Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by the Democratic Health Network Local Government Information Unit (PH 45)

  The Democratic Health Network (DHN) was set up by the Local Government Information Unit (LGIU) to provide policy advice, information, research and the exchange of good practice on the developing relationship between local government and health. The DHN has over 70 members, the majority being local authorities, but also including health authorities, primary care groups and trusts, community health councils and trade unions. The LGIU is an independent research and information organisation supported by more than 150 councils and the local government trade unions. The DHN's evidence below is largely from a local government perspective in the sense that it is based on a very broad and inclusive understanding of public health influenced by many of local government's traditional functions.


  The Government's analysis of the broad socio-economic causes of ill-health is welcome. However, there is a danger that the socio-economic model may be unhelpfully distorted by a narrower medical model within some of the new organisational structures.

  To a great extent, effective health partnership have been created despite the proliferation of new initiatives, rather than because of them.

  The content of Health Improvement Programmes (HIMPs) is increasingly centrally driven, creating a tension with local priorities focusing on prevention. The community plan, rather than the HIMP, should perhaps be seen as the health improvement programme.

  While an area-based approach, like that of the HAZs may be effective for very small areas, such an approach only partially deals with those with greatest health need and may not be the best way of addressing the needs of particular groups.

  PCGs and PCTs are in danger of exacerbating the democratic deficit within the NHS. Even where primary care plans have been based on HIMPs, there has often been no public consultation. Joint consultation strategies and innovative participation techniques should be encouraged. There are serious concerns about the ability of PCGs/PCTs to deliver partnership or joined-up work. Lay members have an important contribution to make to health policy making. Partnerships with local authorities are hindered by the lack of statutory places for elected councillors on PCG/PCT boards and by the absence of any places for District Councils. There should be moves towards greater coterminosity.

  The Minister for Public Health should be able to make a contribution to decisions about fiscal and other financial policies.

  The concept of non-medical Directors of Public Health is welcome. There should be more joint appointments with local authorities, perhaps as a transition to local authorities taking on the public health function.

  It is probably too soon to gauge whether current policy is reducing health inequalities. HAZ areas are too small to impact on the national levels of health inequality. National policy outside the health arena will have the greatest impact on health inequalities.


    "As far as the overall determinants of health are concerned, and in terms of what might be done to improve the health status of the people, less than 10 per cent of the relevant determinants are to be found within the sphere of NHS activities. The remaining 90 per cent are dependent upon decisions made elsewhere in the economy . . . it is these decisions which must be influenced by any public health policy which is to have meaningful outcomes" (School of Public Policy, 1998, p 41).

  1.1  A new partnership agenda for health has emerged since the election of the present Government. This agenda has embraced a socio-economic analysis of the causes of ill-health and health inequalities which has been widely welcomed by local government and its partners in health improvement. This analysis makes it clear that the health of the population will not be substantially improved nor will inequalities in health be redressed if only a national treatment-oriented health service, overseen by the Department of Health and the NHS Executive, is engaged in these services.

  1.2  However, there is increasing concern, among those involved with the broad public health agenda, that the socio-economic model of health may be distorted by a narrower medical model within some of the new organisational structures, such as the Health Improvement Programme (HIMP) planning processes and Primary Care Groups and Trusts. The Inquiry of the Health Committee is, therefore, welcomed by the Democratic Health Network as a timely investigation into the best structures for promoting and delivering public health. Each of the headings singled out by the Committee is addressed below, although comments under one heading often have a bearing on another. The DHN's comments are based on its own research and on contributions from its member organisations.


  2.1  There is an emerging consensus extending well beyond local government and its health partners that, however well intended, there are too many zones and plans to provide an effective organisational infrastructure for tackling the root causes of ill-health and health inequalities. To a great extent, effective health partnerships have been created despite the proliferation of new initiatives, rather than because of them.

  2.2  The DHN is particularly concerned with the relation between HIMPs and community plans. On the one hand, the production of the community plans (or community strategies, as they are called in the Local Government Bill) is a statutory duty on local authorities to address the economic, social and environmental well-being of their communities. On the other hand, the lead for the health improvement programmes, which ought surely to make a significant contribution to that well-being, rests with health authorities.

  2.3  The DHN's experience is that there is consensus that the HIMPs should focus on prevention. However, the content of the HIMPs is increasingly centrally driven by the NHS Executive, and is required to focus on achieving the national NHS targets, with clear links to the NHS Service and Financial Frameworks (SAFFs). There is a real tension here with the need to look to broader local priorities to increase prevention of ill health. As one local authority has described it: "an early agreement to keep the plan short and sharp has been overturned due to the demands of the NHS Region to include all kinds of health service information. We have also found that as time has gone on, the HIMP has skewed more and more towards health service interests and treatment services. It has become less of a partnership document and more of a health service document to which partners sign up. We fear this may lead to the HIMP not being implemented by all the partners, who begin to feel marginalised".

  2.4  The real opportunities for imaginative strategies on prevention appear to lie in what is incorporated into the residual parts of the HIMP document after all the centrally-determined requirements have been complied with. The local authority quoted above, despite the reservations expressed, has ensured that the HIMP contains two local priorities on poverty and on young people that fit well with the local authority's own response to community needs.

  2.5  In areas where the PCGs/PCTs relate to distinct communities and are coterminous with either district or unitary authorities "Himplets" or Locality Action plans, if they are inclusively built up, can make a significant positive contribution. The real challenge is to make them dynamic and for them to feed into the decision making of both PCGs/PCTs and local authorities. And for reasons discussed below, this is not always easy.

  2.6  Nonetheless, many local authorities, in beginning to draw up their community plans, are incorporating explicit strategies on community health. There is a view that, if a socio-economic approach to health is taken, and health partners adopt a primary preventative approach, then the community plan, rather than the HIMP, should be envisaged as the health improvement programme, which, in the experience of DHN members, tends to adopt a more medical approach. The HIMP could then be considered as the health service implementation plan for the overarching community strategy.

  2.7  Some local authorities are currently exploring whether or not the client based chapters of their local HIMP can be incorporated within a joint strategy, community plan and joint investment plan document. Such a document would include demographic information as well as needs assessment; set out a clear strategy for the specific client group and targets for local development; and outline plans for the development of community care services and joint investment that would cover preventative initiatives and partnership working.

  2.8  While there is a feeling that there are too many "zones" and that the interaction between them is not as well co-ordinated as it should be, the concept of identifying areas of greatest need and targeting action and resources towards these has begun to take hold. Indeed, some local authorities which do not fall within an official "zone" have adopted this principle in their approach to tackling health inequalities. One such council has adopted a poverty and health profile, which has assisted in identifying "areas of special action". It now aims to assess the needs of these pockets of deprivation and to adopt an integrated approach to tackling the root causes of ill health within the identified areas. To do this, the council needs to ensure that health improvement and the reduction of health inequalities is perceived to be a mainstream and core element of local authority business. The council believes it is already beginning to see a significant cultural shift, prior to the piloting of a health impact assessment. This has been illustrated in the development of the local air quality strategy, where priority has been given to those target areas that are within specified "areas of special action". Further consideration is being given to aligning housing strategy priorities with the air quality priority areas and the "areas of special action".

  2.9  A note of caution on the general principle of Health Action Zones, as a means of tackling national health inequalities, should, however, be sounded. As Davey Smith and Gordon (2000) and others have pointed out, an area-based approach only partially deals with those with greatest health need, since most deprived areas of the type identified for HAZ status contain only a minority of poor households and a majority of non-poor households. Davey Smith and Gordon give the example of the Tyne and Wear HAZ area where there are 1.1 million people, the overwhelming majority of whom are not poor nor do they have bad health. In addition, it is not clear that the HAZ areas have been defined on the basis of greatest health need, since they are allocated on the basis of competitive bidding, the criteria for which do not appear to be exclusively related to need. Davey Smith and Gordon point to the Luton HAZ where the health needs of Asian women will be particularly addressed. But Birmingham has many more Asian women and is not a HAZ area. A geographically-based HAZ system may not, therefore, be the best way of addressing the needs of particular groups within the overall population.

  2.10  However, an area-based approach can be effective, at least in terms of medium-term solutions, where the area in question is small, carefully identified and where local people are involved in identifying needs and solutions. An example of this is the London Borough of Sutton which has integrated a health needs assessment of residents on a large council estate with a regeneration programme within which employment was identified by the residents themselves as a health need (described in Campbell (ed), 2000). This deprived estate is located in a relatively very affluent area which would be very unlikely to attract funding under the HAZ scheme. In this case, the local authority feels that the project integrated well with the local HIMP, but only because the health authority had been part of the original SRB bid, led by the local authority. If this had not been the case, there is a danger that the HIMP might have been developed in isolation from broader anti-poverty, regeneration initiatives.


  3.1  Like many others, DHN members have expressed a certain cynicism at the re-launch of the Health Education Authority as the Health Development Agency, involving as it has done the loss of a significant number of jobs and the narrowing of the HDA's remit. It is somewhat difficult not to see the creation of the HDA as a cost-cutting exercise. Nevertheless, the emergence of a new organisation may provide the opportunity for a clearer focus on community-based health improvement strategies, with the provision of advice and support to local authorities as well as to the traditional health promotion providers.

  3.2  The Health Development Agency would be well placed to provide advice on effective measures within the local authority and partnership setting and to disseminate good practice in order to promote innovative public health initiatives. As a national body with (we understand) a planned regional structure, it ought also to be in a position to make representations to government on the basis of evidence, on national policies that would assist in addressing health inequalities. While there is much that can be done at the local level within individual communities and within regions by health partners, including local government, the inequalities between communities and across regions are a matter for national policies. The DHN believes that the Health Development Agency could play a role in educating government about such matters.


  4.1  Little evidence has been seen to date of PCGs engaging with the public health agenda. While small scale initiatives have been implemented at a very local level, the PCG boards seem unable to dedicate their resources to focusing upon health improvement while having to deal with structural change, the clinical governance agenda and the development of a commissioning agenda. Without the development of a specific public health function within the PCG/T is it difficult to see how they will fully embrace this agenda.

  4.2  The establishment of PCGs is in danger of exacerbating the democratic deficit within the NHS. Even where primary care development plans have been based on HIMP priorities, there has often been no consultation with the local public. There does not appear to be a strong lead from the Department of Health in relation to integrating primary care plans with HIMPs; to encouraging PCGs to be involved with or accountable to local communities; or to ensure that they work in partnership with local government. A recent DH circular (HSC 1999/246: LAC (99)40) with an organisational and accountability chart of the PCT management structure makes no mention of the HIMP, of local government or of accountability to local communities. All the accountability is upward through health structures.

  4.3  Whilst there is the capacity for PCGs to engage smaller populations than those of health authorities in a dialogue about priorities, PCGs/Ts need to learn to work within the mechanisms that are already in place, often set up by local government, to help them to do this. Very few GPs have any knowledge of local government, and in the main they appear to distrust it. Only the more enlightened GPs appreciate the added value of involving patients/users in decision-making. The DHN is aware of at least one PCG that has declined an invitation to have a health slot within a local community forum, instituted by the local authority. Another local authority has written to us to say that the core aims of a proposed PCT include no mention of partnership working, the HIMP, proactive prevention, or interaction with and participation of the local community. While this authority feels that closer working under the Health Act with the health authority and community trusts has improved consultation and participation, it has serious reservations about the ability of the proposed PCT to deliver any kind of partnership or joined up work.

  4.4  Close working relations between local authorities and PCGs are hindered by the fact that elected councillors have no statutory right to a place on their boards and that, in the case of non-unitary District Councils, neither officers nor elected members of local authorities have such a right. This is a matter of great concern to DHN members who feel that it is difficult for local councillors to engage with their PCGs and PCTs on broad public health matters while there is an ambiguity in the Government's attitude to them. On the one hand they are expected to be "community leaders". On the other hand, the enormous potential contribution of such community leaders appears to be sidelined, as far as PCGs/Ts are concerned. This is not just a matter of hurt feelings. The statutory presence of social services officers on PCGs and PCTs, while it is important, seems to confine the local authority contribution to professional social care, thus undermining not only local authorities' attempts to mainstream health issues across all their functions but also their democratic role. Unless the new health agenda permits governance in joint working to be as broadly representative, transparent and accountable as local authorities' own structures, elected councillors may become hesitant to invest energy and resources in new initiatives where they do not seem to be perceived as significant partners.

  4.5  In general, the vital message for Government is the importance and added value of the contribution of non-executives to health policy making. If this does not happen PCGs/PCTs will almost certainly become provider-driven organisations with a very narrow clinical perspective. The DHN was very concerned that the Commissioner for Public Appointments, in her recent report on appointments to health bodies, appeared to take the view that elected councillors, by virtue of their local authority membership, have a vested interest which should disqualify them from the boards of health bodies such as PCTs. The DHN rejects the view that it is somehow wrong for local councillors to speak up for the overall interests of their communities.

  4.6  Coterminosity of boundaries between PCGs and local authorities has been a contentious issue. The DHN was pleased to note the recommendation of the Cabinet Office's Performance and Innovation Unit's report, Reaching Out (HMSO, 1999), that there should be a move towards coterminosity of boundaries at regional level and for closer working between health regions and Government offices of the regions. However, there is also a need to address the issue of coterminosity at the PCG/local authority level and the DHN would welcome Government guidance that coterminosity should be brought about as soon as it is practicable.

  4.7  However, despite the fact that the PCG/PCT management structures and boundaries do not currently facilitate the engagement of elected councillors, or of other community representatives, there are still some interesting experiments in closer working taking place on the ground. For example, some PCGs have co-opted officers or members of District Councils as members of their boards.

  4.8  There are also interesting examples of joint consultation strategies between health and local government, including local PCGs (the example of Kingston-upon-Hull is described in Campbell 2000). Such strategies are important in ensuring that communities are consulted in a consistent way, that duplication is avoided and that interrelated concerns, which include health, are addressed by policy makers in a joined-up way. We would like to see greater encouragement of such joint consultation strategies and of innovative participatory action techniques to ensure that community consultation on health does not have the tokenistic character it has sometimes had in the past.

  4.9  Recommendations for Government action on PCG/PCT structures should include, at the very least, a statutory role for local councillors within PCG/PCT strategic board structures, as well as a statutory role for District Councils, currently entirely lacking. The DHN is aware of a small number of GPs who are advocating that PCGs be accommodated within the structure of the local authority. Their view is that local authorities have a better track record of operating within budget and that elected councillors could provide the political steer required to ensure democracy within the NHS.


  5.1  As the Committee will be aware, the creation of the first Minister of State for Public Health was widely welcomed by those concerned with general health improvement and, in particular, with the reduction of health inequalities. However, there was considerable concern that the second incumbent was given the more junior post of Parliamentary Under-Secretary. Whatever the reason, this was perceived as a demotion of the role and as an indication that the Government was less concerned with public health than with the "downstream" aspects of acute health care, which undoubtedly attracts more political attention.

  5.2  Because of the intense, and understandable, pressure on governments to concentrate on the treatment side of health, the preventative aspects need a strong champion within government. In particular, a champion is needed to ensure that the Government follows through the implications of its analysis of the socio-economic causes of ill health. This means that the Minister for Public Health should have a say in the very broad business of government and should be able to make a contribution to decisions about fiscal and other financial policies, since changes in tax and benefits are likely to have a significant impact on the public's health in the long term. Perhaps the best contribution the Minister for Public Health could make would be to ensure that a long-term perspective is a feature of the Government's thinking and policies on health; to ensure that the public understands this thinking; and to ensure that health impact assessments become a mainstream feature of policy decisions across all Government departments.


  6.1  Following the merger of health authorities and the formation of PCTs, consideration will need to be given to the future role and position of Directors of Public Health. The idea that Directors of Public Health need not be medical doctors is very welcome. The public health cadre would be enriched by the inclusion of those with an understanding of health determinants and health inequalities gained through a non-medical route, for example through experience of anti-poverty work. Such non-medical DPHs would, of course, need a sufficient understanding to be able to manage the more technical epidemiological aspects of the role, if these remained with the post, but there is no reason in principle why these aspects should not be managed by leaders of diverse backgrounds.

  6.2  One danger in having a non-medical DPH is that the status of the post and its authority among the medical professions would be reduced. This would not be a good reason for failing to widen the public health leadership cadre, but it will be important for the Government to give public support and to make clear how vital it considers the broad public health function to be in health improvement and in reducing health inequalities.

  6.3  If the new role of health authorities is performance management and organisational development, there is little reason why the Director of Public health needs to be situated at this level. The new PCTs will certainly need the support of the public health function if they are to tackle the health improvement agenda. This public health support is not necessarily best located exclusively with the health authority, however. There is a view that the location of the public health function within health authorities has encouraged in some places a blinkered and limited view of public health with an over-emphasis on clinical issues. For example, contacts tend to be through clinical networks.

  6.4  In some areas, there has been a move towards joint appointments between health and local authorities and this is welcome, in that it recognises the contribution of local government to public health. There is still a long way to go before some DPHs fully recognise the role of local government in health improvement, across all its functions. The DHN is aware of one jointly-appointed DPH who insisted that he was employed by social services and the health authority, not by the local authority. This might suggest that, to understand the full range of local authority functions and their potential contribution to public health, the DPHs ought to be even more closely integrated with local authorities, perhaps returning to their original role as employees of local government. There is also a strong body of opinion that better and more informed decisions would be made across local authority functions, including housing, economic development, leisure, education, youth services, planning and transport if there were an input from public health and that, for this additional reason, public health should return to local government

  6.5  Despite the reservations expressed above, a move towards more joint appointments of DPHs would be welcomed, perhaps as a transitional arrangement. One model for joint working on public health might be that of the Youth Offending Team, a partnership team steered by the Community Safety Board, which is not directly under the control of any one partner but is accountable to all of them.


  7.1  It is probably too soon to gauge whether or not current policy is reducing health inequalities. What is clear is that inequalities in health increased substantially in the last two decades of the 20th century and that drastic measures are required to reverse this trend (see for example Shaw et al, 1999).

  7.2  The present Government has taken the first step in recognising the broad socio-economic causes of health inequalities, and specifically their links with poverty. There is a growing consensus among health researchers that the conditions of the first years of life play a hugely significant role in the health of individuals. The greatest impact on health inequalities is therefore likely to be brought about by social and economic policies that improve the conditions into which children are born and live their early life. By the time individuals have reached adulthood, it is almost certainly too late to make significant inroads into health inequalities within their own generation. But the circumstances of parents (their education, whether they are employed, the housing in which they live, the type of food they can afford and to which they have access, how their transport needs are met) will affect the health of their children.

  7.3  Therefore any Government that wishes to make a significant impact on health inequalities must take a long-term view of reducing inequalities in the health of the next generation by improving the life chances of the most deprived of this generation. The kind of action that would bring this about would require great courage on the part of a Government. It would require explicit recognition that the most effective action to combat health inequalities would take place outside of what has come to be thought of as the health arena; and it would also require action at a national level to bring about greater equality in income. The present Government has taken some tentative steps towards the former, but it is not clear how far its policies will take it towards the latter.

  7.4  Current initiatives to address health inequalities ought perhaps to be thought of as pilots, rather than as answers in themselves. There are many new partnerships being forged in Health Action Zone areas and there are examples of health issues being more closely integrated with broader social and economic initiatives. But, as Dorling (2000) points out, even if action in the HAZ areas reduced mortality to the average, they are too small to impact on the national levels of health inequality.

  7.5  However, given that national fiscal and welfare policies are more likely to impact on health inequalities than narrow health-service based initiatives, the impact of HAZs and of public health policy, narrowly understood, may not, paradoxically, be the best measure of the effect of Government policies on health inequalities.


  Campbell F, (ed) (2220), Building Healthy Communities: the role of local government in health improvement, Democratic Health Network, LGIU.

  Davey Smith G, and Gordon D (2000), "Poverty across the life course and health" in Pantazis C and Gordon D, Tackling inequalities: where are we now and what can be done, Policy Press, Bristol.

  Dorling D (2000), "A mortality league table for Cabinet ministers?" in Pantazis C and Gordon D, Tackling inequalities: where are we now and what can be done, Policy Press, Bristol.

  Performance and Innovation Unit (1999), Reaching Out: the role of central government at regional and local level, HMSO.

  School of Public Policy, University of Birmingham (1998), Future Prospects for Public Health: Local Authority and Health Authority Collaboration, Occasional Paper 14.

  Shaw M, Dorling D, Gordon D and Davey Smith G (1999). The widening gap: health inequalities and policy in Britain, Policy Press, Bristol.

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