HC 1048-III Health CommitteeWritten evidence from the Transport and Health Study Group (PH 173)

1. The Transport and Health Study Group is a scientific society of health and transport professionals studying the relationship between health and transport and promoting consequential policies.

2. Founded over 20 years ago in the UK we are now expanding internationally with a European Committee alongside our UK-based Executive Committee.

3. We believe we are the only public health society constituted on an interdisciplinary basis for another discipline to study, together with public health, the health implications of the work of that partner discipline. In June a similar organisation is to be launched in spatial planning.

4. We give evidence since societies such as ours could play an important role.

5. There could be scope to establish similar bodies in fields like marketing, economics, food and agriculture, housing, welfare, crime and disorder, human relations, education, community development, youth work, culture and media, public finance and probably others.

6. In our evidence we

explain the role of transport in health (scientific references can be found in our e-book Health on the Move 2);

discuss how societies like ours could contribute and the implications for Public Health England and the role of the Secretary of State;

support, in that context, the BMA proposal that each Government department should have a Public Health Director;

discuss the role of Parliament in public health, even though this is not within the specific scope of the enquiry;

discuss, from our own experience, the role of DH and the Attorney General’s office in litigation to protect the public health;

assert. using transport as a case study for local government involvement in the wider determinants of health, that;

DPHs must have status across the whole of the local authority and be professionally independent;

the Health and Well Being Strategy must influence other strategic documents (in our case the Local Transport Plan);

there is a role for district councils, supra-upper-tier authorities and parish councils;

discuss the contribution societies such as ours can make to training and the way professionals from partner disciplines can form part of the public health workforce;

discuss, using transport funding as a case study;

the problem of ring fencing only NHS public health funding; and

the scope for innovative financial approaches involving benefit-capture.

The Health Implications of Transport

7. We have described the links between transport and health in our recently published e-book, Health on the Move 2 available at www.transportandhealth.org.uk

8. Briefly they are as follows.

9. Obesity results from imbalance between food intake and energy output. Physical activity is important - the evidence that physical activity has declined during the epidemic is stronger than the evidence that calorie intake has increased. A major component is the decline in walking and cycling. As walking and cycling is easily incorporated into everyday life it forms a significant part of an obesity strategy. Healthy transport policy would promote walking for journeys under a mile, cycling for journeys of up to five miles and the train/cycle combination for longer journeys.

10. Powerful scientific evidence shows the importance of social networking to health, so much so that the Alameda County study found a three fold difference in all causes mortality between the least-supported and most-supported groups, and McKee found that areas where more than 46% of the population were members of clubs and societies escaped the ravages of the Eastern European alcohol epidemic resulting from the decline of the Soviet Union. Therefore the finding by Hart in Bristol, replicating earlier work by Appleyard & Lintell in San Francisco, that people have fewer friends if their streets are heavily trafficked raises far ranging questions about the role motor traffic has played in deteriorating community spirit. Healthy transport policy would restrict traffic flow in residential streets and give priority to community use.

11. Speed is important. Kinetic energy rises with the square of the speed. Healthy transport policy would reduce speed limits and require the fitting of speed governors.

12. Vehicle exhaust emissions contribute to asthma, cancers and climate change.

13. Other issues include transport for disabled people, transport crashes, access to health-promoting services (including the countryside, other opportunities for physically active recreation, and shops stocking cheap healthy food), encouragement of safer transport systems such as rail, the contribution of transport poverty to health, rural deprivation and traffic education.

Public Health England and the Role of the Secretary of State

14. The Secretary of State should represent health across Government. The above issues should be high on the agenda for DH relations with DfT.

15. Societies such as ours should be invaluable eyes and ears for the Secretary of State and PHE should support them.

16. Some years ago we applied to DH for funding of administrative support to our group and received indirectly ongoing support of one day a week of an Agenda for Change band 5 worker. That’s the only support we have ever received although we have repeatedly outlined services that we could provide if we were managed more substantially instead of being dependent on the time our members can squeeze into busy day jobs—or, more frequently, their own spare time. A Secretariat supporting various organisations like ours, promoting new ones and linking them to DH could contribute to central public health infrastructure.

17. DfT has shown more interest in transport and health than DH and includes it in briefing papers for the Local Transport Plans. Without an established mechanism to capitalise on that, DH misses many opportunities.

18. Things may change with the establishment of Public Health England. However the separation within DH structures of PHE, Policy and CMO suggests that the vision of a single public health body has already been undermined and the role of PHE as a civil service body does not command confidence in its role as a more open body. Indeed Public Health England seems to be much more limited in its scope than we had hoped, sometimes seeming to be little more than the taking in house of the HPA.

Public Health Directors in Government Departments

19. We support the BMA proposal for a Public Health Director in each Government department (using the term “Public Health Director” for posts which serve an agency and confining the term “Director of Public Health” to posts which serve a population.)

20. No Government department would function without a high level link to the Treasury. The same should be true for Health.

21. We congratulate DfT on attempting this through overhauling its own Chief Medical Officer post. This has been less successful than hoped because

The post was too junior. Although the individual recruited was quite capable of working at a more senior level, the status of the post seems to have constrained its potential.

It did not have professional support from CMO’s office in DH.

Civil service roles prevented an open professional dialogue with the public health specialty.

Rigid tendering rules prevented full use of expertise in the field for important tasks.

The agenda was set by DfT itself rather than by a public health needs assessment.

22. This pilot experience allows lessons to be learned in going forward. We believe that these posts should:

exist in all departments;

be appointed at Director or Director General level;

be supported from PHE;

be professionally led by the Chief Medical Officer who should approve their agendas;

write an annual independent report on the contribution their department has made to the health of the people;

be appointed on contracts, such as NHS consultant contracts, which permit participation in a free professional interchange of ideas; and

be able to make use of, and engage in mutual support with, sources of expertise in the field.

The Role of Parliament

23. The promotion of walking and cycling is central to the response to obesity.

24. Which Select Committee is responsible—Transport because it is a transport policy or Health because it is health strategy? What actually happens is that it falls between two stools.

Litigation for Protection of Public Health

25. We were involved in 2003 in litigation for judicial review of a railway closure decision, the Oldham Loop Line. The line was being closed for conversion to a tramway. The Directors of Public Health for Greater Manchester were co-claimants.

26. Replacing the stopping service on the line with trams was uncontentious. We had good working relationships with the Greater Manchester Passenger Transport Executive which initiated this plan and have excellent relationships still with their successor body Transport for Greater Manchester. The closure however was carried out by the National Rail Authority and it is here that the problem arose.

27. From our standpoint, we said the line should remain open for use by heavy rail trains to retain the fast train service. This was part of an ongoing policy of ours that the prohibition on mixing light and heavy rail on the same track was risk averse, and on balance damaging to health because of its restraining effect on rail development. We (and others) had succeeded a few years previously in persuading the Railways Inspectorate of this but the Minister was wrongly advised that the old policy still applied. We were deeply concerned that such a state of ignorance about railway operation could exist within the body responsible for rail franchising. The PTE had a good reason for not doing this (the cost of resignalling) but we didn’t know that and it was never mentioned at any time in the closure process nor was it mentioned in response to our litigation.

28. From the standpoint of the DPHs the issue was that they had given public health advice that part of the line be converted in such a way that it could easily be turned into mixed use if demand developed for freight. This advice had been ignored on the technical grounds that only passenger services were relevant to railway closure proposals. The issue therefore was failure to include public health advice amongst the issues weighed in the balance.

29. DH and the Attorney General’s office were unhelpful. The DPHs were officers of the Crown bringing the action in the public interest but Treasury Solicitors saw it as their role to defend the decision, by seeking to strike the case out on the grounds that the claimants were not juristic persons and also by threatening to incur substantial costs. We responded by applying for an order to limit costs. The DPHs proposed that as the dispute was between two emanations of the Crown the Attorney-General should arbitrate and we consented to withdraw from the action if this course of action was agreed between the two Crown parties but the proposal was ignored.

30. In the end common sense broke out in Greater Manchester. The PTE (which had not been involved in carrying out the closure process) agreed to receive and consider the public health advice and the case was discontinued. In the discussions which resulted the PTE accepted the advice about the northern part of the line and gave us the sensible and entirely acceptable explanation as to why mixed use was unviable.

31. A number of issues arise from these events but the following are relevant to your enquiry.

There is no statutory duty on public bodies to take public health advice into account.

There is no support for DPHs in processes of this kind. Whilst the pursuit of legal proceedings in the High Court would be highly unusual, participation in, for example, planning processes should be more routine. Some form of legal support is needed.

The legal status of DPHs in such processes is in doubt. Since this point was raised the BMA (which provided almost half the funding of the case) has suggested that the office of Director of Public Health should statutorily be granted corporation sole status. In this capacity, which would be separate from its role as an officer of an authority, it should be an NHS body. Although initially advanced by the BMA only as a technical solution to this technical legal problem it could potentially have other benefits as well.

The Attorney-General’s office thinks issues of this kind lie outwith its remit. Actions taken by officers of the Crown in the public interest should be very much in its remit.

Transport as a Wider Determinant of Health for Local Government Action

The DPH Must Act Across the Council

32. In a local authority, the Director of Public Health will see walking and cycling provision as the highest priority for the highways budget but the Borough Engineer may see it as a much lower priority. How does that conflict play out?

33. This example from our own field will be matched by similar examples elsewhere—density of housing against protection of open space, quality of work against growth at all costs etc

34. Ultimately such judgments must be made by elected members. But whose voice is heard round the management table? Who has the right to put their view to elected members? Who has the right to place their view in the public domain?

35. Directors of Public Health must have access to the highest level of management, an acknowledged role in challenge, and a right to access to elected members or full Council. There are other officers of the Council who have this right enshrined in statute. It should be true of the DPH as well.

The Health and Well Being Strategy and other strategic documents

36. A survey has suggested most Health and Well Being Strategies will not address transport. We find it hard to understand how a strategy can discuss obesity (as it must) yet ignore active travel.

37. If it does address this issue, what is the relationship of the strategy to the Local Transport Plan?

38. If the strategy is written independently of other strategic documents and then takes second place to them, it will be at risk of being set at nought by decisions made in the commissioning strategies of GP consortia, the business plans of NHS providers and a number of local government strategies that impact upon health.

39. The Health and Well Being Board must have powers to require compliance with the strategy in the health and social care field and at the very least a high level of attention to it in other fields.

District Councils in Two Tier Areas

40. District councils in county council areas have important functions relevant to public health, not least housing and environmental health. They are close to local communities and are best placed to bring about cultural change, including change related to walking and cycling and the communal use of streets.

41. Each such council needs its own dedicated public health adviser with the same role that a DPH has in an upper tier authority. It could have

its own DPH;

a designated Deputy DPH seconded from the public health department of the County Council; or

its Director of Environmental Health may take on an expanded role.

Supra-Upper-Tier Authorities

42. The Mayor of London, the Combined Authorities in city-regions, the Joint Boards of metropolitan counties and the police commissioners of large constabularies all have significant powers relevant to public health. These include the transport powers of the Mayor of London, the Combined Authorities and the metropolitan Passenger Transport Authorities.

43. They need public health advice, which could come from

a Public Health Director appointed to a specific authority;

a DPH appointed to serve the population of a metropolitan county or city-region or Greater London; and

a lead DPH drawn from a collective of the DPHs of the county.

Parish Councils

44. Parish councils are close to local communities. They have responsibility for footpaths.

45. It would be silly to suggest that they should have their own public health specialist, but a local GP or health visitor could act as their health adviser.

Workforce

46. Issues like the health impact of transport and spatial planning must be included in the academic curriculum of public health training and of partner disciplines.

47. One way to provide public health trainees with experience of the wider determinants of health is to place them with organisations like ourselves.

48. Some of the members of our society from a transport background are well placed to contribute to the public health workforce.

49. There is a dilemma here. Retention of the medical specialty structure (albeit with non-medical entrants) and consultant status is essential for the standing of public health in the NHS and also for avoiding local authorities sidelining the public health challenge process by appointing unqualified people. Without registration of non-medical specialists there is a danger that local authorities would appoint doctors as the DPH (for their professional standing in the NHS) and then appoint non-medical people to other jobs, re-establishing the medical/nonmedical divide. On the other hand too rigid a structure would produce a divide between the specialist and non-specialist workforce, would be severely unfair to some individuals and would block career advance for much of the present workforce.

50. The solution is to retain the specialty structure but to develop flexible pathways to specialist status.

Funding

51. Only the NHS contribution to public health funding will enjoy the protection of NHS status in the public spending plans or be ring fenced in the local authority. Some extremely important public health programmes lie outside that protection. Walking and cycling is an example.

52. Health on the Move 2 advocates substantial infrastructure investment including new international high speed rail networks, new integrated public transport networks, new walking and cycling networks and new high speed broadband investment. Section 20.7 of the book discusses the scope for innovative financial approaches involving benefit-capture. This is an approach which may have wider potential eg in financing alcohol preventive programmes that are ultimately funded by NHS savings.

June 2011

Prepared 28th November 2011