Members present:
              Mr David Hinchliffe, in the Chair
              Mr David Amess
              John Austin
              Dr Peter Brand
              Mr Simon Burns
              Mrs Eileen Gordon
              Mr Stephen Hesford
              Siobhain McDonagh
              Mrs Marion Roe
              Dr Howard Stoate
                 RT HON MR ALAN MILBURN, a Member of the House, Secretary of State for
           Health, and YVETTE COOPER, a Member of the House, Under-Secretary of
           State, Minister for Public Health, examined.
        665.     Colleagues, can I welcome you to this session of the
  Committee, which is the last oral evidence session of this inquiry, and
  particularly welcome our witnesses, the Secretary of State and the Minister. 
  We are very pleased to see you.  I know it has been a pretty tough week and
  we appreciate the time you are giving to the Committee today.  Can I ask you
  briefly to introduce yourselves to the Committee?
        (Mr Milburn)   Yes, Alan Milburn, Secretary of State for Health.
        (Yvette Cooper)            Yvette Cooper, Minister of Public Health.
        666.     As you know, we have been holding this inquiring for some
  months now.  We have had the opportunity to take evidence from a range of
  agencies, individuals, organisations and also had a number of visits related
  to the inquiry, and I think it is fair to say from my perspective that we have
  seen a great deal of positive evidence of very clear progress in public
  health, but one of the issues which it will not surprise you I would like to
  raise with you, an area of some contention, concerns the organisational
  structure of public health which we have currently.  We have had substantial
  evidence from a range of sources raising questions about the current location
  of the public health function within DHAs, indeed very serious questions have
  been raised about the whole future of DHAs with the developments in primary
  care and primary care trusts, et cetera.  I would be interested in
  establishing, first of all, what your views are as to the future location for
  the direct function of public health at local level.  Some of us at the
  veteran stage of the Committee go back prior to 1974 and, as you well know,
  recall a model that certainly I believe operated more effectively in relating
  to elements of policy in local government that were able to drive changes in
  policy forward in a way we have not managed to do since it was detached from
  local government.  Can I begin by asking you about your thoughts on that
  general area?
        (Mr Milburn)   I am tempted to say, Chairman, it was before my time, but
  that would not get me off to a very good start.
        667.     But you have read about it.
        (Mr Milburn)   Yes, I have, and I have also thought about it quite a lot,
  and I know you and other members of the Committee have strong views about the
  issue.  What is true and what is common ground amongst all the participants
  in this debate is that if we are going to improve public health, that is more
  than the job of the National Health Service, point one.  Point two, much of
  our effort should be focused upon dealing with some of the determinants of ill
  health.   I think that is also common ground, whether it is poverty, poor
  housing, environmental problems.  However, in the end it seems to me that
  public health in purpose is about achieving certain health outcomes and
  although there would be a myriad of views about where best to locate the co-
  ordination function, because inevitably wherever you draw the boundaries there
  will be a whole host of local organisations or indeed national organisations
  which will have a bearing on the health of the public, in the end somebody has
  to hold the ring.  The question really is, who best should do that, who is in
  the best position to do that.  It seems to me - and I have thought about this
  and I have thought about the arguments you and others have made in relation
  to local government - in the end since it is a health function and a health
  purpose, probably that location is best done on a local level in the Health
  Service.  However, what is also clear is that we cannot have what I have
  described in the past as the ghettoisation of either health or, more
  particularly, the public health function within the National Health Service,
  and there are some real issues about how best we break public health out of
  its ghetto.
        668.     Do you not accept that that ghetto arose from the disposal of
  public health in 1974 ---
        (Mr Milburn)   No, I do not.
        669.     --- and its detachment at that point from local government? 
  I was a councillor pre-1974, as I believe was John Austin - a very young
  councillor, I hasten to add - and recall very vividly the role of the Medical
  Officer of Health who held to account in a very serious and important way the
  individual committees of that local authority.  I see at local level some very
  worthy reports from our Directors of Public Health - I have two local
  authorities in my area, as you are aware - some excellent reports making some
  very positive proposals but it is not attached to the driver of policy that
  those reports relate to in any meaningful way.  That worries me because prior
  to 1974 we saw the attachment of these recommendations to the ability to
  deliver change on things like smokeless fuel and a range of issues which the
  local authority could clearly concentrate on - slum clearances and that kind
  of thing and I know we have moved on from those days - but it was a very
  important relationship with the Government function.
        (Mr Milburn)   You are right that there are a number of drivers or a
  number of interventions which are necessary in order to improve the health of
  their local communities, that is absolutely true, and local government will
  have a very important role in regard to its environmental health functions,
  its transport functions, social services or education, and so does the
  National Health Service.  Whichever way you cut the cake, as I was saying,
  there would be a need to better co-ordinate functions, and certainly that was
  true of the pre-1974 situation.  You say the Medical Officer of Health played
  an important role but, for example, if they wanted to influence rates of
  coronary heart disease or interventions in coronary heart disease, then they
  had to make the leap over the boundary into the National Health Service.  That
  was just a function of the way the Medical Officer of Health and the related
  public health functions were organised.  So I think that sometimes this game
  of structural musical chairs which we are all interested in inevitably,
  because we have to get the location right, becomes a bit of an excuse for a
  lack of co-operation.  I think reorganisation becomes an excuse for lack of
  co-operation.  What is true is that we need to improve the means of co-
  operation, there is no doubt about that, and on the ground, as you know, in
  many parts of the country now there is much closer co-operation than there has
  ever been, indeed there are statutory duties to co-operate for the first time
  which we put through in the 1999 Health Act.  That is becoming evidenced I
  think now in the way that you see, for example, in some areas - largely where
  there are co-terminous health authority and local authority boundaries - joint
  appointments of Directors of Public Health.  I do not have a problem with
  that, I think it is a perfectly sensible thing to do but I think we need to
  assess its impact.  When you talk, as you did, about drivers and leverage,
  there are some interesting international experiences here too more at a
  national level than at a local level.  In New Zealand in the 1990s, as members
  of the Committee are aware, there was a similar debate going on about the
  location of public health policy-making at a national level.  The then
  Government in New Zealand decided to separate the public health functions,
  through a Public Health Commission which was established in 1993, from the
  Ministry of Health, particularly to try to beef up the public health function
  because there was a feeling, as perhaps the Committee is feeling, that public
  health was getting ghettoised.  That seemed a very sensible idea.  It
  certainly gave a higher profile to public health in New Zealand, but the
  consequence of doing so was that the real life intervention impact in terms
  of public health was actually diminished, and it was no surprise that in 1995
  therefore that Public Health Commission which had been established two years
  earlier was abolished.  It is very, very important in my view we keep in mind
  that what we want to do is to drive public health ever more into the
  mainstream of the National Health Service, precisely so it has greater
  leverage as far as access to Health Service resources are concerned.
        Chairman:   There is a division so I adjourn the Committee for 15
  The Committee suspended from 4.09 pm to 4.23 pm for a division in the House
        670.     You were answering, Secretary of State, the initial question. 
  I believe, Minister, you were indicating you were wanting to come in?
        (Yvette Cooper)            Only briefly to add, Chairman, that if the argument
  is that we should have closer working around public health in local
  government, that local government could play a greater role in terms of public
  health and could have more public health support, I think that is absolutely
  right and I think we would agree with that, whether it is through joint
  appointments which some areas are experimenting with, whether it is through
  the local strategic partnerships or whether it is through closer working
  around the community plan or health improvement plans.  But if the argument
  is we should take public health out of the NHS, that I think would be a
  massive mistake.  There is so much potential for further work to be done in
  the NHS especially in primary care around public health, I really strongly
  think we need to keep that public health function in the NHS.  Even on top of
  all the work which is done on public health at the moment by the NHS, there
  is so much more we could do, that we should be building on, particularly in
  primary care.
        671.     One of the issues that the Committee have been concerned with
  is the role of health visitors, and some of us remember when they were
  employed within local authorities in a much closer working relationship with
  local authority services like housing and social services, and that is an area
  where we picked up very strongly there were arguments we needed closer
  collaboration.  Picking up your point about the location and function and
  looking at it locally but also nationally and again whether public health is
  appropriately placed within the Department of Health - and I know, Minister,
  you said the idea of taking public health out of the Health Department would
  be a crazy and retrograde step - we have had a fair bit of evidence which
  suggests that the function you occupy ought to be much more wide-ranging than
  it is currently and perhaps located, say, in the Cabinet Office or within the
  Cabinet with a role ranging over other government departments.  Can you say
  a little about your views on that and your experiences of working with other
  government departments in the role you currently occupy?
        (Yvette Cooper)            I think it is extremely important to have the public
  health ministerial post located in the Department of Health, I suppose for
  several reasons.  Firstly, in the end, a lot of it is about improving health
  and promoting health, and having access to the vast resources of the NHS, the
  Department of Health and the Chief Medical Officer is incredibly important. 
  Secondly, whilst it is absolutely true that a lot of the work does involve
  cross-governmental working, actually being located in a department makes a
  huge difference.  You will be aware where we have done the Social Exclusion
  Unit reports, the Social Exclusion Unit has tended to draw up the report and
  to drive a lot of the first wave of co-ordination across government
  departments but then the report has been passed on to a particular government
  department to actually lead the implementation.  It is because ultimately you
  want a delivery route rather than simply a co-ordination route, ultimately you
  need a government department backing up, and given that the NHS is the biggest
  employer in the country, it has huge resources when it comes to delivery.  It
  is right that has to be in partnership but I think it would be terribly wrong
  and would be a huge retrograde step and a mistake to leave it behind.  I will
  just give you one brief example of where I think cross-departmental working
  can be very effective, and that is the Sure Start programme.  I am responsible
  for Sure Start but the Cabinet Minister responsible is David Blunkett in the
  DfEE and the Sure Start Unit itself is located within the DfEE, and that is
  quite a novel approach to working across government which involves a very
  close partnership between different departments and it is working very well,
  with my responsibilities both to drive the programme and to chair the cross-
  ministerial group but using resources located in different departments as
  well.  So there are different cross-departmental models you can look at but
  fundamentally it would be a huge mistake to separate public health from the
  big killers - cancer, heart disease.  All the work we are doing on prevention
  has to involve the NHS otherwise we will never make the difference we need to.
        672.     When you are looking at any policy initiative, how do you
  determine who might be involved in developing that initiative?  For example,
  we had the mental health initiative which came out recently where, arguably,
  some of the key players within different government departments have a role
  to play.  You probably know that we were prompted as a Committee by evidence
  we received from the Yorkshire Post newspaper, which you will see as a
  Yorkshire-based MP like myself, which has done a very important campaign on
  sport and the way sport relates to health, and as a consequence of their
  evidence and other evidence we determined to have the Minister of Sport before
  the Committee.  We had a very useful session, I think, listening to what she
  had to say but my concern, and the reason why I raise this point about the
  public health location within government, is that she answered very honestly
  when I asked specific questions about whether she had been involved in certain
  initiatives, which I think she should have been involved in, where on a number
  of developments the Government can claim great credit at a local level which
  should relate to sport, and she had no involvement whatsoever.  How do you,
  not just with you but in other areas where the Minister has a part to play,
  ensure they are involved, because in that case clearly she was not and in my
  view she should have been?
        (Mr Milburn)   I think there are always improvements which can be made,
  of course there are, but the machinery for cross-government working now in
  this Government - and certainly that is the view of the people who have been
  around in previous times - is immeasurably enhanced.  I think the commitment
  to joint working is a big commitment.  On the public health front you will
  remember when we published Our Healthier Nation White Paper, of course it was
  my Department which was in the lead but there were contributions from other
  relevant departments, of course there were.  Issues like sport obviously would
  relate to DCMS.  On one of the important Our Healthier Nation target areas,
  the prevention of accidents, we worked closely with colleagues in the DETR,
  DTI, DfEE, across the piece.  The point about this is that in a sense it is
  rather like a local co-ordination function, wherever you locate it there is
  still going to have to be co-ordination, and where there are co-ordination
  issues and where there are boundary problems then inevitably you hit
  difficulties.  But what I believe absolutely fundamentally is that if you take
  the public health function out of the Department of Health and if you put it
  in a ministry like the Cabinet Office, what you remove is the Minister of
  Public Health and all of the officials and all of the machinery and indeed all
  of the financial leverage which goes with a location in a big spending
  department.  For example, this year I think the Department of Health will be
  spending between 40 and 50 billion and it is one of our commitments that we
  want to see a growing proportion of that resource spent on public health
  measures - defining cancer, coronary heart disease and so on and so forth -
  by contrast, I think the Cabinet Office has a budget of less than 200
  million.  In the end, money talks because it provides you with leverage to get
  things done.  There is an argument about whether or not we need to do more
  within the National Health Service to better focus growing resources on
  prevention, on tackling inequalities, on intervening sooner rather than later,
  and that is a perfectly reasonable debate to be had and I think all of us sat
  around this Committee table would think there is a lot more to do, of course
  there is, but actually the chances of doing it, it seems to me, are decreased
  and not increased if you strip out the public health function from the
  mainstream Health Service delivery functions.
        673.     In simple terms, how do you avoid treating policy issues in
  separate boxes?  The best example I think we had with the Sports Minister was
  when I raised the initiative of healthy living centres, which I think is an
  excellent idea, and I see a very clear connection between the role of sports
  clubs and healthy living centres, but there had been no connection between
  your Department on this issue and her Department.  What I am trying to say is,
  how can we ensure structurally that that happens, that, to me, a fairly
  obvious connection at local level is made nationally and locally in a way
  which is not being made at the moment?
        (Mr Milburn)   I think two things.  First of all, there is a big
  commitment to do this across the Government and Our Healthier Nation is an
  expression of that but the truth is it is early days.  It is the first time
  we have had a Public Health Minister, the first Public Health Minister was
  appointed in 1997, and I think that was the right step to take and it allows
  us to focus on these issues in a way perhaps politically which has not always
  been possible in the past.  It is a positive step in the right direction but
  there is a big commitment across the piece to improving the health of the
  nation.  If you take the argument to its logical conclusion I think you are
  left with some pretty anomalous potential structural arrangements, because
  most of us would agree that poverty has a bearing on ill health.  That is
  certainly the position in the Black Report, in the Acheson Report, it is the
  position that many people in the medical and health service field would agree
  on.  The Government has a big commitment to abolish child poverty, I think it
  will make a huge contribution to improvements in public health and to
  narrowing health inequalities, but the logic of the argument, with respect,
  is if we believe that child poverty is going to be a major determinant of
  improved health then why do we not take the public health function out of the
  Department of Health altogether and put it in Her Majesty's Treasury?
        674.     Something we could think about actually!
        (Mr Milburn)   I am not going to give you ideas, Chairman, because I am
  slightly worried you will recommend that!
                               Dr Brand
        675.     Is it not already?
        (Mr Milburn)   You can say that, Dr Brand, I cannot comment!
                               Mr Burns
        676.     We have a Department of Health that has overall
  responsibility for improving and enhancing patient care and the health of the
  nation, and it does seem odd to seek to take out public health and give it to
  the Cabinet Office or the Treasury, or whoever else, because it just becomes
  diffuse and to my mind ridiculous.  Can I ask the Parliamentary Under-
  Secretary whether the structure of the Department of Health at the moment
  means that she, as Parliamentary Under-Secretary, is answerable solely to the
  Secretary of State, as certainly under the last Government the Parliamentary
  Under-Secretary who was responsible for mental health, children's issues, drug
  abuse, alcohol abuse, et cetera, had no Minister of State above them, they
  were answerable directly to the Secretary of State?  Is your position
  answerable solely to the Secretary of State, or do you have a Minister of
  State above you and below the Secretary of State?
        (Yvette Cooper)            I answer directly to the Secretary of State.
        677.     I am glad you said that because there is a view held by some
  people that if you put public health, which is considered to be a very
  important issue, at Parliamentary Under-Secretary level you have down-graded
  or minimised the issue.  The fact that you, I suspect, and you can correct me
  if I am wrong, are unique in that presumably other Parliamentary Under-
  Secretaries at the Department of Health at the moment have a Minister of State
  above them and under the Secretary of State, surely enhances rather than down-
  grades the role of public health because without having a Minister of State
  to go through you have direct access to the Secretary of State, you are
  working simply with the Secretary of State?  So would you agree with me that
  in fact, presumably, given your line of command and that you are answerable
  simply to the Secretary of State so it is just the two of your within that
  narrow ambit, the whole area of public health has not been down-graded simply
  because it is at Parliamentary Under-Secretary level?
        (Mr Milburn)   Let me answer because it is slightly invidious for Yvette
  to answer questions about command structures in the Department of Health.  I
  know the argument, Mr Burns, that because the previous Public Health Minister
  was at Minister of State level and Yvette is not, somehow or other this
  represents a down-grading.  All I say to you is that nothing could be further
  from the truth.  Not only does Yvette answer to me personally but, in addition
  to that, when Yvette came into the post one of the things I wanted to do was
  better "mainstream" public health within the Department, and that is why
  actually we changed some of the functions around within the ministerial team,
  so that she as Parliamentary Under-Secretary for Public Health has
  responsibility for the two big areas of public policy where we need to make
  rapid improvement in terms of mortality and morbidity rates - cancer and
  coronary heart disease.  That was not the way the Department had previously
  been divvied up.  I did that precisely, one, in order to locate responsibility
  where it should be; two, to ensure the focus was as much on prevention as
  treatment; but, thirdly, to actually "mainstream" the public health function
  within the Department of Health, because I do think there is a tendency, if
  I may say so, with respect, within the public health world, for public health
  professionals as narrowly defined to believe that they are the only purveyors
  of public health.   If that is the case, if we actually believe that it is the
  600 public health consultants and 32 epidemiologists who are going to improve
  the health of the nation, however good they are, frankly we can all go away
  and give up now.  The people who should be "mainstreaming" and delivering
  public health are our 30,000 GPs, our 12,000 district nurses, our 14,000
  health visitors.  They are in the best position to do that and if they are
  going to do that then actually we have to have a line of command, a line of
  delivery, all the way from Richmond House down to Wakefield, Darlington and
        Mr Burns:   Thank you.
                              Mr Hesford
        678.     In terms of this issue, Secretary of State, in 1997-99 the
  Chancellor has made it clear for very good reasons that spending was tight in
  those years in order to stabilise the economy and get rid of the 28 billion
  deficit.  Those in the public health field will have recognised that between
  1997 and 1999 public health had a Minister of State-level occupancy at a time
  when the money was tight.  At a time when others might have felt money was
  coming on stream, the position was, in some people's terms, down-graded just
  at the point in time when that person might be expected to spend some money. 
  Can you deal with that point?
        (Mr Milburn)   I do not know who is making that point but it is a
  ludicrous one.  I would say that this Minister of Public Health has more
  influence and more power within the Department of Health than any previous
  minister who has occupied a previous position, precisely because she is
  dealing with the mainstream issues of cancer, coronary heart disease,
  improvements in public health across the piece.  Rather than being a
  retrograde step, I think that is a huge step in the right direction of
  ensuring that we target in a rather more consistent and effective way than
  perhaps has been done in the past our efforts, the machinery of the Department
  and, most importantly of all, the resources we have available to us on those
  areas, those disease groups, those parts of the country, those sections of the
  population, which need most help.
        679.     In terms of raising the awareness of public health, which I
  know the Minister is absolutely keen on and does a very good job of, would it
  not send out the wrong message to those areas that need support in their job -
  that very difficult job of raising awareness of public health - to have what
  others have described as a retrograde step in terms of the exact status of the
  Minister of Health?
        (Mr Milburn)   If that were the case, it would indeed be a retrograde
  step, but it is not.
        680.     Do you accept that there could be a feeling abroad that that
  is what it looks like?
        (Mr Milburn)   I have no doubt that for various reasons people within
  particular parts of the National Health Service or particular parts even of
  the Department of Health may feel that is the case, but believe you me it is
        681.     It is just that quite a number of witnesses we have heard,
  and no doubt you have seen the transcripts, have made this point time and time
  again and it is something the Committee will have to deal with.
        (Mr Milburn)   Yes, I can understand that, but one of the pleasures of
  my job is that I get a broad over-view of all the issues which come before the
  Department of Health and I am acutely aware of protectionism in many, many
  parts of the field.  It is very, very important that we keep these things in
  balance.  It is very hard for people to argue, when we are investing in the
  way that we are in improvements in coronary heart disease and cancer and
  focusing resources as much on prevention and treatment in the way that we are,
  making, I think, some pretty major - or about to make - improvements as far
  as the diet of the population is concerned, when we are empowering primary
  care to get a population focus as well as just a focus on individual lists of
  patients, that somehow or other public health has been down-graded within the
  Department of Health.  Far from it.  What is very, very important for people
  in the public health field to realise is that the two major policy statements
  we have had over the course of the last couple of months - Our Healthier
  Nation and the NHS Plan - together form the basis, if you like, of a health
  plan for the country, and they are of equal status.  Indeed the NHS Plan
  broadly reflected the aspirations, ambitions and some of the targets within
  Our Healthier Nation but then it went further and suggested, for example, we
  are going to roll out more screening programmes, a greater emphasis on
  prevention and, most important of all, for the first time in this country and
  I think for the first time in any developed country that I know of, we are
  going to set a national inequalities target precisely to ensure the whole of
  the National Health Service, not just one part of it, is focused upon these
  very, very important public health issues.
        682.     Minister, this is a debate about your pay rise, do you wish
  to comment?
        (Yvette Cooper)            I am really touched that people are so concerned about
  my status and my pay.  I just think this is such a trivial argument.  What is
  the title of the minister in charge of public health, is it a Minister of
  State or is it a Parliamentary Under-Secretary?  I do not think most people
  in the country know the difference between a Parliamentary Under-Secretary and
  a Minister of State, and I do not think most people care.  In the end, the
  test is what we are delivering.  What are we delivering on public health?  The
  test of what we are delivering I think is showing huge improvements.  If the
  test is money, there are extra resources going into public health, into
  prevention, into smoking cessation services, into fruit in schools, whatever
  your test, in terms of the extra boost to public health we have seen, building
  on the work which was done under the previous Minister, and the extra work we
  have shown in the NHS Plan, on health inequalities and on tackling some of the
  key causes of cancer and heart disease, is really significant, and that is
  really in the end what people will judge our public health commitment on.
                               Mr Burns
        683.     Secretary of State, can I try and help you?
        (Mr Milburn)   Oh dear!
        684.     As your Parliamentary Under-Secretary has said, it is
  trivial, and it is in one way but it is important in another because of
  misapprehensions which abound in the health area.  Can you categorically
  confirm that my view is right ---
        (Mr Milburn)   You are making me very nervous!
        685.     I am trying to be helpful, keep cool!  If you have an area
  which the Government of the day has prioritised as an important area where you
  want action and achievement, if you have a Parliamentary Under-Secretary
  rather than a Minister of State with no Minister of State above her, where the
  Parliamentary Under-Secretary is directly answerable to the Secretary of State
  and they are working in tandem, it is totally irrelevant whether the person
  is a Parliamentary Under-Secretary or a Minister of State, providing the
  commitment is there and the objectives are vigorously pursued by that
  Government, and that the whole argument is actually time-wasting and
        (Mr Milburn)   I think that is broadly right and frankly I think people
  would be bemused - there will be some people who are not bemused and who find
  this all incredibly interesting and revealing - the vast majority of people
  working in the National Health Service, working in local government, working
  in any arena which has any bearing on public health, let alone the public,
  would find this whole debate a rather bizarre one.
        Chairman:   I have just had a note passed to me asking me which position
  Mr Burns had in the Department of Health.
        Mr Burns:   I did not have a Minister of State over me either!
                               Mr Austin
        686.     I think you have both made a very cogent and convincing
  argument for the location of the public health function departmentally in the
  Department of Health, but can I ask you whether you feel the Minister for
  Public Health within the DoH can really affect the main determinants of health
  - housing, employment, poverty, et cetera?
        (Yvette Cooper)            The biggest determinant of public health I think is
  poverty.  The most important thing we will do over the next 20 years is
  achieve our target to abolish child poverty.  In the end, a lot of that is
  within the power of the Treasury but it is not all within the power of the
  Treasury because it is also about providing opportunities for young people
  from the very start, which is why Sure Start is part of our programme to
  tackle child poverty.  But it is absolutely true that all of the determinants
  are widespread across all the different departments and we will only do this
  if we have all the departments working together.  But we cannot just say that
  the NHS should play no role in that, the NHS should play a huge role in it
  both nationally and locally.
        (Mr Milburn)   Let me add to that very briefly.  When Sir Donald Acheson
  produced his report for us in 1998, he came up I think with 39
  recommendations, something like that, three of which pertained particularly
  to the Department of Health, the rest pertained to the wider governmental
  agenda, and that is right because we all know from our own constituents that
  poor people tend to be iller and certainly they tend to die sooner than people
  who are rather more affluent, so there is a broad cross-Government agenda
  here.  Sometimes though I think that people in the National Health Service,
  faced with this point about the determinants of ill health being so big and
  so deep-rooted, throw up their hands in horror and almost adopt a counsel of
  despair that nothing can be done until you abolish poverty, until you ensure
  nobody lives in a damp house, until you ensure that every person is eating
  five pieces of fruit and vegetables a day.  All of those things need to happen
  but actually it is very, very important that the NHS better focuses on what
  it can do to contribute to improvements in public health.  Of course, some of
  those will be very deep-seated issues and will take time to deliver, but some
  will not.  Providing the will is there and the commitment is there and the
  resources are there, actually we can begin to make a difference quite quickly. 
  I think a good example of that, frankly, is when we decided, when Frank Dobson
  decided, to invest very, very early in the meningitis C vaccine. As I said in
  the debate in the House the other day, being the first in the field is always
  a risky place to be, because when you are out in front it can all go horribly
  wrong.  It did not go horribly wrong, despite some of the adverse comments at
  the time in the newspapers about the dangers of the vaccine and so on.  We
  invested quite a lot of money in it, we concluded a deal very early on with
  the company concerned, in order to ensure that people in this country were the
  first people in the world to get access to a vaccination programme which has
  already saved lives.  I want to see more of that happening and to do that we
  have got to have a proper focus and a co-ordinated focus through the Minister,
  and through her line to me, on public health in a way that has not always
  happened in the past.  That is why I believe that the arrangements that we
  have - and they are not perfect arrangements and they will never be perfect
  arrangements - are the best arrangements that we are going to get.
        687.     Can I take you back to the original question that the chair
  put.  Let us say that you have convinced us of the departmental responsibility
  of location for the public health function but in terms of the local delivery
  of public health, several government departments relate to local government,
  including your own, and you are responsible for social services, child
  protection, all of those areas of delivery by the local authority.  The DfEE
  is involved with the local authority, the DTI, a whole range of public
  departments.  Since I am a dinosaur with the chair and remember the 1970s, all
  of that comprehensive range of functions is delivered by local authorities. 
  You mentioned anti-poverty and local authorities are key players in developing
  anti-poverty strategies.  Does that not therefore suggest that wherever the
  departmental responsibility for public health lies, and particularly now local
  authorities also will be given the scrutiny role of health services, that
  public health should be located at local authority level?
        (Mr Milburn)   No, I do not believe that for the reasons we discussed
  earlier in answer to the Chairman's questions.  What I do believe is that the
  local authorities have a very, very important co-ordinating role at a local
  level and indeed we as a Government have given them certain statutory
  obligations to promote the well-being of their local communities and
  personally what I want to see is much better co-ordination at a local level. 
  As Yvette was suggesting, I think the local strategic partnerships that are
  beginning to roll out across country will provide a very, very important
  vehicle for the Health Service, for local government and, indeed, for the
  contribution of the voluntary sector and the private sector to make a big
  contribution to improvements in the well-being of the local community and
  specifically the health of the local community.  That begs some important
  questions about how best we are going to co-ordinate public health functions
  as widely defined at a local level.  Some parts of the country, Somerset and
  Wolverhampton are two for example, do have joint appointments of directors of
  public health between the local authority and health authority.  That is a
  welcome development.  I think we should assess it but if it makes sense we
  would want to see more of it.  There are issues about the future of health
  action zones and employment action zones, and so on and so forth.  For my
  part, as far as this is concerned, I am completely unterritorial about this. 
  If in some parts of the country we are great closer collaboration, as we are
  for instance in the Chairman's constituency in Wakefield, of the health action
  zones and some of the other partnerships and that makes sense, then we should
  encourage it.  I do not have a problem with that at all.  I think it makes
  absolute sense to do it.
        688.     I am not wanting to challenge your territorial integrity or
  sovereignty ---
        (Mr Milburn)   You are welcome to.
        689.     What you are saying is that the director of public health is
  a key figure in terms of the local authority for fulfilling its public health
        (Mr Milburn)   Yes, I think that is right.  All I would say about that
  is that in terms of the role of the director of public health we want to be
  a bit careful about being overly prescriptive about this.  In some parts of
  the country, particularly where there are coterminous local authority and
  health authority boundaries, it is fairly simple, frankly, to have a joint
  director of public health.  In my part of the world that does not happen to
  be the case.  There is a unitary authority in Darlington and there is a huge
  County Durham and Darlington Health Authority so there is not the
  coterminousity issue.  What we have to ensure, regardless of the
  organisational structure that is put in place, is that the director of public
  health has a close and growing relationship with the local authority precisely
  because of its wider statutory duties but also because of the wider
  contribution it can make to public health improvement.
        Chairman:   Before we move off this important area, you mentioned health
  action zones in my area - and I have taken a close interest in it as the
  constituency MP - and what strikes me about that and a number of other
  initiatives I have looked at is so much of the work and operation of these
  action zones is recreating relationships that I saw in existence in practical
  terms pre-1974.  We were in Scotland looking at a scheme in Glasgow and my
  colleagues who were there will bear witness to the fact that there was a
  health visitor ---
        Siobhain McDonagh:         As old as him!
        Chairman:   Who was as old as me who had worked pre-1974 and was looking
  at this brilliant new scheme that they had got in this particular part of
  Glasgow, the Gorbals area, and she said - and my colleagues will bear out that
  this is correct - it was basically back to what she did pre-1974
  restructuring.  It is not simply abstract debates in this place about where
  we place the function, it is about people at grass roots level having sensible
  structures that enable them to work together.  The worry I have got is all the
  good work we are doing on these initiatives is simply recreating the
  relationships that I saw in existence pre-1974 at a local level.  It will
  certainly not come as a surprise to the Minister. If you want to come back on
  that one, fine, otherwise I will move to Marion.  Marion? 
                                Mrs Roe
        690.     Secretary of State, can I first of all apologise to you and
  the Minister that I shall not be able to stay for the full session and
  therefore the questions I am going to put to you will be disjointed groupings,
  if I can put it that way.  First of all, it is claimed that one way to
  influence the wider determinants of our health is through health impact
  assessments.  Could you suggest any ways for their effectiveness to be
        (Mr Milburn)   I think that is true.  I think that health impact
  assessments have potentially an important role to play in determining whether
  policies, not just in the Department of Health but in the DfEE or the
  Treasury, across government and indeed local government and other
  organisations whether they contribute to improvements in health, one, and,
  two, contribute to the wider governmental agenda which is not just to get
  improvements of health overall for the population but is also to bring about
  improvements for health in the poorest people at a faster rate than the
  average.  I think there is a potential role.  We are looking quite carefully
  at health impact assessments.  There are various tools and frameworks around,
  within government and outside.  Potentially they have an important role to
  play, but they only will have an important role to play, in my own view,
  because they provide a methodology and that is all.  In the end what we have
  got to do across government and within the Department is get the commitment
  and the focus and the resources on improvements in public health, and health
  impact assessments potentially are an end to that means.
        691.     What would be your view on a Health Audit Committee on
  similar lines to the Environmental Audit Committee?
        (Mr Milburn)   It is the first time I have heard that suggestion made but
  in many ways I guess that is the role of this Committee and certainly if you
  have had witnesses from DCMS and from other departments that seems to me to
  be a perfectly sensible and reasonable thing to do, if we all accept that it
  is not just what Yvette and I do, it is not just what the GP does, but it is
  what the local employer does and the local charity and the local council and,
  of course, individuals themselves that will have an impact upon the health of
  the nation.
        (Yvette Cooper)            There has been a lot of work going on on developing
  health impact assessment methodologies and how you would assess them.  One of
  the things we are interested in is whether the Health Development Agency could
  play a role in standardising or evaluating health impact assessments and how
  effective they are.  That is one of the things that we are looking at at the
        692.     Thank you very much indeed.  Can I put it to you, Secretary
  of State, that there are serious concerns that local health improvement
  programmes are losing significance to a multitude of national priorities which
  are passed down increasingly from a centralist health agenda, as a consequence
  of which the public health needs of local populations are being ignored in
  favour of the rush to meet national targets.  Secretary of State, could you
  reassure us that local community specific health agendas will not be squeezed
  out at the expense of what your own Permanent Secretary and also the NHS Chief
  Executive Nigel Crisp terms as the "must dos".
        (Mr Milburn)   It is very, very important that local services, whether
  they are health services or local government services, whether that be
  education or transport functions, are sensitive to the particular needs of the
  local community.  I guess your constituency and mine may be quite different
  constituencies and I guess the communities are pretty different too and they
  will have different needs and it is therefore important that local services
  are attuned to those needs because otherwise they do not enjoy public
  confidence and, frankly, they do not reach the people they need to reach. 
  However, sometimes when this sort of question is asked I do think the people
  rather want to have their cake and eat it because they also want to see a
  proper and strong focus upon some of the big determinants of public health,
  about whether people are getting a decent diet, about whether people are
  getting access to cancer screening services, about whether people are getting
  access to heart operations, and so on and so forth, in a way that brings about
  improvements in health.  You know as well as I do that unfortunately one of
  the things that most characterises the NHS is the fact that there are such
  enormous variations both in performance and access to those services and that
  is why we have got to get the balance right, which is what we are seeking to
  do, between establishing very clear national standards and, if you like, a
  very clear national framework of what must be done.  What must be done is to
  invest in cancer services and heart services, on the prevention side, the
  screening side, as well as the treatment side, not just in some parts of the
  country but in every part of the country.  That is what must happen, but then
  of course it is for the local service to determine how best to deliver that
  national framework.  What we cannot have is, frankly, sometimes the lottery
  of services that we have seen in the past.  Let me finish on the health
  improvement programme because I think it is extremely important.  For me it
  is a very, very important co-ordinating device to try to ensure that the
  national priorities are translated sensitively into local priorities, that if
  there are specific developments that need to take place in local services that
  are required by the local community they are reflected in the health
  improvement programme, one, but, two, that the health improvement programme,
  if you like, should become a focus, just for the local health service (whether
  that be the trusts, PCTs or the health authorities) but also for local
  government input or for employer side input or for voluntary sector side
  input.  For the first time at a very local level what you have is an agreed
  local health plan.  That is what the health improvement programme should be
  about.  If people think that is not happening I would be interested to know
        693.     Could I take you a little bit further down the path on access
  and talk about inequalities of access to medicines.  I wonder if you could
  comment on the National Institute for Clinical Excellence's ability to in the
  words of your own Minister of State for Health, Mr John Hutton "mark the end
  of an era of postcode prescribing in the treatment of Alzheimer's" when in
  fact Wiltshire Health Authority states it cannot afford to provide the very
  Alzheimer's drugs recently recommended by that body?
        (Mr Milburn)   With respect, I do not think that is Wiltshire Health
  Authority's position.
        694.     That is what I would understood but I would be very pleased
  to hear you correct it.
        (Mr Milburn)   I try not to believe everything that I read in the 
  newspapers because otherwise, frankly, I would not get up in the morning - and
  I quite like getting up in the morning.  I saw that in one of the papers and
  I think it was one doctor of the health authority but that is not the health
  authority's position, as I understand it.  I am very happy to send you a note
  on that.
        695.     I would be grateful.
        (Mr Milburn)   There is a broader point.  We set up the in National
  Institute of Clinical Excellence - and I know it was a controversial thing to
  do but I think it was the right thing to do - precisely in the face of the
  lottery in care and prescribing regimes that you describe.  Under the old
  order it was up to the individual GP practice and the individual health
  authority, too, to decide which drugs and treatments were available to which
  patients and inevitably in that situation you ended up with the rather absurd,
  and I think unfair, proposition whereby different people with very similar
  conditions sometimes living in neighbouring streets were getting different
  access to the same health treatments.  That cannot be right and certainly does
  not fit with the principles and values and philosophy of the National Health
  Service, and that is why we have an Institute that can produce clear guidance
  and authoritative guidance to the National Health Service.  From our position
  as Ministers we have made it absolutely clear that it is very, very important
  that when NICE produces its authoritative guidance that that should be taken
  full account of by each and every health authority in the land and there
  should be not opt-outs of taking full account of each and every piece of NICE
  guidance.  As far as Alzheimer's is concerned, as you are aware, the National
  Institute recently produced authoritative guidance on Aricept and two other
  drugs largely found in their favour.  I think that has been broadly welcomed. 
  It will help ensure that these cost-effective and clinically effective drugs
  are available to more people.
        696.     Thank you very much.  If you could send me a note on whether
  that is accurate or not I would be very grateful.
        (Mr Milburn)   I will send you a note on Wiltshire.
                              Mrs Gordon
        697.     The Committee visited Cuba last year and I think we were all
  impressed by how they do so much with so little and how good their health
  outcomes are given that their health budget is only one per cent of ours.  I
  think this is partly due to the fact that their national health service
  started some ten years after ours but they went off in a completely different
  direction.  Ours is basically a sick health service in that most of our
  resources go into the acute sector whereas they went down the road of trying
  to stop people becoming ill simply because they have not got the resources to
  provide for the acute services.  We found going round that this idea of public
  health, health promotion, is deeply entrenched in their culture.  Everybody
  that we have come across in the organisations we have met has given this
  Government credit for taking up the public health agenda and trying to widen
  it and run with it, but it is this cultural thing which is not engrained, I
  do not think, in the same way in our culture.  I would be interested to know
  if you feel we can achieve this cultural shift and how we can improve the
  health structures that we have to bring that about given the pressure on GPs,
  the health visitors who will deliver that service.
        (Mr Milburn)   I think the points that you make are very, very important
  ones and I think it is something we have got to get engrained first of all
  within the culture of the National Health Service to realise it is not just
  a service to treat sick people, although of course that is hugely important,
  but it is also a service that can do much more to prevent sickness in the
  first place.  I hope that we are beginning to shift the balance in the way
  that, for example, we are developing more prevention and more screening
  programmes over the course of the next few years.  I am hopeful that we will
  have more screening programmes for everything from chlamydia to colon/rectal
  cancer when we have got an appropriate test available for people.  We have
  made commitments similarly that when we can get to a position where there is
  an effective and safe test for prostate cancer then we would want to roll that
  out.  We have got to do something more than that as well.  We have got to get
  into the business more actively not just of primary prevention but secondary
  prevention.  Here I think primary care, as Yvette was suggesting earlier, has
  a hugely important role to play.  I think you are beginning to see some of
  this now beginning to happen on the ground.  Traditionally the view has been
  that the GPs' function is effectively to act as gate-keeper into the Service,
  to wait for patients to come through the door and then to deal with them, and
  that produces a lot pressure on GPs and other staff too.  There is another
  very, very important role, it seems to me, and that is the role of getting
  into some of these areas of secondary prevention.  For example, when I visited
  Bradford several months ago I was very, very impressed to see the work that
  they were doing in relation to diabetes, and they have got a large Asian
  population, a high prevalence of coronary heart disease and diabetes.  They
  are now establishing registers of people who are at most risk of those two
  diseases and they are actively intervening at an early stage.  In
  Northumberland the health action zone is doing something very, very similar,
  setting up a register of people who are vulnerable to or have had heart
  disease and GPs and people working in primary care are doing everything that
  they can to get cholesterol levels down.  Their estimates of what they will
  be able to achieve within the next five years - not just in the long and
  distant future but in the immediate future - are very, very impressive.  They
  are saying they expect to save between 150 and 200 lives alone in that one
  county precisely because they are getting into that very active interventional
  business.  That is where the National Health Service, it seems to me, has to
  go.  We have to see a lot more of that.  As I think I have said at this
  Committee before, it has got to get into the provision of more information to
  people.  I do think it is important on public health that we recognise that
  the Service has got a big part to play, but in the end individuals have got
  a big part to play.  Somebody with heart disease or who is prone to heart
  disease might need an operation, they might need a drug, but they will almost
  certainly need a balanced diet and regular exercise and in end that becomes
  their responsibility and we in the National Health Service have got a lot more
  to do to help people through that.
        698.     Some of the organisations, the community projects that we saw
  bottom-up coming from the community, although in some of them the GPs were
  very involved in others they found it almost impossible to get the GP
  involved.  They have had trouble doing that, partly because the GP felt
  overwhelmed already by the workload.  Back to Cuba, the family doctor there
  deals with something like 800 people whereas obviously our lists are 1,000 or
  almost 2,000 for a GP.  Are there any practical measures that the Government
  can take to lift some of that workload?
        (Mr Milburn)   I think there are several things.  First of all, you have
  got to expand the workforce.  The truth is that we need more GPs, we need more
  doctors, we need more nurses, we need more scientists and technicians working
  in the National Health Service and we will get there in the medium term.  I
  think we have got fairly ambitious plans to expand the number of doctors
  working in the Service and certainly the NHS Plan says they want to see an
  extra 2,000 GPs working in the National Health Service over the next three or
  four years.  That should be a minimum.  If we can go faster we should go
  faster.  The more the merrier, as far as I am concerned, because we need more
  family doctors.  That is the first thing.  The second thing is to recognise
  that there has to be a better division of labour within primary care.  A lot
  of people do not need to be seen immediately by the GP but can be seen by the
  nurse.  That is happening in a lot of GP practices already and it should be
  happening in more; I hope that it will.  Thirdly, I think we have got to
  change the terms of this debate actually because in many, many ways
  intervening later rather than intervening sooner increases workload rather
  than diminishes it.  If you have people presenting with more acute problems
  precisely because the NHS, local services, primary care services have not been
  able to establish the registers of those at risk, it is more of a problem. 
  I know all that is easy to say and it is not so easy when you are sitting at
  a GP's desk having to see lots and lots of patients, but that is the big shift
  we have got to bring about and that is about, if you like, changing the
  culture of the Service so that it recognises that this whole focus now on
  prevention is at the top of the agenda rather than way down the agenda.
        (Yvette Cooper)            There are some amazing things going on already in the
  NHS.  I think the Committee has been to the Beacon Project in Cornwall, Hazel
  Stutely's project with health visitors working in the local community, working
  with the tenants' and residents' associations, making a huge difference not
  simply on levels of breast-feeding but also teenage conceptions, levels of
  crime, a huge impact that people working in the National Health Service can
  have working in the community as well.  There are other examples.  There are
  examples of the NHS and primary care working with housing organisations to
  make sure that the people who are prioritised for central heating or
  insulation are families of children with asthma or families with young
  children and so there are all those kinds of examples.  There is work going
  on around teenage pregnancy.  There are GPs and primary care teams playing a
  huge role now in starting to work to prevent teenage pregnancies, mainly
  working with local schools.  It is that point that I think would reinforce our
  previous point.  It is because there is so much starting to happen and really
  starting to spread throughout the NHS, whether it is smoking cessation,
  whether it is working on teenage pregnancy, whether it is work on housing,
  whatever it might be, that now would be the worst possible time to take public
  health out of the NHS at exactly the time we could be driving more and more
  public health work and prevention through the NHS and getting the NHS,
  particularly in primary care to play a much greater role in prevention than
  it ever did, than it ever did before 1974, than it ever has done ever in its
                              John Austin
        699.     Can I come in on the point made about the Beacon Project. 
  All of us were greatly impressed by the work Hazel Stutely and others have
  done there but up and down the country in the projects we have been to one of
  the key players has been the health visitor, as you recognise, and also the
  role of school nurses as well.  I know that the Government has done a great
  deal to redress the rundown in recruitment and training of nurses but in the
  specialist area of health visiting, in our previous inquiry on the staffing
  requirements of the NHS, one of the most alarming statistics we saw was in the
  reports that came from the CPH, BMA and others about the likely age range and
  the retirement and drop-out rate of health visitors.  Are you confident that
  within the general desire to get more nurses into the specialist areas like
  health visiting that the training is being expanded sufficiently, and what are
  the implications for the training of health visitors, not just the quantity
  but the content in terms of the new public health agenda? 
        (Yvette Cooper)            We really see a lot of the work around community
  nurses as part of all of the work of nurses and the expansion in the size of
  the nursing population working for the NHS is something that has to happen in
  terms of the community-based nurses as well.  There is a lot of work that has
  been going on to develop leadership functions and training through the health
  visitors' and school nurses' development fund, trying to improve the training
  and support for health visitors and school nurses across the country.  I think
  we should not under-estimate quite how vital they are.  School nurses were
  absolutely vital to delivering the Meningitis C vaccine.  We would never have
  got the entire under 18 population of this country offered the Meningitis C
  vaccine in the space of around 15 months if it had not been for the role of
  school nurses.  We just could not do it.  We do very much see the commitment
  in terms of expanding nurses as one which applies to community-based and
  district nurses as well.
        700.     Can I  come on to the general initiatives that the Government
  has undertaken.  No-one welcomes more than I do the very high priority that
  your Department gave at very early stages to public health.  The commissioning
  of the Acheson Report very shortly after the Election, the creation of the
  post of Minister of Health are initiatives that all of us around this
  Committee would very much welcome.  Indeed, when Professor Acheson came here
  he commented on the very positive steps which the Government had taken in the
  light of his report.  We have got the policy initiatives of health action
  zones, health improvement programmes that have been mentioned earlier.  But
  now we have the new NHS Plan.  Has the new NHS Plan eclipsed those initiatives
  in any way and placed new priorities on the National Health Service?
        (Mr Milburn)   I do not think it has.  I think the sovereign role of
  public health and the job of tackling health inequalities and the bigger focus
  on prevention is very much at the heart of the Plan and what we have now got
  to do --- in the end writing plans is easy and devising policy is easy,
  delivering it is sometimes more difficult.  What we have got to do is make
  sure that the Government's intentions to improve public health and tackle
  health inequality are embedded within the Health Service at every level and
  there too we have tried to change the institutions in such a way that they
  will deliver what we all want to see delivered - improvements in public health
  and the health of poorer people, getting better health opportunities.  So, for
  example, as you are aware, for the first time now we are measuring and indeed
  rewarding the performance of local health services, recording not just how
  well they do on waiting times and the traditional acute sector agenda but how
  well they do, too, in improving health outcomes, ensuring there is fair access
  to services (the point that was raised earlier) and the performance assessment
  framework that we have includes these two vital measures about health outcomes
  and fair access.  I think it is fair to say that as a consequence of doing
  that not only does it hold the local health service to account against our
  broad objectives but it provides some very positive incentives for the local
  health service in every part of the country to take seriously precisely these
  two issues, how you ensure fair access, for example screening services where
  we know that although in this country we have done incredibly well in
  screening services, cervical cancer and so on and so forth nonetheless it is
  true that poorer women tend to use those services less than others and there
  are big differences according to ethnic minority background too.  If we are
  going to make the big improvements that we want to see in cancer survival
  rates and we want to save the number of lives that we do and people suffering
  from and dying from cancer, then we have got to get into these difficult areas
  and make sure that there is genuinely fair access.   One of the ways you do
  that within the National Health Service is to measure the performance of every
  local service and to hold people to account against the objectives that we
  have set.  It is not just a question of writing a plan or embedding prevention
  in a plan, it is also saying to the service this has got to happen and these
  are the ways that you have got to account for it happening.
        Chairman:   Have we politicians not got some responsibility to broaden
  out the debate to include in the political mainstream issues of public health
  in a way that certainly was not case from our point of view at the last
  General Election where our pledge related to one issue on health which was
  waiting lists.  You can ask anybody in the Health Service if you want to
  evaluate how effective the Health Service is there are a number of
  measurements and that is not one that I would have in mind.  Looking at how
  we broaden out the debate in ways you are describing and looking at targets
  way beyond the immediate waiting list initiatives, etcetera, are you
  optimistic that in the next Election we might have a somewhat more mature
  debate on health ---
        Mr Amess:   No chance.
        John Austin:   No chance if you are involved.
        Mr Amess:   I am replying to all the rubbish we have to listen to.
        701.     Do you understand the point I am making?  I think we have a
  responsibility to get the debate widened to include the very important areas
  you are talking about.  In a sense, certainly at the last Election, I do not
  think that my Party did that in a meaningful way. 
        (Mr Milburn)   I think your Party, my Party, our Party ---
                               Mr Burns
        702.     Different wings.
        (Mr Milburn)   There are no different wings in the Labour Party, unlike
  others I could mention!  I think our Party and our Manifesto did have a focus
  on issues like cancer and heart disease and so on and so forth.
        703.     But key issues --- 
        (Mr Milburn)   Let me finish the point.  I think it is very, very
  important that there is a proper and mature debate about these issues and, of
  course, improvements in health and improvements in health services are not
  just about improving waiting times for hospital treatment but improvements in
  waiting times for hospital treatment have an enormous bearing on the health
  of the population because, as we all know, people are waiting too long for
  heart operations.  That is a fact of life.  Thankfully because for the first
  time the Government has had the courage to earmark funding for coronary heart
  disease in a way that perhaps should have happened in the past, I am confident
  that we will get those waiting times down.  We will grow the number of staff,
  we will invest in the treatments, and we will invest in the secondary
  prevention too.  So there is not a contradiction I do not think ---
        704.     I am not saying there is a contradiction.
        (Mr Milburn)   Nor do I think there is a conflict.  If the argument
  becomes treatment versus prevention, that is the wrong debate.  It is about
  how we ensure that the Health Service is both focused on treatment and
  prevention.  Coronary heart disease is a good example, if I may say so,
  because when we pushed our coronary heart disease National Service Framework,
  our blueprint for tackling the appalling incidence of heart disease we have
  in our country, which incidentally is more concentrated in deprived parts of
  the country than others, the focus was as much on prevention as it was on
  treatment.  That is the first time we have done that, sadly, where policy has
  been rounded enough and, in your word, "mature" enough to recognise that if
  you are going to bring about big improvements in public health let alone
  tackle these appalling health inequalities you have got to do the two things
  at the same time rather than assuming that inevitably it either/or.  It is not
  either prevention or treatment; it has got to be both prevention and
                              Mr Hesford
        705.     Can I pick up on something Mr Austin was dealing with a few
  moments ago.  One of the strongest statements you made today was your support
  for the health improvement programmes.  I personally welcome that.  There is
  evidence that within local authorities, health authorities, PCGs/PCTs, the
  priority of HImPs is slipping down the agenda.  You also said in terms of
  public health delivery that you are not territorial - partnership working, all
  that sort of thing.  In terms of tangible benefits could you say something
  about the suggestion which we have heard quite a lot of merging the HImP
  programme with community plans? 
        (Mr Milburn)   I think in some parts of the country already what you are
  seeing is the health improvement programme where the health authority is in
  the lead (because somebody has got to be in the lead) and the community plan
  where the local authority is in the lead and because many of the contributors
  are the self same contributors - local government, the Health Service, the
  private sector, the voluntary sector and so on and so forth - in some parts
  of the country already there are shared objectives and common values that
  underpin the community plan and the health improvement programme.  That seems
  to me to be a perfectly sensible thing to do.  I do not have a problem with
  that.  One of my own objectives for local government is to cut down on the
  number of plans that they have to prepare.  We impose all sorts of bizarre
  statutory obligations on local government to prepare plans until they are blue
  in the face.  In the end I am not interested in plans, I am interested in
  delivery.  I would rather have people working in local government on
  delivering services rather than writing plans about delivering services.  I
  know one is easier than the other, but actually we pay people to deliver
  rather than simply to plan. We have to see a reduction in the number of plans
  that we ask for in central government, we have some responsibilities in that
  regard.  If we can see a closer relationship between health improvement
  programmes and community plans that seems to me to be a perfectly reasonable
  thing to do.  What we should do is assess in those areas, I think, again, in
  I think in Wakefield, the community plan process and the health improvement
  programme process do have some share objectives and common values and so on
  and so forth.  We should assess what gains are made for precisely that level
  of cooperation.  If we think that that is beneficial then surely we should
  learn a lesson from it.
                               Mr Amess
        706.     I certainly applaud the role of nurses in schools.  I have to
  say to our minister for the Department of Health we have a desperate shortage
  of school nurses in Essex, and if there is anything that can be done to help
  I would be grateful.  This is a subject that people laugh about but that for
  parents it is a big problem, that is the problem of head lice, which one of
  your colleagues has raised before.  It is the sort of thing we do not like to
  talk about.  There clearly is a very real and serious problem.  It does appear
  that all the products which are available at the moment do not seem to be
  working. They are very expensive.  There are new sprays and all sorts of
  things coming on to the market.  Unless every child is done - because with the
  little ones their heads get together - it will go on and on and on.  As a
  constituency Member of Parliament I keep getting letters about this, does the
  Government have any strategy to try and do something about this problem?
        (Yvette Cooper)            It is something that I certainly answer quite a few
  letters from MPs on, including correspondence from constituents.  There is an
  approach that is taken, that is supported locally, through the whole schools
  approach.  You are right, the difficulty is finding it and catching it and
  supporting the whole school.  What I can certainly do is send the Committee 
  the details of that.  It is something where we have cross working between the
  Department of Health and the DfEE on that.  It obviously something where the
  whole school becomes involved, it is not simply an issue for the school
  nurses.  On the issue of the school nurses, it is true that there are
  recruitment pressures and it is something that we are very aware of and it is
  something that applies to a lot of sectors.  Certainly our commitment right
  across the NHS and right across the nursing staff is that we want to see
  expansion, although we do recognise that that is not always as easy as our
  intention might be.
        707.     Thank you for sending us the document.  I would like to
  persuade our local authority do something about it.  They will probably say,
  "Where would the money come from".  What is the Government's position at the
  moment concerning the MMR vaccine?
        (Yvette Cooper)            There have been a lot of concerns raised about the MMR
  vaccine.  We take the approach that whenever there are any concerns raised
  about any medicine or any vaccine we always refer it to the expert committees
  that advise the Government on these issues, particularly the Committee on the
  Safety of Medicines also the Joint Committee on Vaccination and Immunisation
  and we seek the advice of the Chief Medical Officer.  That is what we have
  done on this issue.  We have referred all of the research, all of the
  publications, all of the claims that have been made by Dr Wakefield, all of
  the claims that have been reported in the papers to those expert bodies for
  them to examine them in great detail and examine them thoroughly.  Their
  advice to us has been that there is no evidence of a link between the MMR
  vaccination with autism.  Secondly, MMR remains the safest way to immunise
  children against what are quite deadly diseases.  We think it is important on
  an issue like this to follow the advice of the experts and to make that advice
  available to the public.  We should not be in a position of hiding information
  from the public. All of the information that we have been given from the CSM,
  from the expert committees and from the Chief Medical Officer on this subject
  we have made public and we need to continue to do so.
        708.     I know on 8th January you answered a question about the TB
  programme.  Do we have an update as to when the schools can expect to have
  this vaccination programme resumed?
        (Yvette Cooper)            We do hope to be able to make an announcement on that
  shortly.  You will be aware that the vaccination programme has already resumed
  in London.  We are also very conscious of the need to make sure that children
  do not reach the point of leaving school without a catch-up programme reaching
  them in time.  We are very conscious of that. We have held discussions with
  companies all over the world to try and make sure we can get a secure supply
  of the BCG vaccination.  There were problems with the sole supplier that
  persisted over some time that lead to the suspension of the programme.  There
  is certainly a lot of work going on that and we do hope to be able to make an
        709.     When can we expect the sexual health strategy from the
        (Mr Milburn)   Hopefully within the next couple of months.
        710.     Do you have any concerns about the way the morning after pill
  will be administered?
        (Yvette Cooper)            Are you referring to the morning after pill available
  in pharmacists?
        711.     Yes.
        (Yvette Cooper)            This is something which  has gone through the proper
  procedures, through the Committee on the Safety of Medicines and the Medical
  Control Agency.  The company applied for a licence to use this to be able to
  deliver this product in pharmacies for over 16s.  All of the expert committees
  who assessed it said this was a very safe product and this was something that
  could be give in pharmacies.  The Royal Pharmaceutical Society has provided
  very detailed support and guidance for pharmacists to ensure that it is done
  in the proper context, the right kind of questions are asked and the right
  kind of advice is given.  My view is that this is an extremely positive move,
  it is about giving women more access and choice to a product that all of the
  experts say is safe.  It could also make a big difference in terms of bringing
  down the number of abortions and unwanted pregnancies, which are highest
  amongst women in their 20s.
        712.     Two final questions, you and I have been in correspondence
  about the palpatia(?).  For the record, could you say why your expert group,
  I am not challenging it, decided that palpatia(?) should stop in terms of
  breast screening?
        (Yvette Cooper)            Perhaps I should write to you or the Committee with
  the detail on that.
        713.     I would be grateful for that.  I understand that you will be
  visiting the Lupus Centre later this month, which I am very pleased about,
  because we know this effects women between 20 and 40.  The Secretary of State
  spoke earlier about why in the discussion and knowledge it is quite  clear
  that the number of general practitioners do not - I know we have two on the
  Committee - seem to know about sticky blood, and all of that.  Is there
  something that the Government might do if they are persuaded that this is a
  problem that we should address?
        (Yvette Cooper)            We will certainly always look at any new area or any
  particular condition where there might be improvements that could be made. 
  We have to take an evidence-based approach.  We have to look at what works,
  what is properly evaluated and what will make a difference.  Our approach
  right across the NHS is as new techniques become available, as new
  technologies become available we will also find areas that need research. We
  always need to take all of those seriously.
        Mr Amess:   They do not get any money at all to help with their research.
        Dr Brand:   Can I pick up one of the relevant questions that David Amess
        Chairman:   I thought they were all very relevant.
                               Dr Brand
        714.     The issue of sexual health, when the Government reduced the
  public health targets, which were set in Health for the Nation, two to four
  main targets that we got in Saving Lives and Our Healthier Nation, I was given
  an undertaking by the Secretary of State's  predecessor that we would not lose
  sight of the other targets.  Although targets would be local for some of the
  other issue, like sexual health, they would be collated in some form so that
  we could see whether as a nation we were actually delivering the agenda that
  needs to be delivered.  Sexual health is a very good example of that, teenage
  pregnancy, etc.  I have asked this question annually for the last three years
  and I have been told that it will emerge from the system eventually.  Can the
  Secretary of State or the Minister tell me when it will be available?
        (Yvette Cooper)            What specifically are you asking for?
        715.     The previous targets that existed are no longer national
  targets they are now local targets.
        (Mr Milburn)   You mean Health of the Nation targets.
        716.     When will we be able to see how we are getting on as a nation
  in reducing the issues like genitalia infections, teenage pregnancies, etc?
        (Yvette Cooper)            Most of the figures you are talking about, like
  sexually transmitted infections are in the public domain. The Public Health
  Laboratory Service publishes a lot of information about communicable disease.
  There is a lot of information in the public domain already.  We have a
  commitment to demonstrating progress against the targets we have set on sexual
  health.  You are right, one of key areas there is teenage pregnancies, where
  we have set quite clear targets over the next ten years on teenage
  pregnancies.  We are also looking at publishing a text supplement to the work
  that went you on through our Healthier Nation but also which is updated in the
  NHS plan that might also provide more of the kind of information you are
  talking about.  I think our approach with a lot of these things is the
  information is out in the public domain.
        717.     I am not denying there is not a lot of information.  What I
  think is difficult is to get the information in a form that you can track what
  is happening. Where we had 22 targets before we could follow what was
  happening to them, I was given assurance by the previous secretary of state
  that there would be some way of seeing how we were getting on. That would be
        (Mr Milburn)   Can I take that away.  I am sorry I do not have an answer
  for you today.  I will take it away gladly.
        718.     While we are on targets and priorities, it is a bit alarming
  to hear from some of our witnesses that during regional reviews directors of
  public health would not necessarily be invited to take part in a review. 
  Health authorities, on the whole, were questioned about the acute delivery of
  services, waiting lists, and that sort of thing but the public health targets,
  if they existed, were never discussed.  Have we got the right mechanism of
  delivering the public health agenda you talked about so eloquently this
        (Mr Milburn)   I hope we have.  It is very, very important.  This is one
  of the changes that we have to achieve.  If you like, we have to take public
  health out of its ghetto within the National Health Service.  It not just a
  function and it is not just a responsibility that belongs to one part of the
  Service or to one group of professionals.  It is a responsibility for the
  whole service, particularly in primary care it is the responsibility of all
  professionals.  We have to, as I was indicating earlier in answers, have a
  means of imbedding it within the Service. My guess is you share this view, it
  is reflected in your question, that for too long these public health issues
  have somehow been second order rather than at the top of the agenda.  The way
  that we have sought to do that is precisely by making health outcomes and fair
  access to services as important as the patient's experience in a hospital in
  determining how well their local health service is doing and, therefore, being
  able to hold a local health service to account.  As you are aware, in  future
  being better able to reward good performance across a whole range of quite
  complex health service responsibilities according to performance of the
  individual health service, not just on the waiting time issue, but on health
  outcomes and health improvement too.  Within a managed service that is the way
  it seems to me that you stand a better chance of locating responsibility for
  improvements in public health within the mainstream of the NHS, rather than
  simply having it parked to one side, which I think has been the position in
  the past.  That is quite a big change.  I do not pretend that it will be easy. 
  I think there is not a chief executive in the country that does not realise
  that there are certain important priorities for the NHS. Certain priorities,
  in Mr Hesford's phrase, are "must dos".  In the future "must dos" will not
  just be about what happens in hospitals, they will also be about what happens
  in primary care, what happens to improve preventive screening services and
  what happens to bring about what we are all in the business of, which is
  improving health.
        Dr Brand:   You are still talking about the medical model of public
  health rather than the broader model of public health --
        Chairman:   This is coming from a doctor!
                               Dr Brand
        719.     -- which is something that saddens me actually.  We have been
  talking about screening, prevention and some very good things have been done,
  I am not denying that, but that really is improving things very significantly
  for a relatively small number of people at risk.  The broader population
  benefits from the broader issues of the environment, housing, nutrition, which
  have been touched on, but they are not actually delivered through the Health
        (Mr Milburn)   Hold on. With respect, and nor could they ever be.  Unless
  you want to have a rather Stalinist approach to government - I know that is
  my reputation, Dr Brand, but as you know I am much more amenable and flexible
  than he ever was.
        720.     I am still alive, I am very grateful for that.
        (Mr Milburn)   One of these days I will convince you of that. Unless you
  are going to have one supremo who is responsible for every governmental
  function then, of course, there are going to be different departments with
  different responsibilities, absolutely right, but with one big objective.  If
  you ask me to define what the Government's big objective is overall, it is to
  ensure that there is genuine opportunities for every section of society in
  every part of our country, that is what we are about.  The Health Service
  happens to encapsulate that but so do our ambitions to abolish child poverty
  or to create full employment or to ensure that everybody has a decent home and
  a decent environment and good public transport services and less crime on our
  streets.  Those are the Government's broad objectives. All of these have a
  direct bearing on the health of the population and on people's health
        721.     I agree entirely that the health outcomes will probably be
  the best measurement of how successful the Government is at actually creating
  an enabling society. Can I ask a specific question about the role of health
  authorities versus health trusts.  I do get a bit confused as to whether we
  still have a commissioner/provider split when I look at the Health Bill that
  going through at the moment, where delivery trusts are going to be directly
  influenceable and rewarded by the secretary of state as with the influence of
  health authorities.  We also see that each trust by statute has to have a
  Patients' Forum to influence its delivery.  The minister of state quite
  specifically said that this was a Patients' Forum and not a Community Forum. 
  That worries me slightly because trusts are actually very good at influencing
  ex patients of their brilliance and how wonderful they are.  They tend to be
  fixed on the medical delivery of acute services, whereas the health
  authorities are allowed to have an ad hoc arrangement of public involvement. 
  If health authorities have to deliver the public health agenda, which is not
  always the most popular in the short-term, how are they going to be able to
  have enough influence over the trusts, given that the trusts are going to have
  very powerful advocates in the statutory Patients' Forum?
        (Mr Milburn)   I do not think the premise of your question is quite
  right.  I do not believe it is purely the responsibility of the health
  authority to deliver improvements in public health. Perhaps we will not get
  as far as we need to get.  It is the responsibility of the whole service, of
  community trusts, mental health trusts and most importantly of all primary
  care trusts, all of these organisations have a huge part to play. Within the
  primary care sphere I believe that - I was talking earlier about the role of
  GPs and other primary care professionals will play - the advent of primary
  care groups and now primary care trusts, for the first time, give primary care
  professionals the opportunity to have a proper population-based focus, to
  focus on the needs of its overall population, of 100,000 people or 70,000
  people or 150,000 people.  That allows, in my view, at least the potential for
  primary care professionals to get into another arena of activity that is
  hugely important in determining the health care and the Health Services on
  behalf of its local population. If GPs or as other primary care professionals
  you find there are particular problems amongst their patients, for example
  with poor housing, lack of central heating or damp homes, whatever, for the
  first time through the primary care trust group have you the opportunity of
  doing something about it, not least in relation to the roles that PCTs will
  play with local government.  I think all of these organisations within the
  health service, not just the health authorities, have a responsibility to play
  on the Patients' Forum.  I am completely unapologetic about that.  As recent
  events have rather demonstrated all too graphically, the lack of direct
  patient influence, of patients being on the outside rather than the inside of
  the National Health Service have not always got their families, their
  relatives the right sort of results from an NHS that is supposed to about,
  primarily, serving the interests of patients.
        722.     I thought the NHS was there to serve the interests of the
  community from which its patients came.  It is the concentration on the narrow
  user group rather than the broader community that gives me some  concern when
  we are talking about the delivery of public health.
        (Mr Milburn)   On the Patients' Forum side they will be comprised of two
  groups, although I do not think they are particularly distinct.  People who
  use the Health Service, and use it on a regular basis, they have some insight
  into it.  Actually, listening to what patients have had to say and listening
  to their concerns and complaints and, more importantly, imbedding the
  patient's voice within the National Health Service at a local level will make
  a real difference.  That is one group. The second group are patient
  organisations within the local community, the local MS Society, the local
  Alzheimer's Disease Society.  These local groups are drawn from the local
  community but have a particular interest and have a particular expertise which
  we ought to bring to bear for the benefit of the local community and patients
  in general.
        723.     I have no doubt they will be formidable advocates for the
  particular delivery of a medical treatment service.  Can I turn to the local
  delivery of public health.  I was very pleased to hear you say that you
  recognise that there are far too many initiatives, and too many plans are
  having to be drawn up.  I hope that the Department will consolidate some of
  that.  Can I ask whether the plan is to base the joint working predominantly
  on health geography or local authority geography? It is easy for me, I am as
  coterminous as one could possibly be.
        (Mr Milburn)   You are at ease with yourself, are you?
        724.     I am totally at ease with myself.  The health improvement
  programme clearly may have a different area from the community plan. I also
  find that the health improvement programme, because it cuts across a number
  of local authorities, is not the ideal unit to be looking at a local
  community.  I think we should be starting to talk about sub HImPS and a
  smaller population that should create HImPs based on a district or unitary
        (Mr Milburn)   Some of that is happening on an ad hoc basis, the
  so-called HImP-lets.  One of the amazing things about the National Health
  Service is it does manage to engender all sorts of interesting language which
  has a passing acquaintance with the English language on occasions.
        725.     Almost as good as politicians.
        (Mr Milburn)   Some of that is beginning to happen, and why not? 
  Certainly within my own area, Darlington, it is a very different place from
  the Teesdale and the East End of Durham, the old mining communities, and they
  have very different health problems.  We have to have some ability and some
  flexibility to plan for the needs of the specific local population.  I do not
  have a problem with that.  As far as this issue of coterminousity is
  concerned, I think this is quite a difficult issue for all of us.  The truth
  is there will never be a perfect set of boundaries.  You are the dealing with
  different organisations of different traditions, different cultures, different
  representatives and accountability structures.  That is bound to be the case. 
  All that I say to people in the NHS, whenever they come to talk to me about
  this, because the NHS likes nothing better than a really good reorganisation,
  and it has had lots of them.  It has lots of experience in doing it.  All that
  happens, or what tends to happen whenever you have a reorganisation is that
  by and large people's eye is taken off the ball and in the end what happens
  is that rather than concentrating on getting the services delivered or the
  services improved or the health of the local population improved people start
  jumping into a position and wondering which job they are going to get.
  Sometimes we need to reorganise and we need to change things in terms of
  structures and institutions within the local service.  Sometimes it is better
  to take your foot off the accelerator rather than always pressing it down.
                               Dr Stoate
        726.     Minister, one of big public health issues I am interested in
  is men's health.  Can I say I am pleased you have been helpful and very useful
  in the Men's Health Forum, working inside and outside this place, to tackle
  the big inequality facing men at the moment.  One of the issues I really want
  to talk about is how as a GP we can try and improve health across different
  groups.  We were told recently that the Health Education Authority carried out
  a survey and only 11 per cent of GPs understood what the New Age targets were
  for exercise.  What that really means for me is that perhaps GPs are not as
  focused on the side the public health agendas as they might be.  How do you
  think we can get GPs more on board with the Government's target for delivering
  public health.  I do not think at the moment they understand what you are
  trying to achieve.
        (Yvette Cooper)            There are some GPs in some parts of the country who
  are doing quite amazing work around public health and who are leading the way
  in showing what can be done, whether it is around coronary heart disease
  prevention or whether it is around teenage pregnancy.  It is interesting on
  the issue that you mentioned, on exercise, the programme called Health Walks
  that has been funded by the New Opportunities fund quite recently as part of 
  the Healthy Living Centres programme is all about improving access to exercise
  and working through primary care to do that.  That has been driven by a GP. 
  That has been driven by primary care.  There are some very goods examples. 
  The question is how you spread those examples across the country.  Primary
  care does now have a duty and responsibilities for public health and health
  improvement.  What we need to do is to build on that over time. It will take
  time.  We should not have any illusions about the fact there are no swift
  solutions. There is a huge amount going on in primary care, with the shift of
  primary care trusts in many areas.  I think there is a huge amount that can
  be done.  Perhaps most will be done if we see primary care as a team and not
  simply as the role of GPs, so the work that nurses in primary care do, the
  work that health visitors do, the work, increasingly, that community midwives
  may be doing if they are linked in, and so on and so forth. There is a broad
  programme of work, it will take us some time.  The more that we have targets,
  for example, health inequalities target, for example, the work on smoking
  cessation and, for example, the implementation of the national service
  framework for coronary heart disease, which requires a lot of work at local
  level and through primary care, the more progress we will see in this  area.
        727.     That is fine.  As you said, there are extremely good examples
  of where GPs and primary care teams have been extremely innovative with
  excellent results.  My worry is there is a vast bulk of GPs who are struggling
  day-to-day to see 50 patients a day, sometimes more, plus on call.  I find it
  quite difficult to grasp the actual concept of public health and how it is
  that we are trying to make any real difference.  They feel swamped and
  overwhelmed and they wonder what it that they can reasonably achieve.
        (Yvette Cooper)            Primary care groups and primary care trusts will be
  the mechanism for doing that.  They will have responsibilities on public
  health and on health improvement.  As a trust or as a primary care group they
  will need to show progress and to make progress and to be involved in the
  partnerships with other organisations at the local level.  That does not
  necessary mean that all GPs within a primary care trust will instantly change
  the work they are doing, or anything like that, it does mean that as a whole
  the primary care trust is the mechanism. Obviously it is going to involve more
  training and support for people in the new kinds of functions.  It may also
  be very much about the kind of teamwork, or it may be that particular GPs
  specialise in particular  areas around public health.  The honest truth of
  this is that I think it is an area with huge potential.  We have not worked
  out the way in which it is going to work and a lot of it will be about the way
  it develops at a local level.  You can just see some of the ways that some
  primary care trusts in some areas picked up smoking cessation and are doing
  a lot of work there.  There is huge potential. What we need to do is follow
  what is working in different areas and make sure that other areas can learn
  from it.
        728.     Are you convinced that PCTs are the right vehicle to deliver
  this programme?
        (Yvette Cooper)            They are such a massive resource.  GPs are seeing
  people on a day-to-day basis.  People come into their surgeries with health
  problems that are often linked to all kind of different social problems or
  economic problems locally. You have health visitors who are working with
  families with young children at a critical stage of a child's development. 
  What happens in the first year of a child's life can have a huge impact not
  simply on their health later on, but also on their education opportunities and
  how they develop. Community nurses, people who are working in the local
  community at a very tangible level. It could be something as simple as
  identifying who it is that is suffering from fuel poverty by just a simple
  question to them when they come to have a flu jab, the primary care nurse
  asks.  The potential for all of these health professionals, who have huge
  contacts with the community, and also with other organisations in the
  community, the potential for them to deliver improvements in public health I
  think is massive.  It will take us a lot of time and we have to be very
  realistic about the capacity of the NHS.  It is a time of great change and
  resources will only come on stream over time.  The potential is huge.
        729.     It is interesting what you said about very young children and
  the contact they can have with health professionals.  It might interest you
  to know that in Cuba the GP visits every child under one personally every day
  until they are one.
        (Mr Milburn)   Are you advocating that?
        730.     No, I think my colleagues would lynch me. You said it was
  easy for a GP, a health professional, a health visitor or a practice nurse to
  pick up poverty or housing problems.  That is fine and they do.  What do they
  do about it?  I still do some medical work, if I see somebody in that position
  now what I say is, "Go and see your MP", and they come and see me again.  That
  is the matter, Secretary of State, to pick up.  You can  pick up these issues
  of poverty, GPs know about these things, but what can a GP do about them?
        (Mr Milburn)   There are things that can be done for the individual
  patient, a referral to the local authority, and so on and so forth.  That is
  not the trick we have to pull off.  What we have to pull off is a means of
  harnessing the expertise of people in primary care with the knowledge that
  they gain from their contact with people in the community in order to
  formulate locally based approaches and strategies to deal with particular
  problems that you and Dr Brand see in your surgeries. There will be particular
  pockets of problems in particular areas, as there are in my own constituency.
  Some parts of the constituency are relatively affluent, some are pretty poor
  and they have specific needs.  I think based on that knowledge what we need
  to do through the PCT structure, because it is operating at the level of the
  general population rather than a specific group of patients on a doctor's
  list, at that level what we to have to do is get the PCT working together with
  the local authorities and the other players in the community to formulate
  answers to the specific problems that walk through the doors of GPs surgeries
  either to see the family doctor or the local nurse.  That is not easy to do -
  of course it is not - but the point about this is that there is a bank of
  knowledge, both in terms of expertise about solving problems and indeed about
  the nature of problems themselves, that is located absolutely in the heart of
  primary care.  I do think this is an important issue in terms of how we frame
  this whole debate around public health.  I said earlier that if we think that
  public health is just about certain professionals within the National Health
  Service delivering certain services we will not get anywhere.  Public health
  is about how you mainstream these issues right into the heart of the Health
  Service onto the front-line of the Health Service and I think the PCT
  structure offers the potential of doing that precisely because over time you
  will see - and I am convinced of this and in the best places it is already
  happening - greater co-operation and greater collaboration with local
  government services, not just social services but environmental health
  services, transport services, education services too.
                               Dr Brand
        731.     I think it is very ironic that we are having this discussion
  whilst the local government settlement is being announced because one of the
  reasons why I went into politics was because one got very frustrated because
  one recognised there was a problem but there were no delivery mechanisms.  I
  think the only way you are going to get primary team members to reach their
  potential and start doing the work is to show that when they do the work there
  is a result.  When I refer people to me as an MP I am almost as frustrated as
  a GP because fuel poverty and damp housing is not something I can change there
  and then and that is extraordinarily frustrating.
        (Yvette Cooper)            But it is something where there are some local
  delivery mechanisms in some places being set up.
        732.     You need funding.
        (Yvette Cooper)            In some places they have set up partnerships where the
  local authority has got a programme of improving insulation, central heating
  and so on so they build a partnership with the local health service on how are
  we going to prioritise, who is going to get the heating first, who is going
  to get the help.  There is all kinds of work going on on home energy
  efficiency schemes and support to tackle damp housing.  Those problems exist. 
  The problem is matching them with the people who need them most and the Health
  Service is actually a brilliant way to match people but only if the
  co-ordination mechanisms are in place, and they are in some places and they
  could be in many more.
        Chairman:   Can I say we will adjourn for ten minutes.
  The Committee was adjourned from 18.02 to 18.12 for a division in the House
        733.     Colleagues, could we recommence.  I hope we can conclude in
  just over 15 minutes.  Before we move away from the point Howard raised, he
  mentioned men's health and certainly one of the issues that has come out as
  a concern in this inquiry is the extent to which we have a lot of work to do
  in that area.  As a Committee we feel quite strongly we need to look at that
  very closely.  One of the issues that struck me in some of the visits we did
  was the fact that the front-line workers who were addressing this were
  primarily female and I wondered whether if any of the initiatives looked at
  the way in which you may involve more men in advising men on male health and
  looked at possible alternative models.  I am involved in something you may be
  aware of on testicular cancer.  I will not go into the rather laddish messages
  we put across but it is an important health message targeted at male
  spectators of sport.  Have you any examples of how you are addressing this as
  an issue and the staff involved in front-line advice giving?
        (Mr Milburn)   The best one that springs to mind is again in Bradford. 
  Certainly on my visit there I had an opportunity to meet some of the male
  primary care staff, community staff, who were providing health promotion
  services but in a rather different way than perhaps they had been provided in
  the past.  They were doing lots of "surgeries" in pubs and clubs and getting
  an incredibly good response, it has to be said.  There is quite a bit of that
  in various places and some of the health action zones (not all but some of
  them) have helped to pioneer some of that work.  I think there are some quite
  important lessons that are to be learned.  It is true that basically men are
  not as forthcoming as women are about some of these health problems and
  actually it is important that we therefore have the debate with men on terms
  that they relate to and understand and in some of the venues that they feel
  comfortable in.  That struck me as a very good example but I am sure there are
  very many others.  The issue is, as always in the NHS, how you generalise from
  the particular and make sure those examples of good practice become more
  generalised across the piece.  I am optimistic about this because I think that
  both for women and more men there is such an obvious and growing interest in
  their own health.  You can see that whether it is in types of magazines that
  have been sold, the growth of gyms and fitness studios or whether it is the
  number of sports shops on the high street.  People are more and more
  interested, quite rightly, in health issues that affect them, not necessarily
  Health Service issues either, about their own health.  The issue is how best
  the National Health Service, which has tended to give a fairly passive
  response to demand, can relate to quite a different order of interest in the
  population about people's own health.
        (Yvette Cooper)            I was going to say that it is not even just about the
  services, it is also the health information that we provide.  I think the
  traditional approach of the health information campaigns has been to target
  women.  It has been the traditional approach.  You think about women as the
  guardians of family health so health messages go to women rather than to men. 
  That perpetuates a situation in which men feel less empowered when it comes
  to talking about health, that health is not something to do with them.  It is
  something we have made a conscious effort to address with new campaigns.  So,
  for example, the teenage pregnancy campaign is very explicitly as much about
  boys as it is about girls, and is very conscious of the different approaches
  that boys and girls might take or different things that might resonate and it
  is very  clearly about teenage boys as much as it is about teenage girls. 
  Equally, the flu jab campaign we did involved Henry Cooper.  We have been very
  conscious of trying to make sure that the campaigns that we run are as much
  about men as about women.  Another interesting point I would make is that
  health inequalities issues between low and high income become very clear here
  as well because what you see over time is high income men catching up with
  women when it comes to life expectancy but low income men falling further and
  further behind.  You also have to look at inequalities in terms of income as
  well as the differences between men and women. 
                               Dr Stoate
        734.     If I could ask a couple of specific questions, Secretary of
  State.  A bit of a booby for you really: why has it taken so long to publish
  Sir Kenneth Calman's Report on public health function, which has been promised
  for some time now?  Is there a particular reason it has not been published? 
  Do you intend to publish it quickly and, if not, why not?
        (Mr Milburn)   I hope we can publish it quickly.  I hoped we might have
  been able to publish it this week but for various obvious events we have not. 
  It is literally on the stocks and it has been with Ministers and it will be
  published, I hope, within the next few weeks.  The major reason is that we had
  a change of Chief Medical Officer and it was important that Liam Donaldson had
  an opportunity to put input into it.
        735.     My next question is about the fluoridation of water.  When we
  took evidence from the Sandwell Authority, which is a most deprived area, when
  they fluoridated the water 13 years ago they found dramatic improvements in
  the health of kids under 14 in their oral health, particularly in fillings. 
  What is your Department doing about the fluoridation of water?  Why is it not
  being rolled out across the country, do you have any plans to do so?
        (Mr Milburn)   As you know we commissioned a study from the University
  of York which was published in October last year.  It was an important study,
  yet in some ways it was disappointing in that it did not in the end make clear
  any firm recommendations for action.  What it concluded, as you remember, is
  that overall the fluoridation of water had a positive oral health impact.  If
  the people from Sandwell have told you that then their evidence bears that out
  to you.  As far as they could see from the evidence there were not adverse
  health risks associated with the fluoridation of water but nonetheless they
  went on to say that there was not as much primary research around, and the
  primary research that was around was pretty dated.  They recommend that we
  needed more research and, indeed, that is what we are doing.  We are talking
  to the Medical Research Council about how we can go about getting more primary
  research.  The problem of doing that is that it takes time.  If you are going
  to have a whole series of population studies it is going to take some time to
  get.  There are very different views about this, as you know.  My post bag is
  full of very different views on this issue.  I suspect that members around
  this table have different views.  My own view is there are probably big
  benefits in fluoridation.  As with all things, we have to make the policy
  decisions on the basis of the best evidence.  Indeed, I think it is true of
  public health policy generally that we think we know what works very often but
  sometimes there is just not an evidence base for it.  If we are going to
  invest public money and we are going to develop new strategies and new
  interventions then, above all else, we have to be pretty sure they are going
  to work.
        736.     I am disappointed more is not being done. The Americans have
  done it now for the last 20 years. They have a wealth of evidence and, as far
  as I am aware, very little adverse evidence. If a country like America can
  accept it wholeheartedly, virtually all American states are fluoridating their
        (Mr Milburn)   I am happy to send you a copy of the report.  We
  commissioned the report precisely because there are so  many different views
  about this and to try to get a clear evidence base for any policy decision we
  took.  As I say, the conclusions of the report were clear in one regard but
  were not in another and, therefore, we have to act appropriately.  However,
  that does not mean that in the meantime there will not be discussions,
  particularly in those parts of the country where we know there is poor oral
  health, deprived areas in particular, with the water companies about pressing
  forward the fluoridation schemes.
                           Siobhain McDonagh
        737.      We have already heard earlier on about how you feel that the
  target for reducing child poverty is probably the biggest single commitment
  the Government has made and is going to have an impact on public health.  Can
  you tell me what other Government measures have had an impact on public
        (Mr Milburn)   The measures that will have an impact, a lot of these
  things are for the long-term rather than the short, are around the whole
  effort we are making to improve people's standard of living and to provide
  more opportunities for them.  I think the things we are doing to lift people
  out of property are particularly significant here, whether that is child
  benefit, the minimum wage, the Working Families' Tax Credit, the New Deal, and
  the measures we are taking to enhance the  employment opportunity and to make
  sure that if people are in employment they have a decent living wage.  These
  are important measures.  I think the New Deal for Communities, the single
  regeneration budget investment, and so on, are also significant because along
  with Sure Start what they do is target resources in those parts of the country
  which need most regenerative effort and require, frankly, additional resources
  in order that we give people precisely the opportunities that have been
  available to some communities but not to every community. I think these
  measures are very, very important, reflecting Dr Brand's earlier point, they
  are very, very important measures in their own right, but they are also very
  important public health measures too.  Over time they will pay dividends. 
  There is little doubt about that.  If Black is right, if Acheson is right, if
  Donaldson is right, if a wealth of science expertise and medical opinion is
  right then lifting people up and creating, in the crudest of terms, a fairer
  society is bound to have an impact on people's health opportunities too.  I
  think a fairer society and a healthy society are two sides of the same coin.
        738.      How can performance in tackling health inequality be better
  managed?  How can you enforce targets and monitor progress, given than the 
  rest of the health service is run like that?
        (Mr Milburn)   It is very, very important the development we announced
  in the NHS plan.  There was a lot of to-ing and fro-ing about this.  There
  were very mixed views about this.  In our Healthier Nation we said that we
  would press ahead with a policy of local health inequality reduction targets
  and some of that has been happening through the health improvement programmes,
  and so on and so forth.  There was a debate inside the Department and in the
  Modernisation Action Teams about whether we should press ahead with national
  inequality targets.  My own view, and Yvette Cooper's too, was that that was
  the right thing to do.  In the end you have to believe that what we have been
  talking about in terms of child poverty reduction and the interventions that
  we can better make in health are going to produce the right results.  One
  thing that is crystal clear about the NHS as a managed service is that if you
  set a target that influences behaviour.  It influences behaviour amongst
  clinicians and amongst managers.  The fact that we are going to have, for the
  first time, a health inequality target, I hope we well be announcing before
  too long, I think will gear the Service to better recognising that this is a
  very important arena of activity for us in a way that has, perhaps, been
  neglected in the past.  We have  brought in new expertise to help us do that. 
  We have brought in Don Nutbeam, who is a professor of public health of the
  University Sydney, to lead our public health effort and specifically to help
  us with the devising of an effective but also a challenging health and
  equality target.
        739.     I am only a very new member of the Health Select Committee
  and I have really enjoyed my time on it, particularly hearing about the local
  schemes and the really imaginative ideas that people have about regenerating
  their areas and improving health.  All our discussions show they go hand in
  hand.  One of the things that has come up as a minor issue is that the NHS can
  often be the biggest employer, the most well resourced organisation in any
  constituency or any borough. Do you think the NHS understands its role as
  employer, as an owner of property, as an owner of land, as a planner, in
  relation to what it could do to be involved in these particular regeneration
  schemes.  Do you think the Department and NHS Executive actually understand
        (Mr Milburn)   I think the frank answer to that is probably, no, we do
  not or the NHS does not. There is real work to do there. It is absolutely the
  case, in my constituency, and I guess in most others, if it is the true that
  the NHS employs one in five of the public sector work force and one in 20 of 
  the whole country's work force, and it is going to be a growing work force,
  that must be reflected in most constituencies in the land.  The NHS has some
  broad responsibilities, as Dr Brand was indicating earlier, not just to the
  patients that it serves but also to the wider community that it serves.  It
  is a very important local employer generally.  We try to encourage it to get
  involved at a local level with the New Deal to provide employment
  opportunities for the long-term unemployed and for the youth unemployed. 
  Although there has been some success there I think a lot more can be done. 
  As far as regeneration efforts are concerned I think probably the most
  significant thing we have done to date, and I think we need to do more, is the
  announcement we made in the NHS plan that we would have joint public health
  groups jointly reporting to the regional offices of the NHS through the NHS
  Executive and to the regional offices of government. That will, I think, allow
  something to happen that has happened sufficiently to date, which is that in
  all of these big regeneration schemes, whether they are New Deal for
  Communities or the Single Regeneration Budget or whatever for the health
  benefits and the health impact of those schemes to be better recognised from
  the outset.  What I want to see is a lot more NHS input into regenerated
  activity both at a regional level, but at a local level as well.  
                              John Austin
        740.     Could I just follow on on that because you talk about input
  there but you are talking about input on the basis of ensuring there are good
  health outcomes from regeneration schemes.  I think clearly in the ones I have
  looked at there have been measurable or potentially measurable health
  benefits, but there have been very few regeneration schemes which have been
  health-led rather than health being a positive good coming out of the economic
  and education schemes, or whatever it is.  Do you think there is much more
  scope for looking at health becoming a driver and health being a regenerative
  engine itself? 
        (Mr Milburn)   Yes, I think there is scope for some of that and, indeed,
  I am considering at the moment the next wave of major capital developments
  within the NHS following from the first and second wave of PFI and other
  schemes, including the one in your own area.  Of course, you always have an
  eye on the potential broader impact that a major scheme of this sort can have
  in the local community.  If you are going to spend 100 million, let alone
  200 million or 300 million, and we have got some very, very big initiatives
  now coming through in terms of hospital developments in particular, they can
  not only provide the local community with a better local health service but
  potentially they can also have a very big knock-on effect into regenerative
  and economic development activity in a local community too.  We try to do that
  at a national level, but I think the point that was being made earlier was
  that that needs to be replicated right down the command chain to both regional
  and local level, and I am convinced there is a lot more that can be done in
  that regard.
        741.     Are there any urgent final points Members want to raise or
  any points either of the ministerial team want to make?  If not, can I thank
  you both for coming along today.  We are most grateful to you and I hope our
  report will be of some help. 
        (Mr Milburn)   I am sure it will.
        742.     Thank you. 
        (Mr Milburn)   Thank you.