APPENDIX 31
Letter from the Secretary of The Nuffield
Trust to the Clerk of the Committee (PH 59)
I note that you are conducting an Inquiry into
Public Health. I enclose a copy of:
— an editorial written by myself, published
earlier this year; and
— the proceedings of a meeting which
The Nuffield Trust organised in Oxford to consider whether we
need a new Public Health Act.
I hope that this material will be of interest
to the Committee.
10 July 2000
EDITORIAL
Challenges to public health in the new millennium
Of all the medical specialities, it is public
health that by its very nature is most affected by political,
social and economic changes. Therefore the challenge to public
health in the new millennium will be deciding how to adapt to
the simultaneous changes in all these areas created by the forces
of globalisation. Diseases will travel faster than ever before,
as will the information (and misleading pseudo-information) about
how to treat them. Information and mobility will bring great wealth
to some and the troubles of the very poor, especially their health
problems, closer to all of us. Existing political power structures
will be challenged by the power of big business and, perhaps,
small organisations, ranging from legitimate and well-meaning
pressure groups to terrorist organisations, newly empowered by
modern information technology. International organisations such
as the European Union, will develop as an attempt by nation states
to rescue their power by sharing it.
The last great paradigm shift in social development
was the industrial revolution of the 19th century. The transformation
of an agrarian, socially stable society with little political
or physical mobility into an urban society on the move in every
sense, which was most noticeable in the United Kingdom but was
mirrored throughout much of the world, shares many parallels with
the impact globalisation will have. Back then the UKs 1848 Public
Health Act and its successors were the finest examples anywhere
of public health helping to shape a social transformation in a
humane direction. The UK can once again take a lead in this by
asking "do we need a Health of the People Bill?" Despite
the gathering pace of globalisation, nation states still for the
moment have the capacity for meaningful action and leadership.
The approach to public health established by
the 1848 Act, as well as by other Acts introduced in the last
century, certainly led to dramatic improvements in the health
of the people. These Acts have continued to be effective in both
preserving and promoting health even though there have been major
changes in the structure of central and local government, the
introduction of an NHS and the privatisation of such fundamental
public health provisions as water supply and sewerage. But with
devolution, European law and changes in disease occurrence and
demography, the laws governing public health need updating and
tidying up. In a democracy it is actually important to know who
is responsible for what. No one should be able to avoid blame
and no one should be required to accept blame for matters that
are beyond their control. We have come close to that on recent
occasions.
The determinants of health had, on the whole,
little to do with the health service, and public health has been
over medicalised in many countries. Local authorities in particular
play a crucial part. The assessment of the lessons from The
Health of the Nation are that local authorities were undervalued
and marginalised and it is clear that these lessons have been
learned by the present government. A positive health approach
with local strategies, locally owned, offers a way of getting
local government and local people more actively engaged in a public
health agenda.
To improve and maintain health requires international
and national co-ordination because the factors that influence
health know no boundaries and although the needs of different
areas, for example, urban and rural, will vary, central co-ordination
and leadership is crucial.
Furthermore, devolution in the United Kingdom—a
feature of many other countries—has led to the establishment
of a Scottish Parliament and a Welsh Assembly with significant
devolved law-making powers and in Scotland "including overall
responsibility for the NHS in Scotland and public and mental health".
Beef on the bone has already been raised as early business in
the Assembly and the Parliament and different practices may be
adopted on either side of the English borders. These developments
have important public health implications, and Canada and Australia—countries
with a federal structure—can provide examples of how to
tackle the problems that will certainly arise.
In his Annual Report for 1998 the CMO for England
said "The 1848 Act has a Board of Health, a high-level committee
to oversee the changes proposed. Perhaps something similar would
be useful now". Perhaps it would. Those attending the Nuffield
Trust Christ Church workshop in July 1998 certainly thought so.
In the United Kingdom it may also be necessary
to strengthen the role of ministers—especially that of the
Secretary of State for Health—in relation to those matters
for which they do have direct responsibility, such as international
negotiation and maintaining a broad policy overview. It is their
job to ensure, whether through legislation or otherwise, that
the responsibilities of the key players are clearly defined and
to satisfy themselves that effective structures are in place for
improving the health of the people. The Secretary of State, as
the public health minister in the United Kingdom cabinet, will
need clarity about their role and that of ministers responsible
for public health in the nations of the United Kingdom. A high
level advisory council of experts and representatives of countries
and regions is needed to provide the necessary authoritative advice
to the secretary of State so that he is able to give the necessary
leadership. This Council must have the ability both to devise
and collect the appropriate information that is crucial for the
execution of policies. It must also have the power to publish
and disseminate information, which may be uncomfortable for ministers,
to influence public knowledge and behaviour. Recent concerns about,
for example, BSE and genetically modified foods demonstrate the
need for ministers to have access to public health experts and
for the public to be reassured that the advice they receive is
sound and independent. None of this is new and much of what we
advocate returns us to the position that public health had at
the end of the last century
It is also important to distance ministers from
certain matters, such as the collection and dissemination of information
and statistics about the health of the people and the factors
that affect it. An independent body—a commission or board
acting as the champion for the health of the public and operating
at arms' length from central and local government—could
do much to meet those two needs, and strengthen public confidence
in the public health function.
The European Union has now firmly put its badge
on public health as a subject but there is a lack of overall co-ordination
of public health across the different directorates of the Commission.
We also need to work out how institutions such as the WHO European
Regional Office, which possesses significant resources and expertise,
can be harnessed successfully to the benefit of Europe as a whole
and in a way that would be both helpful and effective. If in the
next few years the United Kingdom successfully develops its own
public health function, achieving the right balance of harmonisation
and subsidiarity in the context of Europe, devolution and the
renewal of local government, it would be well placed to take the
initiative and provide a lead on public health in Europe as well.
Reprinted from Journal of Epidemiology and
Community Health, January 2000, Vol 54, No 1, p 2-3.
John Wyn Owen, Nuffield
Trust
NUFFIELD TRUST NOTE NO 7
2. PUBLIC HEALTH
IN THE
NEW MILLENNIUM
Report of a workshop held at Christ Church, Oxford,
on 14-15 July 1998
(The workshop was held under the Chatham House
Rule, so these notes, while recording the main points of presentations
and discussion, do not mention individual participants by name.)
SESSION 1: ESTABLISHING
THE FRAMEWORK
Background and objectives of the workshop
The Nuffield Trust has a long standing interest
in public health, the most recent evidence of which was the award
of the 1997 Rock Carling Fellowship to Professor Walter Holland.
Professor Holland reviewed the history and considered the challenges
currently facing public health; his monograph, Public health,
the vision and the challenge, written jointly with Susie Stewart,
was published by the Trust in June 1998. At a seminar to discuss
Professor Holland's conclusions, held at the Trust in December
1997, it was noted that 1998 would mark the 150th anniversary
of the original 1848 Public Health Act, and this raised the question:
what advice should be given to parliamentary counsel on drafting
a possible Health of the People Bill.
In 1998 there were a number of influences at
work which the authors of the 1848 legislation did not have to
take into account. Most obviously, the issues arising from the
government's programme of devolution raised questions of potential
for diversity and the need for co-ordination across the United
Kingdom; and at the same time, the wider European dimension of
public health should not be ignored. Here experience in other
countries could provide useful pointers. In Australia, for example,
agreement had been reached on a commonwealth Public Health Law,
which the individual states had then had to find ways of accommodating,
looking at local and national issues, drivers of change, human
rights and ways of commonwealth and state governments working
together.
The objectives of the Christ Church workshop
were:
— to examine the current legal framework;
— to consider possible improvements
to this framework;
— to consider the need for a mechanism
to co-ordinate and monitor public health policy; and
— to consider proposals for reform.
The workshop was divided into two main sessions:
on day one the framework for discussions was considered, with
the help of expert overviews of the United Kingdom and European
legal positions; on day two problems and the need for change were
discussed in groups, whose conclusions were presented in plenary
sessions before a final summing up discussion.
UNITED KINGDOM
LEGAL OVERVIEW
The workshop was considering the question: how
might parliamentary counsel address drafting a new Public Health
Act; but underlying this was the wider question: is new legislation
the most appropriate way forward? In approaching these questions,
a number of areas were explored:
(i) How is Public Health law defined at the
present time?
From the papers circulated for the workshop,
it was clear that there was no currently generally agreed definition
of "public health"; equally the term "law"
is used with a range of meanings in different contexts; and there
is no single code to refer to in resolving legal matters. Instead,
law can be defined in a number of overlapping ways:
Law defined by subject matter:
A review of the tables of contents of Halsbury's
Statutes and Halsbury's Laws showed clearly that in statute
law there is no coherent recognition of public law.
Law defined as a particular institutional form:
— legislation: primary and delegated;
— judicial: common law and wider judicial
principles;
— quasi-legislation: circulars, codes
of practice, guidance notes, which, though without formal legislative
status, may in practice be extremely influential.
Within this framework there are overlapping
powers: for example, the public planning system includes a public
health dimension.
Law defined as powers to act:
For public authorities, the power to act is
limited by the ultra vires doctrine: in the narrow sense,
this is concerned with whether a body has the power to act; in
the wider sense, though a body may have a prima facie power,
it may offend judicial principles to use it. For private individuals,
and organisations, there is a general freedom to act unless prohibited
from doing so, or limited by other private interests or by regulatory
law.
Law as the substance of what can be done:
This is not limited to what is laid down in
formal documents, but may be based on administrative practice,
or what commonly happens and is defensible.
Law as the procedures to be used:
Procedures may be explicit in statute or quasi-legislation,
or implicit in judicial principles.
Law as control or accountability:
Law in the public sphere is seen by some as
primarily concerned with controlling public bodies and holding
them accountable.
Law as a set of values:
A range of different values has been incorporated
into the law, but there is a particular emphasis on individual
rights, which will be made more explicit with the passing of the
Human Rights Bill.
(ii) Where do we want to go?
In terms of a legal response to this question,
the main concerns from the background papers could be summaried
as:
— the use of broad principles, such
as the precautionary principle, to guide action and their treatment
by the courts, and other reliance on the common law;
— rights of participation and how these
are treated by the courts;
— the limits of duties and discretions,
rights and duties, using the example of resources;
— the forms in which new powers are
granted, and the issue of accountability;
— an institutional approach.
(iii) The use of broad principles and other
reliance on the common law
The language of broad principles can be used
in statutes, but in practice the courts have not been happy with
broad concepts and have regarded their interpretation not as justiciable,
but as a policy matter. Interpretation of broad principles therefore
needs to be incorporated in guidance: Acts of Parliament alone
are not enough.
(iv) Rights of Participation
Rights of participation are not in themselves
a problem: judges are happy to uphold them if a question of how
to go about things is involved. But the question should be considered:
is participation necessarily always desirable? An alternative
view would be that such rights should be targeted carefully, and
used judiciously, or concern with the democratic deficit may come
to be considered more important than effective decisions.
(v) Rights and duties and the use of discretions
Recent cases show that there can be a wide range
of types of duties, from the general or target duty to the very
specific; and this can place judges in a difficult position in
determining the precise nature and extent of the duty in question.
In imposing a new duty, therefore, it is important to be clear
whether it is a duty to think about, to consider, or to do, as
this will have important implications for drafting.
(vi) powers for public bodies—a new
framework?
The questions of the need for new powers, clarification
of existing ones and removal of possible barriers to effective
action, which are central to consideration of the future of public
health, are currently being addressed in the context of local
government, following the publication in February 1998 of the
government consultation paper Modernising local government:
Local democracy and community leadership. Here, as in public
health, the issue is, how new powers should be formulated. The
inhibiting effect of the ultra vires doctrine has been
criticised:
— it results in legal uncertainty;
— most statutes are not drafted with
its restrictive formulation in mind, so that purpose or "function"
is not always defined sufficiently clearly or widely;
— this results in increased emphasis
on judicial interpretation;
— there can be a lack of understanding
on the part of the judiciary of practical and political realities;
— time and resources are wasted;
— further legislation may be needed
to reverse impractical decisions;
— innovation is inhibited; and
— in the absence of a positive constitutional
statement, the status of local government appears in an essentially
negative light.
There are a variety of ways by which the inhibiting
effects of the ultra vires doctrine could be addressed:
— "sticking plaster" legislation,
designed to remedy specific problems, but without necessarily
resolving the underlying issue;
— sanction schemes, which allow the
Secretary of State to grant a sanction to an item of account that
is contrary to law;
— a combination of "sticking plaster"
legislation and sanctions, as seen in the recent Hunt Bill;
— private Acts and bye-laws: less relevant
to public health than to local government;
— reform of section 137, in connection
with:
— the new economic, social and environmental
power proposed for local government;
— reform of the ultra vires
doctrine itself;
— the "new framework": a
wider version of the combined "sticking plaster" and
sanctions approach, this would provide extremely wide enabling
powers, under which local authorities could bring schemes to the
Minister, supported by schedules of necessary legislative amendments
and statements of the effect these would have; this approach has
the potential for great creativity, through the question of accountability
needs to be addressed; and it could be applicable in the field
of public health;
— creation of a power of general competence:
a solution not apparently favoured by the government currently,
but which would make for easier operation within the authority,
without displacing, judicial control;
(vii) An institutional approach
Either a new institution can be created, with
new powers and/or existing powers taken from other institutions;
or existing institution(s) can be redefined. The former is likely
to be time consuming and require substantial legislation, but
creates the opportunity to rework existing law and rethink strategy.
Co-ordination of existing institutions may be initially more attractive
(and will in any case be necessary to some degree if a new institution
is created) but to be effective may itself require legislation.
Overall, it may be suggested that if only relatively
minor change to powers is necessary, then the existing legal framework
supplemented by administrative guidance is likely to be the simplest
and most effective way of proceeding. If more major change is
envisaged, it is likely that new powers will be needed, to be
vested in either existing or new institutions. The creation of
a new executive body for all public health functions could be
unwieldy, time consuming and divisive, but with appropriate enabling
legislation a new body could be effective in harnessing relevant
expertise, devising procedures for co-ordination, issuing guidance
and, on the model of the Audit Commission, providing accountability.
This could be a way of achieving a balance between diversity and
flexibility on the one hand and effectiveness and control on the
other.
OVERVIEW OF
EUROPEAN PUBLIC
LAW
The legal basis of current public health initiatives
at the level of the European Union is found in Articles 3(o) and
129 of the EC Treaty as amended by the Treaty of Maastricht of
1992. These will become Articles 3(p) and 152 of the EC Treaty
as amended by the Treaty of Amsterdam. Not until this treaty was
the general public health function brought into European law.
There are, however, a number of other areas of European law, for
example those concerned with the environment and water quality,
which clearly have public health implications. But in terms of
implementation, the nub of the problem is the relationship between
public health law and policy and other areas of EU law and policy.
Article 3(o) addresses the need for a high level
of health protection in the activities of the Community as set
out in Article 2. The question is, however, whether Article 3(o)
addresses the need for a high level of health protection in the
context of the overall goals of the EU. What is not at all clear
is whether the provisions of the Article 3(o) take priority over
the overall economic, social and political objectives of the EU
as set out in the various treaties. As a corollary, the question
of whether Article 3(o) is justiciable—ie of whether the
Article can be examined by the courts—also arises. Article
129 sets out duties governing public health policy, requiring
the Community to contribute towards ensuring a high level of human
health by encouraging co-operation between Member states, and
if necessary supporting action "directed towards the prevention
of diseases, in particular the major health scourges, including
drug dependence, by promoting research into their causes and their
transmission, as well as health information and education."
It also states that "Health promotion requirements shall
form a constituent part of the Community's other policies".
In practice, Article 129 has proved problematic;
it was a compromise, and it soon became clear that there was no
consensus about its meaning, with some Member States seeing it
as setting limits to any expansion of European Union public health
activities. A Resolution of the Council and the Ministers for
Health in 1993 accepted the need for collaboration, but left responsibility
for public health policy, "except where the Treaty provides
otherwise", with Member States. The Resolution was very much
disease-based; it set out broad criteria for activity in pursuit
of public health in guidelines annexed to the main text. These
set out as objectives, "adding years to life" and "adding
life to years", and provided broad criteria for the selection
of areas of activity.
In response to the Resolution, the Commission
in 1993 put forward proposals for a Framework of Action, which
contained a number of different and potentially conflicting analyses
of public health: as promoting economic improvement; and as a
good in itself and an ethical and legal obligation on Member States.
The framework for action led to the selection of areas arising
under Article 129 designated for programmes of work, including:
health promotion; cancer; AIDS and other communicable diseases;
drug dependence; and health monitoring. Other initiatives moving
towards finalisation include: injury prevention; pollution-related
diseases; and rare diseases.
Overall, there is a lack of coherence in these
activities and no clear agreement on where public health policy
should be going. This became especially clear with the BSE crisis,
which was the catalyst for recognition in the EC that public health
had not been adequately sorted out. There was, however, no evidence
of awareness of what should be done, and although the crisis ensured
that public health was on the agenda at Amsterdam, European monetary
union was the main preoccupation there. Article 152 was a late
addition, tabled by the Dutch government and adopted without prior
discussion. It has been argued that the adoption of Article 152
represented a missed opportunity; the Dutch concern was specifically
to provide for individual Member States to be able to control
standards for blood supplies, transplantation and blood safety
[section 4(a)]. The problem of co-ordination on public health
across different areas was not addressed, and harmonisation of
the laws and regulations of Member States was specifically excluded,
without any discussion of whether this was appropriate. The question
of methods for assessing the impact of policies on public health
was omitted from consideration, partly because of the difficulty
of securing agreement on interpretation.
The general conclusion from this review is that
European public health policy is in a state of flux; the need
for a more integrated approach has been recognised by the Commission,
which has suggested a future policy based on three "strands
of action":
— improving information for the development
of public health;
— reacting rapidly to threats to health;
and
— tackling determinants of health through
health promotion and disease prevention;
but the administrative problems have not been addressed,
and there is as yet no framework for dealing with possible detrimental
effects on health resulting from policy development in other areas.
Action under Article 152 cannot take place until the Treaty of
Amsterdam has been ratified by all member states.
DISCUSSION
There are, it was thought, recognisable similarities
between the situation faced by Chadwick in the period leading
to the 1848 Act and the present: now, as then, the art of the
possible should be recognised, with the added problem that making
progress is much more complicated at the multi-country level.
Ensuring the public health dimension is taken into account could
also be complicated even at the local regional level, as shown
by the recent experience of the Council of the North East in seeking
to link public health in with economic regeneration.
From a historical perspective it was interesting
to see where the different frameworks started, as a way of understanding
how the law looks the way it does. In the UK, in 1848 there was
no national social policy—all social policy was local, by
contrast with the late 20th century and in the mid-19th century
social, housing and other related concerns all came under public
health; 20th century specialisation could therefore be seen as
part of the process of losing coherence about what public health
is. It is also worth noting that the mid-19th century approach
was discretionary.
Europe has now abandoned harmonisation in favour
of subsidiarity. Health protection is a broad notion, but attention
at the European level focuses primarily on a narrow range of specifics,
which might appear something of a contradiction. The origins of
the European approach lay in the original pre-EEC institution,
the Iron and Steel Community; reflecting this, the original European
legislation was concerned with the protection of workers in these
industries, and this led to the emphasis on productive work and
on health protection, with a levy to fund research into the latter.
There were divergent views about the usefulness
of health impact assessment: from one point of view, experience
with the ineffectiveness of family impact policy statements led
to scepticism about the likely impact of health impact assessment
on policy; on the other hand, there was greater confidence in
the potential of the approach, for example in the field of transport
policy.
The difficulties in the EC of achieving co-ordination
across the 25 Directorates General of the EC were recognised as
perhaps a more serious problem than the broad generalities of
Article 152. However, section 1 of Article 152 is a very high
flown statement of intent, and the Article raises but does not
resolve two main issues: how to get co-ordination assured, or
even started, around public health across all the Directorates;
and how to ensure the health dimension was recognised in decision-making
in all areas; health impact statements would be a way of achieving
this, though the approach would have significant implications:
for example, in the area of tobacco subsidy, a health impact statement
would make current policy unsustainable.
The influence of underlying constitutional systems
was recognised: unlike the UK, which has no written constitution,
European institutions were created, of necessity, with formally
documented objects: the preamble to the European treaties made
explicit and central to the institutions of the EC the achievement
of economic and social progress through the creation of a free
internal market. This economistic approach created an underlying
problem in developing an approach to public health at the European
level. But the Community is nonetheless committed to a high level
of health protection, which makes it necessary to devise a method
of assessing health impact. Two approaches are possible here:
to adopt broad statements of intent without specific meanings,
which would be added later; or to make specific and rigid rules.
These also could be seen as the enabling versus the statutory
approach.
In this context it was suggested that it could
be helpful to revisit the role of the UK Medical Officer of Health,
whose work was based on a system of notification, registration
and advice; as a starting point it would be helpful to establish
uniform notification and registration practice across Europe.
A reliable intelligence base is needed to inform policy, which
would vary locally, unless common action has to be mobilised to
respond to a crisis, for example BSE—and there is a remarkable
lack of mechanisms to achieve such mobilisation.
It is also important to remember that public
health is a local government as well as a health concern and that
this in turn means partnerships and joint planning mechanisms
are necessary. In the UK, local authorities are now required to
produce community plans, and this provides an opportunity to draw
strands together, while addressing the democratic deficit and
modernising the agenda.
SESSION 2: THE
PUBLIC HEALTH
OVERVIEW
Presentation
The starting point of the workshop, the 1848
Public Health Act, represented a remarkable overview, and although
there are some contemporary concerns, for example waste disposal
and planning procedures, that it did not cover, in general its
provisions still hold good at the end of the twentieth century.
However, there will be in the coming months a number of opportunities
to present the outcome of a review of public health so as to influence
its future development:
— the Chief Medical Officer's project
to strengthen the public health in England, meeting on 30-31 July
1998, could take into account the conclusions of the workshop;
— the Chief Medical Officer's annual
report meeting on 18 September 1998;
— the follow up to the Our Healthier
Nation green paper: this could be influenced if Ministers
were persuaded that there were clear and practical measures that
they could support;
— so far Parliamentary time for a new
Public Health Act has not been possible and the pressure of other
new legislation in the manifesto makes obtaining time in the near
future unlikely. However, opportunities of using other legislation
to further the public health agenda, and in particular control
of communicable diseases, may arise and need to be fully exploited.
Given these opportunities, the question is what
provisions, if any, should be proposed. There is a great potential
for health, the term "potential" combining the idea
of real power, the idea of a gap between the actual and the possible,
and the notion that something could be done. It was argued that
current knowledge is sufficient; it would be perfectly possible
from what is already known to draw up a list of the 10 key questions
that should be dealt with to improve the health of the people,
without waiting for the result of further research. There are
however a number of factors that should be born in mind in formulating
recommendations.
— Firstly, the term "public health"
itself is very restrictive; by being linked to a specific group
of people it inhibits consideration of the broader agenda of "the
health of the public", which is concerned more with quality
of life than with living longer: the health of the public should
be linked with the idea of happiness as well as that of the absence
of ill health. Thus a change in culture is needed, from "public
health" to "the health of the people".
— The 1848 Act created a Board of Health,
now lost. It would be worth considering whether there is a need
for some sort of national institution, chaired by the Minister,
with a subordinate network of regional bodies, and at "district"
level a local authority—health authority link. At present
there is no organisation with specific responsibility for supporting
the public health, and the system lacks the capacity to deliver
what Ministers want.
— Change almost always takes place
in response to crisis.
— Improving health involves not just
the NHS, but also employment, housing, education and a whole range
of other influences.
— Health is a political issue; if politicians
are not in favour of change, it won't happen.
— The role of women in health is crucial.
— Research is important in increasing
the knowledge base.
— The influence of values should be
recognised as the basis of much political decision-making.
— A means of addressing bioethics questions
at a national level is needed; a National Bioethics Committee
might be the way to achieve this; a number of time-limited or
permanent committees look at specific bioethics issues; the advantages
and disadvantages of replacing the present arrangements should
be considered.
— Public participation must be an integral
part of the process.
Specifics which would have a major impact on
public health include legislation on, for example, housing , Transport,
tobacco and alcohol. And violence is a major problem in contemporary
society, with a particular significance in health terms.
DISCUSSION
There was some concern at the UK tendency to
try to deal with problems by creating new institutions. In the
public health context, however, though the health authority offers
potential, there is no formal link between it and the local authority—and
past experience of attempts at joint working is not encouraging,
although the new government is committed to achieving improvements
here. At regional level, there are NHS Executive Regional Offices,
but they are generally not connected with Regional Government
offices, so something is needed to achieve co-ordination. And
at national level, though there used to be a Committee for the
Health of the Nation, there is nothing. In consequence, although
there are mechanisms such as the Public Health Group in the Department
through which public health concerns can be considered before
they reach the Minister, the most obvious means of access to the
Minister is by writing direct. Although we know a lot about how
to improve health—and healthcare—for example, on tobacco,
the problem remains that nothing much is being done.
The question of how the workshop could best
contribute to the debate was considered. For example, there is
good evidence that income differentials have an important influence
on public health; under the previous government this was largely
disregarded, but it is not clear whether the present government
would be more sympathetic to addressing the issues involved. There
are other areas, too—fluoridation for example—which
are recognised to be political, and which, if Ministers decide
to do something, will become politically contentious. But nonetheless
there is a need for action in support of pronouncements.
At the local level, it was argued, the problem
centres on giving hope to the community, and in particular to
young people—and there has been very little about children
in any of the recent publications. However, there is a political
will to do something different, and locally to challenge existing
activities and programmes, to look at what is being done, for
whom and why: there is an emerging culture of change, which starts
with making a connection between what's being done locally and
the health of the public. In this context, the links between local
government and Primary Care Groups will be critical, though it
is by no means clear these have been thought through. But there
is an opportunity now to refocus links.
The significance of globalisation—which
was not an issue in 1848—should be taken into account. There
is an increasing willingness to address concerns that can be broadly
categorised as "environmental" at international level,
while more "communitarian" issues are being dealt with
at local level. The difficulty here is that the quality of local
activity is very variable; this raises the issue of what kind
of legislative framework would be fit for purpose for public health.
Accepting that structure should follow function, the sheer complexity
of the issues to be addressed could be seen as the major difficulty.
If it is accepted that there is wide agreement on what needs to
be done—and the NHS R and D programme has been focused on
this—the question becomes, how do we do it. In public health,
research is needed into how to implement change, where our understanding
is still at a very primitive level, and we need to develop methods
to research the effectiveness of interventions.
The need to involve the public, the extent to
which the public could influence public health directly, and the
relationship between individual rights and social factors was
considered. The 1848 Act, it was pointed out, put the rights of
society above those of the individual. In contemporary society,
many of the changes needed for the improvements in the health
of the public are negative: stop smoking, stop speeding; it was
doubted whether legislation could achieve outcomes of this kind.
In considering the rights of society, it was
suggested, it would not be possible to turn back the tide of individualism;
but the concept of social capital could be valuable in changing
the approach to thinking about risk: there is some sort of a shift
in culture going on at the moment, and this should be recognised
as part of the context of discussions about public health.
The importance of public health surveillance
was stressed: continuing reports, year on year, covering for example
road safety, can achieve results, and getting information into
the public domain is important. An independent organisation that
could achieve this would be valuable: surveillance of health systems
with a duty to report on health inequalities would be of major
importance. For example, there are wide variations in hospitalisation
rates across the country: is this the result of better health
in some areas, or worse access to care? The public are going to
demand explanations for the differences they learn about, especially
in the information age, and a national level institution would
be able to respond to this. Moreover, in the new millennium any
debate will be in the context of a Freedom of Information Act:
which may be expected to usher in an era of openness and opportunities
for constructive, creative intelligent "trouble making".
If a new institution—a Commission for
example—is to be recommended, the work of existing agencies
will need to be reviewed. One area in which a new institution
could be of great value would be disseminating examples of good
practice. There are, for example, good local examples of projects,
involving the public and with much to offer; indeed, engaging
people has to be done at local level: examples include smear testing
projects, healthy heart programmes, working with children to combat
crime; health living centres and Health Action Zones offer examples
of worthwhile and effective initiatives. What is needed is a structure
that ensures that this local learning and these local successes
are disseminated nationally.
This raised the question: could a legislative
underpinning be envisaged that would bring together all these
concerns: the notification/registration/advice theme, the surveillance
requirement, information and explanation, dissemination of good
practice, and the other public health concerns identified in the
discussion. It was pointed out that this range of concerns would
require the broad framework approach in any legislation with the
trade-offs this would involve. But if it was accepted that something
was needed, then a condition of success would be to convince people
of the need for action.
SUMMARY OF
SESSIONS 1 AND
2
Starting with the legal overview, it is noticeable
from the lists of statutes presented in Halsbury that 1959 was
a watershed in British politics, when the rush to legislate began:
three quarters of the legislation listed in Halsbury dates from
after 1959—although earlier legislation tends to be consolidated
in subsequent statutes, in public health as in other fields. The
consequence is that the citizen is entirely bewildered by all
this, except at the local level: we're not short of legislation,
we're overwhelmed by it. But if we turn to Europe, we find it
lacks a satisfactory political and legal structure, and isn't
capable of dealing with public health issues.
In addition to this, it has to be recognised
that globalisation is now a public health issue. And when we come
to consider inequalities, it is important not to forget the law
of unintended consequences: for example, the effect of the Lottery
on the incomes of the poor. The law has been presented in all
its majesty, but the problems of public health resemble an impenetrable
octopus.
In modern politics, the first essential is a
point of authority, focus, influence, so any programme must start
by achieving this. The task for the workshop might therefore be,
first, to be clear about the ten things that could be done quickly;
the principle of ubiquity should be kept in mind; and anything
proposed must provide a point of focus, at the centre of power
and able to undertake research, investigations, and—essential
in today's world—engage in propaganda. Without this, it
will be impossible for the individual to get a notion of what's
happening; and it should happen at the centre, to provide the
basis for local engagement.
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