APPENDIX 15
Memorandum by the Chartered Institute
of Environmental Health (PH 27)
Founded in 1883, the Chartered Institute of
Environmental Health (CIEH) is a professional and educational
body, dedicated to the promotion of environmental health and to
encouraging the highest possible standards in the training and
the work of environmental health professionals.
The Chartered Institute has approximately 9,000
members, most work for local authorities in England, Wales and
Northern Ireland. As well as providing services and information
to its members, the Chartered Institute also advises government
departments on environmental health and is consulted by them on
proposed legislation relevant to the work of environmental health
professionals. The Chartered Institute became the WHO/EURO Collaborating
Centre for Environmental Health Management in 1993 and in that
role we are engaged on capacity building projects within the European
Region.
In 1997 the CIEH published "Agendas for
change", the report of the independent "Commission on
Environmental Health" set up "to consider the principles
of environmental health and their application to the health of
individuals and the pursuit of sustainable development of communities".
The Commission concluded that the model of public health within
the NHS was not sustainable, as action was starved of resources
by the insatiable "treat and cure" model of care within
the UK.
This evidence uses Agendas for change as a base.
The CIEH would be happy to provide the Committee with copies to
help to further illustrate the points made.
1. INTRODUCTION
In Britain there have been officials to look
after the public's health since 1848 (Annex 1). In the early days
bad housing, with inadequate drainage systems, coupled with poor
water supplies and contaminated foodstuffs were at the root of
much disease and ill health. As more was learned about the way
the environment can affect health, so the job of Sanitary Inspector
and Public Health Inspector evolved into the present day Environmental
Health Officer.
The work of today's Environmental Health Professionals
(EHPs) is extremely varied. The majority of EHPs are employed
by local councils, and have the task of protecting people living
or working in their area. They work in either generalised or specialised
departments; generalist EHPs are responsible for all aspects of
environmental health in a particular part of the district; specialists
work alone or as part of a team responsible for a particular aspect
of environmental health, such as air pollution or food safety,
throughout the council's area.
Health is not just the absence of disease it
is a state of complete physical, mental and social well being,
(WHO). It follows that public health improvement means tackling
a broader front than disease or manifestations of ill health.
Such an approach is difficult, it can be costly, it is certainly
"long term" before improvements can be detected. Politically,
for these reasons, there is more to be gained by short-term policies,
"quick fixes" that concentrate on the creation of new
ways of doing things, new administrative structures, addressing
shortfalls in areas where resources have been lacking and removing
political "banana skins". But this does not improve
the nation's public health.
The NHS, while accepting that a proportion of
its resources are put to ambitious and worthwhile preventative
actions nevertheless primarily focuses upon the treatment and
care of illness and disease, perhaps it should be renamed as "the
illness service". Health Authority Boards do not appear to
consider issues concerned with preventive health very often. The
greatest strides taken in this country in relation to public health
have been borne out of the mass vaccination programmes, the engineering
works of the mid 19th century and the creation of social and welfare
structures that addressed the needs of the poor. We need to get
back to holistic vision of Government with clearer actions to
address the future.
Reference has been made to the environmental
health commissions report "Agendas for change" published
in 1997. That report illustrates a new way of approaching the
issue of public health and how the concept is inextricably entwined
with that of sustainable development. The report identified that
responsibility for the improvement of public health falls to a
much wider group of people and professions than has traditionally
been the case. Such people need to be made aware of the fact that
they do not need to have "health" in their job title
to make a major contribution to its improvement. Attached at Annex
2 to this evidence, is an example of a public health audit carried
out within Gravesham Borough Council. Such an approach is not
unique but serves to illustrate the point that there is more to
public health than the medical model. Such audits are useful exercises
which we would commend.
2. CO -ORDINATION
National and local government once had Public
Health as a major purpose. It was a model that was copied to great
effect in the countries of the former Soviet bloc. It still exists
there and is currently undergoing a revival. Here in the UK the
specific function was removed in the 1970s and as illustrated
in the annex the consciousness of local authorities in relation
to their role in improving public health conditions needs to be
raised. Local government politicians no longer attach much priority
to public health. The seeming remoteness of the NHS structures
and the lack of coterminous boundaries do not help. Boundaries
of authorities concerned with public health are different, illogical
and do not relate to economic, social or geographic features of
an area. London is a prime example of illogical administrative
boundaries. An area that perhaps the new Mayor's office will help
to address.
Co-ordination across organisations is often
difficult, especially where the organisations are fundamentally
different in geographical area, purpose, structure and in accountability.
In maintaining, promoting and delivering the public services that
comprise public health services the tasks of co-ordination are
formidable. Services, that are vital to the health of population
such as the provision of rented housing, are leaving the public
sector. That former role is being reduced to the role of commissioning
or regulating. A necessary safeguard that must be retained and
strengthened is that of the Environmental Health regulating service.
Governance of areas is different for aspects
of health related services, some authorities have a degree of
democratic accountability others report through layers of bureaucracy
to Ministers. There is unease about lack of democratic accountability
in the NHS and increasing central control of local government.
Funding regimes are different in NHS and local government with
the only common feature being ultimate central control. New funding
is always at the margin and often to be bid for. Management culture
is different and diverging in authorities. For example "Best
Value" applies to local government but not to the NHS.
Staff are educated and trained differently and
separately (a matter which is currently under investigation by
Healthwork UK with a view to providing specialist standards in
public health). If manpower planning exists at all it is usually
too little and too late. Staff professionally attached to different
Institutes and Associations have few bridging mechanisms across
Authorities. Environmental Health Professional Bodies on the other
hand are striving to work across national and regional boundaries
to agreed standards of education, training competence and practice.
Political interest and commitment would improve the performance
of those services, which can do most to improve the determinants
of health.
Regional government in England although promised
is emerging very slowly and (so far) with no remit for health
despite this being a strategic issue. Matters however appear to
be developing more positively in Wales and Scotland and in Eire
the Environmental Health service is delivered through Health Boards.
We support the sovereign right of nations to
seek to improve standards of public health but believe that minimum
international standards and obligations should be set and met.
It is encouraging to see the development of EU standards for environmental
parameters, water and food standards and the greater EU involvement
in public health. In that regard it would appear from WHO data
that the UK could be under achieving in comparative measures of
public health. Common data sets across Europe would enable even
more comparisons to be made.
The common data sets for Public Health in communities
need to be supplemented by Environmental Health data. We would
suggest this as a role for the Regional Public Health Observatories,
to collect and collate data to show how health parameters are
shifting over time and at small area level. We would suggest the
need for data at polling district level is necessary otherwise
deprivation effects will be masked.
Given the historic problem of collecting data
from local authorities we suggest the need for a specific statutory
duty laid on a named individual, to submit the requisite information.
3. INTER-OPERATION
OF RECENT
ZONES, CENTRES,
PROGRAMMES AND
PLANS
Inevitably experience of these initiatives is
patchy, the areas where co-operation is evident are the best known
but we suspect there are areas where achievement is minimal. In
our view the need is for true strategic partnerships. Partnership
working is now expected but can be very difficult, slow and expensive,
not least in staff time. We do wonder how realistic it is to expect
General Practitioners to devote a great deal of time to these
approaches.
Competitive bidding for funds as introduced
by the last Government is wasteful for the losers and can be distracting
for the winners. We doubt the value apparently placed on innovation.
Public Health is not "rocket science". It is about doing
basic things well. The role of Environmental Health is being undervalued
in this process. Other than in the well established "Healthy
Cities" or where there are long standing strategic partnerships,
the initiatives are stressing health service and social service
links and undervaluing not only Environmental Health but also
Housing Education and Community Safety.
Co-operation and consultation are good in principle
but difficult in practice across institutional barriers and of
validly involving the public living in deprived communities. Are
these initiatives perpetuating inequalities as they are hardest
to progress in the most deprived communities?
We believe public health requires a coherent
structure of governance to deliver joined up solutions. Political
ownership is required as well as managerial commitment. At present
the NHS and most doctors, certainly General practitioners, are
concerned with patients not populations or communities. Local
government is concerned with education, care and infrastructure
maintenance with some capacity to regulate. Many of the services
vital to public health are now controlled/operated by agencies,
companies (water, waste, transport, catering, care, cleaning,
leisure) housing associations and charitable bodies. The former
public utilities are of particular concern. In order to address
some of these issues the following recommendations we believe
will be of value:
1. That the models established for joint
responsibilities between the police and local authorities for
community safety should be replicated for public health and that
strategic and operational responsibility for public health should
rest jointly with "health" and local authorities.
2. Local authorities should be required by
law to establish a public health forum, develop a public health
strategy and action plan and report annually to the community.
3. Long-term performance monitoring against
Performance Indicators should result in financial saving being
from health authorities to local authorities (or vice versa)
if it can be demonstrated that either organisation's activities
has resulted in savings for the other.
4. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
The Health Development Agency appears to be
concerned with England only; somewhat at odds with the need for
joined up government and international developments.
We welcome the approach to mapping research
and developing educational standards. There is undoubtedly a need
to collate evidence, evaluate it and disseminate the product leading
to best practice. We are concerned however, that there may be
parallel investigations or work taking place and an audit of what
is currently being investigated or researched and by whom may
be an extremely useful exercise to undertake.
We are committed to assisting the HDA to develop
an approach to positive and practical governance of health with
an emphasis on preventing ill health. This will require thinking
outside traditional health service boxes to truly influence the
determinants of health. We are concerned about the future of health
promotion after the demise of the HEA. The present solution appears
ill considered.
5. THE ROLE
OF PGC'S
(SIC) AND
PCT'S
The introduction of more acronyms confuses everyone!
Forming PCG's seems to have been entirely an
obsession of the NHS, as does the desire to become Trusts. There
can be little public interest in such moves but yet an expectation
that primary care be available and to a good standard when required.
Once more this development seems to be a dissemination
of governance of health, possibly motivated by the philosophy
"divide and rule by central government". It does not
diminish the need for joined up strategic working. We are principally
concerned about the difficulties of working across yet more boundaries,
with communities, to produce different but hopefully complementary
plans to improve health and public services.
Important as primary care is, it should not
distract from the need to constructively address preventive health
measures and those issues which contribute to overall quality
of life in communities. That includes community safety, noise,
maintenance of the built and green environment, air quality, water
quality, nutrition, workplace health and safety and housing standards.
6. THE ROLE
OF THE
MINISTER FOR
PUBLIC HEALTH
We very much welcomed this appointment as we
also did the stress on health in the developing governance of
Wales, Northern Ireland and Scotland. It can only be helpful to
have a minister ensuring that some account is taken of public
health implications in government policy and practice. As yet
it is too early to assess the impact of the incumbents which was
thrown into question by tobacco advertising and by the downgrading
of the role shortly after inception. The continuing impact of
tobacco marketing and use in the UK is of great concern to us.
How many of these developments and failures lie at the door of
the Minister is impossible to judge. What we hear is the rhetoric
about the problems, the solutions required are slow to emerge
even as plans.
We are concerned that there is no clear exposition
of UK Public Health policy despite the ministerial post. We perceive
no clear political championing of the issue, no specific targets
about preventing ill health and about promoting good health. Rhetoric
and aspirations do not amount to policy and a muddled infrastructure
will not deliver. Such targets as there are can only be described
as disease prevalence reduction not health targets.
7. THE ROLE
OF THE
DIRECTOR OF
PUBLIC HEALTH
Officers with this title operate at regional
and area level. They would appear to command relatively few resources
with which to tackle the role implicit in their title. Regional
Directors have little or no contact with local authorities and
are perceived as NHS officers. We believe they should have a key
role in regional governance.
At Area level the DPH also appears to be primarily
a senior medical adviser to the NHS, exercising an important role
in clinical governance. To Local Authorities they can exercise
considerable influence in a public health crisis by dint of expertise,
good communication and liaison skills but they wield little power,
even in a crisis.
In many areas service contact is primarily through
social services with perhaps one opportunity to present an annual
report to a committee or sub-committee of the Council. Despite
the above, contact with the local authority is probably better
than the contact elected members and Directors of Services enjoy
and with the Area Directors of other health related services,
central government officers, agency and utility officers.
The location of DPHs within the NHS would seem
to us to be questionable if they are to be a force for strategic
change in communities. We would ask "why is the Department
of Health not represented in the Government Offices for the Regions
by such a senior officer"?
8. THE EXTENT
TO WHICH
CURRENT HEALTH
POLICY IS
REDUCING HEALTH
INEQUALITIES
Frankly it is difficult to be very positive
about this. We would recognise that the thrust of much government
policy, in seeking to address poverty, is helpful but standards
of housing, nutrition, domestic hygiene and environmental maintenance
are not improving in the judgement of our members who spend their
days practising environmental health in communities.
The health of an individual will be the product
of their interaction with their environment, with other people
(eg as vectors of disease) and their personal choices about lifestyle.
While anyone may be predisposed to succumb to a particular "medical"
condition and this is beyond intervention in most cases, all of
us can only make very limited choices about our environment and
the people with whom we have contact. Exercising personal choices
about lifestyles is the privilege of the minority, rather than
the majority despite the lofty words of those who would exhort
us to eat well, exercise, not smoke, drink etc. For very many,
social exclusion and environmental degradation reduces life to
an existence that is constantly under threat by the poor housing
in which they live, the unregulated jobs they are forced to do,
the poor quality of food that their low incomes permit or the
extent of their personal isolation whether by reason of age, infirmity,
social and family circumstances or where they live in relation
to the services they require.
Personal life styles are not improving amongst
the poor; smoking, drinking alcohol to excess, use of narcotic
drugs and obesity is not being tackled and the community environment
for the poor is dirty, unkempt, littered, threatening, often derelict
and depressing to the human spirit. The contrast in environmental
quality across society is offensive.
The stress on addressing poverty through governance
is welcomed but is proceeding slowly and mainly through the stimulus
of work, much of which is very low paid casual and part time.
Benefits are improving only slowly and are clearly too low for
us to be optimistic about the health chances of the children of
the poor. Such children, as seen daily by our members, too often
live in squalor, dereliction, disrepair and lacking adequate warmth,
food and intellectual stimulation.
We are not denying the importance of good quality
medical services, they are vital for those whose health status
falls for whatever reason. We are arguing for greater emphasis
on removing and regulating those things in life, which inevitably
determine whether and when we need medical intervention in order
to restore us to good health.
We believe that responsibility for maintaining
and improving public health is a joint, multi-agency issue but
with statutory responsibility being placed firmly on local authorities
and local "health" authorities.
Some regulatory developments are welcomed; the
establishment of the Food Standards Agency in particular and an
expressed desire for better governance of health and safety at
work. It remains to be seen whether some of the issues about which
we have campaigned for many years are finally addressed however,
eg licensing of food premises, certified training of food handlers
and food premises management, licensing of houses in multiple
occupation, adequate standards of housing.
Many needs are not being addressed eg housing
standards are deteriorating for the poor and little is being done
to improve public transport leaving many poor people isolated
socially and economically. Environmental standards in our towns
and cities remain a disgrace for a wealthy country and we are
undoubtedly slipping down European league tables on issues such
as litter, graffiti, fly tipping, recycling, potholes in roads
and uneven pavements. We are convinced that such environmental
issues have a health impact on the poor, physically and mentally
and degrade the society essential for healthy communities.
The health white paper was virtually silent
on preventive health although the impact of bodies such as the
HDA, Regional Observatories and Workforce Plans could make a beneficial
impact in the long term. We will be pressing for recognition of
the benefits of Environmental Health in the work of these bodies
and plans.
9. CONCLUSION
We are aware that our comment on the issues
you have requested are not in the main founded on solid evidence
based work. They are comments and views based on our involvement
in public health policy development over the last three years
and the perceptions of colleagues in the field. As such we believe
they have as much validity as any empirical evidence. We are concerned
that as a county we are losing our way, tangled up in administration,
bureaucracy, lack of co-ordination and the wrong conceptual illness
based model. We believe that with a revised model for delivery,
better clarity between the various agencies that deliver public
health and a wider understanding of the roles of others, greater
advances can be made. The CIEH is committed to that aim and wish
to be amongst the vanguard of those who can take positive action
to achieve wider improvements in public health as such we would
be pleased to address the Committee on these matters.
We are sharing our evidence with the many bodies
with whom we ally ourselves in seeking to improve public and environmental
health. We refer in particular to:
— The Royal Environmental Health Institute
of Scotland;
— The Environmental Health Officers
Association of EIRE;
— The UK Public Health Association;
— The Common Agenda Group on Public
Health;
— The Royal Institute of Public Health
and Hygiene and Society of Public Health;
— The National Society for Clean Air
and Environmental Protection;
— The Faculty of Public Health Medicine;
— The Chartered Institute of Housing;
and
— The Institute of Wastes Management.
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