Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 460 - 479)




  460. You spoke about the pressure that you are under personally, Dr Archard, and I sympathise with that; your comments that your colleagues see that you ought to be there, doing what you call proper work. I was interested in the outline comments in your evidence that general practice is and always has been based on the concept of personal doctoring which they would regard as proper work. What I am interested in exploring is whether we need to be much more radical about how we use our GPs, how we train our GPs, how we place our GPs. I say this on the basis that this Committee a while ago went to another country—I will not mention where—in which the role of the GP is fundamentally geared to public health. They are in a position to influence the direction of decisions on local issues in a way that certainly you are not in any way in your work here. The training of hospital doctors requires them, when they are qualified, to have spent at least two or three years working as a community based family doctor. The family doctor lives in the community where they serve, along with the local community nurse. They are from the community, quite frequently. They are very different people to the kind of GPs I know. The last thing they would want to do is live in the community in which they work and I understand why. I worked in social services. I would not particularly want to volunteer to live in the area where I was doing child protection and mental health work. Do we not need a cultural shift here somewhere and look much more radically than we are doing at issues such as training, how we recruit our GPs, where they come from and how we do enable you to be seen to be doing proper work when it is not necessarily personal, face to face doctoring?
  (Dr Archard) I absolutely agree with you, 100 per cent. It is our colleagues who need to recognise that proper work is also not necessarily face to face medicine. The other thing is that people evolve and if you had suggested to me, when I was a medical student, that I would be addressing this Committee today I would have laughed at you. Indeed, it was exactly the same when I became a general practitioner. People evolve; people become interested in different things and this is why I am here today perhaps. This has to be addressed because if you go into the current partnership model, by and large that is where you will be for the next 25 or 30 years until you retire. Your job is set out in front of you; there is no career structure. You become a partner and there you stay. That is it. Until recently it has been quite difficult even to move partnerships. If you try to change your career structure, the only way you can do it is to take the sorts of risks which I have implied. Because that is not recognised I believe either generally by colleagues or the government, it is an extremely difficult step to take. This does put the brakes on the sorts of projects and priorities which we feel should be undertaken and public health is one of them.

  461. You talk about career structure. Do you see any opportunities within the move towards PCTs, where I see in my area individual GPs within those PCTs specialising in certain areas? Do you see a possibility that that might offer some sort of career structure and within that career structure the possibility that some of the public health specialism within that PCT may be on offer?
  (Dr Archard) What do you mean by "specialism"?

  462. What I am seeing in my area is that within PCGs you have a lead GP for such and such an area or such and such a specialty.
  (Dr Archard) Do you mean a clinical specialism?

  463. Indeed, yes. Is there a way in which we may look at addressing the issue of the career structure point, which I think is a very valuable point that you have made; I am on board with that completely and I am sure our two GPs who are not here today would be. Is there not a way of building in a public health function within that? Can we explore that? Is it something you have looked at?
  (Dr Archard) The model that I have written about would suggest a third, a third and a third, in which one third is in face to face clinical practice so you do not lose touch. One third would be involved in local priorities such as PCGs, PCTs or whatever, appraisals and education. One third would be on national agendas such as college agendas or the GMC or whatever. That is the way I would see it, but these career structures would be agreed on an annual basis such that people would know what they would be doing. If we did this, it would give general practitioners and the public protected time. These sorts of areas could be addressed properly. They would therefore, by implication, be resourced. For example, they would not be tacked on to the end of a busy surgery.

  464. And it will be seen as proper work.
  (Dr Archard) Yes.
  (Dr Heath) The idea of GPs with a special interest in public health is a very constructive one, but the problem about the wider proposal that GPs should develop clinical special interests, is that it has the potential to make the whole public health problem much more difficult.

John Austin

  465. Can I come to the issue of health visiting. Since the Acheson Report, there has been quite a lot said about the positive role of health visitors. Yet, it appears to be a diminishing resource in many areas. What do you think the role or the potential role is for health visitors?
  (Ms Amadi) We need to recognise that there are a lot of other community practitioners out there working and complementing GP services, one of them being health visiting. Looking at the roles that they are involved in, often times you can see that they are not given the authority to optimise the services that they can bring.

  466. What do you mean by that? Can you be more specific?
  (Ms Amadi) A health visitor working in a particular community may see a range of health problems that she can address, but without resources she has no control over budgets. It is very limited in terms of who she can work with. Often, you will find examples where really good health initiatives have been produced and the health visitor has gone through the process to create resources and to provide services and that is a real problem because health visitors are very well qualified to perform a large amount of functions, but because of the way that health authorities, PCGs and PCTs have functioned to date, they have been prevented from carrying out that role.
  (Professor Drinkwater) From the Alliance perspective, there are some issues here around capacity and who does what within the patch. There are some issues around career structure for community nurses. What we have at the moment by and large is a system whereby people become district nurses or health visitors and they stop at that point and that is their career. For a number of people that may be fine but it does create some problems within the system, particularly if you are looking at our own PCG where you have a number of G grade nurses who have been getting pay increases so that the system is loaded towards the top end; and a number of people who have been there for a number of years who are going to be retiring. Where do you recruit behind that and how do you get people into the system? There are some issues about the skill mix that is required to deliver the services that are required to meet the needs of that community and it is about having a broader range of skills than a single health visitor, for instance. Phillip has already talked about the Families First project which is local people as a resource to support the health visitors who are trained. There are then nursery nurses who should be part of that system linked to health visitors and linked to school nurses. There are some issues about how you build that career structure and equally at the top end, in terms of the way that system is moving, if we are going to retain people within the system and hang on to them, they need the opportunity to develop their skills and careers. That is around the notion of nurse consultant posts. Again in our own patch, we have a specialist nurse, child and adolescent mental health who was a school nurse, a specialist nurse, drugs, alcohol and young people, who was a health visitor and a specialist nurse, community, coronary, rehabilitation, who was a health visitor. There are opportunities there and there are roles there. Those roles need to be managed and need to fit within a system. You also need to back-fill that and the major problem at the moment is getting people into posts behind that because there are some issues about recruitment of nurses into the system and the need for more nurses within the system.
  (Ms Jackson) We believe there should be a major overhaul of post registration training for community nurses. At the moment, there are eight specialist practice pathways. That puts practitioners in little boxes. What we would like to see is a breakdown of those boxes which breaks down the barriers. Health visitors and school nurses have been recognised as having a public health function, as have other community nurses. We would like to see exploration of a common public health nurse, public health practitioner, public health visitor, whatever title you want to put on that, where there is a common core, but we are not advocating for a generic nursing role here. What we would be advocating for is a common public health practitioner who would have a focus perhaps on the elderly or the under fives or adolescents. That would then fit in with what is coming out in terms of Higher Level Practice from the UKCC and nurse consultants because there could be a career pathway developed for these particular nurses. We do need to start quite quickly with the post registration training for nurses. At the moment, we are trying to fit our current practitioners into the new roles and the training, as it currently stands, does not equip practitioners to take that forward.

  467. One of the criticisms of the training of health visitors is it is too short; it is too clinically focused and does not specifically address public health skills. It also raises a more controversial question: why does a health visitor have to be a qualified nurse? Some people would argue that the career of a health visitor is one which should be a separate, independent career and is not an extension of nursing. How does the CPHVA react to that?
  (Ms Jackson) The CPHVA would take the view that a health visitor should be a qualified nurse. It is the nurse education, pre-registration education, which gives you a set of skills and knowledge to enable you to take a more holistic view within health visiting functions.
  (Ms Amadi) I would agree with that, rather than risk developing very skilled community health workers without—it is almost one of those things that are intangible that you have with the general nurse training.


  468. I am very interested in this area because on the Committee years ago, when I was first a member of the Health Committee, we looked at midwifery. It was the report into community childbirth, you will recall, when the chairman was Nick Winterton. We went to Holland and we saw the professional role there that was coming across between the GP and the midwife, and we were very impressed by the function that was occupied by this particular individual. Do we not need to think more radically about how we train people for public health work? We tend to think in chunks and a lot of the concerns we have had expressed to us with regard to public health relate to the fact that we are bogged down by the medical model. Is there not an argument that we ought to be—picking up John's point—doing that not just in relation to your function but other professional functions as well, because certainly when we looked at the relationship between health and social services in the Committee we saw no arguments against blending, for example, the role of CPNs with social workers on the mental health front. Should we not be exploring these areas to pick up the point that public health is not just about medicine, it is about much much bigger issues that perhaps we are trained to miss because we are so blinkered in our professional roles? Do you accept that point and, if so, what do we do?
  (Ms Amadi) I think you made a good point that we need to explore alternative ways of providing the service. In terms of a health visiting service we need to be thinking of that as a service with the health visitor working as part of a team and that team being from a variety of different sources where different professionals from different backgrounds and statutory and non-statutory organisations are all working together. That is one way of working things through. I cannot say I have the absolute answer on that. It is something that needs to be tried and tested and experimented with, sure, but there is a public health role that health visitors are very well equipped to provide.

Siobhain McDonagh

  469. A very local view—I am always struck by the isolation of health visitors and by their isolation from the whole political and public processes. I have seen people at my advice surgery who have had letters from health visitors about their housing and I think, "This is clearly written by somebody who knows nothing about public casing and does not know how to assist their particular client or patient." I have offered to go and talk to health visitors about how the council does the housing and how it works, in an attempt to empower them, but do you think that GPs and health visitors have very little connection with local authority services or how to best assist?
  (Ms Amadi) I would hope not. That be the situation in particular areas—because there will be a variety of quality of service that clients would get—where the health visitor may well be over-worked and over-loaded and where there is a high volume of clients with the same problems and the same issues. It may well be that there could be times when the health visitor is slightly out of step with what is going on, but I do not think the health visitors would not know.
  (Ms Jackson) I would hope your experience is not a general experience. There are varying degrees of service, if you like, across the country. Can I pick up on the public health training issue that you were raising. There is a tripartite advisory group that is meeting and we are part of that, along with the Faculty and the Royal College of Public Health and Hygiene. That is looking at public health specialist practice but at a very senior level and that would be multi professional. So it is doctors, nurses, environmental health officers, everybody that would have public health as part of their remit. A consultation paper is coming out from the Steering Group in January. Maybe there is a need to look at that, not at that senior level at which the qualification is going to be but perhaps at a more basic level. There are lots of questions there and I think it would be worth exploring.
  (Dr Crowley) I think the key to tackling the major public health issues affecting disadvantaged areas around inequalities is everybody seeing their role in it and also seeing the role of local people in that. The Families First model is only one example of how there is a certain power in training and supporting local people to provide peer support and peer advice to people experiencing social exclusion. Sometimes professionals will struggle to overcome the barriers there and working in partnership with trained local people who have not gone through professional training previously could be an additional arm, if you like, to what we do.

John Austin

  470. I want to go back to the training and qualifications. We have had a similar discussion about directors of public health and whether they need to be doctors or not. On the issue of the health visitor, I think Ms Amadi said that the pre-registration training for nurses provides the body of knowledge that is needed for the health visitor. No doubt you saw the article in the Nursing Times last month where Sarah Crowley, Professor of Clinical Practice, was saying the reverse, that we could easily design a three-year degree programme for health visitors with any necessary elements of nursing included in it. "There are many health visitors who work closely with nursery nurses, family welfare and community development workers, who have the potential to become expert health visitors and who could take advantage of such an option." Would you fundamentally disagree with that view?
  (Ms Amadi) I would tend to say that I would like to see that be tested and the results evaluated.

  471. The phrase came up a couple of times earlier about the "public health nurse". Could any of you define what you mean by "public health nurse" and how that differs from a health visitor?
  (Professor Drinkwater) Essentially that came in the paper around Newcastle West's Primary Care Group where we have a public health nurse within the patch who is, by training, an occupational health nurse. She comes by a somewhat different route and that has some interest and advantages in terms of helping to retain people in jobs, looking at long-term sickness absence and a whole bundle of issues around employment. In terms of a more generic role at the level of PCG/PCT there is an issue. The housing bit is quite a good example in that at the moment you have across the patch health visitors or GPs each writing notes on patients' behalf looking at housing.

Siobhain McDonagh

  472. Sometimes.
  (Professor Drinkwater) If they can be persuaded. The bottom line is that that system does not work. It is a crazy system. Where we have moved that to in Newcastle is there is now a nurse within the housing department who is funded through the PCGs. To an extent it is about how do you put in place systems that support individuals rather than leave it all to individuals, and I think that is the role of the public health nurse within the patch. The individual health visitors cannot do it on their own. They have to operate within a system that is agreed by the primary care group or trust and somebody has to be responsible for ensuring that that is delivered and that is why you need somebody who takes a lead. It is a lead role in terms of the public health agenda within the PCG and the PCT. I think that is then all about using health visitors and the knowledge of health visitors and community nurses around needs assessment and what is going on within their patch. Community nurses visit a lot of old people at home. Very often they live in damp, sub-standard housing which is cold and poorly insulated. It would not be beyond the wit of man to say why do they not take in a thermometer with them which they stick on the wall and as part of what they do in terms of nursing assessment, they could record the temperature and humidity within the house if it is damp and then refer it on to the housing department. That is not going to work unless you put it within a system and make it everybody's responsibility in which case somebody has to collect the data and ensure that is being done systematically.

Mr Burns

  473. I wanted to pick up a point. You were talking about GPs writing letters to housing departments to help on housing. Would you not agree, though, that that system is in a large proportion of cases totally discredited because the housing departments tend to look at them as pro forma letters and disregard them because due to the pressures of work on GPs they will write those letters to get the person out of the surgery. It is a ludicrous situation.
  (Professor Drinkwater) I entirely agree, they are totally owe discredited and not worth the paper they are written on.

  474. But GPs still find their arms twisted up their backs by patients and it is easier to send a letter than put your foot down and say—
  (Professor Drinkwater) That is why you need a system that is agreed across the patch and there must be a route and a signpost in terms of how that operates.

  Chairman: MPs have not dissimilar practices in my opinion.

  Mr Burns: Speak for yourself, Chairman. You are a braver man than I am!

  John Austin: I do not want to suggest that there was once upon a time a golden age of pre-1974 local government, but in my local authority we had in the health and welfare department an army of health visitors—perhaps a little army of health visitors—and some of them were specialist health visitors who were only working with the elderly. Increasingly health visiting is seen almost exclusively in my area as being concerned with young children and that may be the right decision. When the health visitors were within the health authority it is my view that there was a much more co-ordinated approach in terms of relationships with housing. I was interested to hear you say you have a nurse within the housing team.

  Chairman: Is it not tokenistic compared to what we had pre-1974, which was basically the local authority anyway? We are gradually going back to pre-1974, this golden age that John and I remember!

John Austin

  475. It does strike me that we do now have this fragmentation, whether we are looking at the planning process, community plans, or HImPS not coming together, or whether it is where people work and how it is structured.
  (Professor Drinkwater) I agree for all sorts of reasons that there has been fragmentation not least around health visitors, and why they are focused around children is there is a whole bundle of agendas around child protection and risk and issues to do with community trusts having to focus health advisers in that area. How we move away from that and begin to take a broader view and look at more effective systems, I do not know. I do not think we are going to go back to re-inventing pre-1974 local authorities but the next best thing might be primary care trusts where there is real partnership with local authorities.
  (Dr Heath) Can I support the point that Chris making about skill-mix. I often think it is good to use a real example where the system is not working. In my particular practice we are seeing an exponential growth in the number of young families where one or both parents either have a psychotic mental illness or have a serious drug problem and you just see these children going down the pan and there is no way to salvage these families at the moment. Maybe it is Families First sort of initiatives but our practice used to have six health visitors one of whom specialised in the elderly and it now has one just out of training. There is no way that she can offer any sort of agenda let alone the public health agenda. Meanwhile, the universal service is failing the most vulnerable part of the next generation. I think that sort of example is a good test of what needs to be in place and what is not in place.

  476. You raise an issue there about the supply of qualified health visitors and I think perhaps the Committee does need to take some evidence in looking at nursing shortages to identify the particular position with health visitors. Even if you were adequately staffed with your health visitors—
  (Dr Heath) They have said we do not need them.


  477. Who is "they"?
  (Dr Heath) The community trust.

  Chairman: They allocate the numbers within your area and you do not need them according to the community trust?

John Austin

  478. If you had available to you the number of health visitors you felt you needed to operate reasonably, there is still this conflict, is there not, between the universal role of the health visitor and the issue that you are raising of targeting?
  (Dr Heath) Yes.

  479. Even if we had more resources there would still be an issue as to whether the resources would be adequate.
  (Dr Heath) Yes, and I think, reiterating what Chris said earlier, we are never going to do anything about health inequalities unless we target in a very systematic way. Yes, you have to ensure a certain minimum level of provision for everybody but after that you have got to target the people with the greatest problems.

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