Examination of Witnesses (Questions 500
THURSDAY 14 DECEMBER 2000
A RYLANDS, MS
500. In your area but it is not true everywhere.
(Dr Rylands) No.
(Dr Tiplady) I would like to point out that certainly
in my district we have local authority representation throughout
the planning structure for health improvement programmes. We have
a very important programme board which we set up for promoting
good health because the local authorities, not the Health Service,
were complaining that they did not think enough emphasis was being
given to the promotion of good health. We now have a health board
promoting good health and that will be chaired by the local authority
501. If it is not happening in all areas and
it is happening successfully in yours, do you think there is some
need for guidance from the Department of Health?
(Dr Rylands) There is a duty of partnership now and
it may be that some people have managed to do it more quickly
than others because of the historical relationship that already
existed. I think some of the other initiatives that are around
have expedited that. For instance, I know the health action zones
which we have and which Peter has as well have brought local authorities
and health authorities together to work on those plans. I think
it is happening, albeit slowly.
(Dr Tiplady) It is always a good plan to share examples
of good practice.
502. Could I direct this question to the BMAalthough
the RCN may have a view on it. On our visit to various community-based
public health projects in the South West of England we were told
that GPs were often reluctant to become involved, indeed could
not be dragged kicking and screaming to be involved. Can you suggest
why this should be and what can be done in practical terms to
increase their participation? They are at the front line and if
they are divorced from the projects going on, that is sad.
(Dr Tiplady) We both work very closely with GPs and
primary care groups. My experience is that GPs are under enormous
pressure to join in by coming to meetings and they often feel
paralysed by meetings"death by meetings" is the
phrase. I think there is a certain truth in that. After all, a
primary care job is about developing primary care, not assisting
the health authority to carry out its functions. I think the answer
is that we should expect and hope GPs that would be involved in
the things they can contribute best to and there are other areas
to which public health can make the best contribution. The answer
is we should be working closely together. I do not think it is
a question of money; it is time. GPs have a limited amount of
time and there is an enormous number of meetings to which they
are invited. I try to engage them in what I think are the important
(Mrs Naish) I think there are several fairly obvious
issues as well though. One of them is that nurses and doctors
are primarily educated to work with individuals. To get them to
make that huge shift into population thinking would need quite
a lot of investment in education, which is not currently going
on. Secondly, there are some difficulties, as an ex-health visitor,
when you are in the field. There are two things; one is what people
expect of you. What they want you to do is work with the person
in front of you at that moment. There is always the tension of
how to balance this. I am not surprised that GPs do not get involvedand
I know they are not on the whole involved in community schemesbecause
their workload is predicated on working with individuals and individual
(Dr Rylands) It goes back to the point I made earlier
about education and training and it is about enabling general
practitioners and other professionals, who are more used to dealing
with an individual case load, in a sense to take that population
perspective and then see an opportunity, as was described, to
change their career focus slightly or to engage in a wider range
of activities. There are different ways of doing this. Some may
say you can go off and become a public health practitioner (and
a lot of my colleagues have had a general practice background)
or you might take the opportunity to do a sabbatical or ensure
there is some public health training within a vocational training
scheme for general practitioners. The Master of Public Health
I did was extremely multi-disciplinary. We had teachers, nurses,
environmental health officers, occupational health practitioners,
GPs, and specialist registrars. You gain so much from that environment
that even if you go back to being a jobbing GP you take with you
a completely different perspective that changes the focus of your
503. Do you think that there should be much
more emphasis on preventative health care in the training? We
are an "Ill-Health" Service and GPs, quite rightly,
see their role as dealing with sick people and making them better
and the preventative health side has not had great emphasis.
(Dr Rylands) I think the GMC has recognised that to
some extent and the new medical curriculum has suggested that
there should be much more emphasis on public health. That is not
a medical speciality, but as a core underlying theme that makes
medical students in particular think about why people have the
lifestyles and life behaviours they have and what are the causes
of ill-health. Much more of the medical training is about working
with other disciplines as they go through their training programmes.
In Liverpool, nurses and doctors and physiotherapists are doing
their training together to a large extent and that can only be
(Ms Gough) Can I just make a comment while we are
talking about training and education. I am very keen that if people
want to go on to do a Masters in Public Health that they are given
the opportunity to do so, but funding is quite an issue. In the
role that I have begun working on and developing I have had to
fight to get funding to do my Masters, which I hope to start in
Birmingham in September. I could not get any funding from my region
or my own local school of nursing and health authority and I have
been funded by the Black Country Education and Training Consortium.
This is an issue where we do not give opportunity and we do not
encourage people. I am motivated, enthusiastic and I like to do
innovative things, but if we are going to expect people to deliver
a service like this we need to put our money where our mouth is
and provide some funding. You do not have to resource community
developments and training issues out of your own pocket all the
time. I have already funded a degree out of my own pocket. I also
fund some community development. Here you are in your two days
a week public health role and there is no more money, no more
resource, so when I have developed parenting packages and domestic
management packages and taken young lone parents shopping to do
budgeting and very basic things that will provide our next generation
with a better quality of health, the money for that shopping round
the local market is out of my own pocket. I do not have a problem
with that but I should not have to do it. It is an issue. It is
only a very small amount but I still should not have to do that.
504. Do you feel that with any new money that
has to go to the NHS, the emphasis should not be on this end of
primary care but preventative health care?
(Ms Gough) I think it is a very important part of
training and I think it should be combined. You have got to have
medical input alongside social care and I think it is important
to try and combine it. As we heard earlier, if you choose to be
a district nurse or a health visitor the career pathway is into
management so you either become an assistant general manager or
a general manager or, as is happening now, you can develop a career
in public health if you want to do that. What we need is back-up
training and funding to enable practitioners to go along that
pathway and also matching salaries. The work that I do, especially
working with things like New Deal for Communities, is very stressful
and you need training and input. You look at the salaries of public
health directors and they are on, say, £55,000 and I earn
£25,000 for 34 years' experience, sometimes 15 hours a day
three or four days a week and weekends because if you are working
with communities they are out working themselves during the day,
so if you want meetings with communities they are in the evenings
or on Saturdays.
(Mrs Naish) Just coming back to that question, what
one needs to do is engage the public in some of these debates
about public health because at the moment the public see the Health
Service, as you know, as about delivering acute care. There are
some real issues about how we engage the public in some of the
debates on how we spend Health Service resource and engage them
in spending on public health issues.
505. Can I come back to the relationships with
general practitioners. I was interested in the BMA witnesses saying
that in their area that it was not a problem, it was not an issue
and there was a relationship between the current health function
and general practices. I would be interested to know how you created
that relationship and also how you see the PCT development impacting
on the on-going relationship.
(Dr Rylands) If I can answer from my perspective.
I cannot give you chapter and verse because the relationship already
existed when I took up my post. There had been links between the
Public Health Department and the localities, as they were then,
across the Wirral.
506. You heard my earlier question.
(Dr Rylands) They certainly know who I am
507. I saw your expression.
(Dr Rylands) I have a lead role for a couple of things
across the district.the GPs in my Primary Care Group, and,
I would hope, the other practitioners within the Primary Care
Team, although to a lesser extent. I wonder if I asked the health
visitors whether they would know who I am, some of them would,
GPs certainly do. It is historical. It has been about the Health
Authority and the Department of Public Health being prepared to
offer the time of an individual, it has been doctors and public
health specialists, to the localities, the subsequent GP Commissioning
Pilot that we became and then the PCG. It has been there and negotiated
and is actually used. I am a cooperative board member, even though
I have an official position in the Primary Care Group, and that
is true for a number of our neighbouring districts, it is not
unique to the Wirral. I am involved in clinical governance; in
the health improvement programme; in specific clinical areas;
in working with lay representatives in terms of community and
public involvement. We have a public health facility which is
part funded by the PCG and by the Health Authority, who works
very closely with the primary care team, the local authority and
the voluntary sector. It is about relationships and getting to
know individuals. I think in health authorities where they kept
their Public Health Department remote as an advisory service it
will not be successful.
508. You see a distinction between the approach
of some health authorities in terms of public health, as something
far more hands-on, traditional, even in advance of the current
(Dr Rylands) In terms of developments around primary
care trusts there has to be somebody with public health expertise.
What has happened in our location is that they have seen that
that needs to be somebody with additional training, not just somebody
who might have walked past the Department of Public Health on
occasions. I think that is quite important from a professional
point of view but also from an expertise point of view.
(Dr Tiplady) In my case I was a GP before public health
so I have always put high priority on maintaining relationships
with primary care teams. As the commissioning of primary care
groups developed because we are so closely involved with them
it was very easy to identify what they wanted from public health.
For some time now we have had each primary care group, and they
are all hoping to be PCTs next year, there are three of them,
having a notional of one day a week from one of the consultants
in the department and also the same amount from the Health Education
Department. This fits well with what they do. It is about local
needs assessment and promoting health, but also some of the jobs
that they simply find it difficult to do because they do not feel
properly trained or they simply do not have the right time to
do it. Doctors are involved in looking at various treatments and
assessing the effectiveness of treatment that the GPs are not
sure about. It works well. We also have one doctor, the same doctor
is notionally allocated to each of the four local authorities.
509. The BMA obviously places much importance
on health impact assessments. In your evidence you said that the
most important new process proposed was in the Green Paper, "Our
Healthier Nation Health Impact Assessment". You said, "We
believe that HIA might become as important to public health as
the control trials have become to clinical medicine". You
then go on to say, "Whenever any consultation paper from
another Government department is commented on by the Department
of Health or Local 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". Can you expand on that a bit, please?
(Dr Tiplady) The principal or the detail at the end?
510. Both aspects. You think it is very important.
We would like some information as to how you think this can all
be delivered in practice.
(Dr Tiplady) The evidence based clinical practice
is now a fact of life. All clinicians are expected to have a lifelong
commitment to evidence-based practice. Evidence is now accumulating
and it enables authorities, whether it is local, regional or at
national level to make assessments of the impact that that policy
is going to have on the health of the community. It seems to us
that this ought to be done as a matter of routine. When policies
propose they are going to change the way services are managed
or resourced we ought to know what is going to happen to the health
of the community. The real excitement, of course, of health impact
assessment is when it extends beyond the margins of traditional
medical approaches, like how effective tablets or pre-hospital
thrombolysis is going to be. One of the very first examples which
was published was the health impact of Manchester Airport.
(Dr Rylands) Liverpool University is at the forefront
of that. We have had several pilot studies done in our local community,
it is not just about health impact on policies but also on new
developments. There is a new astronomy development happeningwhich
is a big thing in Birkenheadin conjunction with one of
the local academic institutions, and a health impact assessment
is being done on that. As Peter says it looks at not only medical
issues but it concentrates on things like what is the impact of
increased traffic flows, what is the benefit of having increased
employment in that area and the resources that will follow, a
new tourist and academic development. That is something that public
health practitioners have developed a lot of skills in and worked
with the local community to make sure their voice is heard in
looking at what the effect of such developments will be.
511. I was thinking, Dr Tiplady, you could have
an interesting challenge if it was proposed to close Sellafield,
an assessment to cover that issue.
(Dr Tiplady) That happens all of the time. We do know
what that would involve. It could be closed but it would never
Chairman: You said that.
512. I just want to pursue this a bit more.
It does all sound wonderful in theory and if this all worked we
might as well pack up and go home, it would solve all of the problems.
Yours is an organisation which has plenty to say for itself. Do
you not think there is a slight tendency to go through the motions,
tick a box, yes we have done HIA? Do you really see that?
(Dr Tiplady) I hope not. I think the BMA, not just
the BMA but public health practitioners in general, are deeply
committed to the idea of measuring the impact of policies and
medical practice so you can see what is going to happen. We have
national objectives, like reducing the levels of coronary heart
disease, mortality and improving levels of mental health and health
improvement programmes, and others come up with often very complex
proposals to achieve this. What is missing is the assessment of
how effective that is going to be in achieving the objectives
before the resources are changed to invest in it. We have had
for far too long in the Health Service considerable investment
made in services that have not shown their worth.
513. I heard your opening statement, the way
that it has panned out. This is not something that the BMA is
going to lose interest in, you are going to monitor what is happening
and we will have pronouncements on this.
(Dr Tiplady) Not pronouncements.
(Mrs Naish) One of the most obvious candidates for
the health impact assessment, which should include inequality,
is local authority policies. The local authority makes decisions
all the time on things like transport and where you site roads
and speed limits, that has an effect on the accident rate and
that can actually increase inequalities in childhood accidents.
That is the most obvious candidate for health impact assessment,
the local authority policies.
(Dr Rylands) If I can give you an example, we have
a large hospital that has severe car parking problems
514. Join the club.
(Dr Rylands)there is actually going to be a
health impact assessment on how what parking issue might be addressed.
One of the options will be to start charging, because we are one
of the few hospitals that does not charge, and immediately hackles
start to rise. There are two sides, and many more, to every argument,
and a health impact assessment might start to tease some of those
out. That is being done in conjunction with the local authority
as part of a big transport plan.
Mr Amess: Could you privately send me your conclusions?
You can charge but you will still have an absolute problem with
515. One of things that kept cropping up is
how many initiatives there are and how many different schemes
there are, Health Action Zones, HiMP, Community Plans, Sure Start,
and there are so many different streams of funding, which are
sometimes hard to pull together. Is there one thing that you can
suggest as a way to simplify the whole system?
(Dr Tiplady) There is a model developing, the National
Treatment Agency, for drug misuse, where the objective is that
all of the sources of funding would be identified for it for a
county and the commissioning of those services would be done through
the Drug Action Team, which is a county-wide organisation. Drug
action teams have been variable in their effectiveness. I think
I belong to a good one. We have been complimented on good partnership
work. That is a model for the future, where all of the funding
sources are to be identified and then the commissioning is to
be done through a single multi-professional, multi-agency, top
level, highest commitment organisation. Our Drug Action Team has
chief officers of all of the organisations in Cumbria, including
the two health authorities.
(Dr Rylands) I would support that. It is more than
we are trying to develop. We have a health and social care partnership,
which is multi-agency and multi-disciplinary and there are a number
of subgroups that are looking at priority areas. For instance,
the implementation of the MFS, Mental Health, heart disease, et
cetera and the health authority and the local authority are working
together to try and identify the resources and asking those groups
to think about how services should be commissioned and the implementation
of the various initiatives. To go back to the question you mentioned
earlier about prevention, that will enable a multi-disciplinary
group to say, "Hang on, we are not going to spend it all
on more tertiary cardiac services, we are going to look at exercise
and life-style as well. It does mean that you identify that part
at an early stage and not 10 months into the year.
(Ms Gough) We have a system in Wolverhampton which
is very similar to the one Alison has just explained. Even when
we move into PCTs, which we are not in yet but we will move into
fairly shortly, they are the movers of the health economy, so
that as PCTs and PCGs we can respond to local need with that pot
of money and develop those services where they are needed.
516. Any points which anybody wants to add?
If not, thank you once again for your written evidence and for
coming along today. We are very grateful, it has been a very useful
session. As this is the last session of the Committee before Christmas,
I wish everyone the compliments of the season.
(Dr Tiplady) And from us too. Thank you very much.