Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 1-19)

23 FEBRUARY 2005


  Q1 Chairman: Colleagues, could I welcome you to this session of the Committee on the Government's Public Health White Paper (Cm 6374) and a particular welcome, Secretary of State, to yourself and your colleagues. We are very pleased to see you here again. Would you like to each briefly introduce yourselves to the Committee and then I know, Secretary of State, you want to make a brief opening statement.

  Dr Reid: Perhaps I could do the introductions then. This is Dr Fiona Adshead, who is the Deputy Chief Medical Officer, and Melanie Johnson, who is a Minister in the Department, Chairman, both of whom, I have to say, were central (I think more central than myself) to the publication and the work behind the White Paper. You rightly said that any introduction content should be very brief indeed, and I will be. Basically I just want to say that for many, many years we had had discussions about the outcomes we wanted to see in public health, so the consultation and the White Paper is not about the outcomes we want to see. We know that we want people to do a little more exercise, to give up smoking, to avoid obesity, and so on. It was more about how we achieve it, and in particular how we get the balance between encouraging people to live healthy lives and get healthy outcomes and the balance of freedoms that people have to live their own lives. That really was a large part of the consultation. I think that the White Paper consultation we carried out showed a couple of things very, very clearly indeed. The first was that people did not want us dictating to them how they lived their lives and that came through very strongly. On the other hand, they did want three things, I think. First of all, they wanted advice and support to help them make their own decisions, particularly in terms of information. Secondly, they wanted where possible the resources to back them up in implementing the healthy decisions that they made. Thirdly, they wanted protection from the unhealthy decisions of other people, if you like, in the case of smoking for example, and in particular for children. So that is the context in which we published the White Paper and that, as briefly as I can, sets the balance we tried to achieve in the White Paper, Chairman.

  Q2 Chairman: Thank you very much. I think it is appropriate to place on record, as I did in the obesity debate two weeks ago, our appreciation as a Committee that the Government has listened to a number of the points that we have made on public health and we appreciate that. Can I begin by asking a question basically about the overall period that the current Government has been in power and my impression very early on was that we, for the first time in many years, as a government took public health seriously. We saw a range of initiatives which were very welcome. Health Action Zones, for example, impacted on areas such as my own in a very positive way. Then I gained the impression that somehow the public health agenda went off the boil, probably towards the end of the last Parliament. Early on in this Parliament we got into debates around targets and waiting lists. There is nothing wrong with that, but it took us away from mainstream public health. We got into debates around Foundation Trusts and we got into debates around choice, basically looking at the acute sector and how people use the acute sector. What guarantees have we got now that public health arising from the White Paper will remain in the mainstream, in the engine room of your health policy?

  Dr Reid: I do not think that is an unfair characterisation of the chronology as it happened, because there was a White Paper. Tessa Jowell was heavily involved in it, for instance. But I think certainly when I came in, just less than two years ago, I saw a sequence of things as being necessary to be done. The first was to build up and to continue to build up a huge capacity in the NHS to make up for the years of under-investment. Then it was to introduce the degree of not quantity but quality, and that is where we got into the controversial areas, Foundation Trusts, and so on. But once we had caught up with where we ought to be, or got nearly to where we ought to be, we then had to look forward and to prevent so many people becoming ill and putting such a drain on the health service. So it was not just a good thing to do, it was a timely thing to do and in fact a necessitous thing to do. That is the first reason why public health will stay in the agenda because we are putting in the biggest ever increases in health in the history of the NHS over the longest period and quite frankly I do not think anyone can reasonably expect that to go on after 2008. There may be increases but they will not be to this extent. Therefore, as Wanless (among others) has pointed out, it is necessary for us to pay more attention to public health, to reducing the need to treat sickness through the public health work. The second reason why I think it will stay in the agenda—provided always that this Government is re-elected, Chairman—is that we are now committed publicly not only to a whole range of general aspirations but to very specific 170 recommendations and very soon the delivery plan, which we will publish, and that will be a public commitment by the Government. That will be impossible, even if the Government wanted to, to withdraw from. So there are good pressures both in terms of circumstance and in terms of our commitment.

  Q3 Chairman: One of the problems in politics is that we politicians tend to have short-term goals, inevitably, because we are tied to a four or five year parliamentary cycle and the General Election. How do you see it being possible within the political environment that we all operate in to ensure that public health becomes as big a player in the political ball game as hospitals, doctors, nurses, or waiting lists, because clearly any public health measure which you are taking now may impact in a minimum of 10, 20 or 30 years' time in a way which could possibly (but may not) reflect better on a government of a different party? I have always found this a major dilemma politically, in that public health does not have any real immediate short-terms gains, it is the long-term gain, and us politicians tend to work primarily in the short-term. What can we do about shifting that point?

  Dr Reid: First of all, I think in terms of importance health consistently is the most important issue in all opinion polls. Occasionally the economy goes above it or drops below it, occasionally law and order goes above it or comes below, but if you look at the last couple of years health is always at the top. So it is top of people's agenda and it is changing in the nature of concerns about health. You only need to look at magazines, newspapers, and so on. There is far more discussion on what we call public health issues now—exercise, diet, and so on—than there ever was before. So it is there in the public's agenda. The second thing is that I do think, and perhaps this is immodest, that this Government has taken a longer term view of certain important issues than perhaps previous governments. The truth is that we would not be able to put money into the health service, for instance, unless we had taken a long-term view of the economy because for the first two or three years we reduced debt and we reduced unemployment and people were saying, "Spend the money now." We said, "No, we will spend it on reducing debt and reducing unemployment because thereafter in the long-term we will be able to sustain big increases on the health side." I think exactly the same is true of health, and Wanless points that out. If we want to maintain a health service at a good, high level of quality and fast access to people in this country we will have to do two things apart from investing in the health service. The first thing is to shift as much as possible from secondary acute care through to primary and do it in the community, and even before that to stop people having to go to primary or secondary through good public health programmes. So the seed corn of the future of having an effective NHS and funding it is to have an effective public health policy where we lay the seeds now and we will get the benefits, hopefully, in five, 10, 15, 20 years' time. That is why, for instance, we bring in fresh fruit for kids at school. That is not going to yield any benefits for the country, though it will for those children in the next three or four years. But over five, ten, fifteen, twenty years kids who are used to eating fruit rather than chocolate all the time will be a huge boon for the country.

  Q4 Chairman: In a couple of months' time, possibly, I may be sitting at home with my feet up watching you guys racing around like idiots fighting a General Election! What guarantee are you going to give me today, without betraying any secrets, that when I am watching the television and the debates between you and whoever from the other parties on health the real issues you are going to be talking about are public health and not solely hospital waiting lists or hospital building programmes? They are very important, I accept that, but what I am saying to you is, are you going to shift this agenda in a way in which in a General Election public health is going to become a sexy political issue in a way in which it has not been for a long, long time?

  Dr Reid: I think we have already done that. I cannot remember in my lifetime so many debates and discussions on, say, exercise, fitness, obesity, smoking, drinking, as we have had in the past three or four years in this country. I genuinely think it is at the top of the agenda and I think it will continue there. Even if you were sitting at home with your feet up—which I doubt very much, knowing your proclivities and your energies, Chairman—I will bet that you will have a pedometer on your belt to remind you to go out and do a bit of walking. Even if you do not have that, you will recall that on the television set you are watching there will be an NHS digital programme which will be largely dedicated to advice on health, and next to you will be a telephone where you will think of calling up Health Direct, which we are bringing in, other than NHS Direct. You will then get a whole series of magazines which we are producing, which are largely (though not exclusively) targeted on public health issues, at younger men, at younger women, and so on. So the agenda that we are setting even at this early stage, I think, is to ingrain a recognition of the need to have instruments which constantly bring to people's attention the benefits of healthy living—without nannying people—protecting those who have to be protected against the irresponsible healthy attitudes (as some would regard them) of others, protecting children in particular, but making sure through the telephone, through the health trainers which we are bringing in in the community and the education programme—which we can speak about because we want to turn all 1.3 million people in the health service into people who recognise public health rather than just treat the sickness. So if you come in, for instance, to accident and emergency they will not just treat your broken leg but if they know it is the third time you have been in in the last year and you have got drink on your breath, without being over-intrusive people may be able to say, "Do you need any help in another direction apart from your broken leg?" So I think we are going to ingrain that sort of thing.

  Q5 Chairman: So there is hope for all of us?

  Dr Reid: Yes, and one other subject which I was making our views known on this morning in one newspaper is food labelling. We are all very busy people now and when you get off the couch and rush off to buy your food at the supermarket, at the moment unless you have got a PhD in biochemistry and all day, and 20/20 eyesight, you have no idea of the nutritional value of your food. I want to make absolutely certain that busy mums and dads, and even retired politicians, will be able to go to the supermarket and get a simplified form, easily available to them, which indicates the nutritional value of the food they are getting. I have read in certain quarters that we are backing off that. I have to disappoint whatever lobby thinks we are; we are not. I am open about the format. I do not care whether it is 1, 2, 3, or A, B, C, or the colours of the rainbow, but we are going to have food labelling for the people of this country and if we cannot get it voluntarily here then I have already opened discussions with the European Commissioner on it and we will be pursuing a European-wide measure on that. So public health is here to stay.

  Chairman: We will probably touch on that particular issue in a few moments. Jon.

  Q6 Mr Jones: Thank you, Chairman, and you are welcome to come down to Cardiff with your pedometer—as you are, Minister. I want to refer to the Wanless Report. Wanless asserts, Minister and Secretary of State, that better public health will save the National Health Service money. Do you agree with that assertion and do you agree with the spending projections, the different projections of potential savings which could be made according to Wanless?

  Dr Reid: I agree with the general point and I met, obviously, with Derek Wanless on this and as I indicated at the beginning, I do not think this is an add-on in terms of the future economies of health care in this country; it is an essential ingredient in making sure that we have got a sustainable long-term health care system. I would make one qualification for that: whatever we do in health, if we are successful it brings us bigger challenges because if we are successful people live longer in greater numbers and therefore have to be taken care of longer. Having said that, I do agree with Derek Wanless. The real question becomes, I suppose, to what extent you are willing to curtail people's freedom to have their own choices in life in order to reach the outcomes which give you not only the maximum health benefits but the maximum economic efficiency in the provision of health care. That is why I said at the beginning, Mr Owen Jones, that there is a balance between the two. But in general I agree with Derek Wanless.

  Q7 Mr Jones: You anticipate the next question. My next question is, in the scenarios that Sir Derek describes he describes the fully engaged scenario. A fully engaged scenario has a target, according to Sir Derek Wanless, of 17% of the general population smoking by 2010, which is the current level in California. You have rejected this target in favour of a less ambitious one. Other than enabling more choice, do you have any other reason for that?

  Dr Reid: The first thing to say is that some of the targets that we have put out Derek Wanless regarded as over-ambitious and some of the targets he thought were less ambitious than they ought to be, though more ambitious than the ones be criticised four or five years ago, particularly in the case of smoking. The fact of the matter is that I doubled the target reduction for smoking because we were going to reduce it originally down to 23%. I doubled that, and secondly I put a very important proviso in it which I think is as important as anything, and that is that reduction should apply to all social classes. That, to me, was as important as achieving a reduction, which was basically middle-class people giving up smoking. So contrary to what you may have read in the press, I want to make sure that right across social classes we get that reduction. Now, when you reach a decision as to how far you can go the important assumption which is built into the White Paper on all sorts of issues is that you cannot achieve and get towards what Derek Wanless in this country by direction. It is not acceptable to do it by direction because if you are going to achieve all of these targets by direction then you would not get to the stage where it was compatible with the sort of mature adult lifestyle and life choices which people in this country want. So where we introduced the target in smoking, it was what I thought was realistic to get it down to around 20%, which will have reduced from 48%. Other countries have taken a more stringent view on, if you like, the prohibitive side of things. In Scotland, for instance, they have decided to go for a complete ban on smoking. I came to the conclusion that that was not a good thing on health grounds, apart from anything else, because you get a displacement of smoking from some pubic areas to the home—and most of the evidence about passive smoking is about the home—but in any case if you look at the reduction we have had in England in smoking in recent years, the figure we are at now is higher than the reduction in Scotland. So it is a matter of getting a balance between what we felt was reasonably achievable—and not just in smoking but across a whole range of areas. The fully engaged scenario of Wanless would in some cases require a degree of government dictation to you about your life which is not acceptable in modern Britain, in my view.

  Q8 Chairman: Can I just intervene? We are going to talk about smoking in some detail later on, but just to clarify, you made the point that in Scotland you were concerned that banning smoking in pubs would displace it to the home. Have you got some substantial evidence to prove that, because certainly there are people who have put to us the alternative argument that many people who smoke do so only when they have a drink and if they did not smoke when they were drinking in a pub they would not smoke at home?

  Dr Reid: That is anecdotal when people tell you that, I am sure, because I speak with some considerable experience of smoking and drinking, if you do not mind me saying so. There are not that many people who endanger their lives hugely by smoking only when they go out to a pub and the truth of the matter is that we do not have a great deal of evidence on that because there are not that many places where we have had long-term prohibition of all smoking outside the home, but what we do know, for instance in Ireland and we would anticipate in Scotland, is that a %age of people who previously went to the pub to smoke will now get a carry-out and take it home. I think the %age in Ireland is about 15%. That is not the primary reason for reaching the decision I reached, Chairman. I reached my decision on smoking because I felt that we had achieved a balance between protecting the public who did not smoke and who wanted a smoke-free atmosphere—and the legislation was introduced to protect the public, not to force you to live a certain lifestyle because if we do that and force you to do that which remains legal we start on a whole series of questions like why should we allow you to box, or drink, or whatever and then still be treated on the health service. So the primary purpose for which I brought in the legislation was to protect people from the smoking of others, that is passive smoking, but in addition to that I am saying as an observation (it was not the primary reason why we did it) it is also my view that there will be a displacement if you allowed no smoking in any public place whatsoever. In our case we have got 90% of pubs and restaurants which will be non-smoking, but there will be some areas. So if you allow none whatsoever there will be a displacement (as in Ireland) from people who previously went to the pub who will take drink home. Now, I assume they will smoke at home and most of the passive evidence we have got on smoking is based on people who live with smokers. So that is a secondary point.

  Q9 Mr Jones: Can I come back, because this conversation you have just had with the Chairman illustrates one of the most important parts of the Wanless Report, which was not about specifying what we should do but specifying how we should do things and how we should make choices about what we do. Sir Derek Wanless stated that measures to improve public health should be based on considerations of evidence and cost-efficiency. In that discussion you were assuming that evidence from Scotland would show something—

  Dr Reid: But I think there is something missing from that quote. The decision about how you dictate to people about how they live their lives has to be based on more things than just evidence and efficiency, it has to be based—

  Q10 Mr Jones: If you will allow me, I am accepting the argument that we have to make this balance. I am only trying to explore a different argument about when you are balancing what works and what does not work you can take into account whether you should or should not do it for reasons of choice but you still need to have a sound evidential basis for deciding, does this work anyway? He expressed a dearth of evidence on the cost-effectiveness of many, many programmes. Do you accept that there is an argument that there often is not evidence?

  Dr Reid: I do not accept it on the main one because my memory is that, ironically the main one is that he did not think smoking cessation services—

  Q11 Mr Jones: No, no, forget smoking. I am not talking particularly about smoking.

  Dr Reid: That was his main one, as I remember. I will stand corrected. But on smoking cessation services, I believe they are very effective. I think we have got another 240,000 people in the last year who gave up smoking.

  Q12 Mr Jones: We will ask questions about smoking again, but I am just trying to ask you about the methodology, not—

  Dr Reid: I am giving you an answer. No, I do not accept his view that in some of these major areas on which we have based our proposals in the White Paper, including in areas where he thought there was insufficient evidence, we have not had the evidence. I do accept in the question the Chairman asked me about the future that I do not have the evidence on that, and that is why I made it plain it was not my primary purpose. I do think we should base it on evidence, that contention I agree with, but some of the conclusions he then reached about some of the services which were directed towards public health not being evidentially based I do not accept.

  Mr Jones: Let me give some specific examples, and I am going to move away from smoking. I am sure others will raise smoking questions later on. The Chairman quoted approval for Health Action Zones. I am not aware of the evidential basis or the cost-effective basis for Health Action Zones, and if there is a good evidential base and a cost-effective base then obviously we should be continuing with that.

  Chairman: Jon, can I just say I quoted the example of one constituency where I saw some very positive developments.

  Mr Jones: Anecdotal information.

  Chairman: Anecdotal, what I saw up in the schools. That is what made me feel that it was a positive initiative at the time.

  Q13 Mr Jones: Nevertheless, the point is there was an initiative, Health Action Zones, which does not exist any longer. I am not saying whether that was a good initiative or a bad initiative, but has the Department conducted any work to establish an evidential base and a cost-effective base for this? Did it work cost-effectively or did it not work cost-effectively?

  Dr Reid: The answer to that is—and I will try and wrap it all together—I agree with the challenge that these should be evidentially based. I disagree with some of the comments you made about specific areas. There are some areas on which we do not have evidence, and if you look at the White Paper what we propose, and certainly what we are doing, is evaluating evidence now. For instance, on drinking we are doing an audit of both treatment and identification of drinking. I would have liked to have gone further but in some areas there was not the evidence that we needed. In the case of Health Action Zones, which you mentioned, we are now carrying out an evaluation of the cost benefits of Health Action Zones.

  Q14 Mr Jones: Will the Committee be able to see that?

  Dr Reid: If I could take advice on when we would expect that.

  Miss Johnson: Ken Judge has carried out an evaluation of Health Action Zones for us and we could give you the information and the evaluation report within the next couple of weeks, I am sure.

  Q15 Mr Jones: Excellent! Can I turn to another initiative which, Secretary of State, you mentioned earlier, health trainers. Is there any evidence for the cost-effectiveness of health trainers?

  Dr Reid: Yes, the fact that lots of people spend lots of money on it.

  Q16 Mr Jones: That is not evidence for the cost-effectiveness.

  Dr Reid: Is it not?

  Q17 Mr Jones: It is evidence that people can be persuaded to spend a lot of money. There is a lot of things in the market that people spend a lot of money on which are not necessarily effective.

  Dr Reid: In health terms?

  Q18 Mr Jones: In health terms, yes.

  Dr Reid: Like what, for instance?

  Q19 Chairman: Cosmetic surgery?

  Dr Reid: That is not really down to health and we do not provide that on the NHS precisely for that reason. I say this in half-jest, Mr Owen Jones: most of the times that people pay money for in health is access to gyms, sports equipment, involvement in various sports (skiing, running, and so on) and in cases where they have sufficient money personal trainers to give them advice on training routines, and so on. Most of these things appear—and I do not have the statistical evidence in front of me to illustrate that this is intrinsically a good thing, but most of this seems to me a good thing. The evidence is being supplied to me from left stage even as we speak and if I was sufficiently educated to read very good writing I would be able to tell you. "Peer education works," it says here. So if you have a trainer it helps. Now, look, this is based on a very simple hypothesis which I think there are generations of evidence for, and that is if you want to live a healthy life and you have access to support, encouragement and information, you are more likely to sustain that healthy life than if you do not.

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