Select Committee on Health Second Report

Public Health at the Intermediate Level


96. Health authorities are responsible for identifying the health needs of the local community, establishing how these needs will be met and organising health services for patients. They have a duty to secure improvements in the physical and mental health of their populations by promoting health, preventing ill-health, diagnosing and treating disease and injury and care for those with long-term illness and disability.[116] Health authorities are required to draw up Health Improvement Programmes (HImPs).[117] These are the local plan of action to improve health and modernise services. The HImP process brings together the local NHS with local authorities and others, including the voluntary sector, to set the strategic framework for improving health, tackling inequalities, and developing faster, more convenient services of a consistently high standard.[118]

97. The establishment of Primary Care Groups and Trusts, introduced in the White Paper The New NHS,[119] has had a major impact on health authorities as their traditional commissioning function is moved to PCGs and PCTs. We consider that the current uncertainty surrounding the future role of the health authority gives the Government an ideal opportunity to establish a new structure for public health. We discuss the location of the local public health function at paragraph 126.

98. We wondered whether health authorities would therefore become redundant. The CMO told us he believed a strategic body at area level was necessary and noted: "there are planning functions [and] multi-agency functions which are larger than would be present at the PCT level".[120] Other witnesses agreed that an intermediate organisation was appropriate as existing regional bodies were very large in terms of the population that they served and PCGs/Ts were very small.[121] We also heard how some health authorities were merging and that in future health authorities would probably cover larger populations than at present.[122] David Panter, of the NHS Confederation, commented:

"I believe very strongly that the majority of the current role of health authorities quite rightly migrates to primary care trusts, and health authorities need to pick up a new mantle around a broader strategic planning role, [including] performance management."[123]

99. Mr Panter's view ties in with the Government's proposals for health authorities in Leadership for Health[124] which set out their two main functions, brought together in the HImP: to ensure that service improvements for local people are coherently planned and delivered and to provide strategic leadership for improving health and tackling health inequalities. We agree that health authorities should have a strategic role. However, we have two main concerns.

100. First, it is unclear whether - within the NHS - the local public health function should be led by the health authority or the primary care trust. Both organisations have a responsibility to improve health. The Secretary of State commented that he:

"[did] not believe it is purely the responsibility of the health authority to deliver improvements in public health. ... 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."[125]

We asked the NHS Alliance whether there was a potential risk that public health would "fall between two stools" between health authorities and PCTs. They agreed it was a danger, and that the functions for each body needed to be clearly defined.[126] They envisaged public health practice being carried out by PCTs and the data collection and performance management role being carried out by health authorities.

101. The NHS Confederation argued that health authorities should have a leadership role in public health, although they acknowledged that the lead agency for a local area might differ depending on local "skill-mix".[127] The King's Fund raised the issue of whether the new "slimmed down" health authorities would be capable of sustaining the public health function.[128] Other witnesses considered that primary care trusts were best placed to lead on public health.

102. This debate again raises the issue of the lack of leadership for public health.[129] The National Heart Forum commented that "what is needed is not structural change but a clear definition of roles and responsibilities so that there can be no abdication of accountability and to ensure local level leadership".[130] It is feasible that a public health leadership role could exist within health authorities, local authorities and PCTs, albeit for different functions. We agree with the Secretary of State that health authorities are not solely responsible for improving health, however we consider that the strategic lead for public health must be clarified. The "plethora of partnerships" make it vital that there is clear strategic leadership of public health at a local level. Whatever arrangements are made, leadership should be strong, explicit and should have clear lines of accountability.

103. Second, we are concerned that the role described for health authorities in the NHS Plan focuses too much on performance management to the detriment of the broader role concerned with the health of local populations.[131] Professor Popay noted that if health authorities' role focuses solely on performance management "that would be a local disaster for public health, if nothing is handed to the local authority".[132] We also heard how there may be a tension for the health authority's Director of Public Health, between the independent public health role and performance management.[133]

104. There is also the issue of whether health authorities possess the requisite skills in either breadth or depth to take on a leadership role. As we mention in paragraph 88, there is a risk that public health expertise in health authorities will become diluted due to movement of the workforce into primary care trusts. We are also concerned that if health authorities role is focused on performance management, this would require different skills and competencies to the strategic, leadership role. Avon Health Authority, amongst others, noted that the public health agenda could only be delivered with a significant investment in the development of public health capacity, particularly within primary care.[134] Concerns about a lack of capacity in public health arose time and again during the inquiry, most notably in primary care, but also in relation to health and local authorities, the community and voluntary sector, the regions, and within central government. The Faculty of Public Health Medicine called for the development of the skills of public health practitioners, particularly within primary care.[135] We recommend that the Government, if it is serious in its commitment to public health, ensures that NHS organisations and local authorities have the proper resources, including staff, to enable them to take forward their public health responsibilities.


105. As we have already discussed, the underlying causes of ill-health are closely associated with employment and income, education, housing, environment and the quality of everyday life, including social networks, family relationships and the extent to which individuals feel in control of their lives. A recent joint Health Education Authority and Local Government Association (LGA) report, Making the Links,[136] outlines how poverty and unemployment contribute to health and social problems and accelerate the decline of local neighbourhoods. It also describes the effects of poor housing on health and how the multiple effects of deprivation can exacerbate other problems, isolate people and erode social ties.[137] Health improvement therefore requires action by many different players at local, intermediate and national levels. This was expressed in the White Paper Saving Lives as a "contract" between individuals, communities and government. Saving Lives recognizes that, whilst individuals take some responsibility for their own health, "communities working in partnership through local organisations are the best means of delivering the better information, better services and better community-wide programmes which will lead to better health".[138]

106. Local authorities are at the heart of this community development: they have experience of working closely with local people; they have established partnerships with a broad range of organisations, such as the community and voluntary sector and local businesses; and, crucially, they can influence many of the economic and environmental factors which affect health. For example, local authorities have responsibilities for air quality management, environmental health, food hygiene, housing, leisure services, education, planning, community safety and transport.

107. Councillor Rita Stringfellow for the Local Government Association (LGA) told us that: "[local government sees itself] as having a very strong community leadership role"[139] which requires it to bring together a range of individuals and organisations. This leadership role has been underpinned by local authorities' new powers set out in the Local Government Act 2000 to promote the social, economic and environmental well-being of their areas. In other words, local government has a wider role than service provision. It must also develop: "a sense of vision or direction, for integrating, or 'joining up', the work of various agencies at the local level for the benefit of local communities".[140]

108. The improvement of people's health is of major benefit to communities and as such is intrinsic to local government's new powers. Tony Elson, Chief Executive of Kirklees Metropolitan Council, commented that he would not distinguish public health from well-being.[141] The LGA promote the view that, as health is more than simply the absence of illness, local government should lead the public health agenda.[142] We welcome this recognition that public health should be at the heart of local government. One of our concerns is that since the removal of the public health function from local authorities, public health has been sidelined. Indeed, Mr Elson described how local government had "lost its interest in health" as various functions were transferred, and that "too many of us within local government ... see problems in terms of social regeneration issues without thinking of the health component of it".[143]

109. We consider that local authorities have a vital role to play in improving the health of their communities and have influence over a greater number of factors affecting health than the local NHS. We strongly support their new power to promote well-being and recommend that this leads to public health being placed at the core of their initiatives and strategies. We welcome the attempt to do this by some local authorities. We discuss the location of public health locally at paragraph 126.

110. The LGA believes that the local authority community planning process provides a practical mechanism for achieving effective community leadership. The Local Government Act 2000 requires local authorities to develop a community plan, in partnership with other bodies - working with their community to set priorities for the planning and delivery of services. We recommend that health should be a key element of the local authority community plan. We discuss this further at paragraph 142. Other ways to ensure health is at the heart of local authorities are through performance management which we discuss at paragraph 204 and the facilitation of partnerships with the NHS, which we discuss at paragraph 136.

111. The NHS works in partnership with local communities in a variety of ways. The NHS Plan announced the establishment of a Healthy Communities Collaborative, to spread best practice on effective ways of working in partnership with local communities to improve health and well-being. The Healthy Communities Collaborative will use the formula in place in the Primary Care Collaborative and Cancer Collaborative for spreading best practice and test its effectiveness for addressing public health issues, such as prevention of coronary heart disease. The Healthy Communities Collaborative will work closely with the Neighbourhood Renewal Unit, Home Office Active Community Unit, New Opportunities Fund, and Public Health Observatories to spread best practice, which will include training and quality standards, to local authorities and NHS organisations. The Healthy Communities Collaborative is being led, under the Inequalities and Public Health Task Force, by Hazel Stuteley, whose previous work in community regeneration in a deprived area of Cornwall we describe below. We commend this approach to spreading best practice.

112. Another Government initiative which deals with community development is Healthy Living Centres. These were proposed in the Department of Culture, Media and Sport (DCMS) White Paper The People's Lottery[144] as part of the initiative to use lottery money to fund new projects in health, education and the environment. Such projects were intended to be community based with no standard blue-print, with aims such as tackling social exclusion and improving access to services. To date five HLCs have been announced. For example, the St Sidwell's Centre, Exeter, which we visited, targets disadvantaged young families. Some £200 million has been provided so far for the centres and the aim is to have 20% of the population within the catchment area of HLCs by 2002. Again, the emphasis is on local partnerships and community involvement: the HLCs have to demonstrate they support "local partnerships, in particular Health Improvement Programmes".[145]


113. We visited a particularly notable scheme which showed how community based action could deliver gains that went well beyond simple health improvement in a health led regeneration scheme. The Beacon Project on a housing estate in Penwerris, Falmouth, Cornwall was awarded a Nye Bevan award in 1999 for its remarkable contribution to health improvement. The project was founded in 1995 by two health visitors, Hazel Stuteley and Phil Trenoweth. Penwerris is the poorest ward in Cornwall and has 6000 inhabitants. Out of 135 district councils, Penwerris has the highest number of poor households, the highest proportion of children in houses with no wage earners, the second highest number of lone parents and the second highest level of female and male unemployment. The topography of Falmouth makes the estate hard to view in its entirety from the main roads: we were told that even many residents of the town had little sense of what the Penwerris estate was like: it was a "hidden problem". Before the Beacon Project was initiated, the estate was characterised by a spiral of decline. Local industries had shut down and there were high levels of violence and intimidation by a minority of residents, increasing incidence of depression, a high prevalence of respiratory and chest problems, poor access to services, the lack of any sense of community and "a widespread feeling of abandonment among residents".[146]

114. Hazel Stuteley organized a series of "listening forums" so that tenants and residents could share their views and experiences; representatives from the statutory sector attended these meetings. In December 1995 Penwerris Tenants and Residents Association and Old Hill Community Association were formed and they successfully bid for capital challenge funding: some £1.2 million was awarded to improve insulation and heating. In 1996 the Beacon Community Regeneration Partnership, a tenant and resident body, was formed to oversee the spending of the money, which had been topped up to £2.2. million by Carrick District Council.

115. The money was used to install central heating and otherwise improve the fabric of the properties; to refurbish a play area to give a focus for activity for local youngsters; to instigate a neighbourhood watch scheme; to create a popular parent and toddler group; to introduce traffic calming measures; to facilitate liaison with police and schools; and to bring about "the rebirth of community spirit" by means of numerous social activities such as luncheon clubs, coach outings and jumble sales. Not all the changes required major expenditure. We were told that one of the most effective measures was the decision to paint dreary looking blocks of flats in bright colours. Time and again those involved in the scheme emphasised to us that it arose as a result of partnerships: as well as representatives of the residents, the headmaster of the local school was closely involved, as was a local policeman, community health workers and district councillors. GPs had not, however, played a prominent role. The local pub landlord was a key figure, with his premises being made available for many of the meetings and local activities.

116. The results of the project have been nothing short of remarkable:

  • Post-natal depression is down by 80%
  • The number of children on the child protection register is down by 60%
  • The child accident rate is down by 50%
  • The overall crime rate is down by 50%
  • Residents' fuels bills have been cut by £180, 306
  • Boys SATS results have improved by 100%; girls by 25%

The community now has a police station, a job centre, a benefits office, a tenants' and a residents' association; they plan to have a young person's contraceptive centre and a community dentist. Several of the residents are themselves employed in the local regeneration team.

117. The Prevention and Modernisation Inequalities Team asked Hazel Stuteley to record what made the Beacon project work. In her memorandum to the Team she explained that its achievements had far outweighed her expectations:

"Although I founded the project, no one has been more astonished than I by the health and social outcomes achieved by this community. It would be neat, but untrue, to claim that from the outset my aim was to reduce Child Protection by 60%, post-natal depression by 70%, crime by 50% etc etc but that was what happened. In fact my main aim was to engage other agencies to do outreach work for this abandoned community. That did not happen."

In defining why the Beacon Project had been such a spectacular success Hazel Stuteley picked out several factors. We would like to draw attention to the following:

  • the adoption of a "bottom up" approach
  • change driven by local partnerships
  • she, as a health visitor, had a high community profile and was trusted
  • key local tenants and residents led the initiative
  • convivial settings had been chosen for the community meetings
  • services had been delivered in unfamiliar, but accessible, settings (eg laundrettes, pubs)
  • low key policing by a community liaison PC and intervention by a female housing officer to diffuse neighbourhood disputes had been effective
  • statutory services came to be regarded as partners rather than enemies since meetings took place on neutral ground

118. The Beacon Project shows the profound potential of health improvement. The momentum created by local partnerships and communication was extremely impressive. A virtuous circle of social and health improvement created tangible gains over a wide range of indicators in a surprisingly short period of time. What is interesting for us to observe is some of the unexpected benefits of the project, how physical and mental health improvement, public safety, community spirit, educational achievement and employment opportunities have fed off each other in a symbiotic and synergistic relationship. The Department is to be congratulated for recognizing the achievements of the Beacon Project.


119. One way for local authorities to develop their communities is via social and economic regeneration. There exists a vast array of initiatives and strategies in regeneration, all aimed at removing some of the problems associated with deprived, often urban, areas. At the national level these include the Government's recently produced Urban and Rural White Papers[147] and the work undertaken on neighbourhood renewal by the Social Exclusion Unit (SEU).[148] At the local level there are many initiatives including:

  • Single Regeneration Budget (SRB)
  • New Deal for Communities
  • Sure Start
  • New Commitment to Regeneration
  • Urban Regeneration Companies

Local authorities work with a wide range of partners on regeneration, including:

  • DETR
  • the Regional Development Agencies
  • the Government Offices for the Regions
  • housing associations
  • local regeneration partnerships
  • learning and skills councils.

120. In 1998, the LGA carried out a survey to map local authority action aimed at tackling health inequalities.[149] This found many local authorities actively using social and economic regeneration initiatives to improve the health of their communities. We also took evidence on how health improvement was being incorporated into regeneration. We heard about the Black Country Health and Regeneration Task Group, part of the Black Country Health and Regeneration Consortium. The task group is chaired by Valerie Little who is also the Director for Health and Regeneration - a joint appointment between Walsall Council and Walsall Health Authority. Ms Little told us that she saw this unique role as a public health post that would "enable [her] to see the public health dimension into economic development, the planning department and the regeneration division".[150] We strongly support this kind of initiative.

121. We are concerned, however, that health improvement is not a major driver of regeneration schemes; it tends to be an "add-on". Tony Elson explained that one reason why health was not a major influence is because regeneration projects are funded by DETR.[151] For example, the Single Regeneration Budget objectives do not mention health.[152] This means local authorities have to reinterpret the goals that are set for the regeneration programme in ways which allow them to incorporate health objectives.

122. A consequence of this is that it is hard for health authorities to become involved in social regeneration projects. There has so far been only one successful health authority-led SRB bid. This was by Redbridge & Waltham Forest Health Authority, in partnership with a range of organisations and community representatives. We took evidence from Teresa Edmans, of Redbridge and Waltham Forest, who was involved in this bid, she said: "The Single Regeneration bid that we wrote was about how you could create stepping stones for local communities and the benefits of local people becoming employed".[153] We commend this vision of how regeneration can be effected by a health authority and believe that this practice should be more widely disseminated.

123. We heard about a lack of co-ordination between the DoH Regional Offices and the Government Offices and RDAs and are concerned that not all of these are coterminous.[154] We welcome the NHS Plan proposal to establish single, integrated public health groups across NHS Regional Offices and Government Offices of the Regions, with a view to regenerating health alongside other aspects of the region.[155] We discuss public health at the regional level at paragraph 221 but we believe Government and DoH Regional Offices should be coterminous.

124. The complexity of funding arrangements for regeneration and community development can also affect their long-term viability, a particular problem for smaller community-based projects, and divert scarce resources into bidding for money from multiple funders. We discuss the bidding process in general at paragraph 165.

125. The NHS must also explore its role as an employer, contractor and procurer of goods and services and and its potential as an investor in local communities. The NHS is the biggest employer in Europe and is due to spend £52 billion in 2001-02. Moreover, NHS hospitals often have on their own doorsteps communities suffering high unemployment, which in turn has a detrimental effect on the health of local populations. The NHS itself can therefore play a key role in the regeneration of local communities, although this is too seldom acknowledged. Substantial new resources have been injected into the NHS with the NHS Plan and as a result a great many new jobs are being created, both within the NHS and within companies supplying goods and services to the NHS. Staff are being recruited from outside the UK, and too little attention is paid to developing employability within disadvantaged communities in the UK. We asked the Secretary of State about this. He conceded that the impact of the NHS on regeneration has been a neglected issue and acknowledged that a lot more could be done.[156] We recommend that the NHS Executive gives urgent consideration to developing a pro-active role for the NHS in area-based regeneration and neighbourhood renewal. In particular, we recommend that the substantial resources of the NHS at all levels are used, as far as is practicable, to improve health through direct and indirect employment and through its procurement and planning functions.


126. Ever since the public health function was removed from local government and placed with the NHS at the time of the 1974 reorganisation of the health service there has been lively debate over the merits of that shift. Critics maintain that the function would be better served if it were returned to local government instead of being overshadowed by the narrower health service agenda or being diverted into NHS management concerns which are not public health's core business. Their view is strengthened by the uncertainty over the future role and function of health authorities following the creation of primary care trusts. It is likely that there will be fewer health authorities and that their functions might differ but as yet the Government has not pronounced on the issue. In such a climate it is attractive to propose shifting the public health function.

127. However, these claims are disputed by those who consider that the public health function is better placed to influence health by remaining within the NHS. Dr Edmund Jessop, DPH, West Surrey Health Authority, told us that as a DPH for a health authority he had "command and influence over the entire resources of the NHS which are enormously greater, I suspect, than the local authorities could bring to bear".[157] He also considered it was "slightly artificial to distinguish between medical health and wider health. If you think about how you bring improvements in the mental health of the population you need health service staff as well as tackling the wider determinants of health. It produces a much more effective programme if you can integrate those two".[158]

128. Dr John Woodhouse, DPH, County Durham and Darlington Health Authority, also supported the continuation of the current arrangement on the grounds that a major upheaval would endanger the public health function and put it back in "the doldrums" which occurred after the 1974 shift of the public health function from local government.[159]

129. We are not entirely convinced by the defensive tactics displayed by some of our witnesses. But we are persuaded by the dysfunctional effects of major structural change which invariably fail to meet expectations. We support the view expressed by the majority of our witnesses, including several DsPH, that joint accountability needs to be developed for public health wherever it lies. There is probably no right answer to the vexed issue of which is the optimal location for the public health function. Pros and cons can be deployed for either option. For example, leaving public health in the NHS risks the function forever being eclipsed by a downstream medical agenda in which upstream notions of prevention and health improvement remain of marginal concern. The reality, as many witnesses told us, is that the urgent forever drives out the important. On the other hand, local authorities have yet to realise their full potential when it comes to public health and there is therefore a risk that placing the public health function with them will achieve little in the absence of strong political support.

130. We are also mindful of the weight of evidence from witnesses, including those sympathetic to a return of public health leadership to local government, testifying to the fact that the central issue is not so much one of structure and location but rather one of culture and mind set. The challenge is how to achieve effective sustainable partnerships across agencies. Merely relocating the public health function would not in itself achieve this outcome or improve the effectiveness of public health and its practice. Indeed, it could make it more difficult to achieve by diverting attention from it. We note that the Local Government Association does "not seek to take over the management of public health".[160] It told us: "Simply moving health functions into local government would [not] necessarily resolve some of the issues and barriers that there may yet be. It is about working together wherever people are placed".[161] Its view is that "local solutions are going to be most effective".[162]

131. Mr David Panter, Chief Executive of Hillingdon PCT, suggested that "where the management of the public health function sits is neither here nor there. There are going to be different local solutions for that, but that function must be supporting the broad range of organisations - local government, health, the voluntary sector and the business sector - in helping to carry out their role in promoting public health".[163] Mr Panter was more concerned about the need to ensure the existence of an "appropriate critical mass of public health expertise and, therefore, much more inclined towards looking at a public health resource centre type of approach".[164]

132. We are persuaded by the argument put to us that major structural upheaval in the location of the local public health function is not the answer however attractive it may appear. There can be no return to the past. Rather, we believe ways must be found of providing incentives to ensure that the public health function delivers across the entire health system regardless of where it happens to be positioned.

133. Mr Tony Elson, Chief Executive of Kirklees Metropolitan Council, suggested that Local Strategic Partnerships offered "a way out of the structure debate, out of 'who sits where' debate because I think there are functions in local strategic partnerships which need to be supported by a team of people with expertise, and public health is one of the key elements of that".[165]

134. Complicating the issue further is the rapid emergence of primary care trusts which have as one of their roles the health improvement of their communities and the reduction of health inequalities. Public health is struggling to come to terms with this new organisational landscape and it is likely that much of the focus of its activity will need to be located within PCTs. Indeed, unless this happens PCTs are likely to regard the public health function as one they do not 'own' and are unable to influence. There is experimentation with different models of organising public health in the context of PCTs. For example, Oxfordshire Health Authority is attracted to the idea of a managed public health network which would allow all public health practitioners to 'buy in' to the network at the appropriate level of population.[166] This is not dissimilar to the proposal for a resource centre model put to us by Mr Panter.

135. We note, too, that there is considerable experimentation taking place at local level in the organisation of the public health function with innovative joint arrangements between health and local authorities being put in place. These include joint appointments of DsPH and others working in public health, and joint health units of the type being established in Manchester. We believe that there should be a presumption in favour of joint appointments. We recommend that these arrangements be monitored and supported where they appear to work. They should be urgently evaluated in order to establish their impact and effectiveness. If they work then their uptake should be actively encouraged elsewhere. We believe that the way ahead lies in local solutions in preference to central prescription. But Government must also ensure that best practice from these local developments is rapidly mainstreamed so as to avoid a gap opening up between the leaders and laggards.


136. Partnerships are a key feature of the Government's modernisation programme for public services including the NHS and local government.[167] They are seen to be essential to overcome fragmentation between services and to avoid duplication and an inefficient use of resources. A 'whole systems' approach to providing services is consistent with the policy of 'joined-up' government and the support for integrated care involving primary and secondary prevention as well as treatment. All of these have in common a commitment to partnership working. Indeed, in the absence of partnerships they would be unlikely to succeed. The long-term nature of community regeneration and health improvement means that sustainable, long-term funding and robust partnerships are vital.

137. This recognition of the need for partnership-working is to be welcomed. However it can also lead to problems. Valerie Little gave us an example:

"We have what we refer to locally as a plethora of partnerships, because it is quite a Government flavour at the moment. So everything is done in partnership and if you are not careful you can end up with an awful lot of partnerships ... The recent DETR guidance on local strategic partnerships and a desire to rationalise this a little bit was very welcome. Then I had the direction from the Department of Health to set up a Modernisation Board in every health authority, which was like a partnership but not quite the same and did not match the local strategic partnerships. We are now trying to make all that fit together."[168]

138. Although the evidence suggests that partnership working is improving, in general progress remains patchy and uneven. This is despite partnerships having been a priority in one guise or another for over a quarter of a century; joint planning was one of the key themes of the NHS reorganisation in 1974.

139. Partnerships carry with them high transaction costs. There is a dilemma, therefore, in making an optimal trade-off between the costs incurred in partnerships and the benefits to which they give rise. Often the outcomes may be intangible or not immediately evident or cannot be traced back to the partnership directly. We accept there is obvious "collaborative advantage" when something is achieved that could not otherwise have been achieved. But we also believe there is the potential for "collaborative inertia" where the rate of output is slow and where even successful outcomes involve a great deal of energy and hard work. The short history of Health Action Zones is testimony to the salience of these issues. Collaborative advantage has been the hallmark of some HAZs, often those which already had a history of effective joint working like Sandwell, but collaborative inertia is evident in many others for a variety of reasons.

140. A difficulty with current partnership arrangements, as we have already noted, is the number of different initiatives. Making the Links describes the numerous regeneration community and area-based initiatives, which involve different boundaries and separate partnerships.[169] The problems of co-ordinating local initiatives were outlined in Reaching Out, a report by the Cabinet Office's Performance and Innovation Unit.[170] This looked at how central government initiatives could achieve better integration at regional and local level. It found that such initiatives are often run separately and not linked together. This reduces their effectiveness and imposes unnecessary management burdens on local organisations. Reaching Out recommended a greater focus on strategic outcomes of central government initiatives affecting local areas, with success judged against these. The Social Exclusion Unit has also suggested a number of ways to improve co-ordination in its national strategy for neighbourhood renewal.[171] In its evidence to us, the HDA argued that:

"The inter-relationship of several major strands of government policy needs to be made much clearer. For example, there are the neighbourhood renewal strategy, Sure Start, the various zone-based initiatives, as well as planning mechanisms such as HImPs, community plans and regional development strategies. Each has its own goals and targets and measures of success. People need to be able to understand the relationships among them (and the links between goals to do with economic success, social regeneration, eliminating child poverty, sustainable development, quality of life, well-being and health)."[172]

We endorse this view and recommend that the Government clarifies how the various strands of policy are connected to provide a more coherent policy framework. Otherwise there is the risk of serious failure in partnership working. Paradoxically, the danger of so many partnerships in existence is that a new order of fragmentation will occur.

141. A similar problem is evident in the plethora of overlapping local plans and strategies in existence. Tony Elson noted:

"At the moment we are bedevilled by far too many planning processes. ... we have more than 40 statutory plans which local authorities have to produce and they are all driven by separate sets of guidance and separate government departments requiring separate presentational styles."[173]

142. Increasingly, the separate status of HImPs and Community Plans is unhelpful and potentially dysfunctional as well as increasing the workload on already overstretched agencies. Some witnesses expressed concerns about HImPs. Central Southampton Primary Care Group termed them "disease dominated" and tending to marginalise the "wider agenda". They also commented on the weak links between HImPs and other regeneration plans.[174] The Local Government Information Unit's Democratic Health Network described HImPs as being "skewed more and more towards the health service interests and treatment services" arguing the HImP has become less of a "partnership and more of a health service document".[175] The LGA commented that HImPs are sometimes developed "in a vacuum".[176] The HDA noted that early HImPs have not defined targets and also suggested that "public involvement in HImPs, particularly that of minority ethnic groups, has been hard to achieve".[177]

143. We heard how, in many areas, health and local authorities were developing joint community strategies and HImPs, or were incorporating the HImP into the wider community strategy.[178] We commend this joint-working and consider it a key way of making health a core objective for local government. In their evidence to us the King's Fund commented it was "disappointing" that the NHS Plan did not look at the integration of Community Plans and HImPs.[179] We agree. The evidence from Manchester Health Authority is persuasive on this point:

"It may be more effective for all agencies to focus on one (local authority led?) plan. This would serve to free up time and resources to implement rather than to write plans."[180]

144. We were persuaded by the evidence from Sandwell and Hillingdon Health Authorities where progress had been made in integrating the HImP and Community Plan. We recommend that other localities should follow suit and that the Government issues guidance accordingly. Such guidelines will require collaboration between all the Government departments involved.

145. The LGA expressed its concern that partnerships which have been established between local and health authorities will be compromised by the arrival of PCTs, especially because of the focus of PCT boards on social services, rather than local government as a whole, and the risk of duplication of effort. We have discussed the role of primary care in public health above.

146. There is a distinction to be made between partnerships and integration. The Government appears to have moved from a position of favouring a system of incentives in the form of pooled budgets, lead commissioning for selected services, and integrated provision to promote partnerships to one of integrated structures in the shape of care trusts. The evidence from Northern Ireland, where there is a system of integrated health and social services boards, is that structural integration is in itself no guarantee of partnership working, which leads us to conclude that the issues have more to do with culture and values than with structures alone.

147. A further obstacle encountered by attempts to secure effective partnerships is the complex bidding processes which exist. We discuss the bidding process below at paragraph 165.

116   Faculty of Public Health Medicine: Developing Public Health in Primary Care Trusts - A Framework for Discussion contains a list of health authorities' functions in relation to public health. Back

117   Health Improvement Programmes were introduced in the White Paper The New NHS: Modern, Dependable (Cm 3807) (December 1997). Back

118   Health Service Circular 1998/167. Back

119   (Cm 3807), para 1.2. Back

120   Q82. Back

121   Q353; Ev., p.323. Back

122   Q348. Back

123   Q348. Back

124   Leadership for Health: the health authority role, NHS Executive, August 1999. Back

125   Q721. Back

126   Q455. Back

127   Ev., p.147. Back

128   Ev., p.473. Back

129   Q158; Ev., p.484. Back

130   Ev., p.491. Back

131   The NHS Plan chapter 6. Back

132   Q158. Back

133   PH31(not printed). Back

134   Ev., p.310. Back

135   Ev., p.504. Back

136   Russell H, Killoran A. Public Health and Regeneration: Making the Links LGA & HEA 2000. Back

137   Younger, T. Let's Get Together, Patient:Citizen, June 2000 p35. Back

138   Saving Lives: Our Healthier Nation July 1999 (Cm 4386), para 1.35. Back

139   Q334. Back

140   LGA response to DETR draft guidance on the new powers, 09/02/2001. Back

141   Q391. Back

142   Ev. p142. Back

143   Q416. Back

144   July 1997. Back

145   Ev., p.10. Back

146   This and subsequent information can be found in Beacon Project: Information Pack, "The Project Story". There is an accompanying video and leaflets. Back

147   Our Towns and Cities: The Future, Delivering an Urban Renaissance (Cm 4911), November 2000; A Fair Deal for Rural England (Cm 4909), November 2000. Back

148   New Commitment to Neighbourhood Renewal: National Strategy Action Plan, Social Exclusion Unit, Jan 2001. Back

149   A Picture of Health? A study of regeneration and health, Local Government Association, 2000; The consortium is a local government-led initiative involving a wide range of statutory, voluntary and commercial agencies to collaborate on the regeneration agenda at sub-regional level. Back

150   Q546. Back

151   Q427. Back

152  Back

153   Q580. Back

154   Ev., pp.489, 389. Back

155   NHS Plan para 13.25. Back

156   QQ739-40; Q580. Back

157   Q394. Back

158   Q394. Back

159   Q396. Back

160   Q334. Back

161   Q346. Back

162   Q334. Back

163   Q335. Back

164   Q347. Back

165   Q418. Back

166   Ev., p.320. Back

167   For example, the Health Act 1999 requires NHS-local government partnership working, and promotes new models of joint working and the pooling of budgets. Back

168   Q527. Back

169   Making the LinksBack

170   Performance and Innovation Unit, Reaching Out: the role of central government at regional and local level, TSO 2000. Back

171   National Strategy for Neighbourhood Renewal: a framework for consultation, Social Exclusion Unit, April 2000. Back

172   Ev., p.126. Back

173   Q418. Back

174   Ev., p.307. Back

175   Ev., p.438. Back

176   Ev., p.145. Back

177   Ev., p.128. Back

178   Q374. Back

179   Ev., p.475. Back

180   Ev., p.324. Back

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 28 March 2001