APPENIX 31 (CONTINUED)
SESSION 3: ASSESSING
THE STRENGTHS
AND WEAKNESSES
OF THE
CURRENT POSITION
Introduction
It was agreed that the workshop should proceed
on the assumption that the meaning of the term "public health"
was understood, and that there would be nothing to gain by trying
to arrive at a detailed definition of it. Broadly two positions
in relation to the current situation can be identified. The first
is based on the proposition that everything that could be done
is being done, nationally, regionally and locally; the appropriate
response is therefore to "let it grow". The alternative
argues that greater momentum could be achieved, through some or
all of:
— reforming existing institutions;
— using current opportunities: the
CMO's project, the White Papers on public health and local government,
the NHS Act, the Freedom of Information Act and, in the European
context, the Treaty on Human Rights;
and that citizenship and the elevation
of the role of women in public health should be at the centre
of the process.
It was proposed that, if there is to be a new
framework for public health, "a major consideration in a
new and complex area is the ability to have a flexible framework
which can refine the law, respond quickly to new situations and
problems and counter the effects of legal uncertainty".
Drawing on the first session, possible solutions
could be in the form of:
— "sticking plaster" legislation;
— a mixture of the above;
— private Act of Parliament;
— a new economic, social and environmental
power;
— a power of general competence;
— a general interpretation statute;
and
— a statement of Constitutional Position.
For this session, workshop participants divided
into three groups, each of which was asked to draw up a list of
a maximum of ten key things the group wanted to change.
Report Back
Group 1
Group 1 identified the following key points:
1. Existing laws—enforcement (public
health function). The group considered whether new legislation
was desirable, and concluded that this is not the primary issue:
it is more important to get the philosophy right.
2. Information (Freedom of Information):
Greater freedom of information is needed.
3. International dimension: It is important
to get the international dimension right: there are difficulties
of enforcement through existing institutions, and the public health
function is missing at this level. Globalisation needs to be recognised
in public health.
4. The balance of society/the individual:
Public health involves human rights, in particular the right of
access to basic amenities.
5. The position of the Department of Health
on public health: Is it appropriate for public health to be a
function of the centre? It is not clear where leadership is coming
from in public health, and this lack of focus gives rise to confusion.
6. The decision to create a new body: If
it is decided a new body should be established, it must be independent
and able to hold the executive to account. And it should promote
a bottom up approach and encourage the spread of current good
practice.
7. Constitutional change: Devolution and
the new constitutional agenda presents new opportunities for public
health and for the bottom up approach.
8. All Party Parliamentary Committee: The
group considered that a separate all party committee was needed
on public health.
9. Dominance of the Medical Model: The group
questioned the appropriateness of the continued domination of
the medical model in public health, and whether the health authority
was the right body to have the lead role:
— public health involves a plurality
of agencies, and needs a framework that reflects this;
— accountability needs to be strengthened;
— current institutional arrangements
at local level are an obstacle to promoting the health of the
public at this level; and
— common officers (with joint local/health
authority appointments) should be considered.
10. New legislation: Any new legislation
should be of a consolidating kind.
Group 2
Group 2's discussion reflected a tension in
the group between drawing up a list and discussing general principles.
Starting with things that could be done, there were obvious examples
like fluoridation of water and tobacco where action would have
public health benefits.
This raised the question: what sort of action:
options would include:
— compulsion/prohibition;
Measures like family friendly policies, involving
for example parental leave, would be another approach.
The group then addressed the question: what
can we do today that we know is good for everybody? They constructed
a matrix as a framework for considering this; the entries under
the "population" column exemplify the approach:
| Population | High Risk
| Damaged |
| Social | Family friendly policies
| | |
| Environmental | Fluoride
Air pollution
Traffic
Cot deaths
| | |
| Biomedical | Tobacco
Food
| | |
| | |
|
Surveillance/registration/monitoring: it was agreed that
the need for this activity should be recognised.
The group then moved on to discuss philosophical general
issues:
— the precautionary approach to risk; and
— the issue of duty care/nuisance.
They agreed on the need for a voice to drive public health
concerns, and decided in favour of a national commission, while
recognising that the regional and local levels also need attention.
Group 3
Group 3 identified 10 key points:
1. Link LAs and HAs:
The group saw linking local and health authorities as an
absolute requirement:
— a range of mechanisms could be identified, from
old Joint Consultative Committees to unitary authorities; and
— there is a need for real structures, involving:
— teams;
— leadership; and
— accountabiity;
— there should be a duty to collaborate, supported
by a common language, and common education and training.
This need not involve legislation.
2. Information and surveillance:
There should be a requirement on local and health authorities
to provide information and a freedom to use it for public health
purposes. This should involve:
— linked data, individually based and openly available;
— a duty to share/use/report;
— involvement at all levels from local to international;
— protocols for data handling; and
— the inclusion in the system of relevant agencies,
eg benefits agencies.
3. Review resources:
Resources should be reviewed across organisational boundaries,
to help redistribute them where appropriate.
4. Ministerial responsibility:
There should be a Ministerial responsibility for public health
on a UK wide basis, to provide clear national leadership.
5. Enhance community development:
Community development should be enhanced as a mainstream
activity: this should involve a requirement to disseminate good
practice.
6. Regional and national expert bodies:
(this should interact with 5 above).
Expert bodies should be set up, not as elitist, but as a
means of ensuring protection for independent advocates ("Proper
Officers") who would be available for consultation, and would
be required to report/deliver.
7. Motivation:
Resources would be needed to reinforce motivation in public
health, and to develop ways of achieving change.
8. Strategy and tactics:
These need to be explicit.
9. Leadership: CDC:
There should be a single lead body/person responsible for
communicable disease control, with proper command and control
at every level.
10. Improved capacity:
Capacity needs to be improved in:
— education/training/development; and
— techniques/"how" skills,
with the object of enhancing the population perspective.
DISCUSSION
The roles of the health and the local authorities in relation
to public health were considered. There was some agreement, firstly,
round the view that the health authority is not the main contributor,
compared to other agencies, of which local government is by far
the most important. Alternatives to the existing arrangements
might involve:
— some form of linking between health and local
authorities;
— the local authority becoming the lead body; and
— the creation of a system of two parallel (health
and local government) pillars, with a new, independent body alongside,
in an ombudsman role, with responsibility for scrutiny.
It would be important that there should be some form of control
in relation to other agencies, for example the water companies,
whose activities have an impact on public health. In the interests
of the rights of the individual, there should be a way of holding
these bodies to account.
Health impact assessment would be one way of establishing
this accountability. It was argued that to be effective, the system
responsible for this would need a quantitative capacity: if there
is to be an explicit human right to public health, then it will
be essential that information is available to support this. Health
impact assessment across government departments is now a recognised
issue, and could be a mechanism for establishing public health
accountability. An independent agency or pillar with a "development"
role, working to bring about change in attitudes, could be envisaged,
alongside the "doing" pillar and the "ombudsman"
pillar.
Recognising that there is already a pool of "good practice"
out in the field, offering considerable potential, it was argued
that funding development on the basis of short term projects is
unsatisfactory. Three-year projects tend to disappear at the end
of their funding, and though a system of evaluation is important,
a longer-term approach to funding development projects that succeed,
beyond the evaluation point, is also needed. Accepting the need
for the discipline of an end point, at which it is determined
what has worked and what hasn't, a case can be made for a longer
term development fund for rolling out projects that have succeeded,
particularly as it cannot be assumed that there will be the capacity
to pick them up elsewhere, so education, training and workforce
development will be an essential part of the process. And it is
important that information about unsuccessful projects should
also be disseminated, while if a project is successful, there
ought to be a commitment to carrying it on, or there is a risk,
not only that the achievement will be lost, but also that the
local community will feel experimented on.
Supporting this, concern was expressed that "projectism"
leads to isolated, self-contained activities, so organising development
work in parallel with established programmes of activity is unlikely
to be successful, though Health Action Zones and health living
centres could be vehicles for reorientation.
Looking at ways of achieving this, it was suggested that
the key task is to find a mechanism for coordinating all the influences
and activities that have an impact or a bearing on public health.
The way to achieve this might be to create a matrix organisation,
perhaps in the form of a Board of Health. A difficulty here is
that increasingly what used to be core local government activities—housing,
education—are being split off into separate agencies: the
reconstruction of local democracy will be a key constitutional
issue for the Government.
SESSION 4: A NEW
PUBLIC HEALTH
ACT: DO
WE NEED
IT, AND
WHAT WOULD
IT LOOK
LIKE?
For this session, participants divided into groups as before.
Groups 1 and 3 were asked to build on their discussions in Session
3, and to consider whether a new Public Health Act is needed;
and if it is not, what else is required and what mechanisms would
be appropriate. Group 2 was asked to continue with their discussion
of underlying principles.
Report Back
Group 3
Group 3 concluded that a new Public Health Act is needed,
to clarify powers, duties and accountability for the measures
needed to improve the health of the people. From this, they developed
the following proposals, which would flow from the Act:
There should be one person at each level: national, regional,
local, responsible and accountable (ultimately to Parliament)
for ensuring action. These people might be called Commissioners
for the Health of the People.
This should be taken as a model for the whole United Kingdom.
The Minister and the Commissioners for Health should be responsible
for strategy and tactics necessary to achieve improvements in
health across all sectors. They should be responsible for establishing
mechanisms for collecting information, and for surveillance, so
as to be able to assess, with a duty to report, the health impact
of activities in other sectors.
They should be responsible for ensuring co-ordination and
integration in local community plans, produced by health and local
authorities, HIPS; this should extend to monitoring the implementation
of these plans, and supporting community development (including
the involvement of geographical interest groups and minority groups).
They should be responsible for ensuring that appropriate
expert bodies are set up at all levels, with the necessary independence,
a duty to report and the freedom to do so.
They should set R&D priorities and commission work on
how to motivate, develop and support change.
Their approach should be inclusive: there would be one body
at each level, looking across all sectors, and building the capacity—and
having the resources—to do so.
Group 1
Group 1 opted for a holistic approach and agreed that, though
the issues are political, they needed to be depoliticised, at
least in some respects. They concluded that a democratic approach
is required as illustrated in the diagram:
This shows the system as ultimately accountable to Parliament
and its Committees; and Government in a symbiotic relationship
with agencies such as the HSC, the HEA. Below this a new system
is needed to link health and local authorities. Where individuals
are concerned, a Bill of Rights may be needed, and a Freedom of
Information Act could be helpful.
To support this system, two arms are needed:
(a) the coercive arm: laws and directives; and
(b) the maintenance arm: bodies like the Audit Commission,
developing the intelligence function, monitoring and reporting,
but without the power to compel. The object is the creation of
a dynamic system, as an alternative to crisis-led intervention.
The role of the Director of Public Health at present involves
too many dimensions; the group concluded that some form of Commission
or Inquiry should be set up to consider this.
The group's proposals were developed from a starting viewpoint
that parliamentary democracy is not functioning satisfactorily,
and a system is needed to protect that rights of the individual.
The division between the monitoring role and the coercive side
was seen as fundamental to this; and the group recognised the
importance of developing a system which would be robust to running
under the regime of the Common Law or under a Bill of Rights.
Group 2
Group 2 identified the following principles as underlying
the debate about the future of public health:
The precautionary principle:
— the burden of proof should be with the developer;
— the principle offered a "third way"
through the evidence/no evidence dichotomy; and
— the principle should link to health impact assessment.
Community engagement
Full disclosure of an equal access to information
"Real" power sharing
Accountability
Integrated overview
Promoting equity and a duty of care in health, at both individual
and population level:
— social, environmental and biomedical.
Social inclusion
Integrated overview/strategy
Sustainable development:
— rejecting projectitis/projectism.
Partnership between agencies
Control of disease
The group proposed a legislative framework for a Contract
for Health between the Government and the People, which would
set out the rights and obligations in a "Third Way"
approach:
| Government | Agencies
| Families/individuals |
| Life style/environment | |
| |
| Health care | |
| |
| Social | |
| |
| | |
|
This approach would involve recognition of a number of values:
— The intrinsic value of the citizen in the community.
— The precautionary principle.
— Integrated overview of an agreed agenda.
— Partnership between organisations.
— Full disclosure and equal access to information.
— Promoting equity and a duty of care.
— Sustainable development and capability assessment.
— Accountability—required at every level.
DISCUSSION
The groups had identified a constellation of rights, duties
and responsibilities:
— duties of notification, registration, information;
— duties to give and receive advice, including the
duty of a possible Commission to proffer advice;
— the responsibilities for individuals and families
involved in the Green Paper's Contract for Health;
— a duty of precaution, which could have interesting
implications in terms of holding organisations accountable; some
concern was expressed that this last might stifle innovation,
and it was agreed that this issue required further debate.
Attention was drawn to the problem of how to prevent Parliament
giving powers of command to the bodies which, in group 1's model,
would be responsible for inspection, development and intelligence.
There would always be a temptation, if such a body was performing
well, to give it additional powers, and with no written constitution,
the safeguard that such a constitution might offer could not be
relied on.
SESSION 5: NEXT
STEPS
Summarising presentation
At an earlier stage in the workshop, three principal opportunities
in the coming months were identified for influencing the future
of public health:
— the forthcoming White Paper;
— the Chief Medical Officer's Project and his annual
report; and
— the forthcoming NHS Bill.
The Health of the Nation put health on the agenda,
but there is a clear need to move from rhetoric to reality; at
the moment chief executives of health bodies are by and large
not committed to public health concerns.
From the discussions so far six key messages or issues can
be derived:
(1) It is important that government provides real leadership—which
must involve clear, consistent corporate messages across the whole
spectrum of government.
(2) There is a need for shared ownership at all levels.
(3) Within the performance management framework there
is a need for clarification of the responsibilities and tasks
of the various agencies.
(4) The question of the lead role, and whether it should
be assigned to health authorities or local government: both organisations
are needed, and should have joint ownership of public health issues.
(5) This raises the issue of the role of the Director
of Public Health: is the job currently impossible? Under current
arrangements, there is a tendency for the urgent to drive out
the important. The managerial agenda and clinical governance are
drawing in the DPH, and raising the question of whether the focus
should be managerial or outside the management of the service.
There is a need for joint targets, objectives and responsibilities,
as well as for a monitoring system.
(6) The related issues of continuity and sustainability:
these in turn raise questions of how to audit the system, of human
resources and strengthening capacity, and of whether it would
be preferable to re-engineer existing institutions or create new
bodies. Whatever courses are chosen, it is important that a means
of evaluating the culture is built into the system, as well as
a mechanism for monitoring progress against recognised milestones.
The timescale for feeding these messages through the three
windows of opportunity identified is a very short one, and a clear
set of action points is needed in relation to each window.
Discussion
It was suggested that the forthcoming local government White
Paper should be seen as a fourth window: an opportunity to shape
local authority responsibilities and to pick up the regional issue.
Taking up the question of ownership, it was argued that there
has been a failure to engage with the public and with the clinical
profession on Health of the Nation, which was in effect a public
health strategy: yet doctors are an important part of the process,
as is also community awareness. This raised the question: where
should responsibility for public health be located? The solution,
it was suggested, might have to be pragmatic, with shared posts
to reflect shared ownership and the need to build capacity across
the local authority/health authority boundary. Public health faces
a decision on how to respond, which could involve a choice between
public health medicine and public health. The public health physician
is slightly marginal in the profession of medicine, having a rare
set of skills, which it is likely will be used to fall in with
the aims of the employer. Where the employer is a health authority,
the outcome is predictable. If responsibility for public health
were moved to local government, public health physicians would
have to start again, and would face a new set of problems, while
health authorities would be left without their skills. It was
suggested that it would therefore be better to leave public health
with health authorities, while using their skills more widely;
this, however, raises a danger that public health practitioners
would be swamped, so their role needs careful definition.
It was pointed out that although responsibility for public
health is specifically given to health authorities, and is therefore
ultimately the responsibility of the chief executive/general manager
of the authority, there has not been any corresponding attempt
to hold chief executives accountable for the health of the people:
the managerial accountability agenda has followed an entirely
different route. This reflects the reality that the major determinants
of health are not in fact under the control of the health services.
On the principle that structure should follow function, it was
argued that the public health profession should be aligned with
the main determinants of health.
From a different perspective, however, it was suggested that
if the medical function was to be retained in public health, then
the individuals recruited to the speciality must be credible medically.
Experience between 1948 and 1974 showed a serious failure in this
period to attract good medical graduates into public health; a
change in the recruitment climate was only achieved with the establishment
of the MSc course at the London School of Hygiene and Tropical
Medicine and the incorporation of Medical Officers of Health (MOH)
within the mainstream of medicine. Concern was expressed that
relocating public health in local government would in all probability
involve accepting a return to this situation, which was regarded
as unsatisfactory by some participants. It was noted that in the
past, the Diploma in Public Health had been the qualification
required by statute for the MOH; but in the course of successive
reorganisations this requirement, and the "Proper Officer"
status of the predecessors of the current Directors of Public
Health, were lost. The issue of multi-disciplinary membership
of the public health profession raised the question of what, if
any, should be insisted upon as qualifications for Directors of
Public health, and the allied questions—if the public health
practitioner were to become independent—of accountability,
standards and regulation.
Reviewing the present position of the public health physician,
it was suggested that the creation of the internal market had
offered the profession a major opportunity to purchase for health,
but the managerial takeover meant that this had been missed. Turning
to the future, it was argued that it was limiting to think solely
in terms of the role of the DPH: the focus of attention should
be the whole range of functions in public health and the "family"
of professions associated with them. The prospective relationship
between health authorities and health commissions was considered,
and the logic of distinguishing between them was questioned: a
Health Commission would necessarily be closely interested in the
Health Authority's purchasing plans. As an alternative scenario,
there are examples in Wales of successful cooperation and joint
planning, with flexibility in key appointments, which enables
working together. Examples could also be found of DPHs with wider
roles, where this was working well; but it was argued that public
health functions should be clearly separated out; and that Public
Health Commissioners might come from a range of backgrounds.
Attention was drawn to the particular problem of the surveillance
and control of communicable disease. At present there is no one
individual or body unambiguously responsible and accountable for
this function; and there is an urgent need, as exemplified in
the case of the 1998 E coli outbreak in Scotland, for clarity
about:
— who needs to be notified in the event of an outbreak;
— what is done following notification; and
— where the resources come from for any investigation
that may be required.
Practical steps for the immediate future were considered.
There was support for the idea of Commissioners for the Health
of the People, with appropriate skills and responsibility for
promoting activity with the goal of the public health; a hierarchy
of such people would be needed, from the national to the local
level. They would be independent of spending departments; they
would have a UK-wide message, though with regional differences;
they would be responsible for ensuring action was taken—a
policing role—and they would be on the outside, looking
at the structure and pointing out what's wrong. A comparison might
be made here with the Surgeon General in the US.
It was agreed that the evidence suggested that in the UK
system the only effective way of getting things done was from
"inside". The Surgeon General currently has no troops,
but in the past his predecessors were responsible for the whole
of the public health service in the US. It was suggested that
Commissioners for Health, to be effective, would need to have
resources at their disposal, and should not be in a purely advisory
role.
Two issues were proposed as fundamental:
(i) the relationship between local government and health,
and the linking role of public health; and
(ii) the question: who is the primary public health adviser
to government?
It was argued that the medical hegemony in public health
is no longer tenable, and ways of drawing in non-medical professionals
are essential, because excluding them is weakening the structure
of public health in the UK, which is otherwise one of the strongest
in Europe.
It was pointed out that under the proposals in the White
Paper, health authorities would merge; and with local government
reorganisation also on the way, the geographical basis of the
two organisations principally concerned would change, at the same
time as Primary Care Groups emerge and there is a prospect of
their evolution into Primary Care Trusts.
It was suggested that responsibility for ensuring cooperation
between health authorities and local government must lie with
Ministers. There is a very large agenda of things that need to
be done, and access to power is essential to ensure implementation.
If, as might well be the case, the proposed Commissioner, like
the present day Surgeon General, has no-troops, then the role
and function need to be thought through very carefully, especially
in relation to Ministers and purchasers. On the one hand it can
be argued that the Commissioner's function should include responsibility
for speaking truth to power publicly, and that engaging the public
is important. At the same time, the importance of the performance
management aspect of the role should be recognised, and "naming
and shaming" may not be the best way to ensure a performance
management function that works.
Looking to the future, one might predict that the Primary
Care Trusts will be the predominant purchasers, in which case
health authorities would be free to focus on public health. And
in the 21st century the role of civil servants may change, with
moves towards participative democracy creating a changed context
in which they become responsible to the public as well as to government.
The issue of professional advice being in the public domain will
therefore be important, as will engaging the public in debate.
Here an external agent (the Commissioner) would be better able
to engage with individuals, and to make information available:
when a body calls for information in the course of an investigation,
it puts that information into the public domain.
There was some concern at the prospect of advocating the
creation of new institutions and mechanisms in an already crowded
landscape, with bodies like CHIMP perhaps potentially a basis
for a new approach—though the roles of these new bodies
are not yet fully developed. There was also some concern that
the track record of public health itself was not encouraging:
in particular, its lack of influence on purchasing was disappointing.
The workshop had touched on a range of problems public health
could address; democratic renewal in particular could be attractive
to government; it was suggested that a useful next step would
be an appraisal of the mechanisms already in existence.
Other questions suggested included:
— what individuals can do for themselves with regard
to health;
— inequalities and the wider social justice agenda;
and
— capabilities and capacities.
The prospect of increased numbers of local people becoming
members of boards offered potential new champions for the public
health cause, and it was argued that progress will depend on making
connections with local communities and empowering people. From
the local government perspective, reinforcing this, there is pressure
from government to work in partnership with other agencies, and
this must involve public health questions such as food and safety
and environmental issues. Little has been said about children
in the public health context, but future success will depend on
healthy schools, work places, neighbourhoods. The public health
agenda, it was argued, should connect with the goal of making
towns and cities healthier places.
This will also involve planning questions, and violence and
law and order issues. There are numerous examples of good practice
improving the urban environment, of urban regeneration, and public
health can be seen as having the ingredients of an agenda to contribute
to this, and at the same time to the social inclusion agenda.
Reflecting on these arguments led to the proposition that
the basic division they reveal about what public health should
be concerned with must be resolved: if the determinants of health
are not so much to do with health services, then public health
is not primarily a health issue. This raises the question of what
public health medicine contributes, and whether its claim to a
leadership role is legitimate. If these doubts are justified,
then there could be an alternative, focusing on a whole range
of environmental and biomedical areas.
In response to this it was suggested that the real challenge
is to return public health to the public, and to enable them to
take charge of their environment: this links to the democratic
deficit and governance issues. Overall, the health of the public
is improving; there are a whole range of determinants, of which
health services are one but not the most significant. It should
be acknowledged that the public health function has been insufficiently
effective and that health commissioning has had little influence
on the health of the people over the last five years. For example,
there is considerable evidence of a powerful association between
income differentials and health experience, but public health
has not yet engaged with this. Finally, it should be recognised
that public health is a broader church than public health medicine.
SUMMING UP:
THE NEXT
STEP
The next task is the production of a paper to influence government:
public health has been around for 150 years, and it is time now
to prepare for the next 150. This paper should be kept simple
and straight forward, and be in the form of a Cabinet-style paper.
The preamble will be crucial, and must persuade Ministers. Some
reference to history will be needed, and the paper should emphasise
that the future is uncertain, and that we need machinery to enable
us to prepare for it.
The major theme of the paper will be arrangements for public
health in the future. In the knowledge that there is no prospect
of legislation in the current Parliament, the principal goal will
be: one sentence in the manifesto for the next General Election,
with the aim of getting a Board or other appropriate structure
into existence by 2004. In this connection little purpose would
be served by extensive detail on any particular type of body or
mode of operation. There should however be one exception: the
point should be made that it is essential that the new body should
be really independent of government if it is to be of use to government
and to gain credibility in the country. The rest of the paper
should provide, as a secondary theme, a summary of the things
that are really urgent, and the actions that can be taken to deal
with them; but these considerations should be presented in a way
that does not distract from the main theme, and the object of
achieving the adoption of the workshop's recommendation at the
policy level.
| 
