
as the HIMP logically falls within the much wider community plan;
the weaker provision in the Local Government Act seems to undermine
the community plans as the main local plan.
3.2 In documents where there are clear linkages
made between plans, as in the Neighbourhood Renewal Strategy and
in the NHS Plan in its reference to Local Strategic Partnerships,
the issue of coterminosity, or indeed the lack of it, has not
been adequately addressed. Local strategic partnerships work best
in areas where the local authority and health authority are coterminous,
although there are clearly issues around primary care groups and
trusts, the new primary care organisations, which may not relate
to either population. Developing a single strategic umbrella in
non-unitary authority areas is complex and more guidance may be
needed about how this can be successfully achieved. We consider
that attention should be given to establishing the optimum size
of population for the effective development and performance review
of over-arching strategic plans, such as community plans and health
improvement programmes, while maintaining local sensitivity at
PCG/T and lower levels of local government.
Community involvement
3.3 We are keen not to overlook lessons
from history when new area-based initiatives such as Health Action
Zones, Healthy Living Centres and Surestart are being developed.
There is a wealth of experience from the Health For All (HFA)
projects around the country, and we are not sure how much of that
is being usefully linked into or integrated with these new initiatives,
particularly in relation to community participation and involvement.
HFA is an approach based on fundamental public health concepts
of partnership, empowerment, participation, equity and primary
care organisations needing and being expected to work in a much
more community development, bottom up mode than GPs, in particular,
have been able—or desired—to do in the past.
3.4 One of our main concerns about all these
new strategic planning processes is the extent to which they are
in reality remote from local people's own perceptions, hopes and
aspirations for health in their own lives, their families and
local communities. Getting closer to local people and enabling
them to inform service planning is an explicit requirement of
the local government modernisation agenda, particularly in relation
to Best Value. Extending and using these principles within the
NHS could bring the two different organisational cultures closer
together and thus strengthen public health partnership.
3.5 Ultimately, we want to see plans and
processes which, like HFA and community development, are not only
cross-sector but able to work at the scale and pace of real people,
so that the local vision which emerges is truly theirs. It is
important that these plans have full local expression, identification
and ownership. We suggest that one way of achieving this would
be for those responsible for leading the development of plans
to brand them in the light of local identities and aspirations.
4. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
4.1 Many people look to the new agency to
define "what works" at the national and regional levels.
This is an important task which we support. However, the task
is both large and difficult. Many interventions are long term
with results and outcomes which may take years to establish; on
the other hand projects with immediate results may not be suitable
for national rolling out because of important local factors. We
believe that these factors underline the fact that the Health
Development Agency should not be drowned by expectations; nor
should innovative and good practice learnt locally be suspended
because national validation is required.
4.2 We greatly value the role the Agency
has already begun to play successfully in bringing together and
promoting more collaborative working between key national, regional
and local partners in public health. Its pro-active and flexible
approach is challenging longstanding cultural and organisational
barriers and creating new opportunities and networks to support
evidence-based health improvement and HIMPs. We look forward particularly
to the development of close links between Agency and UKPHA regional
structures in pursuing our common aims.
5. THE ROLE
OF PCGS
AND PCTS
5.1 We are concerned, although not altogether
surprised in view of the nature and scale of the changes expected,
that the new primary care organisations are not yet delivering
on the wider public health role in the way envisaged in Saving
Lives: Our Healthier Nation. Furthermore, any attempts to
strengthen public health within primary care, through a variety
of named support and/or outposting arrangements, is having the
unintended consequence of fragmenting the existing health authority-based
public health function in some areas. There were recruitment problems
in the public health workforce even before the new primary care
organisations were set up. In particular, small health authority
departments—with or without vacancies—could find it
even more difficult to ensure sufficient critical mass to operate
effectively in terms of range of expertise, and in relation to
professional development and training, while also supporting primary
care—especially if this has to be geographical rather than
topic-based.
5.2 Such difficulties emphasise the importance
of moving rapidly forward the work to develop a skilled, multi-disciplinary
public health workforce through a national framework for training
and accreditation. Locally, however, there is scope for (relatively
scarce and more skilled) health authority public health specialists
to support and develop public health practitioners, such as local
authority and NHS community development workers, health visitors
and health promotion specialists, to realise the potential of
their relationship with and knowledge of practice and neighbourhood
population health need.
5.3 Although we believe that public health
has a very important place in primary care, it is apparent that
the narrow focus on primary medical care and health services is
dominating the agenda in most areas. Work to influence the wider
determinants of health in the local population is often missing
(with a few exceptions, usually funded through regeneration monies).
This is in spite of the efforts we know are being made, particularly
by lay PCG board members and the nurse board members, many of
whom are themselves public health practitioners with a commitment
to the wider public health agenda.
5.4 Also lacking is comprehensive linkage
between the new primary care organisations and the wider public
health role of local authorities, probably not helped by the requirement
for a social services rather than local authority representative
to sit on PCG boards. While some primary care organisations now
involve local government, for example as elected members appointed
to PCT boards as non-executive directors, this is not universal.
In our view this represents a missed opportunity for local government
and health to work together in engaging local people, thus avoiding
the danger of both independently setting out to do this, perhaps
with totally different groups, something which may be addressed
in the development of local strategic partnerships.
6. THE ROLE
AND STATUS
OF THE
MINISTER FOR
PUBLIC HEALTH
6.1 It is clear that this role has a particular
focus on Department of Health initiatives; we believe it must
become a truly trans-departmental role, and be led at Cabinet
level. This would allow the minister effectively to lead and co-ordinate
action on the wider influences on health across government departments.
We commend the model developed for the Social Exclusion Unit,
located within the Cabinet Office with a lead minister working
with all government departments. An equivalent Public Health Unit
would be established in the Cabinet Office and be led by the Minister
for Public Health to continue to develop a cross-sectoral and
trans-departmental national public health strategy. We would like
to see this strategy, and indeed the Chief Medical Officer's annual
report on the State of the Public Health, as was the Social Exclusion
Unit's report on teenage pregnancy, presented to Parliament by
the Prime Minister.
7. THE ROLE
OF THE
DIRECTOR OF
PUBLIC HEALTH
7.1 It is vitally important that the Director
of Public Health (DPH) is a suitably qualified person. It is not
necessary, however, that the DPH is medically trained but that
whatever their background the person occupying the role is supported
by a multidisciplinary team including experts in social science
and research methods, suitably medically qualified individuals
including consultants in communicable diseases, and statisticians.
The role should remain a statutory function, linked to a defined
population and a statutory body with a properly resourced public
health department (which could be a health or local authority),
thus ensuring a strong and independent voice for the DPH to challenge
any organisation or individual whose actions represent a threat
to the health to the local population.
7.2 The role of a Medical Officer of Health
in earlier times (by definition a medically qualified person)
was to report on local health trends and manage community health
services and environmental health services. The current fashion
of separating strategy or commissioning from management and provision
makes this older set of responsibilities unnecessary. However,
the problem with the older view is that it is too narrow also.
The tasks required of a contemporary DPH might include broader
environmental considerations, such as those advanced by Local
Agenda 21, anti-crime or local transport strategies. Indeed, it
should include all of these strategies advanced by a local authority
alongside NHS, voluntary and other partners in the local setting.
We propose not a resurrection of the older role therefore, but
a revival of the spirit of the older role updated for the modern
setting. It is important that the DPH is able to capture the local
imagination by, for example, working alongside citizen groups
and advising the local authority.
7.3 This also calls, therefore, for a local
strategy on information concerning health, well-being and quality
of life, where the DPH plays the role of advocate for local people
in rel of such issues with the local providers of information
services, whether local libraries, leisure services, or other.
It is also important that the DPH's lead be more carefully integrated
with the work of specialists in health promotion and that their
role influences the span of responsibilities, and the work methods
in turn, of the DPH. Clearly, the effective performance of this
role requires a multi-disciplinary, cross-sectoral approach.
- THE EXTENT
TO WHICH
CURRENT PUBLIC
HEALTH POLICY
IS REDUCING
HEALTH INEQUALITIES
8.1 Health inequalities take many years
to appear; they also take many years to correct. The long-term
nature of public health intervention is recognised by many and,
although we understand why there are short-term imperatives for
many public health and regeneration initiatives, we would encourage
a longer-term perspective. Within the national and international
picture, effective public health policies are a necessary but
insufficient condition for achieving a reduction in health inequalities.
We think that the Government should heed the advice of organisations
like UNICEF which are undertaking large scale international studies
of inequalities, particularly as they affect children. If the
main political parties were able to agree broad principles for
tackling inequalities based on this sort of evidence, there is
more chance that successive governments could work over decades
rather than, as now, over four or five year terms, with effective,
long-term strategies.
8.2 We welcome the attention given in the
NHS Plan to the NHS' role in improving health and inequalities,
but would argue that the NHS should not be seen as the major player:
of the 39 recommendations in the 1998 Acheson Report: Inequalities
in Health, only three directly concern the NHS. Some see the present
as a time when public health can be brought back into the mainstream
and out of the ghetto to which it became consigned when captured
by the NHS in 1974. Far from influencing the NHS agenda, public
health became dominated by a somewhat narrow, managerial agenda
focused mainly on health care. We should not forget the lessons
of history.
8.3 We were disappointed, however, that
the NHS Plan gives the impression that the most important role
the NHS can play is to increase access to services and screening,
particularly in disadvantaged areas, places less emphasis than
we would like to have seen on the wider partnership agenda. We
welcome the inclusion in performance management of local NHS action
in tackling inequalities and ensuring equitable access to health
care, but would wish to see the early implementation also of the
new single, integrated public health groups across NHS regional
offices and government offices to support this, ideally through
a joint performance framework, as well as wider cross-sectoral
initiatives.
8.4 Our members tell us that work on HIMP
local inequalities targets is on around the country but that adopting
targets which can be unambiguously linked to action plans and
outcomes is very difficult, even leaving aside the absence of
any national targets which might enable a more focused approach.
9. ALTERNATIVE
MODELS OF
PUBLIC HEALTH
PROVISION
9.1 Rather than promoting an alternative
model, we would support, through the proposals outlined above,
a strengthening of local government's historical role in public
health. We believe that the new power to promote well being in
the Local Government Act, set alongside the HIMP and the flexibilities
in section 31 of the Health Act, demand re-examination of the
possibilities for a civic agenda for health, in which all aspects
of the role of local government and the imperatives for Best Value,
public engagement, local democratic accountability and modernisation
are brought together.
November 2000
|
