APPENDIX 39
Memorandum by County Durham and Darlington
Health Authority (PH 80)
The evidence includes:
| Para | Page
|
| Definitions of health | 1 |
1 |
| Determinants of health | 2 |
2 |
| Improving health and reducing inequalities and exclusion—organisational roles
| 3 | 2-4 |
| Role of PCGs/PCTs | 4 | 4
|
| Role of Directors of Public Health | 5
| 5 |
| Inequalities—present public health policy role of Health Authorities
| 6 | 6-7 |
| | |
Conclusions
1. Addressing public health issues, especially the underlying
causes of inequality and deprivation, is complex and often slow.
It is important to be realistic about what can be achieved.
2. Reductions in poverty and unemployment would have
a profound impact on the health of our people.
3. Real joint working between health authorities and
local government is vital. Many Directors of Public Health would
welcome joint responsibility to health and local authorities.
4. Primary Care Groups and Primary Care Trusts have a
vital role to play in addressing these challenges. Health promotion
services should be placed within PCGs/PCTs.
Ken Jarrold CBE,
Chief Executive, County Durham and Darlington Health Authority
Dr John Woodhouse MA MRCGP MSc FPHM,
Director of Public Health, County Durham and Darlington Health
Authority
1 December 2000
1. DEFINITIONS OF
HEALTH
1.2 There are many definitions of health. For the purpose
of this memorandum we shall use the following definitions:
— Health is the strength to be fully human.
— Health is to have the opportunity to lead as full
and as happy a life as possible.
Neither definition regards freedom from all illness as an
essential prerequisite for health and both definitions recognise
that each individual is unique as is their experience of health.
Both definitions recognise that to be born or become disadvantaged
or diseased should not necessarily mean that an individual will
be unhealthy.
2. DETERMINANTS OF
HEALTH
2.1 The factors affecting health will be well known to
the Committee. In our work we try to keep in our minds all the
factors listed in Appendix 1. We are delighted that there is now
an open acknowledgement of these factors including poverty and
unemployment.
3. IMPROVING HEALTH
AND REDUCING
INEQUALITIES AND
EXCLUSION—ORGANISATIONAL
ROLES
National Government
3.1 Many areas of national policy have a profound effect
on health including economic policy, social security, taxation,
education, crime and disorder, and food safety. Reductions in
poverty and unemployment would have a profound impact on the health
of our people.
LOCAL GOVERNMENT
3.2 Local government has a considerable influence on
the factors that promote or undermine health.
Public Health Services
3.2.1 Environmental health services, consumer protection
and waste and refuse services are the cornerstones of health protection
and promotion.
Environment, housing and planning
3.2.2 The safety of what we breathe, eat and drink is
of paramount importance. The quality of the environment in which
people live has a profound effect. Noise, pollution and visual
impact are all important.
3.2.3 Control of the physical and built environment is
of profound importance. Poor housing can cause respiratory disease,
promote mental illness, lead to injury through accident, and constrain
the lives of those who suffer physical or psychological illness
or disability.
3.2.4 The planning, design, construction and maintenance
of the physical infrastructure of day to day life is also vital.
Roads, footpaths, leisure facilities must be built and kept fit
for their purpose.
EDUCATION
3.2.5 Access to educational opportunity at all stages
of life influences each individual's ability to be socially, economically
and personally effective and able to best determine and control
their own future.
ECONOMIC DEVELOPMENT
3.2.6 The creation of wealth in general supports and
underpins health. However, inappropriate economic development
can have adverse effects for example on the environment. Anticipating
and addressing changes in economic opportunity is essential for
a healthy society.
SOCIAL SERVICES
3.2.7 Personal social services both promote health and
ameliorate the effects of ill health particularly for the most
vulnerable in society.
NATIONAL HEALTH
SERVICE
3.3 Within the health service many public health functions
are discharged, some are easily identified as public health functions,
some are less easily recognisable as such.
Public Health Functions
3.3.1 The most important, is the duty of the Directors
of Public Health to independently assess and report on the health
of the population for which they are responsible. Before the 1974
reorganisation of local government this duty was discharged by
the Medical Officer of health of local authorities. This longstanding
process underpins the setting of local health policy.
3.3.2 The NHS has shared responsibility (with local authorities)
for the control of communicable disease and environmental hazard.
Other population-level interventions include providing immunisation
and screening services.
3.3.3 Much of local health policy is led from within
the NHS, for example, planning the implementation of National
Service Frameworks and ensuring the provision of health services.
3.3.4 In most places, the majority of specialist health
promotion services are based in the NHS. Functions include the
leadership of important programmes such as tobacco control, reducing
teenage pregnancy and promoting physical activity. Health promotion
programmes require the active participation of other agencies,
especially local government.
Primary Care
3.3.5 Primary medical, dental and ophthalmic services
and community pharmacy provide, directly to individuals, interventions
that not only treat illness but also promote and secure health.
Certain groups of health care professionals have particularly
important roles, including health visitors and community, practice
and school nurses.
Hospital Services
3.3.6 Whilst hospital services are predominantly curative,
services such as maternity and microbiology services have a prevention
and public health focus. However, it is easy to forget that when
needed, access to safe and effective health services are perceived
by most people as essential to a feeling of well being.
OTHER LOCAL
AGENCIES
Police and Probation
3.4 Crime and disorder have a profound effect on health
and well being, particularly for the less well off, the young
and the elderly. The police contribute to other important public
health functions, through speed control, minimising the detrimental
effects of alcohol and illicit substances, and by promoting a
sense of safety.
Voluntary sector
3.5 Voluntary sector organisations contribute to securing
and improving health through a wide variety of means. These include
offering practical services to vulnerable people, being advocates
for those not well placed to stand up for themselves, and educators
in relation to particular issues, eg meningitis and child cruelty.
4. ROLE OF
PCGS /PCTS
4.1 PCGs and PCTs are a welcome innovation in relation
to promoting public health. We have seen PCGs become the focus
for much practical public health action. PCGs/PCTs are particularly
well placed to take such action as they are in a position where
they can use local knowledge of their communities to identify
specific needs and commit resources to address those needs.
4.2 PCGs/PCTs are well placed to develop and maintain
important local partnerships, particularly with local government
and it is important that boundaries are co-terminus. Only social
services are formally represented on PCG Boards. It is vital that
PCGs/PCTs develop joint working with other local government functions.
4.3 In County Durham and Darlington we have placed specialist
health promotion services within our PCGs. Three services have
been established, each serving two PCGs. This is working well
and creating real engagement between health promotion, primary
care and local government.
4.4 The development of PCTs should bring new opportunities
for developing the public health agenda. Managing and delivering
community services as well as undertaking PCG functions should
add a new dimension to their public health role. Ensuring that
the public health member of each PCT Executive Board is appropriately
able and qualified will be particularly important.
5. ROLE OF
DIRECTORS OF
PUBLIC HEALTH
Role within Health Authorities
5.1 The DPH is one of the three statutory Executive Board
members that are required of health authorities. Their function
is to report on the state of the health of their local population,
advise the health authority on public health matters, and provide
medical advice to the health authority. In addition, DsPH share
corporate responsibility for the actions of the authority, and
are normally responsible for health authority-based public health
functions, including communicable disease control and screening
programmes.
5.2 Most health authority departments of public health
also support the planning and commissioning of services by the
health authority and PCGs/PCTs. Often other aspects of health
service development or delivery, for example, NHS quality improvement,
are supported by members of the health authority public health
team.
5.3 We have strengthened our public health function by
the appointment of an additional consultant, nurse, public health
analyst, librarian and information assistant. It is important
that the public health function is well resourced. Public Health
Directors have a wide range of responsibilities, including medical
issues within the NHS. They need appropriate support to enable
them to undertake the full range of their duties.
Role in relation to other Local organisations
5.4 We are fortunate in County Durham and Darlington
in that we enjoy good relationships with local councils and other
local statutory bodies. Local councils recognise and welcome reports
on the health of the population. There are many examples of good
joint working.
5.5 DsPH are NHS-based and so do not have a direct responsibility
for advising or supporting local government with their key public
health responsibilities. It has been suggested that DsPH would
be better placed in local authorities, however this would simply
perpetuate the present difficulties, but in reverse. Many DsPH
would welcome formal joint responsibility to both a health authority
and the related local authorities. It has been suggested that
DsPH would be well placed to be formal advisors to cabinets of
local authorities.
6. INEQUALITIES—PRESENT
PUBLIC HEALTH
POLICY
Role of Health Authorities
Poverty and Employment
6.1 Health services can contribute to directly addressing
poverty through facilitating access to welfare advice and other
key non-NHS services. The NHS can make access to such services
non-stigmatising. A particularly good example are the schemes
in County Durham and Darlington where people can gain access to
welfare advice at some GP surgeries.
6.2 The important of the NHS as a major employer should
not be overlooked. In many of the poorest communities it is second
only to local authorities in providing jobs.
Tobacco Control
6.3 Tobacco consumption is highest amongst the least
well off. This leads to a double disbenefit as these are the individuals
who are likely to have the least good experience of health even
without smoking. The new systematic approach to tobacco control
and smoking cessation within the NHS is based on evidence of effectiveness
and is likely to be successful.
Social exclusion and access to services
6.4 The single greatest contribution that the NHS can
make to addressing the inequalities arising from social exclusion
is to ensure that services are accessible to everyone regardless
of geography, language, age etc. It is particularly important
to provide accessible and acceptable primary care services but
specialist services, particularly mental health services, are
also very important. People with access to good services feel
less excluded.
6.5 It is essential that NHS resources are equitably
distributed both within health authorities (to PCGs/PCTs) and
between health authorities. The proposed index of health deprivation
is very welcome.
Teenage pregnancy
6.6 Pregnancy early in life often leads to exclusion.
The NHS leads the efforts to reduce the number of young people
becoming pregnant. The key partners in this endeavour are the
education service and young people themselves. The NHS can provide
better and more accessible services for young people but education
services have a vital role in providing young people with the
knowledge, skills and attitudes to avoid pregnancy.
Crime and Disorder
6.7 The impact of crime and disorder on health is considerable
and disproportionately affects the least well off. Areas where
the NHS is able to influence these factors include substance misuse
and illicit drug and alcohol misuse which have a profound affect
both on those who abuse these substances and on those around them.
However, the NHS is still not able to provide adequate prevention
and treatment services. This is partly due to competing financial
priorities and partly due to the availability of skilled staff.
The new resources made available in the comprehensive spending
review are very welcome.
Education
6.8 There are a wide range of areas where NHS services
complement education services including the needs of children
with educational difficulties. Not only are such children more
likely to come from poorer families but if their needs are not
met they are more likely to become excluded from society. NHS
services such as school nursing, specialist health promotion occupational
and speech therapy are all important in supporting schools.
Social Services
6.9 For many people in need the organisational division
between the NHS and social services seems bizarre and unhelpful.
If the needs of vulnerable people, which include carers, are to
be properly met then the closest possible working relationships
are required. Often close working is undermined by organisational,
budgetary or charging policy constraints.
CONCLUSIONS
1. Addressing public health issues, especially the underlying
causes of inequality and deprivation, is complex and often slow.
It is important to be realistic about what can be achieved.
2. Reductions in poverty and unemployment would have
a profound impact on the health of our people.
3. Real joint working between health authorities and
local government is vital. Many Directors of Public Health would
welcome joint responsibility to health and local authorities.
4. Primary Care Groups and Primary Care Trusts have a
vital role to play in addressing these challenges. Health promotion
services should be placed within PCGs/PCTs.
TABLE 1
FACTORS AFFECTING HEALTH
| Fixed | Social and Economic
| Environment | Lifestyle
| Access to Services |
| Genes | Poverty | Air quality
| Diet | Education |
| Sex | Employment | Housing
| Physical activity | NHS |
| Ageing | Social exclusion |
Water quality | Smoking | Social Services
|
| | Social environment
| Alcohol | Transport |
| | |
Sexual behaviour | Leisure |
| | |
Drugs | |
| | |
| |
| 
