APPENDIX 24
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.
SUMMARY OF
EVIDENCE
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.
1. INTRODUCTION
"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. THE INTER-OPERATION
OF HEALTH
ACTION ZONES,
EMPLOYMENT ACTION
ZONES, HEALTHY
LIVING CENTRES,
EDUCATION ACTION
ZONES, HEALTH
IMPROVEMENT PROGRAMMES
AND COMMUNITY
PLANS
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. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
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. THE ROLE
OF PCGS
AND PCTS
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. THE ROLE
AND STATUS
OF THE
MINISTER FOR
PUBLIC HEALTH
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. THE ROLE
OF THE
DIRECTOR OF
PUBLIC HEALTH
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. THE EXTENT
TO WHICH
CURRENT PUBLIC
HEALTH POLICY
IS REDUCING
HEALTH INEQUALITIES
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.
REFERENCES
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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