SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS
(i) We recommend that health policy should
benefit the less well off on a sliding scale rather than targeting
only the small group who are the most deprived (paragraph 34).
(ii) We see great potential for health
inequality targets to give real bite to the HImP/Community Plan
and to provide a yardstick for Directors of Public Health, Local
Authorities and Health Authorities. We welcome their recent publication
and were particularly pleased to see a focus on health inequality
amongst children. We also recognize that inequalities targets
will only make a difference if effective strategies are put into
place to achieve them. This should include developing appropriate
"baskets" of intermediate targets for each of the headline
targets. Intermediate targets may usefully take account of some
targets set out in The Health of the Nation, as well as locally-determined
targets that are relevant to local conditions (paragraph 35).
(iii) We recommend that every Government
Department has a Public Service Agreement to conduct health audits
and health inequality audits of relevant policies and to work
towards policies which have a positive effect on health. We also
think the Government should consider the advantages of the establishment
of a Parliamentary Health Audit Committee to assess whether or
not departments deliver on this along the lines of the Environmental
Audit Committee. Whilst this is a matter for Parliament, not Government,
we would welcome the considered views of DoH on such a suggestion
(iv) 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(paragraph
(v) We note that both the Scottish and
Welsh NHS Plans accord a higher prominence to the health agenda,
an approach that we welcome (paragraph 44).
(vi) We recommend publication of Sir
Kenneth Calman's report on the public health function without
delay (paragraph 46).
(vii) 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
(viii) 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 (paragraph 50).
(ix) We think it is crucial that the
voices of those intended to benefit from interventions are acknowledged
and that they feel some sense of ownership in the projects. At
the moment, the impression is of grandiose schemes being foisted
on to communities. The most effective interventions that we witnessed
took their strength from local leadership, responsiveness to local
need, and local involvement and participation at every level.
Given the evidence we received relating to the general lack of
involvement of lay individuals in, for example, the Health Action
Zones and Health Improvement Programmes, we believe it is essential
that Government takes action and makes it a condition of further
funding that there is clear feedback and input from those individualsintended
to benefit from public health projects, including children. We
are not convinced that any wider sense of "ownership"
has yet been established (paragraph 57).
(x) It seems to us particularly regrettable
that area-based initiatives have often failed to engage the communities
they aim to serve (paragraph 57).
(xi) The precise status of Health Promotion
England seems to us unclear. The nature of its short term contract,
its relationship to its predecessor body and its means of liaison
with the Health Development Agency (HDA) all seem too opaque.
We are not convinced that this body has the direction, energy
or resources to make a real difference. We would urge the Government
to make clear its plans for the future of health education (paragraph
(xii) We were impressed by the evidence
given by those representing the HDA. We would be disturbed if
this new organization was not properly resourced. We are anxious
to ensure that the HDA will have the resources to be able to assess
'bottom up' projects. We also recommend that its funding should
be ring-fenced and kept apart from mainstream health funding so
that its independence in offering objective advice on 'what works'
in health is not compromised. Establishing 'what works' in public
health will ultimately yield value for money savings (paragraph
(xiii) We recommend that the national
Public Health Workforce Development Plan and Public Health Skills
Audit (mentioned in the Department of Health's evidence) assesses
whether primary care actually has the capacity to take on public
health responsibilities (paragraph 70).
(xiv) If GPs are to be more involved
in wider public health work, particularly of a community development
kind, the Government must find some way of creating a career and
pay structure which enables them to do this and allows them sufficient
time and provides sufficient incentives to facilitate their involvement
(xv) Evidence exists from the USA and
Canada to show that the benefits derived from a programme of home
visits to women who are expecting a baby and then in the first
two years of the life of the baby, are "uncontroversial",
according to Sir Donald Acheson. This evidence should be capitalised
upon to back a government focus on developing the health visiting
workforce and other professions working with children (paragraph
(xvi) We believe health visitors should
work with the elderly or other needy groups, so as to broaden
their skills base to encompass other activities. We would also
like to see a role for health visitors as the key public health
resource for all community health care professionals. We are concerned
that health visitors are not sufficiently empowered in terms of
resources and capacity to carry out wider public health functions
beyond their statutory duties. We also think that there is scope
for greater integration and co-ordination between health visitors,
school and community nurses. We recommend that the role of the
health visitor is reviewed and clarified. We would like to see
it developed as a holistic, public health function (paragraph
(xvii) We recommend that the Government
takes steps to create incentives for community pharmacists to
play a more active role in public health. We welcome the
idea that a pharmacy could act as a more general health resource
centre, thus better utilising the very considerable expertise
of pharmacists (paragraph 81).
(xviii) If the information resources
of primary care are to be exploited, a properly resourced information
management and technology structure will have to be implemented
(xix) The Government must performance
manage public health responsibilities to ensure that PCG/Ts do
take up their new responsibilities meaningfully. It must also
ensure that the relevant training and support is provided to all
PCG/Ts to enable them to do this (paragraph 85).
(xx) We recommend that PCG/Ts should
be required to have an additional designated officer from the
local authority with a broader remit for public health. If PCG/Ts
are significantly to influence health, they must have access to
those local government services which affect the social determinants
of health. PCG/Ts also need to be given more information about
how local government works, so that they can begin to use it more
effectively (paragraph 89).
(xxi) We believe health authorities will
have to work hard to improve their communications with primary
care, perhaps through secondments or work-shadowing, to improve
mutual understanding of the different ways of working (paragraph
(xxii) The Government needs to clarify
exactly what the respective public health roles of the different
tiers of the health system will be (paragraph 93).
(xxiii) A better solution to the problem
of supplying public health advice to PCTs, which will certainly
be needed, might be in the form of managed public health networks,
with which PCTs and indeed Local Authorities could contract for
public health support. It may be that, with PCTs becoming the
predominant purchasers, health authorities could focus on public
health almost exclusively and house such centres of expertise
on a hub and spoke model. It may well be that no one national
solution will cater for the different local situations of different
areas, but guidance and an exploration of this area is vital.
We recommend that the Government conducts a review of the best
way of providing public health support to the variety of local
agencies which require or will require it (paragraph 94).
(xxiv) There are a number of ways in
which primary care could contribute more to the wider public health
vision. The primary care team could become a fulcrum for interagency
work, physically providing a base for various combinations of
'one-stop shop' or healthy living centre or at least creating
an information link to other statutory services. Formalised links
and defined referral pathways to local government departments
such as housing, leisure (such as through the exercise on prescription
scheme) and schools, to name a few, would link the medical health
care team more effectively to the social determinants of health
and the statutory powers who may affect such determinants. On
a wider canvas, health visitors and nurses could lead primary
care involvement with community interventions and development.
The establishment of PCTs should allow Primary Care to take a
broader population perspective. Given that PCGs and PCTs have
as one of their three key functions "to improve the health
and address inequalities of their community" a way must be
found to make public health a viable reality for primary care
(xxv) 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
(xxvi) 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 (paragraph 104).
(xxvii) 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
(xxviii) We recommend that health should
be a key element of the local authority community plan (paragraph
(xxix) 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 (paragraph 125).
(xxx) 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 (paragraph 132).
(xxxi) 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
(xxxii) In its evidence to us, the HDA
"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)."
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 (paragraph 140).
(xxxiii) 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 (paragraph 144).
(xxxiv) We urge that health objectives
are at the heart of neighbourhood renewal strategies (paragraph
(xxxv) We understand there is now a respectable
body of research identifying the success criteria to ensure effective
partnerships. We urge the Government to apply these to its own
proposals to establish new partnerships in the form of Local Strategic
Partnerships as well as to its 'joined up' policy agenda across
government departments. In particular, we recommend that the lessons
from the HAZs emerging from the national evaluation are taken
on board in the development of LSPs (paragraph 151).
(xxxvi) Our strong impression is that
the current role of the Director of Public Health is too vague
and the influence the DPH can bring to bear too little. We were
not struck by any real sense that the DsPH were acting in the
entrepreneurial way the BMA suggest. The DsPH do not seem to us
generally to be providing the necessary leadership in the public
health field (paragraph 157).
(xxxvii) The lack of priority accorded
to population health at the annual health authority review meeting,
and the fact that over half of the DsPH surveyed failed even to
attend the meeting, suggests to us that DsPH do not, on the whole,
carry real weight within the health service. We recommend that
guidance is immediately circulated to require DsPH to be present
at the annual review of the health authority and to require population
health to be an agenda item, a requirement made even more pressing
by the recent publication of the national health inequalities
targets (paragraph 160).
(xxxviii) We note that the Government
is currently reviewing the impact of the annual report of the
DPH. We believe that the annual report of the DPH should adopt
a consistent format to ensure compatibility of data. It should
clearly distinguish between past trends in epidemiology and key
present agenda concerns. We feel that the Health Development Agency
should have an early input into producing guidance to ensure a
far greater degree of standardisation across the DPH report whilst
still allowing sufficient flexibility to achieve sensitivity to
local conditions and needs. Guidance should be issued on the range
of bodies that should be consulted in drawing up the annual report.
For example, Dr Rosemary Geller, DPH for Shropshire, told us she
used the need to draw up an annual report as an opportunity to
visit all relevant organisations and stakeholders once a year
so as to get their input. We believe that, in drawing up the annual
report, the DPH should record the contributions not only of the
statutory sector but also of local, voluntary organisations. The
annual report of the DPH ought to be a critical document in the
formulation of the joint HImP and Community Plan (paragraph 161).
(xxxix) Support for joint health authority/
local authority appointments was voiced by many of our witnesses
and we would regard this as a positive measure. We are not convinced
that the DoH has been sufficiently proactive in helping this come
about. We acknowledge that joint appointments are much more straightforward
in areas where there is coterminosity, though even here they are
the exception rather than the rule. We would argue, as the Cabinet
Office report Reaching Out suggested, that greater moves
towards coterminosity need to be made. But even where there is
not coterminosity we feel that all stakeholders in local and health
authorities ought to be able to agree a strategy to have a Director
of Public Health in post whom they regard as partly their responsibility.
However, we do not necessarily believe that joint appointments
will bring an end at a stroke to turf wars between local and health
authorities. In this regard we would especially like to endorse
the suggestion of Ken Jarrold that, as well as having structures
to bring about joint appointments of DsPH, other structures had
to be effected to make them jointly accountable to each
authority. We also maintain a line of argument from several of
our previous inquiries that the DPH should have ready access to
those in local government, placing population health in the immediate
context of many of the factors - housing, the environment, transport
- which most impact upon it (paragraph 164).
(xl) We recommend that the Government
adopts population-based funding and clear policies for its application
and then leaves it up to local agencies, as part of the HImP,
to get on and deliver on these policies with the appropriate training
in place to equip managers and others with the requisite skills.
At the very least the bidding process needs to be reformed. We
recommend that the Government conducts a review of the bidding
process in the context of public health funding, with a view to
formulating a more equitable system for the allocation of money,
particularly in regard to voluntary or charitable organisations
(xli) We recommend the Government does
more to research and involve the views of children in initiatives
aimed at improving their health (paragraph 184).
(xlii) We recommend that the employment
structures of school nurses be rationalized so as to allow effective
joint working and partnerships (paragraph 186).
(xliii) We recommend that the Government
should support and consult the professional bodies to develop
the school nursing service as a vital public health role. We also
think it would be beneficial if this service could be integrated
with other public health workers in the community (paragraph 188).
(xliv) We note how in countries such
as Cuba and Australia the sporting agenda is seen as part of a
much wider health and regeneration agenda. We believe that better
liaison is essential between all Government departments-notably
DCMS, DfEE, DETR and DoH-if this is to be achieved. Accordingly
we recommend that the Government appoints advisers specifically
to co-ordinate the work of all Government departments to deliver
the sport and health agenda as a matter of urgency (paragraph
(xlv) We are not convinced that DCMS
is the appropriate ministry to have responsibility for sport.
We think it perpetuates the notion of sport as a matter for spectators
rather than participants. We were impressed by the example of
Cuba, where sport is treated as intimately bound up with the public
health agenda. We think that sport, like public health, needs
greatly to strengthen its profile across Government. We would
also point out that the Minister's justification of leaving sport
where it is (that it attracts more attention in a small department)
completely contradicts the Public Health Minister's argument for
retaining public health in the DoH (that it carries more weight
as part of a big department-see below, paragraph 235). However,
we accept that immediate reorganization may be unwelcome, and
would urge the Government to keep under review the location of
sport in Government, with a view to creating much closer links
with public health. As an interim measure we recommend that the
Minister for Sport should become a full member of the key Cabinet
Committee on health policy, the Ministerial Committee on Home
and Social Affairs (Health Strategy) (paragraph 200).
(xlvi) The NAO concluded that there may
be benefits if more GP practices were more active in educating
their patients on obesity, and we would endorse their conclusion.
We believe that the rapid growth in the extent of obesity poses
a major public health hazard and that all health authorities should
regard it as a first order priority. We hope that the publication
of the National Service Framework will encourage health authorities
to take prompt action and recommend that the Department should
monitor health authorities' activity levels and strategies in
this area as a matter of urgency (paragraph 203).
(xlvii) We consider that NHS resources,
time and effort are being directed towards healthcare services
issues, to the detriment of the wider improvement of the public's
health. We recommend that new high level performance indicators
are developed around public health (paragraph 206).
(xlviii) Professor Parish of the HDA
told us that they:
"have been working with the Improvement and
Development Agency for Local Government to see how we can bring
a public health perspective to their best value reviews so that
when they undertake these reviews of local government, we bring
public health to bear"
We strongly support this approach. Local PSAs
are also being piloted and we urge that some of these are also
based on public health (paragraph 207).
(xlix) The Government has stressed the
need for joined-up policy; we believe it should also have joined-up
objectives and a common methodology. We recommend that the DETR
and DoH develop a shared Public Service Agreement based on the
need to narrow the health gap between socio-economic groups and
between the most deprived areas and the rest of the country (paragraph
(l) We recommend that the Government
assesses the capacity of the communicable disease control service,
and in particular that of the PHLS, and takes the necessary steps
to ensure 'surge capacity' is in place. We hope that these issues
will be addressed by the Government in its forthcoming Communicable
Disease Strategy. We would urge the Government to issue its new
strategy as quickly as possible (paragraph 218).
(li) We recommend that the DoH issues
guidance to health and local authorities clarifying the roles
of the DPH and the CCDC. This is another manifestation of the
lack of clear leadership within public health (paragraph 219).
(lii) We recommend the Government revisits
data protection legislation and takes action to ensure that proper
health surveillance at a population level is not jeopardised (paragraph
(liii) We believe, however, that the
NHS Executive Regional Offices could take a greater strategic
lead in public health (paragraph 221).
(liv) 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 (paragraph 223).
(lv) 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 (paragraph 224).
(lvi) 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 (paragraph 225).
(lvii) 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
(lviii) 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 (paragraph 229).
(lix) 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 (paragraph 237).
(lx) 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 (paragraph 239).
(lxi) 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 (paragraph 240).
(lxii) A number of the key themes emerged
throughout the inquiry:
- the need to achieve balance in health policy
between health and health care, upstream and downstream.
We found that the present health policy agenda
is heavily dominated by the NHS Plan with its overwhelming concentration
on acute care, hospitals and beds, and numbers of doctors and
nurses. We accept these are issues of vital importance to the
NHS but we think the case for re-balancing health policy is strong.
- strengthening public health leadership at
We have described the confusion surrounding the
leadership of public health at every level. We call for the Minister
for Public Health to be empowered to demonstrate more positive
and public leadership for improving health and reducing health
inequalities. Stronger leadership at the centre must be matched
by stronger leadership at regional, intermediate and local levels.
- establishing strong partnerships at all levels
for a broad-based approach to public health.
We have endorsed the need for partnerships in
delivering the public health function. We support a more pro-active
role for the NHS in regeneration initiatives, the introduction
of joint posts in public health, and a single Community Plan in
each locality incorporating the HImP.
- placing the emphasis on public health practice
and implementation rather than on knowledge acquisition for its
We consider that insufficient attention has been
given to the application of knowledge and practice in public health.
For too long the public health function has been dominated by
a culture, mind set and training scheme which stresses the epidemiology
and science of public health, rather than its practice in bringing
about change. We hope our recommendations on developing capacity
within public health will encourage the development of practitioners
at all levels who can implement the theory.
- avoiding distracting and probably counterproductive
reorganisation of structures imposed from the centre while allowing
local initiatives to flourish.
We have found a recognition amongst stakeholders
that progress in public health must not rely on structures but
on processes and incentives, coupled with effective and appropriate
performance management arrangements.
- creating incentives for health improvement
We have found an over-emphasis on top-down targets
and performance agreements. Stronger incentives to give health
improvement priority for action are essential.
- building the evidence base in public health.
Knowing what works, why and how, remains a key
challenge in ensuring effective implementation of public health
- learning the lessons from past failures or
partial successes in putting health before health care.
We believe it is imperative that the Government
learns the lessons of previous policy, particularly with regard
to political leadership and commitment, making health improvement
a central priority, and ensuring that local government and other
partners recognise the importance of their public health role
(lxiii) We would welcome a clear statement
of principle by the Government on the desirability of a Tobacco
Regulatory Authority. We feel that our report was one of the most
comprehensive analyses of the tobacco industry ever undertaken
in the UK, had access to documentation that had hitherto been
concealed, and got very much to the heart of the behaviour of
the tobacco companies. We would like the Government unequivocally
to support our recommendation and - when parliamentary time permits
- introduce appropriate legislation to support it (paragraph 248).