Select Committee on Health Second Report

Public Health at the Regional Level

221. The regional level remains undeveloped in respect of the public health function. Currently a typical regional role in public health is to compile and analyse data and performance manage health authority achievements in this field.[301] We believe, however, that the NHS Executive Regional Offices could take a greater strategic lead in public health. The establishment of eight regional Public Health Observatories, which will, inter alia, monitor health and disease trends, advise on methods for health and health inequality impact assessments, and evaluate progress by local agencies in improving health and cutting inequality, will enable Regional Offices to take on a more strategic role.[302]

222. An important function of regions is to encourage social and economic regeneration of their areas. The Regional Development Agencies and the Government Offices of the Regions are the main players in regeneration. We concur with the Secretary of State in his LSE speech that a healthy population is a vital component of a healthy economy. For this reason we think health improvement should be an objective for regeneration projects and we welcome the Secretary of State's comment that he wants "to see ... a lot more NHS input into regeneration activity both at a regional level, [and] at a local level as well".[303]

223. However, we found there is a lack of co-ordination between the NHS Executive Regional Offices, the RDAs and the Government Offices,[304] exacerbated by a lack of regional coterminosity.[305] This has led to a concentration on economic regeneration and has meant RDAs have been slow to embrace health as an important component of this. However there are indications that this is changing and that health is rising up the agenda in regional agencies. For example, there is the welcome move put forward in the NHS Plan to develop joint accountability for public health at a regional level by making the Regional DsPH jointly accountable to the regional director of the NHS regional office and the director of the government office. We support this move and urge the Government to monitor it closely in order to assess its effects on the regional health agenda.

224. We would also urge that there should always be coterminosity between the RDAs and DoH regions to ensure the most effective delivery of services and to demonstrate joined up Government.

225. The Cabinet Office report, Reaching Out, has also proposed greater coherence at regional level.[306] The report suggests that Government Offices are best placed to be the starting point for a better co-ordinated approach. We support the Cabinet Office view that the regional tier has more to contribute to joining-up policy and providing coherence in respect of a raft of initiatives and schemes.

226. A barrier to this development, however, is the uncertainty over future NHS structures, including uncertainty over the regional tier.[307] The prospect of larger health authorities raises a question mark over whether there will be a single intermediate tier below the central department in place of the two tiers of regions and districts, as well as the new primary care organisations. There is a real danger of an unwieldy top-heavy structure emerging in the NHS. We recommend that the Government clarifies the NHS structural arrangements at regional level as soon as possible in order not to divert attention from the public health function at this level for longer than is absolutely necessary.

The Location of the Public Health Function in Central Government


227. The first Minister for Public Health, Tessa Jowell, was appointed at Minister of State level. The fact that her successor, Yvette Cooper, had the more junior title of Parliamentary Under Secretary of State, has been the subject of much comment in the evidence we reviewed. No less a figure than Sir Donald Acheson told us that, in his view, it was "very much a mistake to reduce the status of the Minister for Public Health from a Minister of State to an Under-Secretary".[308] East Sussex and Brighton and Hove Health Authority argued that there was no doubt that the status of the Minister for Public Health "has decreased over the course of this Government". This, they claimed, was "widely seen as a significant problem".[309] The King's Fund similarly contended that "the downgrading of the post of minister for public health was ... regrettable. It not only sends out the wrong message about the importance of public health, it must affect the degree of influence which the office holder can exert across government".[310] The Local Government Association reported "widespread concern" amongst their members over the change in status.[311]

228. We put these concerns to the Secretary of State and to the Minister for Public Health. They dismissed them out of hand. The Secretary of State told us:

"I do not know who is making that point but it is a ludicrous one. I would say that this Minister of Public Health has more influence and more power within the Department of Health than any previous minister who has occupied a previous position, precisely because she is dealing with the mainstream issues of cancer, coronary heart disease, improvements in public health across the piece."[312]

The Minister for Public Health confirmed that she answered directly to the Secretary of State rather than to any intermediary Minister.[313] The Secretary of State told us he had reallocated ministerial portfolios within his Department to give the Minister for Public Health responsibility for policy on cancer and coronary heart disease.[314]

229. We accept the Secretary of State's view that the role of Minister for Public Health has not been downgraded. We think that the fact that so many outside bodies have been quick to argue that the alteration in title equates to an actual diminution in the status of the job is worrying. It strikes us as petty and superficial, and distracts from the much more important debate on how the Minister for Public Health can actually influence the health of the public.


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.[315] 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".[316] 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.[317] 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."[318]

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."[319]

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 animal indeed".[320] 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.[321] 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".[322] 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".[323] 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".[324] 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"[325] 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.[326] 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 government".[327]

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 Cabinet Office:

"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."[328]

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".[329]

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."[330]

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 or £300,000".[331] 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 stronger.

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."[332]

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."[333]

Sir Donald Acheson praised the last two Budgets for their contribution towards reducing inequalities by means of wealth redistribution,[334] whilst Sir Michael Marmot cited research from the Institute of Fiscal Studies to suggest that recent budgets have effected "very clear redistribution by decile".[335] 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.[336]

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".[337] 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.

301   Q440. Back

302   Saving Lives, para 11.30. Back

303   Q739. Back

304   Ev., p.325; Ev., p.490. Back

305   Ev., p.107, Q351. Back

306   Cabinet Office, Reaching out: the role of central government at regional and local level. A Performance and Innovation Unit report, London, 2000. Back

307   Q350. Back

308   Q102. Back

309   Ev., pp.435. See also Ev., p.391. Back

310   Ev., p.476. Back

311   Ev., p.147. Back

312   Q678. Back

313   Q676. Back

314   Q677. Back

315   Q686. Back

316   Ev., p.389. Back

317   Ev., p.479. Back

318   Ev., p.485. Back

319   Ev., p.348. Back

320   Q101. Back

321   Q102. Back

322   Q155. Back

323   Q151. Back

324   Q340. Back

325   Q200. Back

326   Q198. Back

327   Q199. Back

328   Q672. Back

329   Q53. Back

330   Q392. Back

331   Q589. Back

332   Q386. Back

333   Q738. Back

334   Q114. Back

335   Q121. Back

336   Cited BMJ, 3.3.2001, 7285, p.510. Back

337   Ev., p.227. Back

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