Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Dr Tony Jewell (PH 70)


  1.1  I am submitting this short report to the Select Committee in an individual capacity. I am a Director of Public Health and submitted my recent Annual Report for Cambridgeshire to your committee to illustrate the value of such reports to the local Health Improvement Programme and the partnerships concerned with the health of the population. I was invited to submit evidence and this paper reflects my experience as a DPH.

  1.2  As a Council member of the UKPHA I am committed to tackling inequalities in health through modifying the underlying determinants of health such as poverty and the need to see local authorities as key partners concerned with the social, economic, environmental well being and therefore the health of their population. Professionally I am committed to reducing inequalities and through the Cambridgeshire HImP we have forged close relations with local authority partners.

  1.3  There are four central points that need to be made;

    —  To deliver appropriate public health practice in a variety of settings we need a cadre of public health practitioners who represent a broad multidisciplinary background who, following appropriate training, are armed with core public health values and a set of public health competences.

    —  Such practitioners would form part of a multidisciplinary public health workforce.

    —  Public Health practitioners function at different levels of population and in different organisational settings.

    —  Public Health leadership needs to be keyed in to organisations with a statutory responsibility for a defined population.

  1.4  I have structured this submission using your terms of reference headings.


  2.1  One of the characteristics of public health practice is the key question—what is the population of interest? This can, in the case of an individual with Lassa fever, focus initially on a single individual with a communicable disease who needs effective individual management but who poses a wider public health risk. Starting from such an index case the wider public health risks are assessed and appropriate preventive actions taken. These might escalate to international control measures.

  2.2  Another important concept in public health is epidemiological stability, for a specified condition there will be a relevant population size where the incidence and prevalence is predictable within reasonable error limits. Rare conditions may require a national surveillance system and national treatment centres. Eg some rare genetic disorders and new highly specialised treatments commissioned by the National Commissioning Advisory Groups. Others require a regional population of 5-10m to assess needs and appropriate services. These conditions are specified by regional specialist commissioning groups. Other conditions look to smaller populations for example a cancer network looks at over 1 million catchment population. The process moves down through Health Authority populations to small populations, such as Primary Care Organisations where epidemiological stability is seen for common conditions only (heart disease, arthritis, depression respiratory infection, contraception).

  2.3  Usually the population of interest for public health practitioners in the UK is defined by health authority or governmental boundaries. Starting from individuals and communities these governmental structures, in a rural area such as Cambridgeshire, are built from three tiers of local government—Parish Councils and Town Councils, District or City Councils, through Unitaries and County Councils.

  2.4  Above local government we are seeing the development of regional government and their aggregation to Nation State. This then progresses to a UK perspective and so to European (EU), Regional (WHO) and then Global perspectives (UN). At each level of governance there is a defined population of interest and sometimes this carriers the weight of statutory responsibility.

  2.5  At each level of governance there needs to be clarity about the statutory public health function. Nationally there is a Chief Medical Officer within Government and regionally there are Directors of Public Health who, following the loss of statutory regional health authorities in 1996, will increasingly be aligned with regional government. Locally District Directors of Public Health are employed by Health Authorities. In an area such as Cambridgeshire, where there is a County and Unitary Authority (Peterborough), the statutory body of relevance is the Health Authority.

  2.6  The population of interest in the Health Authority is now, not only the resident populations of the five district councils and unitary, but the responsible population of our seven PCG/Ts. In addition to the County and Peterborough we have five second tier District and City Councils who make up the 730,000 resident population.

  2.7  When District Health Authorities in Cambridgeshire were smaller there used to be three DPHs covering the population of Cambridgeshire. If each second tier local authority had a DPH there would be six and if each PCG/T had one there would be seven! One model we might consider is that each PCG/T and its broadly equivalent District Council should have a named public health specialist (at present consultant in public health medicine) who is an Assistant DPH with statutory responsibilities for that local authority and executive committee responsibility for the primary care trust population. Such a position could be open to Public Health Specialists.

  2.8  This could, given the PCG/T population of interest for a Health Authority, be aggregated to HA level. Such Health Authority populations are of sufficient size to make Health Improvement Plans credible for NHS planning. For example for implementing the coronary heart disease National Service Framework requires a service networks involving primary, secondary and tertiary care.

  2.9  The central point here is that there is a local, regional and central government hierarchy in government but the English NHS organisation is often not coterminous below regional levels. Ways need to be found to build public health population responsibilities, which are synergistic with local sensitivity at PCG/lower tier government, while having a sub regional population of sufficient size to enable effective NHS HImP planning and performance review functions.


  3.1  The statutory duty of partnership between local authorities and health authorities has enabled a rapid development of partnership working directed at ensuring Health Improvement Programmes represent a shared agenda. The very process has enabled the development of a shared responsibility within and between partner organisations. The targeting of specific initiatives such as Health Action Zones, Surestart schemes and Education Action Zones was a necessary mechanism to pump prime a targeted approach to tackling disadvantage. However in the longer term these programmes need to be integrated into local plans and so reduce the confusion of accountabilities and the crowding of the arena. All areas have HImPs and the future model needs to be built on that rather than the exceptional targeted communities. Resourcing with appropriately weighted capitation formula will ensure that disadvantaged populations are resourced fairly to meet their needs from mainstream budgets. This should extend to small area neighbourhood levels within PCG/Ts.

  3.2  With the development of Community Strategies lead by local authorities much integration can occur at district level. In County environments like Cambridgeshire the HImP, based on a larger planning population, can still provide the strategic framework. Below this level we look to smaller PCG/T/LA levels to have local partnership arrangements to feed in local needs assessments and implement locally sensitive plans. This is the model we are pursuing in Cambridgeshire. By developing a hub and spoke public health function with our PCG/Ts we can ensure that work is done at local level and more specialist inputs are provided at HA and HImP levels.


  4.1  The HDA is an important development and should be the focus for national expert work on the wider determinants of health, which can build up an expert evidence based approach. The current plan to fund regional HDA appointments is questionable as there is a serious risk that inadequate resource is housed centrally to do the enormous amount of work needed on effective health programmes. The new appointments could be seen as additional health promotion staff in ROs rather than part of HDA critical mass with questions about their added value.

  4.2  The loss of status of Accidents and Injuries, the fourth national contract in Our Healthier Nation, is regrettable. This should be a public health programme supported by the HDA promulgating evidence based approaches to Health Promoting Schools, Healthy Homes, Healthy Workplaces and a Health Promoting Environment. A coherent and evidence based approach to effective health promotion, health protection and neighbourhood renewal and community development interventions should be the task for the HDA.


  5.1  I have already identified these new organisations as key NHS corporate bodies who become statutory when they achieve Trust status and who have a defined population of interest. They already have a health improvement responsibility in addition to providing primary and community care and commissioning hospital and other services. They need therefore to have access to skilled multidisciplinary public health support corporately to work with the Board and management and being represented on the Executive Committee of PCTs. Their staff with a public health function such as Health Visitors and General Practitioners need to have access to public health leadership and specialist support to help the effort within practice populations be built into coherent programmes of action eg successful childhood immunisation.

  5.2  The registered population of PCOs varies from about 60,000 to 300,000 with the proposed median of about 100,000. This is made up of units of general practice registered populations with perhaps 50-60 GPs in a typical PCO. These units are the building blocks for PCOs equivalent to ward populations in local government. The public health function needs to work from within practices, alongside GPs and Health Visitors as well as within communities and neighbourhoods alongside community development workers and other key organisations such as schools and workplaces. The practice based approach offers a rich context for needs assessment, health service programmes and evidence based practice and will rely on engaging the public health workers already out there who are the foot soldiers for local activity and a sleeping public health resource. These include a variety of public health workers employed within local government.

  5.3  A model of public health support to PCOs corporately and GP practices and neighbourhoods in the patch will generate workforce estimates for different types of public health specialists suited to the different roles and settings. This builds on health visitors and other public health nurses, community development and local health promotion specialists to more specialised public health specialists and consultants in public health medicine. A coherent network of public health practitioners can be provided through hub and spoke arrangements which allow for a critical mass of skilled and relatively scarce specialists at HA level who support the HImP, HA wide public health information, training and R&D functions. This hub is linked systematically to PCOs and supports them corporately while also helping to steer and support the practice and community based teams.

  5.4  The DPH at HA level provides the focus for public health leadership across the HImP partners and the Information for Health strategy. This is an integrative function which helps avoid damaging fragmentation.

  5.5  An independent agency would damage corporate links and independence can be achieved by appropriate development of academic and other specialist public health units.


  6.1  The Minister of Public Health is an excellent development within national government. However locating the Minister as a junior post within the DOH severely restricts their impact. The post should be at Cabinet level, perhaps based in the Cabinet Office, with responsibilities that enable a powerful cross government role.

  6.2  The health of the people is the highest law, wrote Cicero, and this means that the health of the population is not a subsidiary government objective but arguably the most important. Why doesn't the CMO's report on the health of the population get presented to Parliament by the Prime Minister? Why isn't the success of government based on achieving Our Healthier Nation strategic objectives of prolonging disability free life expectancy and reducing health inequalities?

  6.3  The success of the Social Exclusion Unit, which is a relatively small team based in the Cabinet Office with access and commitment from the Prime Minister, shows how such a post might work in future. The Prime Minister's personal involvement in the National Plan provides a political opportunity. If not based in the Cabinet Office then within a department with responsibilities for the wider determinants of health such as the Treasury or DETR.


  7.1  The DPH role is of crucial importance as it is a statutory post with a defined population of interest and clear links to a statutory body. The regional DPH lost its statutory body in 1996 but in future is likely to be linked into the regional government tier.

  7.2  District DPHs are currently employed by Health Authorities with responsibility for a defined population and the opportunities for close local authority links. For example the Communicable Disease Control function is based within DPH departments and have proper officer responsibilities within local government environmental health functions. In some metropolitan areas, where there is a reasonable population size and coterminosity with local authority boundaries, joint appointments between HAs and LAs are possible. In County areas, as described earlier, the size of district councils can be very small (East Cambridgeshire District Council with 70,000 population) and there are up to seven local authorities within one HA. The model described of Assistant Directors within PCTs and second tier LAs is possible.

  7.3  Whatever the model there needs to be the link between the DPH and the Health Improvement Programme, and a statutory body with responsibility for the health of a population. It is important to acknowledge the part that Chief Executives and other executive directors can play as champions of health improvement.

  7.4  Departments of sufficient critical mass to support specialisation, teamwork and training are required. The statutory function is a safeguard that enables DPHs to have confidence to challenge local organisations, including NHS organisations and their chief executives and Boards, where policy decisions may threaten the public health and to monitor health impacts objectively. Health Impact Assessment for example need to have that confidence.

  7.5  The DPH annual report is an important vehicle to monitor progress in health improvement and support information about needs and influence the HImP. It should continue to be a requirement and be sufficiently resourced.


  8.1  The policy in Saving Lives—Our Healthier Nation, to reduce health inequalities which is reinforced in the National Plan, is laudable and it would be nice if we had agreed measures. Such measures could be used at local levels and be aggregated to regional and national populations to monitor progress. We have a variety of measures which record many of the underlying determinants of health such as income inequality and neighbourhood deprivation scores. The Treasury will have very detailed knowledge about income inequalities and the distribution of income. Measures of income inequality are available and could be the basis for national targets for redistribution of wealth and greater equity.

  8.2  Public Health measures of outcome have been put together in datasets such as the Public Health dataset so that the inequalities can be mapped very clearly across the country down to very local populations, by area, age, social class, gender and ethnicity.

  8.3  With the development of regional public health observatories, which should integrate local authority and health data, there should be data to support sources which can be aggregated up from quite small populations to local authority/PCO and HA/County levels. Nationally there is intent to pull the data together to provide a Centre for Disease Surveillance and Control. This could be built on the model of the CDC in the USA by linking to the Public Health Laboratory Service Centre for Communicable Disease Surveillance and Control (CDSC).

  8.4  We have the data to establish the extent of inequality and set targets to reduce them. A serious political error was made when OHN did not agree national inequality reduction targets and we have lost time in developing the most appropriate measures and interventions to achieve such targets.

  8.5  Income inequality measures and indices such as the Robin Hood index and Gini coefficients are useful tools. Composite scores such as the DETR deprivation scores are helpful and offer multidimensional health improvement interventions to achieve a shared objective. It is likely that we will need several health outcome targets to take account of life cycle—maternity, childhood, young people, working age and older people as well as other types of inequality by age, sex, ethnicity and locality. Using such data sources we can establish baselines in the wider determinants of health, set targets and measure progress towards reducing inequalities.

  8.6  The National Plans commitment to develop such scores and national targets is to be commended and should be an urgent task for groups such as the HDA to help lead.


  9.1  Over the last 25 years public health practice has been subjected to a number of reviews and changes. The multidisciplinary professionals who make up the workforce share the vision of improving health and reducing inequalities. What they need now is confirmation of their function and place in organisations and settings with public health responsibilities. To deliver the new and exciting agenda their critical mass needs to expand so that the public health function overall is strengthened.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 28 March 2001