Select Committee on Health Minutes of Evidence

Memorandum by the British Medical Association (PH 43)


    "Public health is the science and art of preventing disease, prolonging life and promoting health through organised efforts of society" (Public Health in England, 1988).

  The BMA is both the doctors' professional organisation and also an independent trade union protecting the professional and personal interests of its members. More than 80 per cent of British doctors are members. The Committee for Public Health Medicine and Community Health (CPHMCH) is a standing committee of the Association and represents those doctors working in the fields of preventive medicine and population health who have a key role in the implementation of the White Paper Saving Lives—Our Healthier Nation.

  Public health doctors (directors of public health, other consultants and specialist registrars in public health medicine) lead the public health team in health authorities and health boards. Their role is in four main areas:

    —  protecting the public health;

    —  promoting health;

    —  tackling disease and ill health by promotion of effective—and cost-effective—personal health services; and

    —  ensuring mechanisms are in place to assure the clinical quality of health services.

  Public health doctors are trained, after experience in a clinical speciality, to higher degree level in core skills and experience across the range of fundamental sciences of public health. These include epidemiology, health information, statistics, preventive medicine, health promotion, communicable diseases, environmental health, health surveillance, development and evaluation of health services, social sciences, health economics, management of health services, teaching and research. Many public health doctors go into this postgraduate training after many years of clinical experience, often at senior levels in other specialities.

  Public health doctors recognise that the health of the population is predicted as much by factors such as the cultural, social, physical and economic environment as by health care. Many of the great improvements in health come from clean water, better nutrition, good housing and a supportive social structure. Health care is dependent on factors such as these and good health care is complementary to them and not a replacement. For example, at a population level, improving housing may be as cost effective as many aspects of health care provision.

  The CPHMCH welcomes the opportunity to contribute to the Health Select Committee's inquiry into public health and would be very pleased to present oral evidence and elaborate on any of the points raised within this evidence and respond to any issues the Committee would wish to raise with us.


  The most important new process proposed in the green paper Our Healthier Nation was health impact assessment (HIA), and we believed then that HIA might become as important to public health as the controlled trial has become to clinical medicine. However, some aspects of the methodology for HIA are well established, whilst others need developing, particularly its application to policy development. We believe that the Department of Health should support the development of health impact assessment methodologies, simplify access to databases and monitor the validity and effectiveness of their contents and also ensure it is adequately resourced. Nevertheless, there is already a great deal of experience of HIA, although it has not been so labelled. For example, whenever any consultation paper from another government department is commented on by the Department of Health or a health authority department of public health, a health impact assessment is being performed which, although may be a fairly superficial qualitative assessment, is often based on considerable experience. This screening and scoping perspective is important, but the Department of Health also needs to develop capacity to undertake deeper, more thorough appraisals as required of all policies under the Amsterdam agreement 152.

  Public health doctors are intrinsically involved in the operation and ultimate success of many of public health initiatives. They see them as a very important way of helping people to improve their health and well being but a fundamental obstacle to any partnership at local level is that different participants see themselves as representing different bodies rather than serving the same population. This is beyond the control of public health doctors but manifests itself in different ways such as:

    —  lack of coterminosity—the participants do not serve the same population;

    —  budgetary barriers—the participants see themselves as conserving their own budgets rather than as using resources optimally;

    —  narrowing of vision—participants have limited objectives so feel no commitment to the related objectives of their partners even when shared programmes would clearly lead to benefits; and

    —  limitation of authority—officers of one agency are seen as external to other agencies.

  The CPHMCH believes that the obvious solutions to these difficulties are to work towards far more coterminosity between boundaries of health authorities, local authorities and PCTs and develop much more freedom to move funds between agencies. Specifically, health improvement plans (HIPs) should be constructed at the lowest level of population for which a coherent service can be put together to address a coherent need. They should involve local people and be a reflection of local priorities, as certain specific requirements are not necessarily applicable to all localities. The population level could take the form of:

    —  the neighbourhood for health promotion;

    —  the primary care group for primary care services;

    —  the catchment area for secondary care;

    —  the social services authority for community care;

    —  the district council for environmental issues; and

    —  the county for tertiary and certain large scale issues.

  HIPs are not simply local commissioning plans; they require to be professionally led and to focus on service pathways rather than traditional service units. An external task force should be established to carry out extensive audit on some of these programmes.


  There is a recognised need to develop the evidence base on which public health practices. If the Agency is established to do this, then it has a vital role that could be seen as being equivalent to NICE for clinical practice. However, to function in this way, we believe that the Agency needs far more support from the Department of Health and needs well-established links with academic networks for primary care and environmental sciences. The Agency also needs to be given the opportunity to research developments and initiatives which cannot be evaluated in the short term, for example, the long term effects of health education and prevention.


  The White Paper The New NHS heralded a major re-organisation of the NHS and introduced the establishment of Primary Care Groups (PCGs) and the abolition of the internal market. PCGs proposed a new structure for the commissioning of health services, clinically driven and primary-care led. Health Improvement Programmes (HIPs) are the driving force behind health service planning and have clear priorities on health outcomes, and effective practice. PCGs are thus required to plan for a locality population, working with local communities, other agencies and the voluntary sector.

  The CPHMCH sees the establishment of PCGs and PCTs and the framework of HIPs as offering real vision for not only how the NHS might play a part in the improvement of the public health in the future, but also how the other agencies and local communities might work together on the wider influences of health. We also see many opportunities for those working in public health medicine to develop their roles and demonstrate the value and attributes of both the overview and the skills of public health medicine specialists.

  In particular we see the development of PCTs and PCGs as a primary care-led decision-making on planning and use of resources; and a mechanism for collective decision-making at a local level over resources within a unified budget. We believe this has the potential to remove some of the organisational barriers which have been in place between secondary and primary and community care, between different provider organisations and lead to the establishment of a strategic planning framework that is driven by health priorities. There is scope to strive to develop direct relationships between health and other policy areas such as social, environmental and economic; and initiate a major drive on quality and equity, with a focus on evidence based policy.

  The price to pay for all these radical developments has been another major re-organisation within the NHS and the initially unsettling effects this can have. This has led to many professionals (particularly in primary care and public health) reviewing the part they play and examining where decisions are made. It is clear that many doctors are being asked to operate in the areas in which they feel ill-equipped or lacking skills and experience. For example, GPs becoming involved in the organisation, management and strategic planning of resources; public health doctors working at a more local level with primary care practitioners; to help develop new organisations that appear reluctant to assume these new wider roles and responsibilities. We would like to see an organisational development agenda that recognises this.

  The creation of this new structure within the NHS inevitably raises questions as to how the new structures will operate. We hope the Chief Medical Officer's review of the public health infrastructure will take account of not only developments in primary care, but also the whole range of functions of public health practice including communicable disease control. The CPHMCH is currently considering the communicable disease control function and where it should best sit organisationally in the future NHS, and how it would exert the necessary control across the new organisations. We have been alarmed by some suggestions that it could be removed from DHAs and sited within the new public health observatories. Consultants in communicable disease control need knowledge of disease and epidemiological skills but also an extensive local knowledge and close working relationships with other key players. We hope that the CMO's review of the public health infrastructure will help to address some of these wider issues but are frustrated by the time being taken for the review to be completed.

  We are also uncertain as to the future of many community health services with the development of PCGs and PCTs, for example, community child health services and family planning. We are concerned that this traditionally underfunded sector of the health service will continue to struggle within the new organisational structure and would wish to see ways PCGs could be used to improve the service rather than fragment it.


  The CPHMCH welcomed the appointment of a Minister of Public Health and recognised the potential value of the post. We do, however, have some concerns over the seniority of the post and capacity to influence other Government departments, but this is no criticism of the two individuals who have held the office to date and have worked hard to achieve the confidence of those working within public health. We believe that the role of the Minister should be developed to a far greater extent across inter-Government departments so the impact on health of all Government policies can be measured and assessed. We have met both Ministers and have worked together with them on public health issues. We very much hope that this spirit of collaboration and co-operation will continue. It has been acknowledged that in the past opportunities for collaboration have been missed and the CPHMCH believes there is scope to develop this relationship far more, to the benefit of both the health of the population in general and the medical profession itself.

  The CPHMCH has also viewed with concern the apparent limitations of the capacity and skills base of the public health department within the Department of Health. We believe that as a result of its very limited capacity of trained public health doctors its ability to influence the health components of other Government departments' policies is compromised. It has been the Committee's experience that other Government departments welcome and respond positively to health advice and we deeply regret the failure of the Department of Health to build upon and strengthen this.


  The historical role of public health doctors is to act as the entrepreneurial advocates for health in their population. Their task is to identify the changes that are needed to improve the health of the people and to secure these changes. These will often be major changes over long time scales and face considerable obstacles and vested interests ranging from the slum landlords of the past to the tobacco industry of today. Often their only power is persuasion of organisations over which the public health physician has no direct control and to which he has no direct responsibility, such as local authorities, industry, political groups, etc. Their prime function, drawing heavily upon professional knowledge, entrepreneurial ability, creativity, judgement and risk assessment, has been constant for over a century and will remain constant, even though their more routine bureaucratic functions have changed and will continue to change dramatically as the organisational format in which they work itself changes.

  In particular, the work of district directors of public health and their consultant colleagues includes the assessment of local health needs and problems, the development and implementation of health promotion strategies, leading the authority's work on improving appropriateness and effectiveness of clinical and non-clinical interventions, developing and sustaining relationships with authority members, clinicians, GPs and PCTs, local authorities and the community. They are accountable for surveillance, monitoring and control of communicable disease, including the appointment of a consultant in communicable disease control (CCDC), and they are accountable for the surveillance, monitoring and control of non-communicable environmental exposures and all factors relevant to health. They act as the focus for all local public health advice including ensuring that providers of primary, hospital and community care, including the voluntary and private sectors, have access to adequate and appropriate public health advice.

  The CPHMCH strongly believes that the DPH is not simply a manager of a part of the organisation. The role encompasses leadership, influence via gaining respect as a professional colleague and providing an agenda-setting, ideas-generating role for the health authority. The DPH also acts as an advocate for the population served by the health authority and an independent professional voice (without other vested interests) on behalf of that population. The professional accountability of medically qualified doctors means they have added value in this role. Through his annual report the DPH fulfils an independent public audit function. There is no other part of the organisation (except the Chief Executive) which has a role across all three functions. Under the leadership of the DPH, the consultants in public health medicine will carry responsibility for functions such as needs assessment, public health advice to specific local authorities, or environmental protection that are, in themselves, major functions. The fact that so much of the work of the public health department is achieved through others, including groups external to the organisation, may conceal the importance of these functions if a simplistic head count is the basis of observation.

  Saving Lives—Our Healthier Nation suggested the creation of a new post of specialist in public health "which will be of equivalent status in independent practice to medically qualified consultants in public health medicine and allow them to become Directors of Public Health". When it learn of this proposal the BMA Annual Representative Meeting rejected the implication that the core roles and responsibilities of directors of public health and consultants in public health medicine could be carried out by non-medical specialists, and insisted that every population must have an independent public health physician with the right of free speech and full access to health and local authorities on all issues affecting public health. Public health physicians are well used to the concept of multi-disciplinary team working, indeed most accept that the public health enterprise can only be conducted in a multi-disciplinary framework. This summer, at their annual conference, public health doctors called for the development of a satisfying career structure parallel to that of public health medicine for those who are not medically qualified; and also for the development of recognised, rigorous and relevant qualifications for those following this career path.

  We are extremely concerned, however, about the notion that a health authority or in due course a primary care trust, might be able to function effectively without a public health doctor at the heart of its corporate structure. We have made these points to the Minister for Public health, as we fear this proposal will undoubtedly have implications for recruitment to, and retention in, the speciality of public health medicine.


  The CPHMCH has previously advocated that an authoritative, strategic, independent standing body along the lines of the Law Commission or the Royal Commission on Environmental Pollution be established to report regularly on major public health issues. This would provide an invaluable support to the Minister of Public Health. It would also provide the strategic focus on health sometimes missing in the Department of Health with its focus on health care and waiting lists and its lack of skills in addressing key determinants of health such as poverty, cold damp housing and poor nutrition and pollution.

  Task forces may operate at national/regional or local level. For example, at national level, roles might be:

    —  to inform the Minister for Public health;

    —  to inform all relevant Government departments on their brief in relation to delivering the public health agenda;

    —  ensuring that the public health agenda is the prime factor in determining government policy; and

    —  to pull together, define and disseminate best practice based on evidence in relation to the target areas, for target-setting and for effectiveness of interventions.

  Membership should be governed particularly by the need for specialist experience and expertise and should include representation of those with key responsibilities and accountabilities, key players within and without the statutory sector including users and community representatives. The BMA and other public health interests should help to identify the potential membership. We strongly believe that such a body would be instrumental in reducing health inequalities and improving the health of the population across the country.

  We have been pleased to see the Government has identified a number of priorities for action to promote health and reduce inequalities in the health status of the population. We have been actively engaged in discussions with the Minister on some of these key initiatives, including the development of a national surveillance scheme for monitoring the incidence of accidents. We strongly support the aim to reduce accidents but believe this can only be done effectively when accurate statistics are recorded, and the surveillance is linked to national policy development and implementation. The model of effective practice in this area is established in the USA. We also support the intention to reduce the incidence of coronary heart disease and stroke but believe that targeting of risk factors and of effective early interventions will require deployment of additional resources. We also believe that other projects such as healthy eating initiatives and programmes to encourage physical exercise are vital to reduce inequalities in health and must be adequately resources and supported.

  We make no apology for continuing to argue strongly that the fluoridation of domestic water supplies would be a highly effective preventative health measure and make a significant contribution to reducing health inequalities. The scientific evidence of the effectiveness, safety and cost benefit of fluoridation is overwhelming and demonstrates that it is an effective means of reducing the gap in dental health between those in the highest and lowest socio-economic groups. We urge the Government to act now and introduce this major preventive health measure.


    "it is better to be healthy than ill or dead. This is the beginning and the end of the only real argument for preventive medicine. It is sufficient" (Geoffrey Rose: The Strategy of Preventive Medicine, 1992).

  We would welcome the opportunity to discuss these points or any other related issues with the Health Select Committee.

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