Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 340 - 359)



  340. It is interesting that you mention the health visitors, because we have discussed at some length the health visitors. I certainly recall working in Social Services, as you did, Mr Ransford, before 1974 when health visitors had a very important role in the community, and I have often asked, "Whatever happened to health visitors?" We actually discovered a few in this inquiry and it is interesting that you make that point. Going on to the issue of the medical model, one of the arguments that we have had put to us, relating not so much to the local organisation, but the national organisation, is that the location of the Public Health Minister in the Department of Health needs that public health function and is dominated by that model within the Department at national level. How do you each see the role of the Public Health Minister currently—I do not mean the person, I mean the actual function—to be located within the current Department, for argument's sake it ought to be a Cabinet position, free ranging across the departments rather than being located in one specific department, would you share those concerns and if so, what would be your ideal location for the Public Health Minister?
  (Cllr Stringfellow) I think just as much as it matters at local level that Government is joined-up, so it does at national level, and that the Public Health Minister has a very strong influence on colleagues across other departments. To some extent I think where the Public Health Minister is located should not matter if that is actually happening effectively, but we obviously do not know whether, perhaps, after the election there might be some change in the make-up of Government departments and there might be some opportunity, perhaps, to look at that in a slightly different way than we are able to do at the moment. I think what is important, and the LGA thinks is important, is that there is that capacity for joining-up and that there is an influence across all departments and that departments actually engage in the public health agenda. Maybe the bigger task is actually awareness raising around the importance of public health.
  (Mr Panter) From the Confederation's point of view I think that what we are learning to do within the NHS is increasingly becoming focused on outcomes and then putting the structures in place to deliver that outcome. So our concern would be that the Public Health Ministers needs to be in a position where the Government's outcome that they desire can be best delivered, but that is for the Government to decide where they can be delivered to achieve the outcomes that they want. Then it is reiterating the LGA's perspective about the joined-up nature.
  (Mr Town) I think only to add to that that in terms of the performance management of the way we tackle these public health issues, again, a joined-up approach which could be focused in on one minister would be very helpful to the Service.

Dr Brand

  341. Do you think it is helpful that that minister is always going to be subsidiary to the Secretary of State for Health, we are talking about resources as well? What are the priorities of the Secretary of State for Health, that is really the question?
  (Cllr Stringfellow) I would hope, Chair, that the Secretary of State for Health, indeed, does and would have a very strong view about the importance of public health. How that might happen in the future is difficult to predict, but that is the important point, not so much the status as the importance of the issue.

  342. I asked that question of Frank Dobson when he was Secretary of State for Health and he said he was the Secretary of State for the National Health Service. Now, that is an acute service. As in illustration of the medicalisation of the public health role, I think it is pretty negative to leave it under the Health Service. There is a problem which I think one of you has touched on which is that the public health role, 78 per cent is to do with the visionary joint working and influencing of other departments, but of course there is a very distinct element which is control of communicable diseases and immunisation policy and that sort of thing. Do you think that those two roles traditionally have gone together under a medical model is now stopping further progression? I have described it as the visionary verses the anorak function or directors of public health.
  (Mr Ransford) It is certainly why we submit that the medical model is very important, because, of course, there are essential functions for the health and safety of the public really which must be preserved. It does not necessarily mean that the same person or the same function has to do both things, as long as the links are explicit and clear. I suppose our experience is that so often the skills and the experience needed for the specific functions have dominated some of the visionary stuff which can only be done on a horizontal basis across communities, across services, across Government. Whilst, in terms of your earlier question, I think it is very important that the Secretary of State for Health has a view of public health and how to resource it, so is it essential for the Secretary of State for Education and Employment to do that, the Secretary of State for Environment and Transport and the Regions to do that, and so on, because it is so essential to the society in which we live. So, yes, of course, the function is important, but does it need to be linked to the same person in the same place?

  343. Basically you are saying that, for example, the control of a meningitis outbreak does not need to rest specifically with your Director of Public Health if he is employed within the local government system?
  (Mr Ransford) That is right. You can have responsibility and accountability in different places from actual action. I think we have got away, and will increasingly get away, from the strict organisational boundaries to task and function. Some of the best examples are in joint working between health and local authorities about ensuring that partnership achieves the outcomes, as David Panter was saying, and not get tied up with the organisational process and culture which leads to it.
  (Mr Panter) If I can just give you a practical example, again, from my own patch, Hillingdon. A key feature of it is Heathrow airport, so we are a port health area having particular responsibility for health control. We are currently exploring the use of Section 31 of the Health Act flexibilities to bring together the environmental health component of the local government and the communicable diseases component of the Public Health Department. Actually at Heathrow airport those two groups of staff work side by side—they are employed by two different organisations—and it would be far more effective if they are working together. I think what we are trying to recognise is that actually, like with most medical specialties, public health has sub-specialties of communicable disease, and, in fact, the lead in my part of the world on communicable disease has very little to do with that broader health agenda because all of their time is about communicable disease, which is a very tiny sub-set. So we are exploring using the Health Act to merge those two elements together.

  Dr Brand: Perhaps when we are exploring the position we should be more specific about what functions of the Public Health Department we are talking about. There will be some which are comfortable across departments and some which will remain, presumably, the responsibility of the Secretary of State for Health—communicable diseases clearly should be—but if it is a shared concern with the Secretary of State for Education, it is difficult to know which should take the lead.


  344. Can I just ask a specific question? With the future control of health authorities being uncertain, what would be your objections to shifting the current remaining health authorities' functions into local government, and in a sense, getting back to partly where we were pre-1974?
  (Cllr Stringfellow) There must be an issue about whether it is good to go on having more and more changes.

  345. We are moving now towards PCTs, PCT function, on-going work of district health authorities. Certainly in my part of the world there is a huge debate going on, a heated debate, about the future role of health authorities and certainly whether their role should cover a much wider area than currently is the case. I wonder what your objection would be to what I have just proposed, particularly as the Government are looking at strengthening the role of local government in monitoring the operation of the NHS?
  (Cllr Stringfellow) One of the things I was going to say is that there is a move to merge health authorities and have wider commissioning organisations and, of course, commissioning is going to pass to PCTs ultimately. I just want to make it clear that from the LGA's point of view what we are not seeking to do is poach a particular territory, but simply to say that we can see that working across, as we have described, with health colleagues and working in partnership, working in a joined-up way, may well achieve the same objective as actually having health authority functions moved into local authority. I think we want to keep an open mind on that.

  346. So you are not arguing for the possibility of moving a function into local government, which, of course, was the position of your predecessor organisation some years ago, as I remember? So there has been some fundamental change. Why has there been that change?
  (Cllr Stringfellow) I think the whole modernisation agenda has led to, perhaps, a different attitude, a different context about being less constrained by the organisational dictate and structures and actually looking very much at what works best and what is going to be appropriate in the local situation. I do not think that right across the country simply moving health functions into local government would necessarily resolve some of the issues and barriers that there may yet be. It is about working together wherever people are placed.

  347. We have looked at the future of NHS and the argument we are getting very strongly is that public health is a much wider issue than health as we define health. I cannot see any argument against looking seriously at shunting the entire function back into local government, which takes account then of what is in the national plan about the local government health service, they will then have a clear function which will surely resolve some of these anomalies in the whole operation of public health?
  (Mr Panter) If I can again just to try to illustrate, I think the concern of the Confederation has been that we need to make sure that there is the appropriate critical mass of public health expertise and, therefore, much more inclined towards looking at a public health resource centre type of approach. In my own case, in my own area, there is a health authority, there is a PCT and the health authority is en-route to merge with other health authorities, but we only have two public health consultants and a communicable disease consultant. Those two public health consultants draw upon a broader group of consultants across west London to share expertise and network, and what we are looking at is creating a single public health resource centre for all of west London which could then support all the boroughs and the health organisations within west London. I think there is a danger that if public health is confused with the public health individuals, those medical consultants, there is simply not enough of those consultants to go around in terms of providing adequate support. So there is something still in there, for me, about how you separate out the public health function from the public health individuals, particularly medical consultants.
  (Mr Town) I will just confirm what my colleague says. I think there is certainly a need for strategic planning authorities within the National Health Service as we develop services, as we introduce the modernisation plan, and I sense equally that we have very limited resources and there would be some confusion, I think, if we were to split it up into the current structure of local government.

John Austin

  348. Are the local health authorities not now redundant? What do you perceive as their role? I do not think the NHS plan talks about the performances management of the modernisation agenda, whatever that means, but what is their role?
  (Mr Panter) I think, as somebody who has moved from being a health chief executive to being a Primary Care Trust Chief Executive I have seen both sides and I believe very strongly that the majority of the current role of health authorities quite rightly migrates to Primary Care Trusts, and health authorities need to pick up a new mantle around a broader strategic planning role, partly performance management, but with that broader strategy. If Primary Care Trusts are going to work well they need to work well on smaller populations, ideally co-terminus with local government structures, to get the integration with social care. Health authorities need to pick up those strategic issues which require much bigger populations. So I think, as the modernisation agenda sets out, creating health authorities covering one and a half million population, there are bigger strategic issues that need that size of population and the PCTs cannot pick those up, it is beyond their scope. I think there is a clear role for that structure. One could then argue about how that fits with the current regional arrangement within the Health Service.

  John Austin: The local role is the inter-relationship between the local authority and the PCT and not the health authority, which does beg a question; if you say that the health authorities are too small for the strategic planning role you are suggesting, therefore, amalgamation of health authorities. What is the role of the region?


  349. That is a tough question, John.
  (Mr Panter) I think from the Confederation's point of view it is a legitimate question that is still to be explored, because until we can define—

  350. It is a diplomatic answer as well.
  (Mr Panter) The problem at the moment is that we are still trying to explore what the role of the health authorities are beyond the broad headlines that are set out.

John Austin

  351. Could the region be the one responsible for the strategic planning and the oversight of performance management, and the local authorities, in collaboration with the PCTs, is delivering the local plan?
  (Cllr Stringfellow) In relation to the point that you have just made about the region, can I say that we do have a problem about regional boundaries, because if we are looking at public health and bringing all of the strands of services and planning together. Of course, for example, in the north the government office boundaries are quite different from the NHS executive boundaries, which has been further compounded recently with the National Care Standards Commission and Social Services' inspectorate functions mirroring the NHS executive boundaries. That is not a direct answer to your question, but it does make the point that it would be very helpful if we had co-terminosity at a regional level. If I could, perhaps, pick up more specifically, I represent residents in north Tyneside, which is part of the Tyne and Wear conurbation. Under regional arrangements at the moment there are four sub-regional partnerships—Tyne and Wear is one of them—and I have to say that I am not making a bid for there being wholesale merger of health authorities, but there is certainly some sense in looking at health on the same basis as we are looking at learning, and skills councils, connections, small business service, single regeneration budget funding from the Regional Development Agency and European funding, so there is a synergy at that level that health could do well to be part of.

  352. I am still not convinced about the role for the Health Authority, because I think the example that you put forward is a coming together of agencies who are responsible for delivering services. It seems to me that the Health Authority does not have that role. Why not? It cannot be agencies coming together.
  (Cllr Stringfellow) It is delivering and enabling as well. It is not simply delivering a role for all of the agencies that I have just mentioned. A lot of that is about enabling and providing the glue for things to stick together.

  353. Then my question is: If that is the role of the Health Authority, are they equipped and do they have the necessary skills to do so?
  (Mr Ransford) Certainly it is not the Local Government Association's position to comment directly on the role of the Health Authority except in as much, of course, as it impacts on local government and local government responsibility. Of course, all of these organisations at that strategic level are multi-faceted. Yes, they are delivery agencies, but they are also planning agencies, they are also relating the needs of the population to the services they have provided, they are responsible to work together to get more from the whole, and clearly health is a player at that table, and an essential player at that table, and with some of the more local partnership as well, community safety and drugs and a whole series of other joined-up bodies. What organisation the Health Service has as to support that is a matter primarily, I suppose, at the beginning, for the Health Service, but it is very, very important that health is a player at all of those tables.
  (Mr Town) I think the issue at the moment is that the existing regional health authorities are very large in terms of the population that they serve and Primary Care Trusts are very small in terms of the population that they serve. I would certainly feel that at the time being there is a need for an intermediate organisation which brings together things like clinical networks. We are starting to see significant specialisation in a number of areas of medicine where we need to get teams of people working together across existing NHS organisational boundaries. The health authorities certainly have a role to play in that. Currently they have a significant role to play in managing the Family Health Service function, the GPs, pharmacists and people like that who have separate conditions. There are complaints functions and there are a number of statutory functions that, in my view, would be lost if it was too remote and became part of an organisation that was looking at four million population.

  Dr Stoate: Mr Austin is not totally convinced about the future of the Health Authority.

  John Austin: Going by his own experience.

Dr Stoate

  354. I would like to look more at the Primary Care Trusts in that case, because if we are going to have structures we need to make sure that these are robust, particularly as the structures are clearly changing rapidly and it is very important that we ensure that there are no gaps and problems. I would like to start with Mr Panter and pick up on something from your own Confederation's submission to us. You said; "Before the establishment of PCGs and PCTs, primary care in the NHS had neither the structure to enable a more forward looking approach to address wider community health needs, nor the mechanisms to meaningfully influence strategic planning." That was from your own comments. How successful are the PCTs likely to be in the reduction of the qualities? You are saying in your submission that GPs surgeries previously could not really deliver a public health function, which is fair enough, so what makes you think that PCTs can do what the old GP service could not?

  (Mr Panter) I think it is still early days, but certainly what is beginning to happen is that Primary Care Trusts start to put a support framework around general practice, which enables them to work collectively with each other, drawing upon their practice experience, but pooling that to get a wider perspective. Also we are clear that a key role for the GP is not necessarily to focus on public health, there are a lot of other important things that they have to do. So, again, it is those GPs working as part of a broader team that, as I say, in our own experience in Hillingdon, are the real champions of public health and keep them on the agenda and keep raising it and forging ahead. They are now feeling liberated and empowered in an entirely different way than they have before. When you start to combine that with some of the potential we have through the Health Act to work across into local government, again starting to do things differently, then I think that that does put general practice and GPs in a stronger position to influence. Clearly it is still early days, but so are the nine months in Hillingdon, then we can start to see some of those things that are starting to have an effect.

  355. I accept what you say, except even your own bit evidence seems to slightly contradict that, and it says, "It should be recognised that it is entirely reasonable from new primary care organisations to concentrate their main efforts on developing and improving primary and secondary care services and delivering clinical governance", which rather damps down this function of public health. I am a little bit concerned about the those two slightly contradictory statements.
  (Mr Panter) I think what that contradiction encapsulates is that there is inevitably, in the way in which the modernisation agenda is structured, room for flexibility to meet local circumstances. I was giving you an example of my experience from Hillingdon where we are currently the biggest Primary Care Trust in the country with a quarter of a million population, we are-co-terminus with a borough of London, we have taken into to the Primary Care Trust about 95 per cent of the staff and functions of the Hillingdon Health Authority, so we are in a very different position to engage in some of that agenda than a much smaller Primary Care Trust that might be around a rural town or community who is working collectively, and my colleague may give you an example of where two or three Primary Care Trusts are working collectively on a very similar agenda.

  356. I understand that, but my worry is that you talked about Primary Care Trusts being a collection of GPs and health visitors and so on, which is fine and you have also talked about some functions of the Health Authority, which is also fine, but how good are the links between your PCT and the rest of the Government, because we have heard from the LGA, quite rightly, that the real public health agenda is only very marginally related to health delivery and it is much more related to education and Social Services provision, housing needs, employment and social exclusion? How closely can your PCT realistically influence those agendas?
  (Mr Panter) I think that we are currently waiting on a decision on whether we can have beacon status for the work that we have done with the local government on health strategy. Because we are co-terminus with the borough and because they have been a key partner in helping to shape the Primary Care Trust, we have a series of connections across those other areas. For example, we now also established a Scrutiny Committee for Health in the borough, which is not only looking at the role of the Health Service in the borough, it is also a way in which councillors can scrutinise the other decision making of the local authority around housing, education, leisure, environment in terms of health impact to see whether or not it is in line with the overall objective of the health within the population. So I think our first statement as a Primary Care Trust has been to say we are very keen about supporting that broader health agenda with local government and we recognise that we are a small part of that.

  357. It all sounds very warm and cosy. You say you can scrutinise the other policies of the local council and authorities, but how much can you influence them? It is all very well saying, "We are looking at the housing agenda and we are looking at what local authorities are doing about raising taxes and spending", but how much can you influence those things, because unless you make any actual impact on that you are not actually going to change public health at all?
  (Mr Panter) I would hope that we will have an influence, because the way in which our Primary Care Trust is structured does involve local elected members. It also has an internal structure which is co-terminus with the Parliamentary constituency boundaries. We have worked very hard to engage local elected and nationally elected politicians into the structure so that they also enhance their understanding of both the Health Service and that broader health agenda.

  358. How much do you feel that your local government function is genuinely influenced by a PCT? How much notice do you take in local authorities of what the PCTs say? How much do you let them influence what is decided by councils?
  (Cllr Stringfellow) I can say that across the country it is very patchy and local government, in terms of its progress and modernisation, is at different stages, as is the maturity of Primary Care Trusts, and not everywhere in the country will have Primary Care Trusts come April 2001. If I can just speak to you about my personal experience in north Tyneside, we have a Health Partnership Board that has been established for three or four years and it takes time to evolve. It is important that good relationships are built up and there is mutual trust. The difficulty is that one cannot legislate for that, it is an evolutionary process, but one of the things that we are looking at in terms of scrutiny is that, yes, we are going to have the duty to scrutinise health colleagues, but also how do we actually make sure that health colleagues are a part of our scrutiny process in any event so that we can pick up on the point that David Panter has made in terms of looking at how housing, environmental or other policies impact on health and where we can make changes? There is some evidence of that. There has certainly been some evidence of that in terms of how we have taken the health improvement programme and there has been mutuality about those discussions. It can be very effective, but I think we cannot simply say that there is a set of rules to which everyone must work and it will happen, it is more complicated than that.

  359. Are you not worried then in that case that if you say it all depends on mutual trust, mutual organisation and so on, maybe in some parts of the country it will quite clearly work very well but, equally, in other parts of the country it may be a total disaster. The way you have said it, if it all depends on mutual trust, etcetera, we know—I have been in local government for a long time—it does not always work. There is not always mutual trust. It cannot be legislated for. Perhaps it should be. Maybe we do need statutory influence on each other to ensure that this function does occur.
  (Cllr Stringfellow) Relationships, in a sense, cannot be legislated for. That was the point I was trying to make. In fact, if we look at the National Service Frameworks which are coming through and best value, as it applies now to local authorities, if it is going to be duly best value within health, it comes to a point that Dave made earlier about outcomes being so important. The bottom line is that we are all accountable—in local government, at any rate—to the electorate for making sure that those outcomes are transparent and are successful. If they are not, then there is an electoral price to pay. Equally, the scrutiny role is going to pick up with health and create a greater transparency there. So the frameworks are coming along. We are all keen to end the post code lottery, whether it is in social care or education or housing, because Members will have seen, for example, in the press today, the results of Key Stage 2 in our schools. We see this as one of the critical priorities that we have in local government, in terms of equipping our young people to have the best possible life chances, which also impact on their health status in the longer term. It is very complicated, I think, but nevertheless the frameworks that are coming forward are welcome, because we can work locally to meet local objectives within that framework. I think that means that we are working with health colleagues who, equally, are going to be very much more accountable because the league tables and the other information is coming and being made very public.
  (Mr Town) If I could add to that. For mutual distrust I would read mutual misunderstanding. I think there has been a huge misunderstanding between local government and health, both at an organisational level but also at an operational level. Although we are only eight months old, we have to reflect that PCTs are very new organisations, and that we have made significant progress in engaging GPs as advocates of the local public health. I agree that they may not be the experts, but they are advocates in dealings with local councillors. They are seen as very influential people locally. They are listened to. They have now taken the time to talk to local councillors about local health issues. We have held conferences about mental health issues and learning disabilities issues, at which councillors and GPs have sat together. In my experience—and I have been in the National Health Service for nearly 30 years—this is probably the first time. There is the beginning of a significant change at a local level. We deal with the unitary authority and I certainly find that is easier because there are two PCTs and one unitary authority, so we have a very strong bond, a very strong relationship at a local level. It increases and improves on a weekly basis almost, as one contact, one bit of trust leads to another.

  Dr Stoate: Fair enough. Thanks very much.

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