Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 360 - 379)



John Austin

  360. May I follow this through. We all seem to be agreed that we know what the key determinants of health are, the economics and social requirements, all of that. We know what needs to be done. You said you cannot legislate for relationships and you indicated that relationships are improving within the new structure. Are there any key changes which you think do need to be made to ensure that what we know needs to be done, will actually be done?
  (Mr Ransford) One of the major changes is to ensure that health is central to the agenda. I was on one of the modernisation action teams leading to the NHS Plan. Chapter 13 was one of the products. I do not think it is an LGA view, but I think it ought to be, that it should perhaps not have been chapter 13. It ought to have been a single number chapter. It should have been much firmer and earlier in the plan. Everyone shares in an aspiration and right to good health. Only some of us fortunately have disease or injury or illness which needs to be treated at certain parts of our lives. So I think it is incredibly important that health is at the centre of the agenda. We should build our other services, our curative services, in all sort of senses—not only health ones, but intervention services for people in need—around measures that create that healthier society. Our historical basis for doing these things is based on different factors. I think one of the most important things for local government in this is the new power to be given to promote the social, economic and environmental well-being of an area. Although the best bits of local government have been doing that for years, it is now seen as a positive role. It is not a bossy role. Local government cannot do it on its own but it can bring together through community leadership, local people, citizens, their representatives, the agencies, the public agencies we have been talking about this morning, business, and a whole range of interests, actually to improve health. It is that change of vision and that change of priority which is required.
  (Mr Panter) I was going to add to that—again, we have put it in our written evidence—in terms of a change, this is about that joined-up working at the centre also relating to the performance management arrangements. This is because I think we are getting better across social care and health care at joint performance management; but in terms of the broader objectives, then to have consistency around the centrality of health in those performance management frameworks and targets would be incredibly helpful. All too often we find ourselves, at a local level, as different public sector organisations trying to work for the collective good, driven apart by the different demands in terms of performance management from social government.

Mrs Gordon

  361. Several times during this inquiry we have heard the term "initiative overload". There is an awful lot of different things going on. There seems to be a great interest in experimenting in various new mechanisms, joint directorate of health posts, other joint posts, other new ways of providing health through management networks and joint health units, the ones being developed in Manchester. May I ask the LGA representatives. Do you consider these experiments to be useful, successful, worth spreading? Are they to be positively encouraged or is there a danger that the public get used as guinea pigs for some of the ones that fail?
  (Cllr Stringfellow) It would be good if we could always predict success from the outset but the value of having different ideas piloted is obviously that one can learn from them, take what is best from particular models, and see whether that applies to the local situation. The difficulty, as ever, is that what we need are local solutions for local situations, local contexts. They do vary enormously. For example, what I understand is beginning to work very well in Manchester, might be wholly inappropriate for a part of the country where there is two-tier local government. So it is important that we actually have a range of models. I do not quite see it as experimenting on the public in as much as these ideas have been well thought through in advance and they are seen to be appropriate for local circumstances. One of the things we need to take into account, though it is incredibly difficult, is that local government has that community leadership role. I think one of the DETR consultative documents was called In Touch with the People. Actually being in touch with local communities to see what is going to suit them best is also very important because the models might be great and we could sit around for a long time as a bunch of professionals discussing this, but it is what makes sense to people in their own localities that is important. That is the responsibility that local government has, along with health colleagues, to make sure that what is going on actually does make sense; or, at least, if the structures are very complicated, that they are seen to be seamless from the point of view of the people using them. So I am not too concerned that there is a divergence of ideas as to how we can deliver, as long as we know what it is we are delivering on and that we have the measures to be accountable for that.

  362. There are two questions from that. How do you evaluate some of these experiments? I think also that some of the schemes we have seen were bottom-up schemes, they did start from the community, so how do you actually facilitate that happening?
  (Cllr Stringfellow) In terms of facilitating it happening, we have a lot of experience in local government of community development work. Certainly that is going on in primary care trusts. It is very much about working with organisations, working with individuals at a local level, and getting a sense of what is going to be important to them. Sorry, the first part of your question?

  363. How you evaluate.
  (Cllr Stringfellow) Performance management is obviously a step in the right direction and as schemes are being set up there is a joint need to build in performance indicators and to be constantly checking back. Of course, part of the way of evaluating these things in the future will be through the scrutiny role within local government. There are a number of ways in which that could be approached.
  (Mr Ransford) May I add a codicil to that, in a sense. One of the most powerful of these initiatives is going to be the New Deal for Communities, which is very locally targeted and is not seen as a health agenda at all at first sight. It is seen as a regeneration agenda. Of course, the benefits to the local people and the community are exactly the same. What is being built into that in the best of them is community evaluation. The second point I want to make—I have spent virtually half my operational career in single-tier local government and half of it in two-tier local government—and in two-tier I always used to get told off for calling it two-tier. When I worked in North Yorkshire there were 650 units of local government. In my time the county council had eight districts and over 630 town councils, parish councils, parish meetings. Go to Filey Town Council on a wet December night and you learn what people caring about their community is about! So that sort of model is equally applicable in rural communities at a very local level. There is a model which will deliver massive health gains and is not seen, at the outset, as a health initiative.

  364. A couple of the schemes we have looked at. In one the GPs were very involved but in the other ones we have seen they sometimes find it quite difficult to involve GPs for various reasons: pressure of work, size of the list, etcetera. May I ask what your views are on that: actually involving GPs within the community projects.
  (Mr Town) Where GPs add a value, it is terribly important that they get engaged. One of the things primary care trusts are starting to do is to look at the whole model of general practice and say, "Could some of that time that GPs spend in face-to-face contact be better spent on some of these projects?" If it can be demonstrated that it can, then we have to find ways as an organisation with the GPs concerned to free up that space. There are a number of initiatives that are announced in the Modernisation Plan that are on-going, which would allow those GPs to be freed up to get involved. We have to be clear what the added value of that involvement is rather than it is just a representative role.

  365. The National Health Service Plan affords opportunities for local authorities to scrutinise NHS organisations. Do you think these powers could be directed toward ensuring that the public health agenda is vigorously pursued by the National Health Service? You talked earlier about this division—National Health Service or public health. We know that if you improve public health, then it takes the pressure off the acute services in the long run. It is a long-term thing. How do you see that could be pursued?
  (Cllr Stringfellow) I would hope that this would be at the heart of the scrutiny agenda because so much flows from that. Also, that it would be a two-way process, so that it would not simply be local government and public health, but also finding ways of involving health to look at some of the local government services that impinge on public health.

  366. Have you any views on that?
  (Mr Town) It seems to me that the important bit here is in terms of scrutiny and in terms of performance management in its wider sense, that we get a balance between the "must dos" and the "here and now". So the targets that were set by Government on waiting lists, waiting times, as important as they are, that we try to determine some targets for the longer term health care. One of the difficulties of this agenda is that many of the results will not be seen for 20 to 25 years, so it is terribly difficult to quantify those. So some of the performance measurements at this stage would be based on a beliefs and evidence base rather than necessarily the outcomes. Therefore, we have to come up with something which says, "This is important and we are being measured as organisations on this, not just on the `here and now' stuff."

  367. How can the proper scientific scrutiny or investigation of the initiatives be managed at local government and PCT level?
  (Mr Town) The important bit is that we have a clear understanding of what the anticipated outcomes are, so that there is something to measure it against and for all parties, so that if we are to be scrutinised, the party scrutinising us and the party scrutinised have some agreement in advance as to what it is that is being checked out. We need to agree some measures, some milestones, that would at least demonstrate we are making progress towards that target.
  (Cllr Stringfellow) Could I also add that it is very important when looking at what is going to be a new role for local government scrutinising—although in my own authority we have already got a health select committee that has looked at various health issues quite effectively with health colleagues and it has been a very challenging agenda—it is very important that we take the opportunity to see that the initiatives, for example, such as Sure Start, which bring together all of the things that we are about to fix, sitting round this room, and to see how we can learn from what is already going on in our localities, and applying that to the health agenda. The other thing, which is very important, is that if local government is going to take this role seriously, that we make sure that there are experts who will come in to advise us before we embark on some of these scrutiny activities, so that we have the best possible starting point. I am sure that there is a wealth of experience here in terms of scrutiny and health but it is very important that we do not just rely on our hunches and good ideas but have expertise in there to advise us from the outset.

  368. Do you feel there may be a conflict between local authorities as partners in health and commissioners of health services and scrutinies?
  (Cllr Stringfellow) It is very important to acknowledge—and the Local Government Act is very clear about this—that the executive of the council will be taking a lead role in decisions around commissioning and will be very clearly accountable for that. It will be non-executive members (front-line councillors, as I prefer to call them) who will be taking on the scrutiny roles. So there is going to be a very clear separating-out but I do think it is important that we are as rigorous with our own services as we would be with services coming from other agencies.

  369. You talked about having people with expertise to advise, etcetera. How do you feel about the proposed demise of Community Health Councils? That the new proposals, including scrutiny by local authorities, will lead to better patient representation.
  (Cllr Stringfellow) There are three strands to Community Health Councils. In terms of scrutiny, there will be a much clearer accountability with that role coming to local government. But I do acknowledge that there is an expertise in Community Health Councils that has built up over the years which the LGA nationally is seeking to tap into and to work with. We are certainly recommending that our authorities all have discussions with their current Community Health Councils so that expertise is not lost. In terms of democratic accountability, there is a huge advantage in having the scrutiny resting with local government. I have to say, just as performance might be patchy across local governments and health authorities and primary care trusts, so it has been across Community Health Councils.

  370. I do not know if the NHS Confederation has a view on CHCs and the proposals.
  (Mr Panter) Again, it is about recognising that there is a body of expertise and skill there. As Rita has said, it is patchy around the country, but making sure we do not lose that in the proposed changes and hanging on to that expertise. Particularly, there is widespread feeling within the NHS that in terms of looking at some of those other roles that will come out the demise of the CHC, in terms of the patient advocacy and liaison services, that there is an importance about that remaining independent in some way. Certainly there are a number of proposals around the country, one of which is in Hillingdon, where we are looking at how we can do that, perhaps if we could set up an independent body.

  371. May I ask you about the Local Strategic Partnerships. How do you see them working and how far would they help to provide focused momentum for action to improve public health inequalities?
  (Mr Ransford) I think the Local Strategic Partnerships are absolutely key to all this. They are probably the most essential element coming out of the National Strategy for Neighbourhood Renewal in terms of pulling all this together appropriately at the right level. The health agenda, in terms of people talking about it this morning, is absolutely essential to it, as is the more traditional health agenda in terms of the health services that apply to a community. Local Strategic Partnerships, when working properly, can replace a lot of the confusion around this which has gone on so far. The fact that the National Strategy for Neighbourhood Renewal recommends that you use local authority boundaries as building blocks—not necessarily local authority boundaries but as building blocks—so, for instance, in a county area you might have a Local Strategic Partnership based on two or three districts coming together, and then another part of the county might have another Local Strategic Partnership, and the county council had to reflect both: that flexibility is right. But if we all agree on one model for alignment, alignment of responsibilities and alignment of intervention, this seems to be the key to this because otherwise you tend to get dragged down into organisational solutions, which certainly sitting at this table we all know do not always work. Local Strategic Partnerships do have that strength. They also have this inclusion agenda, which is crucial to all of the things we have been talking about this morning. If Government does back those, it is going to be very important. There is evidence that it might because, of course, the new neighbourhood renewal money is being distributed on the assumption that you have a programme like LSPs in place first.

  372. Do you think public health is an important part of that?
  (Mr Ransford) An essential part of it.

  373. Do you think it is recognised at the moment or does it need to have more emphasis?
  (Cllr Stringfellow) It will be recognised in some areas but there does probably need to be some awareness raising of the public health agenda. In a sense, we can turn this on its head because Local Strategic Partnerships will lead to a more confident community and if those communities are able to participate in training and skills and taking employment, that is going to make a huge difference to the local economy and health and well-being of the individuals in it. So it is absolutely critical. I am a member of One North East regional development agency and we have our regional economic strategy. Whilst we do not have an explicit objective of public health, it really does underpin all of the inclusion agenda. Particularly what comes from the north east tends unfortunately to be scoring at the lower end of the indicators, so promoting the raising of educational standards and good health is absolutely crucial to what comes out at the other end in terms of participation in the jobs market. Making the north east a place where people have the skills that investors want to come and invest in but more importantly than that—a real issue about well-being and confidence—is that if we are going to be successful, we have to grow the businesses which are there at present. One of the issues around that is that we have 19 per cent of entrepreneurs who would be seen to be women, which is about half the average for the rest of the country, so we really have got to get some role modelling here, so that it is going to make a sea change. This is where I think projects like Sure Start need to become a way of life and, if you like, that the idea of entrepreneurship is not just confined to secondary schools but it is right down the Sure Start agenda. That is why we are going to make a real difference in the future.

John Austin

  374. I do not disagree with anything said by any of the witnesses, almost everything that has been said points me in the direction of the written submission that has been made by the Manchester Health Authority, who we will hear from later, that we really need to bring together the community plans and the health improvement programme. Is there not a case for having a single plan? Should the responsibility for drawing that up be with the local authority?
  (Cllr Stringfellow) I am also a member of one of the modernisation action teams, the same one as David, and one of the things we rather hoped would come out in the plan would be that it would be very explicit. There is a synergy between community strategies, as we are going to the call them now, and health improvement programmes. I think that in most areas health improvement programmes are seen as an important subset of community strategies. It is very difficult to separate them out if you look at that from a public health perspective.
  (Mr Panter) The work that is going on in Manchester is not in isolation, there are other examples. In my own patch we have already called the HiMP, the Hillingdon Health and Well Being Plan, and that is lined up to be a chapter of the community plan. The team who led on the development of that is a joint team between health and local government, jointly appointed and jointly funded. There are examples around of where the HiMP and the community plan are coming together.

Dr Brand

  375. You also take on board regeneration and all of the other things through that common process.
  (Mr Panter) That is correct.

  376. Being coterminous is very helpful—as my constituency is—but in those circumstances you can have chief executives of either the local authority or the health authority being accountable for their performance management on these plans. There is clear vertical accountability. What happens with the horizontal accountability? Should that be at local level or departmental level, or both?
  (Mr Panter) Could you clarify what you mean by "horizontal accountability"?

  377. You set out your objectives, your performance indicators and then you get your bit of money, especially on the initiative-itis bits. It is usually your department that is accountable, it may be to the Department of Education and Employment, it may be to the DETR, it may be to the Social Services budget, it may be to the Health budget, or it may be to somebody in the region. It is very confusing.
  (Mr Panter) That is what I was referring to earlier on when I referred to the Confederation's evidence, that more thought needs to be given to that Central Government Performance Management arrangement. You are absolutely correct, although some elements of that have come together quite well recently. Certainly in most initiatives around health and social care the performance management is carried out jointly by the SSI and the regional office, that is incredibly helpful but in terms of the broader public health agenda, having that separation does mean that occasionally there are perverse incentives and conflicts between some of the local partners, because they are being performance-managed in a different way to slightly different objectives or at least with a different emphasis on the same objectives. That can get in the way around some of these initiatives.

  378. Presumably this is even worse in areas which are not coterminous. Your community plan is different from your HiMP. At which level should the plan be held? I am very concerned that HiMPs are a health authority function rather than a PCT function, which I would have thought would be more natural. Earlier you said PCTs, ATOs and local governments should be coterminous, they should then have the ownership of whatever you call the plan. Is that not right?
  (Mr Town) What we have been trying to do in Peterborough is to localise the HiMP so we have the over-arching principles agreed on a county-wide basis, which is also a health authority basis, but at a local level we have looked at those specific issues. For example, in my case I have the only "deprived" population in the whole of Cambridgeshire, so our needs are somewhat different when we are looking at coronary heart disease and mental health. What we have done is localised that in conjunction with colleagues in local government. We do have a local HiMP, we sort of call it HiMP-let, a subversion, a localised version of the HiMP. Having those over-arching strategies that are agreed on a county-wide basis helps to inform that, that the real work and the real outcomes are at a local level.

  379. Is that the evidence of how people are dealing with this across the country?
  (Mr Ransford) It is certainly complex, but it need not be confusing. Certainly having spent a lot of my career—

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