Select Committee on Health Second Report


  (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 (paragraph 36).

  (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 40).

  (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 (paragraph 47).

  (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 62).

  (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 65).

  (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 (paragraph 71).

  (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 74).

  (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 76).

  (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 (paragraph 83).

  (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 92).

  (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 (paragraph 95).

  (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 (paragraph 102).

  (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 (paragraph 109).

  (xxviii)  We recommend that health should be a key element of the local authority community plan (paragraph 110).

  (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 (paragraph 135).

  (xxxii)  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)."

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 149).

  (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 (paragraph 174).

  (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 198).

  (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 210).

  (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 220).

  (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 (paragraph 226).

  (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 all levels.

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 own sake.

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 activity.

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 policy.

  • 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 (paragraph 242).

  (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).

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