Select Committee on Health Appendices to the Minutes of Evidence


Supplementary memorandum by United Kingdom Public Health Association (PH 23A)


  1.1  As an independent UK-wide voluntary association working for improved health and well being through developing and promoting policies which provide the conditions for a healthy life for all and support sustainable development, the UKPHA welcomes the opportunity to amplify on points made in our Outline Submission last July, particularly in relation to certain aspects of the NHS Plan, which was not available at that time. We have organised our evidence in line with the Committee's terms of reference but start by offering the following definition of public health:

  1.2  Public health describes the health circumstances of a society and the most effective means of protecting and improving it. Public health encompasses the science, art and politics of preventing illness and disease and promoting health and well-being. It addresses the root causes of illness and disease, including the interacting social, environmental, biological and psychological dimensions, as well as the provision of effective health services. Public health addresses inequalities, injustices and denials of human rights which frequently explain large variations in health locally, nationally, and globally. Effective public health works through partnerships that cut across disciplinary, professional and organisational boundaries and seeks to eliminate avoidable distinctions. It relies upon evidence, judgement and skills and promotes the participation of the populations who are themselves the subject of policy and action.


  2.1  We welcome acknowledgement in the NHS Plan of local authorities' new powers to improve the social, environmental and economic well being of their communities, and we call for the modernisation agenda to recognise the need for more coherence in related policy initiatives. The Government's public health strategy White Paper Saving Lives: Our Healthier Nation is a broad-based health plan for England. It should now be brought on to the modernisation agenda, and fully integrated with other plans including community plans, health improvement programmes (HIMPs) and local strategic partnership as well as the NHS Plan itself and the national and local implementation plans being developed. We believe that this will engender greater clarity about priorities and funding for health improvement and for reducing inequalities at national, regional and local levels.

  2.2  Our members around the country tell us of the large amounts of effort invested and resourcefulness exercised by organisations and individuals attempting to join up the plethora of national initiatives and plans at local level. The extent of and pace at which local planning is becoming more integrated between local government and NHS varies greatly across the country but in general appears to be happening in most areas. It could move further and faster if there were greater collaboration at regional and national levels, within and between government offices and departments, for example, through routine issuing of draft and substantive guidance concerned with local planning to both local authorities and NHS bodies, and cross-referencing within guidance of key local plans. We would also like to encourage such initiatives as joint performance review at regional level, the issuing of joint regional planning guidance and secondment schemes.

  2.3  We consider, furthermore, that the NHS Plan may betray the misplaced belief that setting up new structures and initiatives, together with a raft of monitoring, audit and inspection arrangements to assess performance, will ensure that change will occur. We assert that, while this might yield the semblance of change, it is arguable whether real, sustainable change will result. We would rather see existing structures and processes being made to work, rather than yet more new initiatives and structures.

Public health is cross-sectoral

  2.4  We believe that public health is an approach, rather than a particular set of processes, and one in which a variety of agencies and individuals play a role. Important work has been undertaken to define these roles, including the long overdue Chief Medical Officer's report on the public health function, but we consider that much of this seems to focus on the NHS. While we agree that the NHS clearly has a very significant part to play, there is also a key role for local authorities and one which is far wider than social care. The public health contribution of local authority services such as anti-poverty strategies, regeneration, leisure, housing, environment and community education is in our view too often ignored or undervalued, something which its inclusion in Best Value or performance management processes could alleviate.

Preventative structures and policies

  2.5  Saving Lives: Our Healthier Nation contains a number of important proposals for a strengthening public health including partnership across government, individuals and communities to co-ordinate and unify public health action. In our view, this promise remains to be fulfilled and should be given high priority. We continue to support this three-way partnership and regret that the importance of this approach was also not mentioned in the NHS Plan and linked to its various proposals, including for example, the Healthy Communities Collaborative, about which we look forward to learning more. While concerned that the NHS Plan focuses mainly on individual lifestyle factors at the cost of interventions at population level, we support the preventive role that individual practitioners such as pharmacists can play through providing informal health information and promoting effective lifestyle interventions for the population as a whole, as well as those affected by inequalities.

  2.6  We would also not wish to overlook, in a public health and preventative approach, the place of the individual as user of the full range of local authority, NHS, voluntary and private services. We assert the importance of cross sectoral collaboration and inclusive service design as ways of reducing inequalities, particularly for those having difficulty accessing services.

  2.7  Without an effective cross-sector infrastructure, public health and prevention strategies will remain largely ad hoc, piecemeal and marginal to health care. We believe that a highly credible set of cross-sector institutional arrangements is required to achieve this, working from an understanding of the root causes of health not of disease, evidence-based and able to operate effectively across organisational boundaries to promote changes which capture the imagination of the ultimate beneficiaries.

  2.8  The long-term benefits of a variety of preventative policy options must be properly modelled, based on current knowledge and assessed in the context of other potential health benefits. If, as seems likely, current patterns of public and private health care expenditure predict an impact upon health that can only be justified in the interests of expedient short-termism, then this should become a matter for political resolution. At present the prevention agenda is mostly obscured by other more immediate concerns, but once public gains can be set against current losses in a rational and well-informed debate, we believe that the issues, and the case for prevention, become clearer.

Workforce issues

  2.9  Effective public health work clearly requires a dedicated and knowledgeable workforce ancillary to nobody and not dominated by any one discipline or setting. Such a workforce must be drawn from a variety of disciplines, function in a variety of sectors and settings, and work participatively with the communities it serves. At present, the public health workforce which, in our view consists of a wide range of practitioners across the local authority, voluntary and health sectors, is divided and disparate with many of its key practitioners cut off from each other.

  2.10  We have been greatly encouraged, therefore, by the proposals in Saving Lives: Our Healthier Nation for enabling people from a wide range of professional backgrounds to be trained and accredited, enabling effective leadership in public health based entirely on public health competence. These proposals are being taken forward by work at the Faculty of Public Health Medicine and in the Tripartite Agreement with the Multidisciplinary Public Health Forum and Royal Institute for Public Health and Hygiene, and by Healthworks UK.

  2.11  However, we have concerns that some of the momentum may have been lost, the delay in publication of the Chief Medical Officer's report not helping in this important area. In particular, we are concerned that the necessary legislation to enable comparability among public health specialists, whether or not qualified in medicine, is not yet contemplated. Similarly, little progress has been made in relation to how training will be funded or on accreditation procedures. We were disappointed that the NHS Plan made no mention of these developments or needs when it is clear that plausible increments in effective public health could be responsible for much more health gain than any plausible increments in health care.


  3.1  We consider that central guidance must make links between community plans and HIMPs explicit, and ensure that, at the very least, they join up. There are currently expectations of two local over-arching strategic plans for health, well-being and quality of life: one free-standing and led by health, and the other part of a much wider strategic agenda, within which health is one element, led by local government. While the Health Act 1999 requires other partners including local authorities to participate in the preparation and review of HIMPs, there is no reciprocal obligation for the NHS to participate in community planning in the Local Government Act 2000. This seems surprising as the HIMP logically falls within the much wider community plan; the weaker provision in the Local Government Act seems to undermine the community plans as the main local plan.

  3.2  In documents where there are clear linkages made between plans, as in the Neighbourhood Renewal Strategy and in the NHS Plan in its reference to Local Strategic Partnerships, the issue of coterminosity, or indeed the lack of it, has not been adequately addressed. Local strategic partnerships work best in areas where the local authority and health authority are coterminous, although there are clearly issues around primary care groups and trusts, the new primary care organisations, which may not relate to either population. Developing a single strategic umbrella in non-unitary authority areas is complex and more guidance may be needed about how this can be successfully achieved. We consider that attention should be given to establishing the optimum size of population for the effective development and performance review of over-arching strategic plans, such as community plans and health improvement programmes, while maintaining local sensitivity at PCG/T and lower levels of local government.

Community involvement

  3.3  We are keen not to overlook lessons from history when new area-based initiatives such as Health Action Zones, Healthy Living Centres and Surestart are being developed. There is a wealth of experience from the Health For All (HFA) projects around the country, and we are not sure how much of that is being usefully linked into or integrated with these new initiatives, particularly in relation to community participation and involvement. HFA is an approach based on fundamental public health concepts of partnership, empowerment, participation, equity and primary care organisations needing and being expected to work in a much more community development, bottom up mode than GPs, in particular, have been able—or desired—to do in the past.

  3.4  One of our main concerns about all these new strategic planning processes is the extent to which they are in reality remote from local people's own perceptions, hopes and aspirations for health in their own lives, their families and local communities. Getting closer to local people and enabling them to inform service planning is an explicit requirement of the local government modernisation agenda, particularly in relation to Best Value. Extending and using these principles within the NHS could bring the two different organisational cultures closer together and thus strengthen public health partnership.

  3.5  Ultimately, we want to see plans and processes which, like HFA and community development, are not only cross-sector but able to work at the scale and pace of real people, so that the local vision which emerges is truly theirs. It is important that these plans have full local expression, identification and ownership. We suggest that one way of achieving this would be for those responsible for leading the development of plans to brand them in the light of local identities and aspirations.


  4.1  Many people look to the new agency to define "what works" at the national and regional levels. This is an important task which we support. However, the task is both large and difficult. Many interventions are long term with results and outcomes which may take years to establish; on the other hand projects with immediate results may not be suitable for national rolling out because of important local factors. We believe that these factors underline the fact that the Health Development Agency should not be drowned by expectations; nor should innovative and good practice learnt locally be suspended because national validation is required.

  4.2  We greatly value the role the Agency has already begun to play successfully in bringing together and promoting more collaborative working between key national, regional and local partners in public health. Its pro-active and flexible approach is challenging longstanding cultural and organisational barriers and creating new opportunities and networks to support evidence-based health improvement and HIMPs. We look forward particularly to the development of close links between Agency and UKPHA regional structures in pursuing our common aims.


  5.1  We are concerned, although not altogether surprised in view of the nature and scale of the changes expected, that the new primary care organisations are not yet delivering on the wider public health role in the way envisaged in Saving Lives: Our Healthier Nation. Furthermore, any attempts to strengthen public health within primary care, through a variety of named support and/or outposting arrangements, is having the unintended consequence of fragmenting the existing health authority-based public health function in some areas. There were recruitment problems in the public health workforce even before the new primary care organisations were set up. In particular, small health authority departments—with or without vacancies—could find it even more difficult to ensure sufficient critical mass to operate effectively in terms of range of expertise, and in relation to professional development and training, while also supporting primary care—especially if this has to be geographical rather than topic-based.

  5.2  Such difficulties emphasise the importance of moving rapidly forward the work to develop a skilled, multi-disciplinary public health workforce through a national framework for training and accreditation. Locally, however, there is scope for (relatively scarce and more skilled) health authority public health specialists to support and develop public health practitioners, such as local authority and NHS community development workers, health visitors and health promotion specialists, to realise the potential of their relationship with and knowledge of practice and neighbourhood population health need.

  5.3  Although we believe that public health has a very important place in primary care, it is apparent that the narrow focus on primary medical care and health services is dominating the agenda in most areas. Work to influence the wider determinants of health in the local population is often missing (with a few exceptions, usually funded through regeneration monies). This is in spite of the efforts we know are being made, particularly by lay PCG board members and the nurse board members, many of whom are themselves public health practitioners with a commitment to the wider public health agenda.

  5.4  Also lacking is comprehensive linkage between the new primary care organisations and the wider public health role of local authorities, probably not helped by the requirement for a social services rather than local authority representative to sit on PCG boards. While some primary care organisations now involve local government, for example as elected members appointed to PCT boards as non-executive directors, this is not universal. In our view this represents a missed opportunity for local government and health to work together in engaging local people, thus avoiding the danger of both independently setting out to do this, perhaps with totally different groups, something which may be addressed in the development of local strategic partnerships.


  6.1  It is clear that this role has a particular focus on Department of Health initiatives; we believe it must become a truly trans-departmental role, and be led at Cabinet level. This would allow the minister effectively to lead and co-ordinate action on the wider influences on health across government departments. We commend the model developed for the Social Exclusion Unit, located within the Cabinet Office with a lead minister working with all government departments. An equivalent Public Health Unit would be established in the Cabinet Office and be led by the Minister for Public Health to continue to develop a cross-sectoral and trans-departmental national public health strategy. We would like to see this strategy, and indeed the Chief Medical Officer's annual report on the State of the Public Health, as was the Social Exclusion Unit's report on teenage pregnancy, presented to Parliament by the Prime Minister.


  7.1  It is vitally important that the Director of Public Health (DPH) is a suitably qualified person. It is not necessary, however, that the DPH is medically trained but that whatever their background the person occupying the role is supported by a multidisciplinary team including experts in social science and research methods, suitably medically qualified individuals including consultants in communicable diseases, and statisticians. The role should remain a statutory function, linked to a defined population and a statutory body with a properly resourced public health department (which could be a health or local authority), thus ensuring a strong and independent voice for the DPH to challenge any organisation or individual whose actions represent a threat to the health to the local population.

  7.2  The role of a Medical Officer of Health in earlier times (by definition a medically qualified person) was to report on local health trends and manage community health services and environmental health services. The current fashion of separating strategy or commissioning from management and provision makes this older set of responsibilities unnecessary. However, the problem with the older view is that it is too narrow also. The tasks required of a contemporary DPH might include broader environmental considerations, such as those advanced by Local Agenda 21, anti-crime or local transport strategies. Indeed, it should include all of these strategies advanced by a local authority alongside NHS, voluntary and other partners in the local setting. We propose not a resurrection of the older role therefore, but a revival of the spirit of the older role updated for the modern setting. It is important that the DPH is able to capture the local imagination by, for example, working alongside citizen groups and advising the local authority.

  7.3  This also calls, therefore, for a local strategy on information concerning health, well-being and quality of life, where the DPH plays the role of advocate for local people in rel of such issues with the local providers of information services, whether local libraries, leisure services, or other. It is also important that the DPH's lead be more carefully integrated with the work of specialists in health promotion and that their role influences the span of responsibilities, and the work methods in turn, of the DPH. Clearly, the effective performance of this role requires a multi-disciplinary, cross-sectoral approach.


  8.1  Health inequalities take many years to appear; they also take many years to correct. The long-term nature of public health intervention is recognised by many and, although we understand why there are short-term imperatives for many public health and regeneration initiatives, we would encourage a longer-term perspective. Within the national and international picture, effective public health policies are a necessary but insufficient condition for achieving a reduction in health inequalities. We think that the Government should heed the advice of organisations like UNICEF which are undertaking large scale international studies of inequalities, particularly as they affect children. If the main political parties were able to agree broad principles for tackling inequalities based on this sort of evidence, there is more chance that successive governments could work over decades rather than, as now, over four or five year terms, with effective, long-term strategies.

  8.2  We welcome the attention given in the NHS Plan to the NHS' role in improving health and inequalities, but would argue that the NHS should not be seen as the major player: of the 39 recommendations in the 1998 Acheson Report: Inequalities in Health, only three directly concern the NHS. Some see the present as a time when public health can be brought back into the mainstream and out of the ghetto to which it became consigned when captured by the NHS in 1974. Far from influencing the NHS agenda, public health became dominated by a somewhat narrow, managerial agenda focused mainly on health care. We should not forget the lessons of history.

  8.3  We were disappointed, however, that the NHS Plan gives the impression that the most important role the NHS can play is to increase access to services and screening, particularly in disadvantaged areas, places less emphasis than we would like to have seen on the wider partnership agenda. We welcome the inclusion in performance management of local NHS action in tackling inequalities and ensuring equitable access to health care, but would wish to see the early implementation also of the new single, integrated public health groups across NHS regional offices and government offices to support this, ideally through a joint performance framework, as well as wider cross-sectoral initiatives.

  8.4  Our members tell us that work on HIMP local inequalities targets is on around the country but that adopting targets which can be unambiguously linked to action plans and outcomes is very difficult, even leaving aside the absence of any national targets which might enable a more focused approach.


  9.1  Rather than promoting an alternative model, we would support, through the proposals outlined above, a strengthening of local government's historical role in public health. We believe that the new power to promote well being in the Local Government Act, set alongside the HIMP and the flexibilities in section 31 of the Health Act, demand re-examination of the possibilities for a civic agenda for health, in which all aspects of the role of local government and the imperatives for Best Value, public engagement, local democratic accountability and modernisation are brought together.

November 2000

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