Select Committee on Health Appendices to the Minutes of Evidence


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.


  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.


  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.


  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.


  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.


  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.


  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.


  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"?


  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.


  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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