Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 720 - 742)



  720. I am still alive, I am very grateful for that.
  (Mr Milburn) One of these days I will convince you of that. Unless you are going to have one supremo who is responsible for every governmental function then, of course, there are going to be different departments with different responsibilities, absolutely right, but with one big objective. If you ask me to define what the Government's big objective is overall, it is to ensure that there is genuine opportunities for every section of society in every part of our country, that is what we are about. The Health Service happens to encapsulate that but so do our ambitions to abolish child poverty or to create full employment or to ensure that everybody has a decent home and a decent environment and good public transport services and less crime on our streets. Those are the Government's broad objectives. All of these have a direct bearing on the health of the population and on people's health opportunities.

  721. I agree entirely that the health outcomes will probably be the best measurement of how successful the Government is at actually creating an enabling society. Can I ask a specific question about the role of health authorities versus health trusts. I do get a bit confused as to whether we still have a commissioner/provider split when I look at the Health Bill that going through at the moment, where delivery trusts are going to be directly influenceable and rewarded by the secretary of state as with the influence of health authorities. We also see that each trust by statute has to have a Patients' Forum to influence its delivery. The minister of state quite specifically said that this was a Patients' Forum and not a Community Forum. That worries me slightly because trusts are actually very good at influencing ex patients of their brilliance and how wonderful they are. They tend to be fixed on the medical delivery of acute services, whereas the health authorities are allowed to have an ad hoc arrangement of public involvement. If health authorities have to deliver the public health agenda, which is not always the most popular in the short-term, how are they going to be able to have enough influence over the trusts, given that the trusts are going to have very powerful advocates in the statutory Patients' Forum?
  (Mr Milburn) I do not think the premise of your question is quite right. I do not believe it is purely the responsibility of the health authority to deliver improvements in public health. Perhaps we will not get as far as we need to get. It is the responsibility of the whole service, of community trusts, mental health trusts and most importantly of all primary care trusts, all of these organisations have a huge part to play. Within the primary care sphere I believe that—I was talking earlier about the role of GPs and other primary care professionals will play—the advent of primary care groups and now primary care trusts, for the first time, give primary care professionals the opportunity to have a proper population-based focus, to focus on the needs of its overall population, of 100,000 people or 70,000 people or 150,000 people. That allows, in my view, at least the potential for primary care professionals to get into another arena of activity that is hugely important in determining the health care and the Health Services on behalf of its local population. If GPs or as other primary care professionals you find there are particular problems amongst their patients, for example with poor housing, lack of central heating or damp homes, whatever, for the first time through the primary care trust group have you the opportunity of doing something about it, not least in relation to the roles that PCTs will play with local government. I think all of these organisations within the health service, not just the health authorities, have a responsibility to play on the Patients' Forum. I am completely unapologetic about that. As recent events have rather demonstrated all too graphically, the lack of direct patient influence, of patients being on the outside rather than the inside of the National Health Service have not always got their families, their relatives the right sort of results from an NHS that is supposed to about, primarily, serving the interests of patients.

  722. I thought the NHS was there to serve the interests of the community from which its patients came. It is the concentration on the narrow user group rather than the broader community that gives me some concern when we are talking about the delivery of public health.
  (Mr Milburn) On the Patients' Forum side they will be comprised of two groups, although I do not think they are particularly distinct. People who use the Health Service, and use it on a regular basis, they have some insight into it. Actually, listening to what patients have had to say and listening to their concerns and complaints and, more importantly, imbedding the patient's voice within the National Health Service at a local level will make a real difference. That is one group. The second group are patient organisations within the local community, the local MS Society, the local Alzheimer's Disease Society. These local groups are drawn from the local community but have a particular interest and have a particular expertise which we ought to bring to bear for the benefit of the local community and patients in general.

  723. I have no doubt they will be formidable advocates for the particular delivery of a medical treatment service. Can I turn to the local delivery of public health. I was very pleased to hear you say that you recognise that there are far too many initiatives, and too many plans are having to be drawn up. I hope that the Department will consolidate some of that. Can I ask whether the plan is to base the joint working predominantly on health geography or local authority geography? It is easy for me, I am as coterminous as one could possibly be.
  (Mr Milburn) You are at ease with yourself, are you?

  724. I am totally at ease with myself. The health improvement programme clearly may have a different area from the community plan. I also find that the health improvement programme, because it cuts across a number of local authorities, is not the ideal unit to be looking at a local community. I think we should be starting to talk about sub HImPS and a smaller population that should create HImPs based on a district or unitary authority.
  (Mr Milburn) Some of that is happening on an ad hoc basis, the so-called HImP-lets. One of the amazing things about the National Health Service is it does manage to engender all sorts of interesting language which has a passing acquaintance with the English language on occasions.

  725. Almost as good as politicians.
  (Mr Milburn) Some of that is beginning to happen, and why not? Certainly within my own area, Darlington, it is a very different place from the Teesdale and the East End of Durham, the old mining communities, and they have very different health problems. We have to have some ability and some flexibility to plan for the needs of the specific local population. I do not have a problem with that. As far as this issue of coterminousity is concerned, I think this is quite a difficult issue for all of us. The truth is there will never be a perfect set of boundaries. You are the dealing with different organisations of different traditions, different cultures, different representatives and accountability structures. That is bound to be the case. All that I say to people in the NHS, whenever they come to talk to me about this, because the NHS likes nothing better than a really good reorganisation, and it has had lots of them. It has lots of experience in doing it. All that happens, or what tends to happen whenever you have a reorganisation is that by and large people's eye is taken off the ball and in the end what happens is that rather than concentrating on getting the services delivered or the services improved or the health of the local population improved people start jumping into a position and wondering which job they are going to get. Sometimes we need to reorganise and we need to change things in terms of structures and institutions within the local service. Sometimes it is better to take your foot off the accelerator rather than always pressing it down.

Dr Stoate

  726. Minister, one of big public health issues I am interested in is men's health. Can I say I am pleased you have been helpful and very useful in the Men's Health Forum, working inside and outside this place, to tackle the big inequality facing men at the moment. One of the issues I really want to talk about is how as a GP we can try and improve health across different groups. We were told recently that the Health Education Authority carried out a survey and only 11 per cent of GPs understood what the New Age targets were for exercise. What that really means for me is that perhaps GPs are not as focused on the side the public health agendas as they might be. How do you think we can get GPs more on board with the Government's target for delivering public health. I do not think at the moment they understand what you are trying to achieve.
  (Yvette Cooper) There are some GPs in some parts of the country who are doing quite amazing work around public health and who are leading the way in showing what can be done, whether it is around coronary heart disease prevention or whether it is around teenage pregnancy. It is interesting on the issue that you mentioned, on exercise, the programme called Health Walks that has been funded by the New Opportunities fund quite recently as part of the Healthy Living Centres programme is all about improving access to exercise and working through primary care to do that. That has been driven by a GP. That has been driven by primary care. There are some very good examples. The question is how you spread those examples across the country. Primary care does now have a duty and responsibilities for public health and health improvement. What we need to do is to build on that over time. It will take time. We should not have any illusions about the fact there are no swift solutions. There is a huge amount going on in primary care, with the shift of primary care trusts in many areas. I think there is a huge amount that can be done. Perhaps most will be done if we see primary care as a team and not simply as the role of GPs, so the work that nurses in primary care do, the work that health visitors do, the work, increasingly, that community midwives may be doing if they are linked in, and so on and so forth. There is a broad programme of work, it will take us some time. The more that we have targets, for example, health inequalities target, for example, the work on smoking cessation and, for example, the implementation of the national service framework for coronary heart disease, which requires a lot of work at local level and through primary care, the more progress we will see in this area.

  727. That is fine. As you said, there are extremely good examples of where GPs and primary care teams have been extremely innovative with excellent results. My worry is there is a vast bulk of GPs who are struggling day-to-day to see 50 patients a day, sometimes more, plus on call. I find it quite difficult to grasp the actual concept of public health and how it is that we are trying to make any real difference. They feel swamped and overwhelmed and they wonder what it that they can reasonably achieve.
  (Yvette Cooper) Primary care groups and primary care trusts will be the mechanism for doing that. They will have responsibilities on public health and on health improvement. As a trust or as a primary care group they will need to show progress and to make progress and to be involved in the partnerships with other organisations at the local level. That does not necessary mean that all GPs within a primary care trust will instantly change the work they are doing, or anything like that, it does mean that as a whole the primary care trust is the mechanism. Obviously it is going to involve more training and support for people in the new kinds of functions. It may also be very much about the kind of teamwork, or it may be that particular GPs specialise in particular areas around public health. The honest truth of this is that I think it is an area with huge potential. We have not worked out the way in which it is going to work and a lot of it will be about the way it develops at a local level. You can just see some of the ways that some primary care trusts in some areas picked up smoking cessation and are doing a lot of work there. There is huge potential. What we need to do is follow what is working in different areas and make sure that other areas can learn from it.

  728. Are you convinced that PCTs are the right vehicle to deliver this programme?
  (Yvette Cooper) They are such a massive resource. GPs are seeing people on a day-to-day basis. People come into their surgeries with health problems that are often linked to all kind of different social problems or economic problems locally. You have health visitors who are working with families with young children at a critical stage of a child's development. What happens in the first year of a child's life can have a huge impact not simply on their health later on, but also on their education opportunities and how they develop. Community nurses, people who are working in the local community at a very tangible level. It could be something as simple as identifying who it is that is suffering from fuel poverty by just a simple question to them when they come to have a flu jab, the primary care nurse asks. The potential for all of these health professionals, who have huge contacts with the community, and also with other organisations in the community, the potential for them to deliver improvements in public health I think is massive. It will take us a lot of time and we have to be very realistic about the capacity of the NHS. It is a time of great change and resources will only come on stream over time. The potential is huge.

  729. It is interesting what you said about very young children and the contact they can have with health professionals. It might interest you to know that in Cuba the GP visits every child under one personally every day until they are one.
  (Mr Milburn) Are you advocating that?

  730. No, I think my colleagues would lynch me. You said it was easy for a GP, a health professional, a health visitor or a practice nurse to pick up poverty or housing problems. That is fine and they do. What do they do about it? I still do some medical work, if I see somebody in that position now what I say is, "Go and see your MP", and they come and see me again. That is the matter, Secretary of State, to pick up. You can pick up these issues of poverty, GPs know about these things, but what can a GP do about them?
  (Mr Milburn) There are things that can be done for the individual patient, a referral to the local authority, and so on and so forth. That is not the trick we have to pull off. What we have to pull off is a means of harnessing the expertise of people in primary care with the knowledge that they gain from their contact with people in the community in order to formulate locally based approaches and strategies to deal with particular problems that you and Dr Brand see in your surgeries. There will be particular pockets of problems in particular areas, as there are in my own constituency. Some parts of the constituency are relatively affluent, some are pretty poor and they have specific needs. I think based on that knowledge what we need to do through the PCT structure, because it is operating at the level of the general population rather than a specific group of patients on a doctor's list, at that level what we to have to do is get the PCT working together with the local authorities and the other players in the community to formulate answers to the specific problems that walk through the doors of GPs surgeries either to see the family doctor or the local nurse. That is not easy to do—of course it is not—but the point about this is that there is a bank of knowledge, both in terms of expertise about solving problems and indeed about the nature of problems themselves, that is located absolutely in the heart of primary care. I do think this is an important issue in terms of how we frame this whole debate around public health. I said earlier that if we think that public health is just about certain professionals within the National Health Service delivering certain services we will not get anywhere. Public health is about how you mainstream these issues right into the heart of the Health Service onto the front-line of the Health Service and I think the PCT structure offers the potential of doing that precisely because over time you will see—and I am convinced of this and in the best places it is already happening—greater co-operation and greater collaboration with local government services, not just social services but environmental health services, transport services, education services too.

Dr Brand

  731. I think it is very ironic that we are having this discussion whilst the local government settlement is being announced because one of the reasons why I went into politics was because one got very frustrated because one recognised there was a problem but there were no delivery mechanisms. I think the only way you are going to get primary team members to reach their potential and start doing the work is to show that when they do the work there is a result. When I refer people to me as an MP I am almost as frustrated as a GP because fuel poverty and damp housing is not something I can change there and then and that is extraordinarily frustrating.
  (Yvette Cooper) But it is something where there are some local delivery mechanisms in some places being set up.

  732. You need funding.
  (Yvette Cooper) In some places they have set up partnerships where the local authority has got a programme of improving insulation, central heating and so on so they build a partnership with the local health service on how are we going to prioritise, who is going to get the heating first, who is going to get the help. There is all kinds of work going on home energy efficiency schemes and support to tackle damp housing. Those problems exist. The problem is matching them with the people who need them most and the Health Service is actually a brilliant way to match people but only if the co-ordination mechanisms are in place, and they are in some places and they could be in many more.

  Chairman: Can I say we will adjourn for ten minutes.

  The Committee was adjourned from 18.02 to 18.12 for a division in the House.


  733. Colleagues, could we recommence. I hope we can conclude in just over 15 minutes. Before we move away from the point Howard raised, he mentioned men's health and certainly one of the issues that has come out as a concern in this inquiry is the extent to which we have a lot of work to do in that area. As a Committee we feel quite strongly we need to look at that very closely. One of the issues that struck me in some of the visits we did was the fact that the front-line workers who were addressing this were primarily female and I wondered whether if any of the initiatives looked at the way in which you may involve more men in advising men on male health and looked at possible alternative models. I am involved in something you may be aware of on testicular cancer. I will not go into the rather laddish messages we put across but it is an important health message targeted at male spectators of sport. Have you any examples of how you are addressing this as an issue and the staff involved in front-line advice giving?
  (Mr Milburn) The best one that springs to mind is again in Bradford. Certainly on my visit there I had an opportunity to meet some of the male primary care staff, community staff, who were providing health promotion services but in a rather different way than perhaps they had been provided in the past. They were doing lots of "surgeries" in pubs and clubs and getting an incredibly good response, it has to be said. There is quite a bit of that in various places and some of the health action zones (not all but some of them) have helped to pioneer some of that work. I think there are some quite important lessons that are to be learned. It is true that basically men are not as forthcoming as women are about some of these health problems and actually it is important that we therefore have the debate with men on terms that they relate to and understand and in some of the venues that they feel comfortable in. That struck me as a very good example but I am sure there are very many others. The issue is, as always in the NHS, how you generalise from the particular and make sure those examples of good practice become more generalised across the piece. I am optimistic about this because I think that both for women and more men there is such an obvious and growing interest in their own health. You can see that whether it is in types of magazines that have been sold, the growth of gyms and fitness studios or whether it is the number of sports shops on the high street. People are more and more interested, quite rightly, in health issues that affect them, not necessarily Health Service issues either, about their own health. The issue is how best the National Health Service, which has tended to give a fairly passive response to demand, can relate to quite a different order of interest in the population about people's own health.
  (Yvette Cooper) I was going to say that it is not even just about the services, it is also the health information that we provide. I think the traditional approach of the health information campaigns has been to target women. It has been the traditional approach. You think about women as the guardians of family health so health messages go to women rather than to men. That perpetuates a situation in which men feel less empowered when it comes to talking about health, that health is not something to do with them. It is something we have made a conscious effort to address with new campaigns. So, for example, the teenage pregnancy campaign is very explicitly as much about boys as it is about girls, and is very conscious of the different approaches that boys and girls might take or different things that might resonate and it is very clearly about teenage boys as much as it is about teenage girls. Equally, the flu jab campaign we did involved Henry Cooper. We have been very conscious of trying to make sure that the campaigns that we run are as much about men as about women. Another interesting point I would make is that health inequalities issues between low and high income become very clear here as well because what you see over time is high income men catching up with women when it comes to life expectancy but low income men falling further and further behind. You also have to look at inequalities in terms of income as well as the differences between men and women.

Dr Stoate

  734. If I could ask a couple of specific questions, Secretary of State. A bit of a googly for you really: why has it taken so long to publish Sir Kenneth Calman's Report on public health function, which has been promised for some time now? Is there a particular reason it has not been published? Do you intend to publish it quickly and, if not, why not?
  (Mr Milburn) I hope we can publish it quickly. I hoped we might have been able to publish it this week but for various obvious events we have not. It is literally on the stocks and it has been with Ministers and it will be published, I hope, within the next few weeks. The major reason is that we had a change of Chief Medical Officer and it was important that Liam Donaldson had an opportunity to put input into it.

  735. My next question is about the fluoridation of water. When we took evidence from the Sandwell Authority, which is a most deprived area, when they fluoridated the water 13 years ago they found dramatic improvements in the health of kids under 14 in their oral health, particularly in fillings. What is your Department doing about the fluoridation of water? Why is it not being rolled out across the country, do you have any plans to do so?
  (Mr Milburn) As you know we commissioned a study from the University of York which was published in October last year. It was an important study, yet in some ways it was disappointing in that it did not in the end make clear any firm recommendations for action. What it concluded, as you remember, is that overall the fluoridation of water had a positive oral health impact. If the people from Sandwell have told you that then their evidence bears that out to you. As far as they could see from the evidence there were not adverse health risks associated with the fluoridation of water but nonetheless they went on to say that there was not as much primary research around, and the primary research that was around was pretty dated. They recommend that we needed more research and, indeed, that is what we are doing. We are talking to the Medical Research Council about how we can go about getting more primary research. The problem of doing that is that it takes time. If you are going to have a whole series of population studies it is going to take some time to get. There are very different views about this, as you know. My post bag is full of very different views on this issue. I suspect that members around this table have different views. My own view is there are probably big benefits in fluoridation. As with all things, we have to make the policy decisions on the basis of the best evidence. Indeed, I think it is true of public health policy generally that we think we know what works very often but sometimes there is just not an evidence base for it. If we are going to invest public money and we are going to develop new strategies and new interventions then, above all else, we have to be pretty sure they are going to work.

  736. I am disappointed more is not being done. The Americans have done it now for the last 20 years. They have a wealth of evidence and, as far as I am aware, very little adverse evidence. If a country like America can accept it wholeheartedly, virtually all American states are fluoridating their water—
  (Mr Milburn) I am happy to send you a copy of the report. We commissioned the report precisely because there are so many different views about this and to try to get a clear evidence base for any policy decision we took. As I say, the conclusions of the report were clear in one regard but were not in another and, therefore, we have to act appropriately. However, that does not mean that in the meantime there will not be discussions, particularly in those parts of the country where we know there is poor oral health, deprived areas in particular, with the water companies about pressing forward the fluoridation schemes.

Siobhain McDonagh

  737. We have already heard earlier on about how you feel that the target for reducing child poverty is probably the biggest single commitment the Government has made and is going to have an impact on public health. Can you tell me what other Government measures have had an impact on public health?
  (Mr Milburn) The measures that will have an impact, a lot of these things are for the long-term rather than the short, are around the whole effort we are making to improve people's standard of living and to provide more opportunities for them. I think the things we are doing to lift people out of poverty are particularly significant here, whether that is child benefit, the minimum wage, the Working Families' Tax Credit, the New Deal, and the measures we are taking to enhance the employment opportunity and to make sure that if people are in employment they have a decent living wage. These are important measures. I think the New Deal for Communities, the single regeneration budget investment, and so on, are also significant because along with Sure Start what they do is target resources in those parts of the country which need most regenerative effort and require, frankly, additional resources in order that we give people precisely the opportunities that have been available to some communities but not to every community. I think these measures are very, very important, reflecting Dr Brand's earlier point, they are very, very important measures in their own right, but they are also very important public health measures too. Over time they will pay dividends. There is little doubt about that. If Black is right, if Acheson is right, if Donaldson is right, if a wealth of science expertise and medical opinion is right then lifting people up and creating, in the crudest of terms, a fairer society is bound to have an impact on people's health opportunities too. I think a fairer society and a healthy society are two sides of the same coin.

  738. How can performance in tackling health inequality be better managed? How can you enforce targets and monitor progress, given that the rest of the health service is run like that?
  (Mr Milburn) It is very, very important the development we announced in the NHS plan. There was a lot of to-ing and fro-ing about this. There were very mixed views about this. In Our Healthier Nation we said that we would press ahead with a policy of local health inequality reduction targets and some of that has been happening through the health improvement programmes, and so on and so forth. There was a debate inside the Department and in the Modernisation Action Teams about whether we should press ahead with national inequality targets. My own view, and Yvette Cooper's too, was that that was the right thing to do. In the end you have to believe that what we have been talking about in terms of child poverty reduction and the interventions that we can better make in health are going to produce the right results. One thing that is crystal clear about the NHS as a managed service is that if you set a target that influences behaviour. It influences behaviour amongst clinicians and amongst managers. The fact that we are going to have, for the first time, a health inequality target, I hope we well be announcing before too long, I think will gear the Service to better recognising that this is a very important arena of activity for us in a way that has, perhaps, been neglected in the past. We have brought in new expertise to help us do that. We have brought in Don Nutbeam, who is a professor of public health of the University of Sydney, to lead our public health effort and specifically to help us with the devising of an effective but also a challenging health and equality target.

  739. I am only a very new member of the Health Select Committee and I have really enjoyed my time on it, particularly hearing about the local schemes and the really imaginative ideas that people have about regenerating their areas and improving health. All our discussions show they go hand in hand. One of the things that has come up as a minor issue is that the NHS can often be the biggest employer, the most well resourced organisation in any constituency or any borough. Do you think the NHS understands its role as employer, as an owner of property, as an owner of land, as a planner, in relation to what it could do to be involved in these particular regeneration schemes. Do you think the Department and NHS Executive actually understand it?
  (Mr Milburn) I think the frank answer to that is probably, no, we do not or the NHS does not. There is real work to do there. It is absolutely the case, in my constituency, and I guess in most others, if it is the true that the NHS employs one in five of the public sector work force and one in 20 of the whole country's work force, and it is going to be a growing work force, that must be reflected in most constituencies in the land. The NHS has some broad responsibilities, as Dr Brand was indicating earlier, not just to the patients that it serves but also to the wider community that it serves. It is a very important local employer generally. We try to encourage it to get involved at a local level with the New Deal to provide employment opportunities for the long-term unemployed and for the youth unemployed. Although there has been some success there I think a lot more can be done. As far as regeneration efforts are concerned I think probably the most significant thing we have done to date, and I think we need to do more, is the announcement we made in the NHS plan that we would have joint public health groups jointly reporting to the regional offices of the NHS through the NHS Executive and to the regional offices of government. That will, I think, allow something to happen that has happened sufficiently to date, which is that in all of these big regeneration schemes, whether they are New Deal for Communities or the Single Regeneration Budget or whatever for the health benefits and the health impact of those schemes to be better recognised from the outset. What I want to see is a lot more NHS input into regenerated activity both at a regional level, but at a local level as well.

John Austin

  740. Could I just follow on on that because you talk about input there but you are talking about input on the basis of ensuring there are good health outcomes from regeneration schemes. I think clearly in the ones I have looked at there have been measurable or potentially measurable health benefits, but there have been very few regeneration schemes which have been health-led rather than health being a positive good coming out of the economic and education schemes, or whatever it is. Do you think there is much more scope for looking at health becoming a driver and health being a regenerative engine itself?
  (Mr Milburn) Yes, I think there is scope for some of that and, indeed, I am considering at the moment the next wave of major capital developments within the NHS following from the first and second wave of PFI and other schemes, including the one in your own area. Of course, you always have an eye on the potential broader impact that a major scheme of this sort can have in the local community. If you are going to spend £100 million, let alone £200 million or £300 million, and we have got some very, very big initiatives now coming through in terms of hospital developments in particular, they can not only provide the local community with a better local health service but potentially they can also have a very big knock-on effect into regenerative and economic development activity in a local community too. We try to do that at a national level, but I think the point that was being made earlier was that that needs to be replicated right down the command chain to both regional and local level, and I am convinced there is a lot more that can be done in that regard.


  741. Are there any urgent final points Members want to raise or any points either of the ministerial team want to make? If not, can I thank you both for coming along today. We are most grateful to you and I hope our report will be of some help.
  (Mr Milburn) I am sure it will.

  742. Thank you.
  (Mr Milburn) Thank you.

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