WHERE SHOULD THE MINISTER FOR PUBLIC
HEALTH BE LOCATED AND SHOULD PUBLIC HEALTH BE A MATTER FOR THE
DOH AT ALL?
230. While the NHS has an invaluable role to play
in curing illness, and could address health inequalities by dealing
with the major inequalities of access to care and treatment among
different social classes, as many of our witnesses suggested it
cannot tackle the underlying causes of ill-health. These are more
closely associated with education, employment, income, 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 and at ease with themselves. As
the Secretary of State himself acknowledged only three of the
39 recommendations made in the Acheson report on health inequalities
pertain to the Department of Health.
The Chartered Institute for Environmental Health suggested: "public
health means tackling a broader front than disease or manifestations
of ill health. It can be costly, it is certainly 'long-tem' before
improvement can be detected".
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.
231. The rationale for giving greater priority to
public health measures is strong. But public health seems to us
too often to have been expressed in terms of ad hoc projects
which, whilst well-intentioned, fail to deliver any profound infrastructural
change. And as we have noted, many witnesses have argued that
the drive for 'quick wins' takes precedence over long-term developments,
even though tackling the root causes of ill-health takes decades,
rather than years or months. Policies that can be delivered through
the NHS are favoured over those requiring action by other sectors.
232. These factors offer a strong case for moving
public health out of the Department of Health. A variety of more
or less radical alternatives were put forward in evidence to us.
Naomi Fulop and Julian Easton of the London School of Hygiene
and Tropical Medicine argued that the "marginalisation"
of public health was "likely to increase once the combined
posts of permanent secretary to the Department of Health and chief
executive of the NHS has been created". They proposed that
the Minister for Public Health should not be located in the DoH,
but should instead be a member of the Cabinet able to bring influence
to bear across Government, perhaps based in the Cabinet Office.
Tony Jewell, Director of Public Health, Cambridgeshire similarly
favoured shifting the post to the Cabinet Office:
"Locating the Minister as a junior post within
the DoH severely restricts their impact. The post should be at
Cabinet level, perhaps based in the Cabinet Office with responsibilities
that enable a powerful cross government role."
The Medical Practitioners' Union also contended that
a broad new remit across the Government was essential:
"The Minister in Public Health should be equal
in status to the Chief Secretary of the Treasury with an acknowledged
interdepartmental role in a department whose remit crosses the
whole of Government and therefore able to deal with Cabinet Ministers
as an equal and, indeed, to be regularly in attendance at Cabinet."
233. Sir Donald Acheson acknowledged that very few
of the determinants of health were within the remit of the DoH.
Nevertheless, he felt that a health service without any responsibility
for health promotion and prevention would be "a very strange
He suggested that relocating the Minister for Public Health to
the Cabinet Office would make the Health Department "look
very peculiar" and would be very disruptive. Another possibility,
he felt, would be to have a separate "strong interest"
within the Cabinet Office to maintain cross-government co-ordination
of public health policy.
Professor Richard Wilkinson favoured a "Minister without
Portfolio, responsible for social development, seen as contributing
to all these different fields equally, crime, educational failure,
health and so on".
More important, in his view, than the precise location of an individual
Minister was an overall commitment on the part of Government to
public health: to adapt a slogan, the Government needed to be
"hard on disease but also ... hard on the causes of disease".
Councillor Stringfellow of the Local Government Association related
the need for cross sector co-operation at local level to the case
for joining up government at national level in the sphere of public
health: "I think just as much as it matters at local level
that Government is joined-up, so it does at national level, and
that the Public Health Minister has a very strong influence on
colleagues across other departments. To some extent I think where
the Public Health Minister is located should not matter if that
is actually happening effectively".
Professor Jennie Popay similarly argued that it is more important
to question "how you put the responsibility for health into
whatever the mix of Government departments is at a national level"
than where the Minister should be located.
234. Dr Donnelly of the Association of Directors
of Public Health pointed out that the cross- cutting nature of
the public health agenda meant that it did " not necessarily
neatly fit into the Whitehall model"
and in an effort to circumvent this problem John Nicholson of
the UK Public Health Association suggested "a Health Unit
similar to the Social Exclusion Unit which could have the same
Prime Ministerial support and Cabinet support and so on".
He was another who felt that there should be a Cabinet role of
"Cabinet linkage" to public health.
Similarly, Sian Griffiths, Vice President of the Faculty of Public
Health Medicine, mooted the possibility of " a Public Health
Advisory Group ... which would allow senior people in the field
to ensure that the public health profile was maintained across
235. We put to ministers the suggestion that the
Department of Health was an inappropriate location for the public
health function. Perhaps unsurprisingly, they were robust in their
defence of the status quo. The Minister for Public Health
argued that the huge spending power of the DoH made it a more
effective agent for enforcing a public health strategy than the
"this year I think the Department of Health
will be spending between £40 and £50 billion and it
is one of our commitments that we want to see a growing proportion
of that resource spent on public health measures - defining cancer,
coronary heart disease and so on and so forth - by contrast, I
think the Cabinet Office has a budget of less than £200 million.
In the end, money talks because it provides you with leverage
to get things done."
The Chief Medical Officer was also in favour of retaining
the existing arrangements, telling us he was "in a much stronger
position working with a set of Ministers who are at the coal face
and who have got links with their ministerial colleagues".
236. We are not entirely convinced by the arguments
put forward by those seeking to keep public health within the
NHS. Sir Donald Acheson's assertion that a Health Department without
a health promotion and prevention agenda would look very odd may
sound plausible, but others would argue that the proximity of
the public health agenda to the NHS has actually inhibited its
development. Ministers' suggestions that the spending power of
the DoH gave added leverage to public health would be more convincing
if it were clear that public health was getting its fair share
of the health budget. This, according to Chris Veal, DPH for Calderdale
and Kirklees, remained unclear:
"I work in the Health Service at the present
time and I find it difficult to understand what proportion of
the Health Service expenditure is actually expended on health
and what proportion is expended in terms of Health Services."
Andy Worthington of Sport England put the benefits
of the link between public health and the spending power of the
DoH in a different context when he remarked: "a [health]
authority with an expenditure on health of about £300 million
often will have a health promotional budget of perhaps £200,000
However, we do think that the enormous spending power of the DoH
is one factor that could be brought to bear in justifying retaining
public health in the DoH. This would be especially demonstrable
if the NHS brought more of a public health focus to bear in its
own expenditure, for example in considering the impact of its
capital programme on local regeneration as we discussed above.
We also accept that major reorganization at central Government
level would be disruptive.
237. We conclude that the present arrangements
do not adequately promote cross-government working. Given the
undesirability of change for its own sake, we recommend that the
public health function remains with the Department of Health for
the present. We would, however, like to see far greater evidence
that it has assumed priority within that Department. If that is
not forthcoming, we think the case for relocation would be much
238. Health Ministers themselves acknowledged that
Department of Health initiatives were not necessarily the key
drivers of public health and that there was a much wider Government
responsibility for the health of the nation. We asked the Public
Health Minister whether she felt she could really affect the main
determinants of health such as housing, employment and poverty.
She told us:
"The biggest determinant of public health I
think is poverty. The most important thing we will do over the
next 20 years is achieve our target to abolish child poverty.
In the end, a lot of that is within the power of the Treasury
but it is not all within the power of the Treasury because it
is also about providing opportunities for young people from the
very start, which is why Sure Start is part of our programme to
tackle child poverty."
The Secretary of State pursued a similar line of
argument when we asked him what he felt had been the main measures
the Government had taken to improve public health:
"The measures that will have an impact, a lot
of these things are for the longterm 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 ... 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."
Sir Donald Acheson praised the last two Budgets for
their contribution towards reducing inequalities by means of wealth
whilst Sir Michael Marmot cited research from the Institute of
Fiscal Studies to suggest that recent budgets have effected "very
clear redistribution by decile".
In addition, a recent study by the Child Poverty Action Group
has revealed that child poverty has fallen by a third in the past
two years, as a result of changes in benefits and taxes.
239. We accept the point that several of our witnesses
made that the exact location of the Minister was not the key issue:
what is more crucial is that the structures are in place to co-ordinate
the very wide public health agenda across Government and the different
countries of the United Kingdom. We are not convinced that this
is yet happening, as the lack of co-ordination between the sports
agenda and the health agenda, for example, made clear.
240. The Government has made a clear commitment to
joint working. This is a particularly useful approach as far as
public health is concerned, for as we have seen, public health
is not strictly a DoH problem but spans the many departments whose
policies impact on the health of the population. Despite the avowed
policy of the Government, and the implementation of some welcome
cross-departmental partnerships, such as the Healthy Schools Programme
and the Sure Start initiative, such partnerships seem to have
developed only in a patchy and piecemeal way. We have heard time
and again how insufficient collaboration at central government
level had made it very difficult for partnerships to work at local
level, because of overlapping partnership requirements, the use
of different performance management targets, progress indicators
and funding arrangements, not to mention different working cultures.
For example, officers from Hillingdon told us how "Smoking
Kills expects schools to be involved in smoking prevention
but there is no relevant Best Value or Audit Commission performance
management indicator to increase the likelihood that this will
be seen as a priority by the local LEA".
We recommend that all cross-departmental initiatives design
in appropriate targets, performance management and progress indicators
for all partners involved at all levels. We further recommend
that departments coordinate initiatives better to avoid unhelpful
duplication of effort.
Saving Lives, para 11.30. Back
Ev., p.325; Ev., p.490. Back
Ev., p.107, Q351. Back
Cabinet Office, Reaching out: the role of central government
at regional and local level. A Performance and Innovation
Unit report, London, 2000. Back
Ev., pp.435. See also Ev., p.391. Back
Ev., p.476. Back
Ev., p.147. Back
Ev., p.389. Back
Ev., p.479. Back
Ev., p.485. Back
Ev., p.348. Back
Cited BMJ, 3.3.2001, 7285, p.510. Back
Ev., p.227. Back