Select Committee on Health Appendices to the Minutes of Evidence




  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:

    —  legislation;

    —  new mechanisms;

    —  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;

    —  sanction schemes;

    —  a mixture of the above;

    —  private Act of Parliament;

    —  local bye-laws;

    —  reform of section 137;

    —  a new economic, social and environmental power;

    —  the New Framework;

    —  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;

    —  register/notify; and

    —  advice/exhortation.

  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:
PopulationHigh Risk Damaged
SocialFamily friendly policies
Air pollution
Cot deaths

  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.


  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.


  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


  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:
GovernmentAgencies Families/individuals
Life style/environment
Health care

  This approach would involve recognition of a number of values:

    —  The intrinsic value of the citizen in the community.

    —  Control of disease.

    —  The precautionary principle.

    —  Integrated overview of an agreed agenda.

    —  Partnership between organisations.

    —  Real power sharing.

    —  Community engagement.

    —  Full disclosure and equal access to information.

    —  Promoting equity and a duty of care.

    —  Social inclusion.

    —  Sustainable development and capability assessment.

    —  Accountability—required at every level.


  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;

    —  the duty of care; and

    —  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.


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.


  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.


  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.

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