Select Committee on Health Second Report

Current Government Policy


37. The present Government first evinced its interest in public health by emphasising the social determinants of health and social interventions to improve health. It set out its action plan for public health in the White Paper Saving Lives: Our Healthier Nation (July 1999). This took as its philosophy the idea that "the social, economic and environmental factors tending towards poor health are potent" and called for "people, communities and Government" to work together in partnership to improve health. The White Paper set four targets to be achieved by 2010 (with interim milestones for review in 2005):

38. A plethora of different initiatives have been launched in an attempt to deliver the twin objectives of improving public health and addressing health inequalities. We discuss below the roles of the Health Development Agency, Health Action Zones, Health Improvement Programmes, Healthy Living Centres, Public Health Observatories and Health Impact Assessments. In addition a mass of other initiatives in the areas of regeneration, education, employment and sport have profound bearings on the health and well being of the public. Finally, as the Minister for Public Health and Sir Donald Acheson himself acknowledged, a number of initiatives from the Treasury have probably been the single biggest influence in the combatting of health inequalities (see below paragraph 238).

39. One of the central concerns of our inquiry, as our terms of reference make clear, was to establish how effectively these different initiatives interrelate. We will examine a number of these in detail below but at this stage we will analyse the evidence we received on the mass of initiatives. A recurrent theme was of "initiative overload", [40] a phrase used by Graeme Betts Director of Social Services in Hillingdon Council. He was one of many witnesses who felt that the individual structures were worthwhile but their sheer multiplicity and lack of co-ordination made them difficult to put into effect. The UK Public Health Association told us that "initiative fatigue is widely reported".[41] Professor Margaret Whitehead of Liverpool University, and a member of the Acheson Committee on Health Inequalities, maintained there was plenty of anecdotal evidence of such a feeling: "from the statutory sector side people are complaining that it is like being at the bottom of a silo, that all sort of initiatives are coming down from the top and they have to deal with them".[42] Health First, the specialist health promotion unit for Lambeth, Southwark and Lewisham, suggested that the various initiatives "are not linking particularly well at the moment". Discussing their local Health Action Zone, they concluded that "the pressure to have early wins by Government is in contrast to the long term development of innovation and sustainability which is supposed to be at the heart of the HAZ".[43] The Royal College of Psychiatrists said that the experience of their members had been that "projects have often been hurriedly constructed to attract funding and are then poorly thought through, poorly co-ordinated and not well evaluated. There is a cynicism about the real impact of this approach and a strong impression that there is a lack of strategic coherence to local plans".[44]

40. Ironically, the very energy and zeal which the Government brought to bear in the battle against health inequalities has, to some extent, undermined their policy goals. Health Action Zones developed too slowly to spend all the money allocated to them in their first year. Each of the initiatives we have reviewed seems to have its own merits. The difficulties have arisen more from their quantity and lack of integration. We believe that the problems in implementing some of the public health initiatives to date are not necessarily short term glitches that will be solved over a period of time. Instead, we believe these difficulties reflect more profound systemic and structural problems which relate to the lack of co-ordination between different Government Departments, statutory agencies, elected authorities and the voluntary sector. Below we set out our recommendations for creating greater purpose, direction and integration of services.


41. The current Government seemed to give a high priority to public health when it took office. The Acheson report was commissioned within two months of the General Election. As we have noted, this report presented a comprehensive and wide-ranging critique of those measures which would do most to reduce health inequalities. Following the Acheson Report, the Government released Reducing Inequalities: an Action Report alongside Saving Lives: Our Healthier Nation, which was then given to a Modernisation Action Team to oversee implementation and incorporate the process in the NHS Plan.

42. So a picture emerges of a government expending a good deal of energy in the sphere of public health in the first months of office. What is, to us, less clear is whether that energy has been sustained and whether it has been channelled effectively. In this regard, the NHS Plan is a key area. The Secretary of State told us that the White Paper Saving Lives: Our Healthier Nation shared "equal status" with the NHS Plan.[45] Indeed, he felt that the Plan "broadly reflected the aspirations, ambitions and some of the targets within Our Healthier Nation".[46] Written evidence from the King's Fund analyses the public health content of the Plan. The following public health initiatives are reported:

  • new national health inequalities targets "to narrow the health gap in childhood and throughout life between socio-economic groups and between the most deprived areas in the rest of the country" to be developed in consultation with stakeholder groups and experts
  • a new health poverty index combining data about health status, access to health services, opportunities for good health
  • a new funding formula making the reduction of inequalities a key criterion of resource allocation
  • new Personal Medical Services schemes for salaried GPs and other NHS personnel by 2004 in disadvantaged communities
  • by 2003 a free translation and interpretation service via NHS Direct
  • an extra £500 million for the SureStart programme
  • a new Children's Fund worth £450 million
  • an enhanced smoking cessation programme with nicotine replacement therapy available on prescription
  • free fruit in schools for children aged up to 6 years old
  • local strategic partnerships developed with the help of the NHS with a view to integrating health action zones with other action zones (education and employment)
  • by 2002 single integrated public health groups formed across NHS regional offices and government offices of the regions. Accountable through the DPH to CEOs of health and government at regional level
  • by 2002 a new Healthy Communities Collaborative to spread best practice, following the formula of the Cancer and Primary Care collaborative
  • by 2003 a new leadership programme for health visitors and community nurses to develop their capacity to work directly with local communities[47]

43. However, the King's Fund also voiced a number of reservations about the Plan: they were "disappointed" that it failed to announce further convergence between the HImP and the Community Plan; they questioned whether the Plan would impact favourably on the development of local partnerships; they queried whether the mainstreaming of partnership working had sufficient emphasis; they were concerned at the fact that the HDA is barely mentioned in the Plan; and they noted that the Plan said nothing about the need to develop effective links between England, Scotland, Northern Ireland and Wales in the public health area.

44. Other witnesses also had misgivings. Professor Sian Griffiths, DPH in Oxfordshire and Vice President of the Faculty of Public Health Medicine, told us that she thought Saving Lives was a very good strategy but risked being lost in the "reformatting" of the NHS Plan. She felt that this posed particular threats to proposals for increasing workforce capacity and building up skills in the community at large, rather than just among GPs.[48] John Ransford of the Local Government Association said that the chapter on public health should have featured much earlier in the Plan (it is chapter 13 out of 16) and that this chapter should have been "firmer".[49] Jane Naish of the RCN praised the proposal for national health inequalities targets and the commitment to a health poverty index, but criticised the lack of a strategy on how public health could be delivered in the field and the omission of the issue of water fluoridation.[50] For the BMA, Dr Peter Tiplady felt that "the root causes of ill health" received little mention in the Plan, believing that it represented a falling off in the early promise of the Government's public health strategy.[51] We note that both the Scottish and Welsh NHS Plans accord a higher prominence to the health agenda, an approach that we welcome.

45. Professor Whitehead, was another who felt that the "initial flush of enthusiasm" for public health had perhaps "cooled off" over the last twelve months. She cited the "muted consideration" of public health in the NHS Plan as a sign of this.[52] She praised the Plan for "the setting of the new overarching resource allocation objective for the NHS: 'to contribute to a reduction in avoidable health inequalities'" as "a world first" adding that she knew "of no other national resource allocation effort that has gone so far towards a focus on public health". On the other hand she felt that the Plan contained a number of flaws. First, although improving health and reducing health inequalities had its own chapter, these themes did not seem to pervade other areas of the plan - so chapter 14, for example, which deals with clinical priorities remained silent on the social, economic and environmental determinants of health. Second, in general the targets and performance indicators in the Plan were expressed as averages and did not give sufficient recognition of the need to monitor the distribution of outcomes across different social and ethnic population groups. Third, the Plan did not specify the need for capacity building for public health efforts including epidemiological expertise and skills in inter agency partnership working, nor did it address the dangers of not maintaining a critical mass of expertise in strategic agencies at local and national level. Finally, no specific resources were earmarked for building up the evidence base on the effectiveness of health promotion: she felt that the HDA had been given a very small budget to investigate a "potentially enormous field".

46. Further grounds for believing that the Government's early enthusiasm for public health has been diverted comes in the lengthy delay in the publication of the report commissioned from Sir Kenneth Calman, the former Chief Medical Officer, into public health capacity and the public health infrastructure. An interim version of the report was published in 1998, so we asked the Chief Medical Officer when the report would be completed and published. Back in July 2000 he told us: "The report has been completed and it is with Ministers".[53] But when we asked the Secretary of State, at the end of January 2001, why it had not been published and when it would be, he replied:

"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."[54]

This strikes us as a weak argument, since the CMO himself told us that, so far as he was concerned, the report was complete over six months earlier. We recommend publication of Sir Kenneth Calman's report on the public health function without delay.

47. We accept the Secretary of State's assurance that the NHS Plan is of equal status to Saving Lives. We particularly welcome the fact that the Plan includes a commitment to health inequality targets. But we believe that a great opportunity to give public health a real impetus has been lost by the lack of emphasis on this area in the Plan. The whole notion of a Plan is of a working agenda. So if it is the case that Saving Lives has equal status with the Plan this should have been made explicit in the Plan itself. Taken with the interminable delay in the publication of the Calman report on the development of the public health function we believe it adds credence to the notion that, for all the laudable Government rhetoric about dragging public health from the ghetto, in the race for resources it runs the risk of trailing well behind fix and mend medical services.


48. The Government has placed great emphasis, over the past three years, on evidence-based policy, particularly in the health field. One of our witnesses, Professor Sally Macintyre of the Social and Public Health Science Unit of the Medical Research Council, argued that many of the problems in judging the effectiveness of the interventions lay in the flawed methodology used to assess their success:

"One of the reasons we have no idea is that a lot of these interventions are not set up in a way that can be fairly robustly examined. The temptation is to take the worst places and give them everything. We do not know whether that is a good thing or a bad thing, whether it would be better to spread that around, we do not know whether harm is caused by having everything going on at the same time. There is this obvious political desire to take the worse places and give them something, but often that is related to who is best at writing bids. I wonder whether some of the ways we allocate things like health action zones, healthy living centres, all these huge numbers of interventions, could not be somewhat more systematic and let us evaluate their outcomes. I have a slightly sceptical hypothesis that the time people spend in partnership arrangements may well be a waste of time. They may be better not doing things in partnership."[55]

49. Professor Macintyre went on to suggest randomised control trials could be employed to assess the efficacy of particular interventions: "You could take all the bad areas and give half of them one initiative each and the other half lots and then another group none and see what happens and then we shall know and we shall also measure the harm".[56] Professor Macintyre's own research suggested that interventions which intuitively seemed likely to have positive public health outcomes could in fact yield unforeseen problems. She cited the example of a cycle safety education campaign in Australia which seemed actually to have led to an increase in cycling accidents amongst boys and children from poorer families.

50. We believe that there is merit in Professor Macintyre's suggestion that area-based interventions should be subject to far more rigorous analysis, although we are not convinced that randomised controlled trials are necessarily practical. We hope that this void can, at least in part, be filled by the work of the Health Development Agency.

39   Cm 4386, p.viii. Back

40   Q528. Back

41   Ev., p.107. Back

42   Q141. Back

43   Ev., p.520. Back

44   Ev., p.521. Back

45   Q682. Back

46   Q681. Back

47   Ev., pp.473-74. Back

48   Q224. Back

49   Q360. Back

50   Q486. Back

51   Q485. Back

52   Ev., p.75. Back

53   Q85. Back

54   Q734. Back

55   Q169. Back

56   Ev., p.189; Q178. Back

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