APPENDIX 28
Memorandum by East London and The City
Health Authority (PH 54)
HEALTH INEQUALITIES—SOMEBODY
ELSE'S
BUSINESS?
The Health Select Committee has just completed
taking written evidence for its latest Inquiry into Public Health.
A jolly good thing you might argue. Whilst National Health Policy
seems to have ditched the wider public health, you could argue
it's a good thing that someone cares. But is that really why they
chose to focus on public health? To cynics a review of all the
action Zones, HIMPs Public health directors and Minister to boot
might be interpreted as an opportunity to signal dissatisfaction
with the lot of us. But no, my sources tell me that the intellectual
and political thinking behind the choice of subject is that public
health was seen as the least controversial of topics they could
choose during the heated NHS Plan season!
Let us then make the charitable assumption that
the Select Committee's purpose is potentially beneficent. So what
should they make of their primordial soup of tasks? The Committee
has been asked to look at interagency working, the role of the
Minister of Public Health and Public Health directors, the Health
Development Agency, PCG/Ts as well as what sounds like an afterthought:
the extent to which current public health policy is reducing health
inequalities. Any serious scrutiny of this last objective would
require the biggest cross-Government health inequalities impact
assessment that had ever been conceived, and so far not yet commissioned.
To help it through the wood and trees that have
died in the name of the endless zoning initiatives and guidance
so far received, let us assume that the Select Committee will
want to come up with solutions that really do help us tackle health
inequalities more effectively than the recent report commissioned
by Public Health Minister Yvette Cooper shows. 1 Taking each of
the remaining five terms of reference in turn. First: how are
the dizzying numbers of Action Zones shaping up? The answer is
slowly. The national research commissioned at great expense to
answer the questions on their effectiveness is only just underway.
Public health programmes to tackle longstanding inequalities take
time. The Government acknowledged this was at least a 10 year
agenda in its white paper—mostly forgotten now "Our
Healthier Nation", and at least a seven year programme for
HAZs. But do the cuts in the HAZ Programme budget this year 2
suggest that ministerial fuses on the public health are getting
shorter? As far as the effectiveness of interagency co-operation
is concerned, this is also the subject of formal evaluation within
the HAZs. There are three obvious changes which need to be made.
First, we should wait for the findings of the commissioned evaluation
before judging. Second, the wisdom of supporting multiple health
authority, local borough HAZs needs revisiting. It seems self
evident that those HAZs such as Sandwell and Brent—each
coterminous with one borough—that have the luxury of focused
cross-fertilisation with relatively few organisations, are likely
to make most progress. If the different government departments
stopped to gather all their "zoning power" together
with the intention of making the most of all the initiatives,
not only would it help us to mainstream the best of the innovations
we are testing, but it would stop the pointless fragmentation
of these potentially important programmes into ineffectual silos.
The model of a Social Exclusion Unit-type approach bringing these
initiatives together across Government would go a long way to
demonstrating cross agency commitment to tackling inequalities
in health.
HIMPs are an essential, but missing element
of most Community Plans. The Community Plan provides an umbrella
for influencing the determinants of health and most HIMPs articulate
the health outcomes and inequalities to be tackled. If we were
required by a joint Duty of Partnership to integrate and agree
these plans, not only would we save paper, we might be closer
to focusing on those budgets such as leisure, housing and education
which are vital elements of the real health budget. The duty to
take into account the findings of Annual Public Health Reports
could also be added.
The work of the Health Development Agency is
also under scrutiny. Its work is essentially still at the beginning.
Most of us never heard anything from its predecessor in the NHS,
so there is only one direction to go.
Little attention has been paid to the health
improvement role of PCGs/Ts yet. First and foremost, there has
to be a well resourced drive to support the development of public
health capacity in all PCTs. While public health departments and
PCGs debate the finer points of the odd 0.2 whole time equivalent
of a public health consultant that they would like, who is planning
how we develop public health skills among all primary care practitioners?
As a GP once said to me: what we need is for every GP to become
the public health director of her/his practice population. To
embed this in PCT development the Select Committee should recommend
three things: development monies to normalise and embed training
in practical public health skills through education consortia;
joint formal recognition of public health training in general
practice and community nursing disciplines and last, but not least,
proper implementation of the Public Health White Paper's recommendation
to expand multidisciplinary public health. Possibly the most fundamental
ingredient to enable PCTs to tackle health inequalities, is that
the local authority is the appropriate boundary for a PCT. This
would resolve many cross agency nightmares that some PCTs will
otherwise face, and increase the chances of proper partnerships
with local authorities whose actions have more influence on health
than the NHS. Non-coterminous PCTs should not be supported. We
received this guidance on Drug Action Teams. We should do the
same for PCTs.
The role of the Minister for Public Health is
easy to define: focus on the wider causes of health and leave
healthcare to the minister for the NHS. The way to achieve this
would either be by making sure that the Secretary of State for
Health is just that, with NHS ministerial portfolios below, or
by moving the public health portfolio to Downing Street. As for
Directors of Public Health, we should all be jointly appointed
to the NHS and local authorities we serve. We should have statutory
backing—emphasised by the duty of partnership—for
this independent advisory role. To do this effectively we will
need to be supported by properly trained public health practitioners
working at all levels of the system to support health improvement.
Ever NHS and local authority organisation should have its named
director of Public Health. There is no reason why we cannot be
drawn from a multidisciplinary group of qualified practitioners
as in academe. If we don't bite the bullet now—the whole
public health function could disappear in a puff of further organisational
change.
July 2000
REFERENCES
(1) The Guardian; 12 July 2000.
(2) Janet Snell; Health Service Journal;
6 July 2000.
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