Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 388 - 399)




  388. Can I welcome you to this part of our session this morning and thank our witnesses for being willing to come along. I am sorry there are rather a lot of you all crammed onto the one table. You are people of great expertise and we felt we could not miss out the opportunity to meet you as part of this inquiry. Can I make an apology that the Committee is rather thin on numbers. We have a debate about to start in the chamber on the health aspects of the Queen's speech and a number of our colleagues are hoping to speak on that. One or two more may disappear, but it is no disrespect to yourselves. You are left with the quality. Can I begin by basically asking you, broadly, about your own definitions? Can you introduce yourselves to the Committee very briefly?

  (Dr Hoskins) I am Dr Ann Hoskins, DPH, Manchester Health Authority.
  (Mr Goodwin) I am Neil Goodwin, Chief Executive, Manchester Health Authority.
  (Dr Jessop) I am Dr Edmund Jessop, Director of Public Health, West Surrey Health Authority.
  (Ms Griffiths) Jenny Griffiths, Chief Executive, West Surrey Health Authority.
  (Dr Woodhouse) I am Dr John Woodhouse, Director of Public Health, County Durham and Darlington NHS Health Authority.
  (Mr Jarrold) I am Ken Jarrold, Chief Executive, County Durham and Darlington NHS Health Authority.
  (Dr Veal) I am Dr Chris Veal, Director of Public Health, Calderdale and Kirklees NHS Health Authority.
  (Mr Elson) Tony Elson, Chief Executive, Kirklees Metropolitan Council.

  389. Basically you are here really, in a sense, to look at the practicalities of the issues we talked about in the first session, because you all have direct hands-on experience of attempting to wrestle with the structures and deal with issues we are concerned about in this inquiry. What I would welcome from one or two of you as a starter is your own definition of public health in the context of what we discussed in the first session. How do you feel we should define public health, looking at it as an issue that does, indeed, involve far more than simply the medical model?
  (Dr Hoskins) I think if we are looking at health, for me it is looking at how we generate health and well-being. I think it is very important that we do not just look at the medical model but we look at the social and economic model as well. It has been shown that just looking at the health model is not going to improve the health of our local population. Speaking for Manchester, who is at the top of the hit parade as the worst health statistic, I speak from the heart on this one.

  390. We will come back to you on what you have done.
  (Ms Griffiths) I would define it very similarly, as you would not be surprised, as all of those activities—we can talk about what they are in a moment—that contribute to the health of the population. That needs to take in the social and economic determinants of health and how we support communities to enable them to become as healthy as possible, as well as the precise programmes that we deliver or organise, which we will talk about in moment, I am sure. I agree with the very broad definition. Even in affluent Surrey we have deprived areas, they are in the top 20 per cent nationally and yet have the same issues, albeit more focused, in smaller pockets that our colleagues in Manchester face.

  391. Just out of interest, which areas of West Surrey do you cover, what are the towns we would recognise?
  (Ms Griffiths) The biggest is Guildford, Woking is the other largest town. We go into outer South-West London, to Spelthorne and the Hounslow area, and at the other end we go right down to the Sussex border. It is a very varied area.
  (Mr Jarrold) The definition of health I try and keep in my mind is that health is the strength to be fully human. If you then look at all of the factors which affect health, which are set out in our evidence and elsewhere, you immediately see that you do have to think about not just the health service but local government, the full statutory and voluntary sector and the community themselves. You do need the broadest possible definition because only by taking that stance you can have any chance of improving health itself.
  (Mr Elson) I would identify with everything that has been said so far. I think that it is a very broadly-based, socially defined term, which I would not distinguish from well-being and from the whole concept of regeneration. I think for me the whole strength of the public health agenda is about trying to create the self-confidence and self-value in people that makes them feel they are fully part of our community, and should give them the power to care about their own lives and promote their own health.

  392. From the debates that we had in the first part of the session you were aware that we explored the placement of the director of public health, we explored the role of local government. What are your thoughts on who should take that leadership role at a local level on public health? I was not totally convinced I got an answer on this question as to why the uncertainty about the future of the health authority could not simply shift the wider public health function to local government, putting it back to what we had pre-1974, which some of us were happy with, were we not, Mr Austin? Doctor Veal, why should you be within Kirklees Council? What is the problem, have you actually undertaken your function within an environment where, surely, you would have more influence on the direct policy impact on public health in the area you cover.
  (Dr Veal) I am quite happy to be within Kirklees Council or another local authority. What is important is that we rely very much at the present time as the Director of Public Health on our influence. We do not have too much control over resources, so wherever I am placed I want to have some greater influence on the disposition of resources. I work in the Health Service at the present time and I find it difficult to understand what proportion of the Health Service expenditure is actually expended on health and what proportion is expended in terms of Health Services. I deliver some of my public health function because I also deliver for my authority a lot of the other issues that have to do with clinicians; that have to do with doctors who are performing badly; the service reviews of acute hospital services; the ability to act as the medical figurehead for the authority from that point of view. I have to do my public health function as a part of that overall goal. I think wherever I go and whatever my role is the important thing is that I am given the authority and the position to be able to address the public health agenda. If it is going to be local authorities, fine, but do not just dump me on a local authority without any support mechanisms.

  393. You would have no objection to moving over, would the other directors feel the same way, that their function would be better placed within a local government setting?
  (Dr Jessop) I feel quite strongly that I would prefer to remain within the National Health Service for three quite distinct reasons. The first is the point that has already been alluded to, to do the job properly you do need resources, so you can be an effective advocate, but you can get a lot further if you do command resources.

  394. Why would you not have, necessarily, the appropriate resources to do your work in local government?
  (Dr Jessop) As the director of public health for a health authority you essentially have command influence over the entire resources of the National Health Service, which are enormously greater, I suspect, than anything than the local authorities could bring to bear because, and my second reason, it is slightly artificial to distinguish between medical health and wider health. If you think about how you bring about improvements in the mental health of the population you need health service staff as well as tackling the wider determinants of health. It produces a much more effective programme if you can integrate those two.

  395. You talk about the resources, surely the resources of the NHS are geared at ill people. The kind of resources you are talking about in the public health domain are largely, so far as they are in the public sector, with the local authorities, the sports centres, the leisure centres, the community centres, housing. These are the resources that are key, are they not, to public health?
  (Dr Jessop) Absolutely. That is half of the story. With respect, you underestimate the commitment, of primary care teams to public health, to smoking cessation, to improving diet, to tackling teenage pregnancy, and a whole range of other programmes.

  396. Some of those are done through schools, youth service and, harking back to our previous existence, things like health visiting within the local authorities.
  (Dr Jessop) They were. My belief is that these programmes are developed and delivered more effectively by teams that are fully integrated, with colleagues, who deliver the more specialist services.
  (Dr Woodhouse) My view is that we should remain in the Health Service. I reinforce the views of Dr Jessop. Many services are fed through the Health Service. I also fear the effects of such a change, because you will remember the post-74 the Public Health Movement went to the doldrums, and I would be afraid that that would happen again.

  397. It was sidelined, that is why it went to the doldrums. It was removed from the reality of the services that impact upon the local community. We have ended up with people who write brilliant reports but they just do not seem to have an impact on the service delivery they really ought to impact on. The old MOH, in my experience as a very young councillor, used to make people jump on some of the committees that I sat on with the reports, they were very objective and hard hitting.
  (Dr Woodhouse) What I would say to you is the director of public health needs access to the NHS and local government. The reality that possibly needs to be remedied here is to have more direct and legislative access to local government. Many of us have this. It happens through developing those relationships, which is time-consuming, and depends very much on personalities.

  398. Taking the last question I put to the previous group of witnesses, if we were starting from scratch what would we do, would we start from the basis of having an integrated health and local government structure, even taking account of the point Dr Jessop made about his resources? If we had a service under one umbrella, whether it be health or local government, these services are under one organisation, how can that impact on the role you could play in relation to public health at local level?
  (Dr Woodhouse) It is very hard to speculate what you might have in the future if you started from scratch. If you started from scratch I would have a completely different structure.

  399. Imagine we had one structure. Say, with the demise of health authorities we could move the remaining health authority function into local government, it would not be that dissimilar to what we had in pre-1974, if we had that kind of structure, you would be based in local government, what impact would that have on what you were able to do, assuming we take account of the resources in question that Dr Jessop quite rightly pointed to, how would that improve what you are able to do now in your role as director?
  (Dr Woodhouse) The fear I would have is that it would distance me from the other health agencies.
  (Mr Jarrold) There are two separate issues running here, one is the wider question of the role of health authorities. Health authorities do a lot of things which are not to do with public health—I assume you do not want to concentrate on those issues this morning, you want to concentrate on the public health issue. If we take the public health issue I think it is perfectly possible to envisage a situation in which public health could function, either under a local government structure or a health structure. What I think is very important is that we develop joint accountability for public health, wherever it lies. You will know that in the NHS plan the regional directors of public health are to be jointly accountable to the regional director of the NHS regional office and the director of the government office. I think that is a very clear indication of the way we are going. I think there would be a strong argument for directors of public health to be jointly accountable to health authorities and local authorities. I think joint accountability may be the key. We then have to ask ourselves, what are the arguments for placing public health within local authorities or health. I personally think there are strong arguments for placing public health within health, one of them is the question of influence over health resources, which is extremely important, and one is the question of scale. It is not possible, really, to imagine a director of public health at every single local authority in the country in the terms of the numbers, the scale of resources and in terms of back-up it is very difficult to imagine that happening. One of the arguments is, I think, is that the new organisations that will merge from health authorities will be on a big enough scale with their local government partners at appropriate levels to develop a strong public health function with the resources and specialisation that it needs. If you are operating with very small populations it is simply not going to be possible to resource and staff independent public health functions.

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