Examination of Witnesses (Questions 484
THURSDAY 14 DECEMBER 2000
A RYLANDS, MS
484. Can I welcome you to this second part of
the session and thank our witnesses for their attendance and written
evidence. Could I ask you each to briefly introduce yourself to
(Mrs Naish) I am Jane Naish and I am policy adviser
at the RCN. I am also an ex-health visitor.
(Ms Gough) I am Jenny Gough. I am a public health
development nurse for the South East Primary Care Group in Wolverhampton
and I have been a health visitor since 1974 so I remember working
in a Local Authority, but I am wearing well!
(Dr Rylands) I am Alison Rylands. I am
a Consultant in Public Health at Wirral Health Authority and a
I am co-opted board member of Bebington West Wirral PCG.
(Dr Tiplady) I am Peter Tiplady, Director of Public
Health in North Cumbria and I am old enough to remember the golden
age you to which refer. I started my career in public health working
as an assistant to the last Medical Officer of Health for Carlisle.
485. Thank you very much. The last witness,
Dr Crowley, made some critical comments about the NHS Plan; you
probably heard her a moment or two ago. Your written evidence,
I understand, was submitted to this inquiry before the National
Health Plan was published. I wonder whether in view of that that
you feel beyond Chapter 13, which relates to health improvement,
that the plan does not offer a great deal on public health. This
is an issue that has been raised by other witnesses. Do you share
(Dr Tiplady) I share some of it. I think this Government
started with such an exciting development with the Green Paper
on Public Health and the White Paper, a Healthier Nation,
which had a powerful and major public health agenda. We were all
delighted to see that. For the first time there was the emergence
of a strategy for health at a national level which recognised
the root causes of ill health. I think it would be fair to say
we have not seen that promise materialised in the national plan.
There are clear resonances of it but the root causes of ill-health
do not figure so much. Public health is not mentioned very often.
I think the most frequent mention of it is as titles of witnesses
rather than as topics within the paper. A structure has been developed
which I think is a very positive thing, but I share some of the
concern that the early promise has not been maintained.
486. Does the RCN have a view?
(Mrs Naish) There are some very exciting things in
the NHS Plan. For one thing, there is the setting of national
inequality targets, which I think most of the organisations that
have been here have been badgering for. There is also the construction
of a health poverty index, and that is very important in terms
of public health. We were quite surprised that the paper ducked
the issue of water fluoridation. That is very important in terms
of health inequalities. But it also duckedand the Green
Paper did so toothe actual process of how you deliver public
health in the field. It remains at a strategic or overview level.
There is nothing in there about one of the two key issues about
how public health departments relate to practice including, importantly,
primary care which you have heard a lot about that this morning
and there is a whole range of issues within that. Also, quite
frankly, at local level most people just do not work together.
Housing departments do not necessarily know social services let
alone the health visitors. Jenny has got lots of examples. If
you want to get a real change in practice you have to get people
locally to work together, rather than just at strategic levels.
(Ms Gough) I think the new NHS Plan gives us lots
of opportunities to work on those links and to work on those partnerships.
A little bit of background; as I say, I have been a health visitor
since 1974 and in 1996 I was given an opportunitythat wonderful
wordto develop a public health role in Wolverhampton alongside
a traditional three-day health visiting caseload. I was given
this job, which nobody else seemed to have done before, to develop
and what struck me as a worker and health visitor along the way
is this lack of information, lack of co-ordination about exactly
what people that are working on the ground do or do not know.
Hopefully, I have been instrumental along the way in developing
and being a resource and being a link for my colleagues. That
is not just as health visitors; that is district nurses, practice
nurses, GP practices and across local authorities and voluntary
organisations. I have not heard them mentioned this morning but
they are a very important part of that integrated team. The result
of work that I did on the ground developing a public health role
opened the door for me. The Director of Public Health found out
what I was doing on the ground and I have been seconded to the
Public Health Department for the last 18 months working alongside
the Director of Public Health both at a strategic and clinical
level. I have been able to widen those links across all boundaries.
This is quite a new development. It has not been a lateral curve;
it has been straight up to the ceiling, but to get colleagues
and to get communities together is certainly a way forward for
487. Can we explore a point that was discussed
in the last session which is about how we address this joint working.
It is very gratifying to see that people can remember the structure
before 1974. I worked in that structure within local government
pre-1974. It worked well and I would put to you the point I raised
with the previous group of witnesses that there is a lack of clarity
about the future role of DPHs and we are all raising questions
about where that function will be in five years' time. Is there
not the opportunity to look quite radically at recreating the
networks we had pre-1974? I worked as somebody involved with child
protection on a day-to-day basis in the same room as health visitors.
It was at the time of the Maria Colwell inquiry so we were involved
with the problems we had with child protection. We had the networks
there that were based on being in the same agency. We had housing
managers within the same agency which made it much easier for
the kind of example Siobhain gave about notes from health visitors.
They could directly influence the process of allocation. Should
we not been exploring the positives of that previous system in
going back to your point about the role of public health directors?
(Dr Rylands) There is an assumption that that does
not happen already when, to my view, it does. The experience that
Jenny has just described is similar to the experience we have
had in the Wirral, for instance, but it has gone the other way
round and the Department of Health has identified health visitors
and decided to further develop their role in ensuring that they
understood what went on at a health authority strategic level,
and to work closely with them in their links with the community,
but bringing in the local authority colleagues as well. I do not
think you have to necessarily be in the same building. That does
not necessarily mean you are going to work together. Partnerships
are about relationships and you develop those as you work together.
I think that is happening, often through the auspices of public
health being the catalyst for change to some extent.
488. You are a consultant in public health.
Can I put to you a concern that I have got about the new public
health departments that arrived post-Acheson. I think what has
been in existence post-74 has been more concerned with public
health science than practice. I am interested in the role of the
director of public health propounded in the Acheson report: "to
develop and evaluate a policy on prevention in health promotion
and on litigation". There is no mention of implementation
in there. You could come back to me and say that you do that,
but what I see in various parts of the country is all sorts of
brilliant reports produced annually, very important reports, making
some very important recommendations, but the person who is responsible
for that report is not in a positionas the old MOH was
in my experienceto get up at a council committee and bang
some heads together about why people were not driving forward
the policy changes that were needed.
(Dr Rylands) I think some of that will change with
the NHS Plan with the whole idea of scrutiny committees and changes
in accountability arrangements, but I think implementation has
become more and more a function of public health. The implementation
of the NSF, by and large, has landed on public health consultants'
and specialists's desks and they are very much responsible, but
working very very closely with their clinical and managerial colleagues
and not just in the Health Service but with local authorities
as well. In the NSF for heart disease, for instance, we have an
enormous linkage with our local authority in terms of leisure,
education and housing to try and ensure we do something about
heart disease. So I think implementation is there as part of our
489. Sticking with you, Dr Rylands, on the issue
of the domination of the medical model, which has been thrown
at us time and time again from a range of witnesses including
medical witnesses. How do you react to that? How do you see that
holding back the process of change which we all think is needed?
(Dr Rylands) That is an absolutely crucial role for
public health practitioners, be they medically qualified or not,
because it is those individuals who can shift from the medical
to the social model. With all due respect to my colleagues in
general practice, they have been trained in the medical model
and unless we do something about further changes to the medical
curricula or we ensure that their vocational training includes
more of a focus on public health, it will still need to be public
health practitioners and that includes health visitors and district
nurseswho understand the social determinants of public
health almost more than anybody because they are there on the
ground with those individuals.
490. Going back to the point made by Dr Archard
about his partners not believing he was doing proper work when
he was away doing public health, you see that being addressed
in the longer term with training?
(Dr Rylands) Yes.
(Dr Tiplady) I feel very clear about the future role
of health authoritiesthey are public health organisations,
and I see an even stronger role for a public health population-based
approach to the community. I have spent most of my professional
life trying to retain the networks that we used to have in the
old days and I put a lot of time into doing that. They are very
strong and we have maintained links with housing managers, with
social services departments, with social workers, with occupational
health departments in the trust, and these are all very positive
features that we have struggled to maintain over time. I see this
as a core function of a health authority in the future in delivering
a public health agenda, but the key to it is that it is a multi-disciplinary
agenda involving a whole range of professionals, not just doctors
and a medical model, and it should embrace all of them.
491. I think it is true to say that governments
are notoriously bad at taking a long-term view, given our electoral
system and given the need to produce short-term results is a great
imperative, although I hope we are trying to change that. In the
RCN memorandum you called for the introduction of performance
management indicators for public health. Do you think these would
be viable given the length of time that interventions take to
take effect? If you do, can you give some examples of public health
performance management targets which you feel would be appropriate
(Mrs Naish) I think the reason the RCN put that in
its evidence was because we think they would be a useful lever.
One of the key things, which I have not heard previous witnesses
today say, is that public health is not particularly mainstream
in the NHS. It is not sexy, it is not high status, if you are
pukka you do not go into public health. I think one of the issues
is getting an organisational corporate hold on public health because
it is very marginalised in the work of trusts, PCGs, still at
the moment, and indeed in health authorities to a large extent.
So using performance indicators as a lever is very important.
The sorts of things that we had in mind could be around the process,
whether it was about community involvement, or it could be about
achieving local targets and the implementation of that. It is
basically to get some kind of commensurate pressure on chief executives,
dare I say this, to other issues they have such as waiting lists.
They have got this other heap of things around waiting lists and
492. You feel that would make a real difference?
(Mrs Naish) That would be just one of the things that
would change the culture.
(Dr Tiplady) I think there are public health initiatives
that do bring results in the short term. It is a mistake to think
that everything is on such a huge horizon that we never get there
so we start mucking about with very wishy-washy performance indicators
and forget the targets. There are two that I would bring to your
attention. One is the fluoridation of the water supply where benefits
are seen very quickly in dental health and certainly fluoridation
results would be seen within the term of one Parliament! Secondly,
in Russia the decrease in life expectancy that took place after
the dissolution of Russia was rapid, suggesting that environmental
causes were very significant in determining life expectancy. What
we all know in public health is that there is a very dramatic
demonstration of how health can change so rapidly, so we do expect
that environmental changes brought about through partnership issues
like health action zones and education action zones will improve
health as quickly as it fell in Russia, so again short-term objectives
may be seen.
(Dr Rylands) Can I make a point to shift the perception
a little bit in terms of the role of public health with trusts,
particularly acute trusts. There are a number in the country that
have consultants in public health medicine and specialists in
public health in post. My local acute trust is one of those. That
not only facilitates reasonable discussion between the health
authority and the trust because we talk the same language, but
also ensures that the public health message is on the agenda of
trust chief executives. It is not only about epidemiological analysis
and being able to interpret statistical information, it is about
ensuring that population perspectives in the health promotions
are starting to be shared with the clinical consultants and nursing
staff across that trust. I think it goes back to the point that
was made earlier today about health being there at every level
right down to the individual and up to a national perspective.
(Ms Gough) I would be very keen to see public health
incorporated in a mainstream service. In Wolverhampton we have
got a director of public health joint appointment with the local
authority and health authority and that has moved things forward
tremendously because we are forging really good links with our
local authority and voluntary organisation colleagues. Looking
at the short term, I agree that you could provide short-term successes.
For example, I have been setting up breakfast clubs within schools.
I kept calling them "quick kills" when I meant "quick
wins" before I was corrected. They are quick wins and they
do show benefits. They are having a great effect on the children
in Wolverhampton schools. I have concerns about short-term contracts
for professionals trying to deliver the public health agenda.
In my own instance I was given contracts on a six monthly renewable
basis. It takes six months to get a community's confidence and
trust. They would not recognise me today because I am normally
out there in my jeans and my Doc Martins or something. I had to
fight every six months because I am so committed to public health,
so enthusiastic and passionate about it, and at my last six month
contract I staged a sit-in in the general manager's office with
my sandwiches and my tin of Pepsi I had asked for my contract
to be renewed time and time again. I had written, phoned and had
no response and was I was determined because the role I had developed
was so important to those communities and to myself because the
links we had formed were too valuable to lose. I think it is really
important that we do have some performance indicators and we do
incorporate public health into the mainstream. Yes, let us look
at things that we can get there in the short term as well.
493. You are a trust?
(Ms Gough) We are a health care trust, yes, we are.
(Dr Tiplady) I did give some thought to what indicators
could be used. This is not by any means a comprehensive list but
I have got a few ideas like monitoring the health status of the
community. That is a simple public health task. Is it done and
how good is it? Does it identify hazards to health in the local
community? What plans have been set up to protect the public from
those hazards? How effective has the public health department
been in mobilising and energising partnerships? Does it provide
a competent workforce to address these issues? What research does
it do into innovations in public health and how does it evaluate
the effectiveness of its own actions? I used to be on the Kerner
(?) Committee for statistics all those years ago and my main contribution
was developing performance indicators for hospital chaplains,
but it was withheld from the file!
494. Could I pose the question that I put earlier
as to why a director of public health has to be medically qualified.
Is it necessary?
(Dr Tiplady) At the moment it is a legal requirement.
495. I know it is a requirement.
(Dr Tiplady) Public health is a multi-disciplinary
speciality and the issue about people other than doctors becoming
directors or specialists is that they should have a proper training
programme which delivers the skills they need to practise public
health and when that is done I think that specialists will be
on an equal footing with doctors and eventually I am sure they
will be competing for the post of director.
496. Do you think there could be a potential
at the present time for splitting the post of director of public
health into two posts, one which deals with the medical responsibility
roles of a medical director of public health and the other more
managerial, epidemiological, social?
(Dr Tiplady) I think that may have the danger of fossilising
the medical model. We are all convinced that is not right way;
the social model is the best model.
(Dr Rylands) The mixture that makes up a public health
medic is a good one, just as the nursing input plus background
and further training adds to the mix, and I do not think you should
try and separate them. I think the two together are what makes
the role effective, as it would be if a general practitioner had
done some public health work or an environmental health officer
had worked on the management of public health. I think it always
goes well together.
497. Earlier on Ms Gough said that in her case
the director was a joint appointment of the health and local authority.
The RCN are, very clearly, powerful advocates of that policy.
Is there any evidence that you have to show that this has worked
or been effective? What impacts have there been which would not
have been achieved if it had been a health appointment only?
(Ms Gough) I think our director is more aware of looking
at the social model of health as well as the medical model of
health. I am now in the public health department because he was
aware of what was going on within local communities. He comes
out to local nurse meetings and to health visitor staff meetings.
He is also on regeneration and partnership boards so he is going
into our local civic centre where our housing associations and
housing local authorities are based. The fact he does not just
set himself apart in the public health department, that he comes
out and sees what goes on in other authorities and in other departments
has made an amazing difference to the way Wolverhampton is now
structured and working, particularly in partnerships, bringing
people in at a local level and he goes out to local communities
as well not just to inform staff but to inform consultants. We
have a consultant in public health now in each PCG area, so if
there are concerns by the PCGs' chief executives, staff, health
visitors, district nurses, GPs, they do have a named person with
whom they can liaise on community development. I have to say that
our assistant director of public health is not a doctor and he
was an Assistant Director of Strategy before taking up his post.
(Dr Rylands) You do not need to have a joint appointment
to be able to do all of those things. I think my director of public
health would be very upset if I did not say that she comes out
of her department and sits on all the regeneration, Objective
1, health action zone groups, etcetera, etcetera.
(Dr Tiplady) I think what would be helpful is movement
in both directions because one of the statements in the White
Paper was that they would anticipate that directors of public
health (or presumably on their nominees) would be invited to local
authority council meetings. In my experience health authorities
have taken up that challenge quite rapidly and usually invite
representatives from the county council and occasionally the districts
to attend health authority meetings. I do not think that is happening
in the other direction and I think that would be very positive.
498. I am grateful for that because the Chairman
mentioned earlier going back to pre-1974 and the old MOH. I can
recall when the MOH published his report, other chief officers
would be quaking in their boots, particularly the housing manager
as he was then, to hear what the doctor was going to say about
the council's housing policy. To what extent is the annual director's
report less powerful than the old MOH one? I think Dr Tiplady
has already answered that question by saying that one way he has
become more powerful is he is going along to council meetings.
Do you think that report can be made a much more powerful document?
(Dr Rylands) Again using the local context, one of
the reasons they are not quaking in their boots when the DPH report
comes out is that they helped to write it and, although the director
of public health is the editor and it is their report, it is much
more about the health of our local population and that includes
all those wider determinants as well as how well the trust is
performing, for instance. We try not to get too bogged down on
what our SMRs are and we try to expand on the community development
that has gone on and the links that have been made with other
(Dr Tiplady) A public health report now can discuss
and make recommendations across a much broader area than we could
in pre-1974 days where it tended to be about the services provided
by the local authority.
499. Does that raise the issue of HiMPs being
separate from the community plan and whether they should be brought
(Dr Rylands) We are bringing them together.