Memorandum by British Medical Association
(WP 73)
The British Medical Association (BMA) is a voluntary,
professional association that represents all doctors from all
branches of medicine across the UK. About 80% of practising doctors
are members, as are nearly 14,000 medical students and over 3,000
members overseas.
The BMA's response is based upon a long-term
interest in public health[143]
and discussion within the BMA on the strengths and weaknesses
of the government's public health white paper, Choosing Health:
Making healthy choices easier.
Aside from its continuing lack of leadership
around smoking and alcohol policy, the White Paper contains several
welcome initiatives as well as some positive proposals.
The proposed investment to develop sexual health
services is excellent but it is important to ensure investment
to increase capacity comes early enough to respond to the expected
increase in demand.
The BMA welcomes proposals to expand school
health services, to incorporate a health impact assessment on
policy across government, and supports the creation of an arms-length
body that will gather data and report on key indicators, as well
as money to support it.
There is little detail behind the proposals
and it is less a plan and more an outline of policy ideas that
are still to be shaped. Therefore the BMA's comments focus mainly
on implementation issues and the need for a clear strategy and
framework to develop these ideas and sustain them in practice.
The proposals outline a medium term agenda and
initiatives that need to be driven forward. The extent to which
forthcoming reviews are absorbed into policy needs to be monitored.
It is appropriate now to look at the practicalities
of the proposals so that they can be developed further. Without
careful reflection on how to progress the proposals to achieve
public health goals, it will be difficult to take advantage of
the current high profile of public health.
1. Will the proposals enable the government
to meet its public health goals?
I. The case of smoking illustrates some
of the higher-order challenges in translating the political philosophy
of the public health white paper into effective action. Proposals
have been developed based on politics rather than published scientific
evidence and public health has become even more focused on health
service delivery.
II. The government's proposal on smoke-free
public places is a really disappointing area in the White Paper.
The government has missed the opportunity to demonstrate leadership
in public health. Creating comprehensive UK-wide smoke-free public
places is the single action that above any other would drastically
improve public health and remove a huge burden from the NHS. It
makes no sense to allow smoking in some pubs putting the health
and lives of employees who work in them at risk. The BMA is also
particularly worried about the time-scale. For every year's delay
at least 1,000 lives are lost to second-hand tobacco smoke UK-wide.
When lives need saving, doctors act immediately. The government
should follow this lead.
III. The Department of Health brought together
a range of experts in task groups and undertook local consultation
exercises around the country. The government heard consistent
messages: a need for a sustained focus on public health, for joined-up
policy across government, strong action on smoking and strategies
to cut excessive and socially damaging levels of drinking.
IV. A whole range of practical measures
were put forward that were widely supported and had evidence to
support their introduction. An example is legislating to make
all enclosed public places smoke-free. But the government has
not taken these fully on board. They have made moves in the right
direction, but not acted with full conviction.
V. During the consultation process, more
than once, the health secretary made clear his discomfort at the
suggestion of an outright ban of smoking in the workplace. It
served to limit a wider public political debate about liberties
in relation to smoking. The overriding aim of the government seemed
to be about not alienating important political constituencies.
The subsequent political decision for partial measures with a
very long implementation period overruled clear advice from the
chief medical officer, expert task groups, scientific evidence,
the lobbying of all health organisations, and the majority of
the public.
VI. The proposals on smoke-free public places
are unworkable, will not achieve the benefits that comprehensive
smoke-free legislation would bring and would be extremely difficult
and divisive to implement.
VII. While the tone of the white paper is
that the proposals reflect a mature balance between the protection
of individual and social liberties, the decision to introduce
a partial ban on smoking exposes policy that disregards an extensive
evidence base that should underpin the public health ethos of
the government.
Proposals are too focused on health service delivery
VIII. A further concern with the proposals
is that they are too focused on health service delivery.
IX. The need for effective cross-department
proposals was a key theme of the responses the government received
during the consultation process. It is widely accepted that the
health of an individual has a myriad of influences, not all of
which are within their control. Income, diet, access to playing
fields, quality of housing and family relationships are all key
influences. Securing good health for all members of society will
mean coordinating policy across different departments to ensure
policy in one area does not undermine policy in another. Achieving
coordinated working on the ground between health, education, social
services and transport policy is a challenge which requires sustained
cross-departmental collaboration and development of synergistic
policies.
X. The White Paper mainly sees public health
from the individual's perspective in terms of helping to overcome
damaging behaviour and developing more tailored services. The
emphasis on the individual is positive and has been a missing
element of public health. Initiatives like the expert patient
programme have great potential. But an exclusively individual
focus runs the risk of missing the critical role of factors outside
the remit of the health department and concentrating too much
on individual behaviour and lifestyle.
XI. Obesity, for example, is not simply
a lifestyle problem that can be solved by allocating a personal
trainer, though this may help. It is a social issue with complex
influences. As the House of Commons Health Committee said in its
report on obesity last year, a strategic framework is needed that
is multifaceted and clearly targeted.
XII. The more traditional focus of public
health still has its merits—the examination of income and
unequal opportunities. The level of poverty is not something that
can be influenced solely by a reform of health services and has
an enormous influence on health status.
XIII. Poor people tend to live in less desirable
neighbourhoods where they have more unpleasant and fewer positive
environmental experiences. As Dr John Reid indicated during the
consultation, poor people are more likely to smoke. Poverty creates
stress, which cigarettes are still wrongly perceived to relieve.
XIV. The BMA is aware that income is not
the sole issue in combating public health inequalities and that
all individuals are variously unequal. However, the importance
of income in relation to health status cannot be ignored.
XV. Greater attention is needed on integrating
different policies across departments so that they reinforce one
another. Poverty diminishes choice and it adds insult to injury
if people are blamed for the choices they have not made because
they lacked the power to make them. Individuals can only make
choices when they are empowered to do so and that this is strongly
influenced by the physical, social and legislative environment
in which they live.
XVI. The causes of ill-health are complex
and there are some limitations in public health policy being located
within the Department of Health. The recent white paper suggests
to us that the government seeks to take public health ever closer
to healthcare and service delivery. In fact, to be effective,
public health must be multidimensional and cross departmental
boundaries.
2. Are the proposals appropriate, effective,
and do they provide good value for money?
I. The majority of proposals are appropriate,
but the BMA is concerned at the length of time it is taking to
develop action. The timetable is not appropriate: why are there
so many built in delays to taking action?
II. The comments below relate to the appropriateness
and effectiveness of different policies on smoking, sexual health
services, alcohol, diet and nutrition, exercise and school health
services.
Smoking
III. The government have justified their
partial ban by linking smoking to eating. There is no logic behind
protecting staff who work in a pub where food is prepared and
served and not those who work in drinking only pubs. Legislation
based on food preparation has important social consequences—in
separating pubs between drinking dens in which smoking is permitted
and others.
IV. The proposed system would be unworkable
and complex to implement. There is enormous scope for creating
loopholes when interpreting the proposals. The proposals create
incentives for pubs and breweries to bypass the proposed regulations,
for example to close kitchens, move them off-site or pre-package
food and meals so they do not contravene the regulations. Another
move might see the creation of private "clubs" which
would be exempt from the ban.
V. The BMA supports the private bill in
the House of Lords to end smoking in all workplaces in Liverpool
but urges the government to follow Scotland's example and introduce
legislation for a simple and comprehensive end to smoking in all
public places.
VI. The BMA was disappointed that further
duty increases on tobacco were ruled out. The BMA would also like
to have seen an agency created to regulate all tobacco and nicotine
products.
VII. The White Paper announces that the
Healthcare Commission will examine what action primary care trusts
(PCTs) are taking to reduce smoking by the end of 2005-06. All
the reviews announced in the white paper need to be held to task.
Sexual health
VIII. The £300 million to develop sexual
health services is very welcome. It is critically important that
quick access to genito-urinary medicine (GUM) clinics is restored,
action the BMA has consistently called for. Access to clinics
is woefully inadequate and services are desperately in need of
money.
IX. The government may see the private sector
having an important role in guaranteeing access to sexual health
services within 48 hours. While there may be an appropriate role
for the private sector in delivering services, offering sexual
health services in supermarkets is inappropriate. Sexual health
consultations usually involve confidential encounters for people.
It is not the same as visiting a pharmacist or opticians in a
supermarket. There are also potential conflicts of interest with
regard to where the staff will come from to deliver these services.
X. A key reason for the current crisis is
because the capacity for treatment is abysmally inadequate. Workload
at GUM clinics has increased by more than 50% over the last three
years yet opening times are sometimes limited to 21 hours a week—and
many services operate from portakabins. An important question
is how the new money to modernise services is going to be spent
to rectify the problems.
XI. Will new money be targeted at the chronic
underinvestment in the clinics that diagnose and treat people
with STIs? The British Association for Sexual Health and HIV estimate
that a third of the money allocated to PCTs is not getting through
to clinics and they are spending the money on alternative priorities.
Will this money be ring-fenced to ensure that it is spent on sexual
health services? How will this be monitored? The aim of improving
access to sexual health services should be added to the key performance
goals of the NHS.
XII. Because the proposed new sexual health
media campaign will happen significantly earlier than the additional
funding for GUM services and a high profile campaign is to follow,
demand will increase still further. The funding to enable them
to increase their capacity must happen sooner rather than later
and before further demand is created and expectations are raised
that cannot be met.
Alcohol
XIII. Action on alcohol is easily the weakest
part of the White Paper. The strongest measure is a pledge to
strengthen the policing of licensed premises to prevent sales
to underage drinkers.
XIV. The strongest initiatives relate to
the anti-social aspects of excess consumption in relation to anti-social
behaviour. While all the attention is at the extreme end there
is little focus on promoting alcohol as a mainstream public health
campaign. There is a need to mainstream the alcohol initiatives
and not focus only on anti-social behaviour and criminal elements.
XV. As the measures focus on excess consumption,
other drinkers may take refuge in a sense that they are not the
ones information campaign are speaking to. It is good that moves
are being made to label unit consumption on products, but there
is also a need to update the measurement of alcoholic units and
public understanding of safe drinking. The measurement of units
is complicated and cumbersome. A clearer definition of units needs
to be developed as part of a mainstream campaign on the effects
of excess alcohol consumption. The allocation of units to different
types of drinks is based on 1985 data and some drinks are now
stronger. A pint of Stella, for example, is three units. Wine
is served in larger glass than in the past and it is generally
stronger, around 13% as opposed to the assumption of 8.5%.
XVI. The dangers of alcohol and the paucity
of measures to tackle its effects mean that radical measures are
required. In 2002 the Health Development Agency considered the
evidence and concluded that only pricing and tax measures could
reduce alcohol intake. The government should be pressed to examine
the experience of the Soviet Union, Sweden and other Scandinavian
countries where drinks are priced according to alcohol content.
XVII. The white paper promises to work with
the drinks-industry funded Portman Group to develop better information
on products. Why isn't the government aiming to work with a variety
of bodies? Why solely the industry?
XVIII. The paper sets in place a number
of reviews that will inform future strategy after the publication
of the implementation plan. There is one on the provision of alcohol
services that will be undertaken by the Audit Commission. It is
important the government is held to task and incorporates findings
into changes in policy.
Diet and nutrition
XIX. The BMA was pleased by the commitment
to more clearly label food. The proposed traffic light system
is a good starting point on which to build. Action is very welcome.
The coding system will help people to understand the differences
between products. It may help people to make better choices. The
BMA will press to improve the sophistication of the system and
the quality of the information it presents.
XX. There is a need to monitor whether the
voluntary code that relies on food manufacturers to comply with
various government targets—for example on maximum levels
of salt—proves to be effective and timely.
XXI. It is important to monitor the Food
Standards Agency's "food and health action plan".
XXII. There are some in-built time limits
to implementation. The White Paper says that if by 2007 the strategy
to influence food advertising fails to make an impact, "we
will take action". The industry has been given three years
to change. There is no detail on the threats that the producers
face or on the framework by which various discussions with the
food industry will be shaped.
XXIII. The White Paper discusses pricing
as a mechanism to improve the consumption of healthier food. This
is a commendable aim. How can it be realised? Can some specific
action be taken to aid access to healthier food to the most economically
deprived?
Exercise
XXIV. When presenting the white paper to
Parliament the Health Secretary said he had taken action to "strengthen
the protection for school playing fields". It is very weak
action, which offers guidance to schools that fields should only
be sold as a last resort and that proceeds from sales should be
invested in activities that will contribute to health.
XXV. In the days after the publication of
the White Paper there were press headlines saying that the government
would ensure children experienced four hours of PE, sports and
exercise in each school week. While this is very welcome, such
initiatives tend to slip as another priority is introduced. The
BMA will want to monitor its implementation and the extent to
which it is sustained.
School health services
XXVI. The BMA would like to see a strengthening
of school health services and a more central role for health in
the school curriculum and policies.
XXVII. Some measures to strengthen school
services seem to lack the backing they will need. The proposal
to have one school nurse per cluster of schools by 2010 seems
to lack ambition. If a "cluster" covers a PCT and PCTs
merge, nurses will cover impossibly large areas. How can one person
lead the scale of change required?
XXVIII. It is often difficult for schools
to set schemes in place, such as the free fruit scheme, because
of bureaucratic obstacles. Headteacher groups should be supported
in examining their schools' public health roles and ways to further
develop health in schools.
XXIX. It also important that, with young
people being set as a priority group, policy does not ignore the
public health needs of other groups.
Value for money
XXX. The Chief Medical Officer has estimated
that going smoke-free would lead to a net benefit to the economy
of £2.3-£2.7 billion annually, equivalent to treating
1.3-1.5 million patients on waiting lists. The CMO also projects
a decline in smoking rates of 4% which would lead to additional
savings for the NHS.
XXXI. A strategy that was able to reduce
alcohol abuse would also make significant savings. Recent work
from the Cabinet Office suggested a culture of binge drinking
is costing the country £20 billion a year, with 17 million
working days being lost to hangovers and drink-related illnesses.
The cost to the NHS is estimated to be in the region of £1.7
billion.
XXXII. Money is crucial to the effective
implementation of the plans outlined above. Overall, the white
paper "envisages" an investment of £1 billion over
the next three years. It is not easy to disentangle this money.
Some is new—money for school nurses and to modernise sexual
health services—but much of it is already in the system
and will require PCTs to spend in new ways.
XXXIII. The BMA worries that PCTs may withdraw
some service to support the introduction of others, which could
undermine the overall strategy. They might, for example, stop
funding intermediate care in favour of initiatives to encourage
self-care.
XXXIV. The BMA is pleased to see the acknowledgement
that more money will be needed for local authorities to undertake
shared responsibilities. Under the "new burdens doctrine",
the Department of Health will discuss with the Local Government
Association exactly how much money councils need to fund major
new joint-working projects with PCTs.
3. Do the necessary public health infrastructure
and mechanisms exist to ensure proposals will be implemented and
goals achieved?
I. Whether public health goals are met essentially
depends upon the infrastructure and mechanisms to translate proposals
into effective and sustainable action. The time has come to put
in place mechanisms to take forward proposals in a coordinated
fashion while monitoring their effectiveness and considering alternative
approaches.
National strategies
II. The BMA was very pleased to see the
promise of health impact assessments being undertaken on policy
proposals across government and by the announcement of investment
on research to improve our knowledge of public health, which will
help regional authorities to begin to develop population profiles.
III. The acknowledgement that the public
trust information from professionals much more than anything that
comes from government is welcome as is the formation of an agency—the
Health and Information and Intelligence Task Force—to gather
public health information, provide data and tackle the weaknesses
in data. They will report to the government every six months on
key indicators. This approach sounds positive. The BMA will wait
to see what the key indicators will be and how they will be gauged.
IV. The BMA also notes that NICE will receive
increased funding to expand its remit into public health. An executive
director for health improvement will be appointed.
V. How will these organisations work together
and their functions be split? Will the Health and Information
and Intelligence Task Force be part of NICE?
VI. A sophisticated public health information
approach is needed that can match resources with changing social
need. An agency is needed to help maintain a wide perspective
on public health goals and whether they are being achieved. It
would collate information and report to government. It would help
support regional centres by developing information systems and
coordinating analysis of policy effectiveness.
VII. Most public health interventions are
instituted in complex environments with many confounding influences.
There is a need to develop research tools for assessment that
do not simply transfer the tools used in controlled environments
such as drug trials. For example, we need methods to combine qualitative
and quantitative data and to develop more rigorous decision and
impact analysis. We need to examine the way measures interact
instead of trying to isolate them.
VIII. An independent assessment of public
health should be carried out and published annually.
IX. It is not only the information strategy
that needs attention. There are also major challenges in moving
the NHS to a health rather than a sickness service. Better managing
the care of those with long-term conditions and preventing costly
and needless hospital admission will require close working across
health and social services. All the key long-term aims set out
in the White Paper depend on effective cross boundary working.
In some areas the White Paper suggests professionals should work
as groups formed around groups of clients, such as children, and
lead to new organisational models. This is interesting but we
worry that there are no worked through models of how these will
work in practice.
X. An implementation plan is due soon with,
presumably, an implementation team. If real progress is to be
made on public health, this team should be used as the basis for
developing an infrastructure for public health that is independent
of the Department of Health.
Developing the workforce
XI. The BMA welcomes the idea to establish
a Health Improvement Workforce Steering Group which can stimulate
action.
XII. There is a lot to be done. There are
four aspects of the workforce that the government need to guide
carefully: (a) developing the capacity for public health expertise,
(b) supporting occupational health, (c) developing new roles,
such as community matrons and personal health trainers and most
importantly (d) how they work with primary care teams.
XIII. The White Paper expresses a will to
attract more public health trainees but does not outline how.
As a matter of urgency the government should increase public health
training places and the number of posts for this specialty.
XIV. There is an aim to have 3,000 community
matrons by 2008. Public health will become a core part of staff
induction. It will become part of the competency framework in
Agenda for Change and the Modernising Medical Careers initiative.
It will be strengthened in the medical undergraduate curriculum.
XV. Personal trainers are a catch-all new
role. They will work under the direction of community matrons
and help people to give up smoking, formulate exercise plans,
eat healthily and better deal with stress. There are some obvious
questions about this new role: how will personal trainers be recruited,
trained and deployed? What will be their working relationship
with other professionals? Will they be seeking to motivate or
inform patients? How will they support them? Where will they be
based? How much face to face time will they give to clients? Will
poorer patients have financial help to access facilities?
XVI. More thought is needed on how to develop
leadership for the development of the public health workforce.
Explore ways to support effective cross-boundary
working across government policy
XVII. The BMA is pleased to see proposals
to strengthen school health services because of the potential
to bring together health promotion, discussion of behaviour, the
assessment of individual needs, and to make health a key part
of the curriculum. Schools are places where it is possible to
bring together different elements of public health in practice.
School nurses, dieticians, psychologists and health promotion
experts can align their work plans.
XVIII. The BMA is also pleased to see ideas
set out for local public health partnerships between local authorities,
PCTs and other key bodies.
XIX. The details of how these might develop
in practice are very sketchy. Working out the practicalities of
this is essential because so much of policy, such as children's
trusts, represent complex organisational ambitions that have yet
to be put in place. In the case of school nurses, only one per
PCT is promised. They will have a lot of ground to cover. If,
as rumoured, PCTs begin to merge then they will have to monitor
an even larger area. The BMA is not convinced the staffing levels
proposed can achieve the policy proposals set out.
XX. More radical thinking is needed on how
health and local government agencies and authorities bring their
work together on the ground, around children, the elderly, and
drug users. A client-based focus would help them coordinate services.
A public health profile of local populations would also provide
a tool for agencies to coordinate their work.
XXI. The BMA would like to see public health
targets added to the key performance goals of strategic health
authorities and local authorities who should work together to
discharge joint goals.
Local strategies
XXII. While an overview of public health
demands a national approach, it is important that there are strategies
at different levels, and that these are joined-up. The BMA is
concerned about the strategic capacity for public health at local
level and particularly within primary care trusts. There is a
great deficit in public health operational capacity. The public
health function is split between regional offices, strategic health
authorities and primary care trusts. Public health practitioners
feel isolated and fragmented, struggling to keep public health
on the agenda.
XXIII. The BMA believes that local government
can have an important role in all three of the areas critical
to effective public health policy: (a) health improvement, (b)
health protection, (c) the planning of population based services
to improve health. Different localities have different needs.
XXIV. Local partnership boards are a good
idea but a lot of thought needs to go into how they are established.
The threads holding the two sectors seem fragile. The document
says that strategic health authorities with specialist public
health skills have the key role in holding the ring between different
partners. Regional directors of public health will have new responsibilities
for ensuring that performance improvement information on cross-government
agendas is acted upon. Local directors of public health will liaise
with local authorities.
CONCLUSION
The BMA welcomes the Select Committees inquiry
in this area.
The BMA is a passionate supporter of public
health initiatives. Over the last few years there has been consistent
debate on how best to employ a public health perspective. There
is a raft of analysis and we now know what needs to be done. Now
is the time for evidence-based action and to reflect upon the
initial proposals for a public health strategy and a plan of action.
This must happen now when public health is currently high on the
political agenda.
February 2005
143 Recent reports include: Healthcare in a rural
setting (2005), Smoking and reproductive life (2004), Adolescent
health (2003), Health and ageing (2003), Housing and Health (2003),
Towards smoke free public places (2002). Back
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