Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 700 - 719)



  700. Can I come on to the general initiatives that the Government has undertaken. No-one welcomes more than I do the very high priority that your Department gave at very early stages to public health. The commissioning of the Acheson Report very shortly after the Election, the creation of the post of Minister of Health are initiatives that all of us around this Committee would very much welcome. Indeed, when Professor Acheson came here he commented on the very positive steps which the Government had taken in the light of his report. We have got the policy initiatives of health action zones, health improvement programmes that have been mentioned earlier. But now we have the new NHS Plan. Has the new NHS Plan eclipsed those initiatives in any way and placed new priorities on the National Health Service?
  (Mr Milburn) I do not think it has. I think the sovereign role of public health and the job of tackling health inequalities and the bigger focus on prevention is very much at the heart of the Plan and what we have now got to do—in the end writing plans is easy and devising policy is easy, delivering it is sometimes more difficult. What we have got to do is make sure that the Government's intentions to improve public health and tackle health inequality are embedded within the Health Service at every level and there too we have tried to change the institutions in such a way that they will deliver what we all want to see delivered—improvements in public health and the health of poorer people, getting better health opportunities. So, for example, as you are aware, for the first time now we are measuring and indeed rewarding the performance of local health services, recording not just how well they do on waiting times and the traditional acute sector agenda but how well they do, too, in improving health outcomes, ensuring there is fair access to services (the point that was raised earlier) and the performance assessment framework that we have includes these two vital measures about health outcomes and fair access. I think it is fair to say that as a consequence of doing that not only does it hold the local health service to account against our broad objectives but it provides some very positive incentives for the local health service in every part of the country to take seriously precisely these two issues, how you ensure fair access, for example screening services where we know that although in this country we have done incredibly well in screening services, cervical cancer and so on and so forth nonetheless it is true that poorer women tend to use those services less than others and there are big differences according to ethnic minority background too. If we are going to make the big improvements that we want to see in cancer survival rates and we want to save the number of lives that we do and people suffering from and dying from cancer, then we have got to get into these difficult areas and make sure that there is genuinely fair access. One of the ways you do that within the National Health Service is to measure the performance of every local service and to hold people to account against the objectives that we have set. It is not just a question of writing a plan or embedding prevention in a plan, it is also saying to the service this has got to happen and these are the ways that you have got to account for it happening.

  Chairman: Have we politicians not got some responsibility to broaden out the debate to include in the political mainstream issues of public health in a way that certainly was not case from our point of view at the last General Election where our pledge related to one issue on health which was waiting lists. You can ask anybody in the Health Service if you want to evaluate how effective the Health Service is there are a number of measurements and that is not one that I would have in mind. Looking at how we broaden out the debate in ways you are describing and looking at targets way beyond the immediate waiting list initiatives, etcetera, are you optimistic that in the next Election we might have a somewhat more mature debate on health—

  Mr Amess: No chance.

  John Austin: No chance if you are involved.

  Mr Amess: I am replying to all the rubbish we have to listen to.


  701. Do you understand the point I am making? I think we have a responsibility to get the debate widened to include the very important areas you are talking about. In a sense, certainly at the last Election, I do not think that my Party did that in a meaningful way.
  (Mr Milburn) I think your Party, my Party, our Party—

Mr Burns

  702. Different wings.
  (Mr Milburn) There are no different wings in the Labour Party, unlike others I could mention! I think our Party and our Manifesto did have a focus on issues like cancer and heart disease and so on and so forth.


  703. But key issues—
  (Mr Milburn) Let me finish the point. I think it is very, very important that there is a proper and mature debate about these issues and, of course, improvements in health and improvements in health services are not just about improving waiting times for hospital treatment but improvements in waiting times for hospital treatment have an enormous bearing on the health of the population because, as we all know, people are waiting too long for heart operations. That is a fact of life. Thankfully because for the first time the Government has had the courage to earmark funding for coronary heart disease in a way that perhaps should have happened in the past, I am confident that we will get those waiting times down. We will grow the number of staff, we will invest in the treatments, and we will invest in the secondary prevention too. So there is not a contradiction I do not think—

  704. I am not saying there is a contradiction.
  (Mr Milburn) Nor do I think there is a conflict. If the argument becomes treatment versus prevention, that is the wrong debate. It is about how we ensure that the Health Service is both focused on treatment and prevention. Coronary heart disease is a good example, if I may say so, because when we pushed our coronary heart disease National Service Framework, our blueprint for tackling the appalling incidence of heart disease we have in our country, which incidentally is more concentrated in deprived parts of the country than others, the focus was as much on prevention as it was on treatment. That is the first time we have done that, sadly, where policy has been rounded enough and, in your word, "mature" enough to recognise that if you are going to bring about big improvements in public health let alone tackle these appalling health inequalities you have got to do the two things at the same time rather than assuming that inevitably it either/or. It is not either prevention or treatment; it has got to be both prevention and treatment.

Mr Hesford

  705. Can I pick up on something Mr Austin was dealing with a few moments ago. One of the strongest statements you made today was your support for the health improvement programmes. I personally welcome that. There is evidence that within local authorities, health authorities, PCGs/PCTs, the priority of HImPs is slipping down the agenda. You also said in terms of public health delivery that you are not territorial—partnership working, all that sort of thing. In terms of tangible benefits could you say something about the suggestion which we have heard quite a lot of merging the HImP programme with community plans?
  (Mr Milburn) I think in some parts of the country already what you are seeing is the health improvement programme where the health authority is in the lead (because somebody has got to be in the lead) and the community plan where the local authority is in the lead and because many of the contributors are the self same contributors—local government, the Health Service, the private sector, the voluntary sector and so on and so forth—in some parts of the country already there are shared objectives and common values that underpin the community plan and the health improvement programme. That seems to me to be a perfectly sensible thing to do. I do not have a problem with that. One of my own objectives for local government is to cut down on the number of plans that they have to prepare. We impose all sorts of bizarre statutory obligations on local government to prepare plans until they are blue in the face. In the end I am not interested in plans, I am interested in delivery. I would rather have people working in local government on delivering services rather than writing plans about delivering services. I know one is easier than the other, but actually we pay people to deliver rather than simply to plan. We have to see a reduction in the number of plans that we ask for in central government, we have some responsibilities in that regard. If we can see a closer relationship between health improvement programmes and community plans that seems to me to be a perfectly reasonable thing to do. What we should do is assess in those areas, I think, again, in I think in Wakefield, the community plan process and the health improvement programme process do have some share objectives and common values and so on and so forth. We should assess what gains are made for precisely that level of cooperation. If we think that that is beneficial then surely we should learn a lesson from it.

Mr Amess

  706. I certainly applaud the role of nurses in schools. I have to say to our minister for the Department of Health we have a desperate shortage of school nurses in Essex, and if there is anything that can be done to help I would be grateful. This is a subject that people laugh about but that for parents it is a big problem, that is the problem of head lice, which one of your colleagues has raised before. It is the sort of thing we do not like to talk about. There clearly is a very real and serious problem. It does appear that all the products which are available at the moment do not seem to be working. They are very expensive. There are new sprays and all sorts of things coming on to the market. Unless every child is done—because with the little ones their heads get together—it will go on and on and on. As a constituency Member of Parliament I keep getting letters about this, does the Government have any strategy to try and do something about this problem?
  (Yvette Cooper) It is something that I certainly answer quite a few letters from MPs on, including correspondence from constituents. There is an approach that is taken, that is supported locally, through the whole schools approach. You are right, the difficulty is finding it and catching it and supporting the whole school. What I can certainly do is send the Committee the details of that. It is something where we have cross working between the Department of Health and the DfEE on that. It obviously something where the whole school becomes involved, it is not simply an issue for the school nurses. On the issue of the school nurses, it is true that there are pressures and it is something that we are very aware of and it is something that applies to a lot of sectors. Certainly our commitment right across the NHS and right across the nursing staff is that we want to see expansion, although we do recognise that that is not always as easy as our intention might be.

  707. Thank you for sending us the document. I would like to persuade our local authority do something about it. They will probably say, "Where would the money come from". What is the Government's position at the moment concerning the MMR vaccine?
  (Yvette Cooper) There have been a lot of concerns raised about the MMR vaccine. We take the approach that whenever there are any concerns raised about any medicine or any vaccine we always refer it to the expert committees that advise the Government on these issues, particularly the Committee on the Safety of Medicines also the Joint Committee on Vaccination and Immunisation and we seek the advice of the Chief Medical Officer. That is what we have done on this issue. We have referred all of the research, all of the publications, all of the claims that have been made by Dr Wakefield, all of the claims that have been reported in the papers to those expert bodies for them to examine them in great detail and examine them thoroughly. Their advice to us has been that there is no evidence of a link between the MMR vaccination with autism. Secondly, MMR remains the safest way to immunise children against what are quite deadly diseases. We think it is important on an issue like this to follow the advice of the experts and to make that advice available to the public. We should not be in a position of hiding information from the public. All of the information that we have been given from the CSM, from the expert committees and from the Chief Medical Officer on this subject we have made public and we need to continue to do so.

  708. I know on 8th January you answered a question about the TB programme. Do we have an update as to when the schools can expect to have this vaccination programme resumed?
  (Yvette Cooper) We do hope to be able to make an announcement on that shortly. You will be aware that the vaccination programme has already resumed in London. We are also very conscious of the need to make sure that children do not reach the point of leaving school without a catch-up programme reaching them in time. We are very conscious of that. We have held discussions with companies all over the world to try and make sure we can get a secure supply of the BCG vaccination. There were problems with the sole supplier that persisted over some time that lead to the suspension of the programme. There is certainly a lot of work going on that and we do hope to be able to make an announcement.

  709. When can we expect the sexual health strategy from the Government?
  (Mr Milburn) Hopefully within the next couple of months.

  710. Do you have any concerns about the way the morning after pill will be administered?
  (Yvette Cooper) Are you referring to the morning after pill available in pharmacists?

  711. Yes.
  (Yvette Cooper) This is something which has gone through the proper procedures, through the Committee on the Safety of Medicines and the Medical Control Agency. The company applied for a licence to use this to be able to deliver this product in pharmacies for over 16s. All of the expert committees who assessed it said this was a very safe product and this was something that could be give in pharmacies. The Royal Pharmaceutical Society has provided very detailed support and guidance for pharmacists to ensure that it is done in the proper context, the right kind of questions are asked and the right kind of advice is given. My view is that this is an extremely positive move, it is about giving women more access and choice to a product that all of the experts say is safe. It could also make a big difference in terms of bringing down the number of abortions and unwanted pregnancies, which are highest amongst women in their 20s.

  712. Two final questions, you and I have been in correspondence about palpation. For the record, could you say why your expert group, I am not challenging it, decided that palpation should stop in terms of breast screening?
  (Yvette Cooper) Perhaps I should write to you or the Committee with the detail on that.

  713. I would be grateful for that. I understand that you will be visiting the Lupus Centre later this month, which I am very pleased about, because we know this effects women between 20 and 40. The Secretary of State spoke earlier about why in the discussion and knowledge it is quite clear that the number of general practitioners do not—I know we have two on the Committee—seem to know about sticky blood, and all of that. Is there something that the Government might do if they are persuaded that this is a problem that we should address?
  (Yvette Cooper) We will certainly always look at any new area or any particular condition where there might be improvements that could be made. We have to take an evidence-based approach. We have to look at what works, what is properly evaluated and what will make a difference. Our approach right across the NHS is as new techniques become available, as new technologies become available we will also find areas that need research. We always need to take all of those seriously.

  Mr Amess: They do not get any money at all to help with their research.

  Dr Brand: Can I pick up one of the relevant questions that David Amess asked?

  Chairman: I thought they were all very relevant.

Dr Brand

  714. The issue of sexual health, when the Government reduced the public health targets, which were set in Health for the Nation, two to four main targets that we got in Saving Lives and Our Healthier Nation, I was given an undertaking by the Secretary of State's predecessor that we would not lose sight of the other targets. Although targets would be local for some of the other issue, like sexual health, they would be collated in some form so that we could see whether as a nation we were actually delivering the agenda that needs to be delivered. Sexual health is a very good example of that, teenage pregnancy, etc. I have asked this question annually for the last three years and I have been told that it will emerge from the system eventually. Can the Secretary of State or the Minister tell me when it will be available?
  (Yvette Cooper) What specifically are you asking for?

  715. The previous targets that existed are no longer national targets they are now local targets.
  (Mr Milburn) You mean Health of the Nation targets.

  716. When will we be able to see how we are getting on as a nation in reducing the issues like genitalia infections, teenage pregnancies, etc?
  (Yvette Cooper) Most of the figures you are talking about, like sexually transmitted infections are in the public domain. The Public Health Laboratory Service publishes a lot of information about communicable disease. There is a lot of information in the public domain already. We have a commitment to demonstrating progress against the targets we have set on sexual health. You are right, one of key areas there is teenage pregnancies, where we have set quite clear targets over the next ten years on teenage pregnancies. We are also looking at publishing a technical supplement to the work that went you on through our Healthier Nation but also which is updated in the NHS plan that might also provide more of the kind of information you are talking about. I think our approach with a lot of these things is the information is out in the public domain.

  717. I am not denying there is not a lot of information. What I think is difficult is to get the information in a form that you can track what is happening. Where we had 27 targets before we could follow what was happening to them, I was given assurance by the previous secretary of state that there would be some way of seeing how we were getting on. That would be helpful.
  (Mr Milburn) Can I take that away. I am sorry I do not have an answer for you today. I will take it away gladly.

  718. While we are on targets and priorities, it is a bit alarming to hear from some of our witnesses that during regional reviews directors of public health would not necessarily be invited to take part in a review. Health authorities, on the whole, were questioned about the acute delivery of services, waiting lists, and that sort of thing but the public health targets, if they existed, were never discussed. Have we got the right mechanism of delivering the public health agenda you talked about so eloquently this afternoon?
  (Mr Milburn) I hope we have. It is very, very important. This is one of the changes that we have to achieve. If you like, we have to take public health out of its ghetto within the National Health Service. It not just a function and it is not just a responsibility that belongs to one part of the Service or to one group of professionals. It is a responsibility for the whole service, particularly in primary care it is the responsibility of all professionals. We have to, as I was indicating earlier in answers, have a means of imbedding it within the Service. My guess is you share this view, it is reflected in your question, that for too long these public health issues have somehow been second order rather than at the top of the agenda. The way that we have sought to do that is precisely by making health outcomes and fair access to services as important as the patient's experience in a hospital in determining how well their local health service is doing and, therefore, being able to hold a local health service to account. As you are aware, in future being better able to reward good performance across a whole range of quite complex health service responsibilities according to performance of the individual health service, not just on the waiting time issue, but on health outcomes and health improvement too. Within a managed service that is the way it seems to me that you stand a better chance of locating responsibility for improvements in public health within the mainstream of the NHS, rather than simply having it parked to one side, which I think has been the position in the past. That is quite a big change. I do not pretend that it will be easy. I think there is not a chief executive in the country that does not realise that there are certain important priorities for the NHS. Certain priorities, in Mr Hesford's phrase, are "must dos". In the future "must dos" will not just be about what happens in hospitals, they will also be about what happens in primary care, what happens to improve preventive screening services and what happens to bring about what we are all in the business of, which is improving health.

  Dr Brand: You are still talking about the medical model of public health rather than the broader model of public health—

  Chairman: This is coming from a doctor!

Dr Brand

  719. —which is something that saddens me actually. We have been talking about screening, prevention and some very good things have been done, I am not denying that, but that really is improving things very significantly for a relatively small number of people at risk. The broader population benefits from the broader issues of the environment, housing, nutrition, which have been touched on, but they are not actually delivered through the Health Service.
  (Mr Milburn) Hold on. With respect, and nor could they ever be. Unless you want to have a rather Stalinist approach to government—I know that is my reputation, Dr Brand, but as you know I am much more amenable and flexible than he ever was.

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