Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 665 - 679)




  665. Colleagues, can I welcome you to this session of the Committee, which is the last oral evidence session of this inquiry, and particularly welcome our witnesses, the Secretary of State and the Minister for Public Health. We are very pleased to see you. I know it has been a pretty tough week and we appreciate the time you are giving to the Committee today. Can I ask you briefly to introduce yourselves to the Committee?
  (Mr Milburn) Yes, Alan Milburn, Secretary of State for Health.
  (Yvette Cooper) Yvette Cooper, Minister of Public Health.

  666. As you know, we have been holding this inquiring for some months now. We have had the opportunity to take evidence from a range of agencies, individuals, organisations and also had a number of visits related to the inquiry, and I think it is fair to say from my perspective that we have seen a great deal of positive evidence of very clear progress in public health, but one of the issues which it will not surprise you I would like to raise with you, an area of some contention, concerns the organisational structure of public health which we have currently. We have had substantial evidence from a range of sources raising questions about the current location of the public health function within DHAs, indeed very serious questions have been raised about the whole future of DHAs with the developments in primary care and primary care trusts, et cetera. I would be interested in establishing, first of all, what your views are as to the future location for the direct function of public health at local level. Some of us at the veteran stage of the Committee go back prior to 1974 and, as you well know, recall a model that certainly I believe operated more effectively in relating to elements of policy in local government that were able to drive changes in policy forward in a way we have not managed to do since it was detached from local government. Can I begin by asking you about your thoughts on that general area?
  (Mr Milburn) I am tempted to say, Chairman, it was before my time, but that would not get me off to a very good start.

  667. But you have read about it.
  (Mr Milburn) Yes, I have, and I have also thought about it quite a lot, and I know you and other members of the Committee have strong views about the issue. What is true and what is common ground amongst all the participants in this debate is that if we are going to improve public health, that is more than the job of the National Health Service, point one. Point two, much of our effort should be focused upon dealing with some of the determinants of ill health. I think that is also common ground, whether it is poverty, poor housing, environmental problems. However, in the end it seems to me that public health in purpose is about achieving certain health outcomes and although there would be a myriad of views about where best to locate the co-ordination function, because inevitably wherever you draw the boundaries there will be a whole host of local organisations or indeed national organisations which will have a bearing on the health of the public, in the end somebody has to hold the ring. The question really is, who best should do that, who is in the best position to do that. It seems to me—and I have thought about this and I have thought about the arguments you and others have made in relation to local government—in the end since it is a health function and a health purpose, probably that location is best done on a local level in the Health Service. However, what is also clear is that we cannot have what I have described in the past as the ghettoisation of either health or, more particularly, the public health function within the National Health Service, and there are some real issues about how best we break public health out of its ghetto.

  668. Do you not accept that that ghetto arose from the disposal of public health in 1974—
  (Mr Milburn) No, I do not.

  669. —and its detachment at that point from local government? I was a councillor pre-1974, as I believe was John Austin—a very young councillor, I hasten to add—and recall very vividly the role of the Medical Officer of Health who held to account in a very serious and important way the individual committees of that local authority. I see at local level some very worthy reports from our Directors of Public Health—I have two local authorities in my area, as you are aware—some excellent reports making some very positive proposals but it is not attached to the driver of policy that those reports relate to in any meaningful way. That worries me because prior to 1974 we saw the attachment of these recommendations to the ability to deliver change on things like smokeless fuel and a range of issues which the local authority could clearly concentrate on—slum clearances and that kind of thing and I know we have moved on from those days—but it was a very important relationship with the Government function.
  (Mr Milburn) You are right that there are a number of drivers or a number of interventions which are necessary in order to improve the health of their local communities, that is absolutely true, and local government will have a very important role in regard to its environmental health functions, its transport functions, social services or education, and so does the National Health Service. Whichever way you cut the cake, as I was saying, there would be a need to better co-ordinate functions, and certainly that was true of the pre-1974 situation. You say the Medical Officer of Health played an important role but, for example, if they wanted to influence rates of coronary heart disease or interventions in coronary heart disease, then they had to make the leap over the boundary into the National Health Service. That was just a function of the way the Medical Officer of Health and the related public health functions were organised. So I think that sometimes this game of structural musical chairs which we are all interested in inevitably, because we have to get the location right, becomes a bit of an excuse for a lack of co-operation. I think reorganisation becomes an excuse for lack of co-operation. What is true is that we need to improve the means of co-operation, there is no doubt about that, and on the ground, as you know, in many parts of the country now there is much closer co-operation than there has ever been, indeed there are statutory duties to co-operate for the first time which we put through in the 1999 Health Act. That is becoming evidenced I think now in the way that you see, for example, in some areas—largely where there are coterminous health authority and local authority boundaries—joint appointments of Directors of Public Health. I do not have a problem with that, I think it is a perfectly sensible thing to do but I think we need to assess its impact. When you talk, as you did, about drivers and leverage, there are some interesting international experiences here too more at a national level than at a local level. In New Zealand in the 1990s, as members of the Committee are aware, there was a similar debate going on about the location of public health policy-making at a national level. The then Government in New Zealand decided to separate the public health functions, through a Public Health Commission which was established in 1993, from the Ministry of Health, particularly to try to beef up the public health function because there was a feeling, as perhaps the Committee is feeling, that public health was getting ghettoised. That seemed a very sensible idea. It certainly gave a higher profile to public health in New Zealand, but the consequence of doing so was that the real life intervention impact in terms of public health was actually diminished, and it was no surprise that in 1995 therefore that Public Health Commission which had been established two years earlier was abolished. It is very, very important in my view we keep in mind that what we want to do is to drive public health ever more into the mainstream of the National Health Service, precisely so it has greater leverage as far as access to Health Service resources are concerned.

  Chairman: There is a division so I adjourn the Committee for 15 minutes.

  The Committee suspended from 4.09 pm to 4.23 pm for a division in the House.


  670. You were answering, Secretary of State, the initial question. I believe, Minister, you were indicating you were wanting to come in?
  (Yvette Cooper) Only briefly to add, Chairman, that if the argument is that we should have closer working around public health in local government, that local government could play a greater role in terms of public health and could have more public health support, I think that is absolutely right and I think we would agree with that, whether it is through joint appointments which some areas are experimenting with, whether it is through the local strategic partnerships or whether it is through closer working around the community plan or health improvement plans. But if the argument is we should take public health out of the NHS, that I think would be a massive mistake. There is so much potential for further work to be done in the NHS especially in primary care around public health, I really strongly think we need to keep that public health function in the NHS. Even on top of all the work which is done on public health at the moment by the NHS, there is so much more we could do, that we should be building on, particularly in primary care.

  671. One of the issues that the Committee have been concerned with is the role of health visitors, and some of us remember when they were employed within local authorities in a much closer working relationship with local authority services like housing and social services, and that is an area where we picked up very strongly there were arguments we needed closer collaboration. Picking up your point about the location and function and looking at it locally but also nationally and again whether public health is appropriately placed within the Department of Health—and I know, Minister, you said the idea of taking public health out of the Health Department would be a crazy and retrograde step—we have had a fair bit of evidence which suggests that the function you occupy ought to be much more wide-ranging than it is currently and perhaps located, say, in the Cabinet Office or within the Cabinet with a role ranging over other government departments. Can you say a little about your views on that and your experiences of working with other government departments in the role you currently occupy?
  (Yvette Cooper) I think it is extremely important to have the public health ministerial post located in the Department of Health, I suppose for several reasons. Firstly, in the end, a lot of it is about improving health and promoting health, and having access to the vast resources of the NHS, the Department of Health and the Chief Medical Officer is incredibly important. Secondly, whilst it is absolutely true that a lot of the work does involve cross-governmental working, actually being located in a department makes a huge difference. You will be aware where we have done the Social Exclusion Unit reports, the Social Exclusion Unit has tended to draw up the report and to drive a lot of the first wave of co-ordination across government departments but then the report has been passed on to a particular government department to actually lead the implementation. It is because ultimately you want a delivery route rather than simply a co-ordination route, ultimately you need a government department backing up, and given that the NHS is the biggest employer in the country, it has huge resources when it comes to delivery. It is right that has to be in partnership but I think it would be terribly wrong and would be a huge retrograde step and a mistake to leave it behind. I will just give you one brief example of where I think cross-departmental working can be very effective, and that is the Sure Start programme. I am responsible for Sure Start but the Cabinet Minister responsible is David Blunkett in the DfEE and the Sure Start Unit itself is located within the DfEE, and that is quite a novel approach to working across government which involves a very close partnership between different departments and it is working very well, with my responsibilities both to drive the programme and to chair the cross-ministerial group but using resources located in different departments as well. So there are different cross-departmental models you can look at but fundamentally it would be a huge mistake to separate public health from the big killers—cancer, heart disease. All the work we are doing on prevention has to involve the NHS otherwise we will never make the difference we need to.

  672. When you are looking at any policy initiative, how do you determine who might be involved in developing that initiative? For example, we had the mental health initiative which came out recently where, arguably, some of the key players within different government departments have a role to play. You probably know that we were prompted as a Committee by evidence we received from the Yorkshire Post newspaper, which you will see as a Yorkshire-based MP like myself, which has done a very important campaign on sport and the way sport relates to health, and as a consequence of their evidence and other evidence we determined to have the Minister of Sport before the Committee. We had a very useful session, I think, listening to what she had to say but my concern, and the reason why I raise this point about the public health location within government, is that she answered very honestly when I asked specific questions about whether she had been involved in certain initiatives, which I think she should have been involved in, where on a number of developments the Government can claim great credit at a local level which should relate to sport, and she had no involvement whatsoever. How do you, not just with you but in other areas where the Minister has a part to play, ensure they are involved, because in that case clearly she was not and in my view she should have been?
  (Mr Milburn) I think there are always improvements which can be made, of course there are, but the machinery for cross-government working now in this Government—and certainly that is the view of the people who have been around in previous times—is immeasurably enhanced. I think the commitment to joint working is a big commitment. On the public health front you will remember when we published Our Healthier Nation White Paper, of course it was my Department which was in the lead but there were contributions from other relevant departments, of course there were. Issues like sport obviously would relate to DCMS. On one of the important Our Healthier Nation target areas, the prevention of accidents, we worked closely with colleagues in the DETR, DTI, DfEE, across the piece. The point about this is that in a sense it is rather like a local co-ordination function, wherever you locate it there is still going to have to be co-ordination, and where there are co-ordination issues and where there are boundary problems then inevitably you hit difficulties. But what I believe absolutely fundamentally is that if you take the public health function out of the Department of Health and if you put it in a ministry like the Cabinet Office, what you remove is the Minister of Public Health and all of the officials and all of the machinery and indeed all of the financial leverage which goes with a location in a big spending department. For example, this year I think the Department of Health will be spending between £40 and £50 billion and it is one of our commitments that we want to see a growing proportion of that resource spent on public health measures—defining cancer, coronary heart disease and so on and so forth—by contrast, I think the Cabinet Office has a budget of less than £200 million. In the end, money talks because it provides you with leverage to get things done. There is an argument about whether or not we need to do more within the National Health Service to better focus growing resources on prevention, on tackling inequalities, on intervening sooner rather than later, and that is a perfectly reasonable debate to be had and I think all of us sat around this Committee table would think there is a lot more to do, of course there is, but actually the chances of doing it, it seems to me, are decreased and not increased if you strip out the public health function from the mainstream Health Service delivery functions.

  673. In simple terms, how do you avoid treating policy issues in separate boxes? The best example I think we had with the Sports Minister was when I raised the initiative of healthy living centres, which I think is an excellent idea, and I see a very clear connection between the role of sports clubs and healthy living centres, but there had been no connection between your Department on this issue and her Department. What I am trying to say is, how can we ensure structurally that that happens, that, to me, a fairly obvious connection at local level is made nationally and locally in a way which is not being made at the moment?
  (Mr Milburn) I think two things. First of all, there is a big commitment to do this across the Government and Our Healthier Nation is an expression of that but the truth is it is early days. It is the first time we have had a Public Health Minister, the first Public Health Minister was appointed in 1997, and I think that was the right step to take and it allows us to focus on these issues in a way perhaps politically which has not always been possible in the past. It is a positive step in the right direction but there is a big commitment across the piece to improving the health of the nation. If you take the argument to its logical conclusion I think you are left with some pretty anomalous potential structural arrangements, because most of us would agree that poverty has a bearing on ill health. That is certainly the position in the Black Report, in the Acheson Report, it is the position that many people in the medical and health service field would agree on. The Government has a big commitment to abolish child poverty, I think it will make a huge contribution to improvements in public health and to narrowing health inequalities, but the logic of the argument, with respect, is if we believe that child poverty is going to be a major determinant of improved health then why do we not take the public health function out of the Department of Health altogether and put it in Her Majesty's Treasury?

  674. Something we could think about actually!
  (Mr Milburn) I am not going to give you ideas, Chairman, because I am slightly worried you will recommend that!

Dr Brand

  675. Is it not already?
  (Mr Milburn) You can say that, Dr Brand, I cannot comment!

Mr Burns

  676. We have a Department of Health that has overall responsibility for improving and enhancing patient care and the health of the nation, and it does seem odd to seek to take out public health and give it to the Cabinet Office or the Treasury, or whoever else, because it just becomes diffuse and to my mind ridiculous. Can I ask the Parliamentary Under-Secretary whether the structure of the Department of Health at the moment means that she, as Parliamentary Under-Secretary, is answerable solely to the Secretary of State, as certainly under the last Government the Parliamentary Under-Secretary who was responsible for mental health, children's issues, drug abuse, alcohol abuse, et cetera, had no Minister of State above them, they were answerable directly to the Secretary of State? Is your position answerable solely to the Secretary of State, or do you have a Minister of State above you and below the Secretary of State?
  (Yvette Cooper) I answer directly to the Secretary of State.

  677. I am glad you said that because there is a view held by some people that if you put public health, which is considered to be a very important issue, at Parliamentary Under-Secretary level you have down-graded or minimised the issue. The fact that you, I suspect, and you can correct me if I am wrong, are unique in that presumably other Parliamentary Under-Secretaries at the Department of Health at the moment have a Minister of State above them and under the Secretary of State, surely enhances rather than down-grades the role of public health because without having a Minister of State to go through you have direct access to the Secretary of State, you are working simply with the Secretary of State? So would you agree with me that in fact, presumably, given your line of command and that you are answerable simply to the Secretary of State so it is just the two of you within that narrow ambit, the whole area of public health has not been down-graded simply because it is at Parliamentary Under-Secretary level?
  (Mr Milburn) Let me answer because it is slightly invidious for Yvette to answer questions about command structures in the Department of Health. I know the argument, Mr Burns, that because the previous Public Health Minister was at Minister of State level and Yvette is not, somehow or other this represents a down-grading. All I say to you is that nothing could be further from the truth. Not only does Yvette answer to me personally but, in addition to that, when Yvette came into the post one of the things I wanted to do was better "mainstream" public health within the Department, and that is why actually we changed some of the functions around within the ministerial team, so that she as Parliamentary Under-Secretary for Public Health has responsibility for the two big areas of public policy where we need to make rapid improvement in terms of mortality and morbidity rates—cancer and coronary heart disease. That was not the way the Department had previously been divvied up. I did that precisely, one, in order to locate responsibility where it should be; two, to ensure the focus was as much on prevention as treatment; but, thirdly, to actually "mainstream" the public health function within the Department of Health, because I do think there is a tendency, if I may say so, with respect, within the public health world, for public health professionals as narrowly defined to believe that they are the only purveyors of public health. If that is the case, if we actually believe that it is the 600 public health consultants and 32 epidemiologists who are going to improve the health of the nation, however good they are, frankly we can all go away and give up now. The people who should be "mainstreaming" and delivering public health are our 30,000 GPs, our 12,000 district nurses, our 14,000 health visitors. They are in the best position to do that and if they are going to do that then actually we have to have a line of command, a line of delivery, all the way from Richmond House down to Wakefield, Darlington and Chelmsford.

  Mr Burns: Thank you.

Mr Hesford

  678. In terms of this issue, Secretary of State, in 1997-99 the Chancellor has made it clear for very good reasons that spending was tight in those years in order to stabilise the economy and get rid of the £28 billion deficit. Those in the public health field will have recognised that between 1997 and 1999 public health had a Minister of State-level occupancy at a time when the money was tight. At a time when others might have felt money was coming on stream, the position was, in some people's terms, down-graded just at the point in time when that person might be expected to spend some money. Can you deal with that point?
  (Mr Milburn) I do not know who is making that point but it is a ludicrous one. I would say that this Minister of Public Health has more influence and more power within the Department of Health than any previous minister who has occupied a previous position, precisely because she is dealing with the mainstream issues of cancer, coronary heart disease, improvements in public health across the piece. Rather than being a retrograde step, I think that is a huge step in the right direction of ensuring that we target in a rather more consistent and effective way than perhaps has been done in the past our efforts, the machinery of the Department and, most importantly of all, the resources we have available to us on those areas, those disease groups, those parts of the country, those sections of the population, which need most help.

  679. In terms of raising the awareness of public health, which I know the Minister is absolutely keen on and does a very good job of, would it not send out the wrong message to those areas that need support in their job—that very difficult job of raising awareness of public health—to have what others have described as a retrograde step in terms of the exact status of the Minister of Health?
  (Mr Milburn) If that were the case, it would indeed be a retrograde step, but it is not.

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