Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by the National Health Service Consultants' Association (PH 38)


  The incentives to become involved in "joined up thinking" remain slight. The customary reward is an invitation to sit on another committee for which there is no payment, and no clear health benefit. PCGs have been funded to attend to core tasks, and this is not usually considered one. Involvement with other agencies tends to be dependent on the enthusiasm and altruism of one or more board members. A few of the more far-sighted Chief Officers make time, but this seems to be the exception rather than the norm.

  PCTs may be able to support a full complement of staff, but the focus is likely to remain on health services. There is so much to be done to improve health services, and the majority of board members will be more qualified to work in this area, rather than the wider public health.


  A Minister of Public Health is of central importance in securing "joined up thinking" across government departments, with regard to public health. The Minister must secure a full complement of advisers to include public health specialists who are not civil servants. A Minister may enjoy the company or ideas of the academics, or those with "fresh" or radical ideas. The best advice may come from people with balanced training and practical experience.


  Directors of Public Health currently tend to work simply as executive members of their Health Authorities. Health Authorities remain preoccupied by health services, and the DsPH often finds it difficult to act as a physician for their community. While a DPH may have the lead on inter-agency work, there needs to be full commitment from the entire executive team, with involvement of the chief executive and chair of the Health Authority.

  The effectiveness of the DPH role is blighted by the fact that there is no clarity about the role or definition of competencies. This makes it hard for people to prepare for the role or to develop while in the role. While the need is for a team leader who is committed to the health of the local community, who has extensive experience, the most experienced may well not apply for such an ill-defined job. There is a school of thought that the DPH should be the Clinical Director of the public health directorate, and as with other Clinical Directors this post should normally be held for about five years.


  Inequalities in health are most effectively addressed through progressive taxation. Governments need to do more on this, within the constraints of popular opinion.

  The next most effective way of addressing inequalities is probably to improve education and opportunities for those in deprived communities. The current attention to literacy and numeracy skills in schools is most welcome.

  Smoking is a major cause of health inequalities, with people less committed to the future succumbing to addiction to cigarettes as immediate gratification. The current investment in smoking cessation is welcome but insufficient. The tax on tobacco is well intentioned, but with the reality of addiction this is effectively a regressive tax on the least well-off. Further tax increases on tobacco should be imposed only after affective cessation services have been put in place. A ban on all advertising and promotions is absolutely essential. Measures need to be taken to ensure that smoking is not portrayed in films or television unless essential to a story. Current guidance is that the same proportion of people should smoke on screen as off—this does not assist with cessation and account needs to be taken of the powerful influence of television characters and personalities. All public spaces should be smoke free.

  Alcohol is a further cause of health inequalities. Those with least to look forward to in the future are more likely to drink in excess. A cessation strategy needs to be developed.

  The National Service Frameworks have placed health inequalities at the heart of health service policy. This is very welcome, with greater equity of access likely to be achieved over the next decade. The impact of health services on health remains slight however, and while the NSFs are backed by evidence of effectiveness and reflect one aspect of public health thinking, they fail to fully address public health opportunities.

July 2000

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