WEDNESDAY 31 JANUARY 2001 _________ Members present: Mr David Hinchliffe, in the Chair Mr David Amess John Austin Dr Peter Brand Mr Simon Burns Mrs Eileen Gordon Mr Stephen Hesford Siobhain McDonagh Mrs Marion Roe Dr Howard Stoate _________ RT HON MR ALAN MILBURN, a Member of the House, Secretary of State for Health, and YVETTE COOPER, a Member of the House, Under-Secretary of State, Minister for Public Health, examined. Chairman 665. Colleagues, can I welcome you to this session of the Committee, which is the last oral evidence session of this inquiry, and particularly welcome our witnesses, the Secretary of State and the Minister. We are very pleased to see you. I know it has been a pretty tough week and we appreciate the time you are giving to the Committee today. Can I ask you briefly to introduce yourselves to the Committee? (Mr Milburn) Yes, Alan Milburn, Secretary of State for Health. (Yvette Cooper) Yvette Cooper, Minister of Public Health. 666. As you know, we have been holding this inquiring for some months now. We have had the opportunity to take evidence from a range of agencies, individuals, organisations and also had a number of visits related to the inquiry, and I think it is fair to say from my perspective that we have seen a great deal of positive evidence of very clear progress in public health, but one of the issues which it will not surprise you I would like to raise with you, an area of some contention, concerns the organisational structure of public health which we have currently. We have had substantial evidence from a range of sources raising questions about the current location of the public health function within DHAs, indeed very serious questions have been raised about the whole future of DHAs with the developments in primary care and primary care trusts, et cetera. I would be interested in establishing, first of all, what your views are as to the future location for the direct function of public health at local level. Some of us at the veteran stage of the Committee go back prior to 1974 and, as you well know, recall a model that certainly I believe operated more effectively in relating to elements of policy in local government that were able to drive changes in policy forward in a way we have not managed to do since it was detached from local government. Can I begin by asking you about your thoughts on that general area? (Mr Milburn) I am tempted to say, Chairman, it was before my time, but that would not get me off to a very good start. 667. But you have read about it. (Mr Milburn) Yes, I have, and I have also thought about it quite a lot, and I know you and other members of the Committee have strong views about the issue. What is true and what is common ground amongst all the participants in this debate is that if we are going to improve public health, that is more than the job of the National Health Service, point one. Point two, much of our effort should be focused upon dealing with some of the determinants of ill health. I think that is also common ground, whether it is poverty, poor housing, environmental problems. However, in the end it seems to me that public health in purpose is about achieving certain health outcomes and although there would be a myriad of views about where best to locate the co- ordination function, because inevitably wherever you draw the boundaries there will be a whole host of local organisations or indeed national organisations which will have a bearing on the health of the public, in the end somebody has to hold the ring. The question really is, who best should do that, who is in the best position to do that. It seems to me - and I have thought about this and I have thought about the arguments you and others have made in relation to local government - in the end since it is a health function and a health purpose, probably that location is best done on a local level in the Health Service. However, what is also clear is that we cannot have what I have described in the past as the ghettoisation of either health or, more particularly, the public health function within the National Health Service, and there are some real issues about how best we break public health out of its ghetto. 668. Do you not accept that that ghetto arose from the disposal of public health in 1974 --- (Mr Milburn) No, I do not. 669. --- and its detachment at that point from local government? I was a councillor pre-1974, as I believe was John Austin - a very young councillor, I hasten to add - and recall very vividly the role of the Medical Officer of Health who held to account in a very serious and important way the individual committees of that local authority. I see at local level some very worthy reports from our Directors of Public Health - I have two local authorities in my area, as you are aware - some excellent reports making some very positive proposals but it is not attached to the driver of policy that those reports relate to in any meaningful way. That worries me because prior to 1974 we saw the attachment of these recommendations to the ability to deliver change on things like smokeless fuel and a range of issues which the local authority could clearly concentrate on - slum clearances and that kind of thing and I know we have moved on from those days - but it was a very important relationship with the Government function. (Mr Milburn) You are right that there are a number of drivers or a number of interventions which are necessary in order to improve the health of their local communities, that is absolutely true, and local government will have a very important role in regard to its environmental health functions, its transport functions, social services or education, and so does the National Health Service. Whichever way you cut the cake, as I was saying, there would be a need to better co-ordinate functions, and certainly that was true of the pre-1974 situation. You say the Medical Officer of Health played an important role but, for example, if they wanted to influence rates of coronary heart disease or interventions in coronary heart disease, then they had to make the leap over the boundary into the National Health Service. That was just a function of the way the Medical Officer of Health and the related public health functions were organised. So I think that sometimes this game of structural musical chairs which we are all interested in inevitably, because we have to get the location right, becomes a bit of an excuse for a lack of co-operation. I think reorganisation becomes an excuse for lack of co-operation. What is true is that we need to improve the means of co- operation, there is no doubt about that, and on the ground, as you know, in many parts of the country now there is much closer co-operation than there has ever been, indeed there are statutory duties to co-operate for the first time which we put through in the 1999 Health Act. That is becoming evidenced I think now in the way that you see, for example, in some areas - largely where there are co-terminous health authority and local authority boundaries - joint appointments of Directors of Public Health. I do not have a problem with that, I think it is a perfectly sensible thing to do but I think we need to assess its impact. When you talk, as you did, about drivers and leverage, there are some interesting international experiences here too more at a national level than at a local level. In New Zealand in the 1990s, as members of the Committee are aware, there was a similar debate going on about the location of public health policy-making at a national level. The then Government in New Zealand decided to separate the public health functions, through a Public Health Commission which was established in 1993, from the Ministry of Health, particularly to try to beef up the public health function because there was a feeling, as perhaps the Committee is feeling, that public health was getting ghettoised. That seemed a very sensible idea. It certainly gave a higher profile to public health in New Zealand, but the consequence of doing so was that the real life intervention impact in terms of public health was actually diminished, and it was no surprise that in 1995 therefore that Public Health Commission which had been established two years earlier was abolished. It is very, very important in my view we keep in mind that what we want to do is to drive public health ever more into the mainstream of the National Health Service, precisely so it has greater leverage as far as access to Health Service resources are concerned. Chairman: There is a division so I adjourn the Committee for 15 minutes. The Committee suspended from 4.09 pm to 4.23 pm for a division in the House Chairman 670. You were answering, Secretary of State, the initial question. I believe, Minister, you were indicating you were wanting to come in? (Yvette Cooper) Only briefly to add, Chairman, that if the argument is that we should have closer working around public health in local government, that local government could play a greater role in terms of public health and could have more public health support, I think that is absolutely right and I think we would agree with that, whether it is through joint appointments which some areas are experimenting with, whether it is through the local strategic partnerships or whether it is through closer working around the community plan or health improvement plans. But if the argument is we should take public health out of the NHS, that I think would be a massive mistake. There is so much potential for further work to be done in the NHS especially in primary care around public health, I really strongly think we need to keep that public health function in the NHS. Even on top of all the work which is done on public health at the moment by the NHS, there is so much more we could do, that we should be building on, particularly in primary care. 671. One of the issues that the Committee have been concerned with is the role of health visitors, and some of us remember when they were employed within local authorities in a much closer working relationship with local authority services like housing and social services, and that is an area where we picked up very strongly there were arguments we needed closer collaboration. Picking up your point about the location and function and looking at it locally but also nationally and again whether public health is appropriately placed within the Department of Health - and I know, Minister, you said the idea of taking public health out of the Health Department would be a crazy and retrograde step - we have had a fair bit of evidence which suggests that the function you occupy ought to be much more wide-ranging than it is currently and perhaps located, say, in the Cabinet Office or within the Cabinet with a role ranging over other government departments. Can you say a little about your views on that and your experiences of working with other government departments in the role you currently occupy? (Yvette Cooper) I think it is extremely important to have the public health ministerial post located in the Department of Health, I suppose for several reasons. Firstly, in the end, a lot of it is about improving health and promoting health, and having access to the vast resources of the NHS, the Department of Health and the Chief Medical Officer is incredibly important. Secondly, whilst it is absolutely true that a lot of the work does involve cross-governmental working, actually being located in a department makes a huge difference. You will be aware where we have done the Social Exclusion Unit reports, the Social Exclusion Unit has tended to draw up the report and to drive a lot of the first wave of co-ordination across government departments but then the report has been passed on to a particular government department to actually lead the implementation. It is because ultimately you want a delivery route rather than simply a co-ordination route, ultimately you need a government department backing up, and given that the NHS is the biggest employer in the country, it has huge resources when it comes to delivery. It is right that has to be in partnership but I think it would be terribly wrong and would be a huge retrograde step and a mistake to leave it behind. I will just give you one brief example of where I think cross-departmental working can be very effective, and that is the Sure Start programme. I am responsible for Sure Start but the Cabinet Minister responsible is David Blunkett in the DfEE and the Sure Start Unit itself is located within the DfEE, and that is quite a novel approach to working across government which involves a very close partnership between different departments and it is working very well, with my responsibilities both to drive the programme and to chair the cross- ministerial group but using resources located in different departments as well. So there are different cross-departmental models you can look at but fundamentally it would be a huge mistake to separate public health from the big killers - cancer, heart disease. All the work we are doing on prevention has to involve the NHS otherwise we will never make the difference we need to. 672. When you are looking at any policy initiative, how do you determine who might be involved in developing that initiative? For example, we had the mental health initiative which came out recently where, arguably, some of the key players within different government departments have a role to play. You probably know that we were prompted as a Committee by evidence we received from the Yorkshire Post newspaper, which you will see as a Yorkshire-based MP like myself, which has done a very important campaign on sport and the way sport relates to health, and as a consequence of their evidence and other evidence we determined to have the Minister of Sport before the Committee. We had a very useful session, I think, listening to what she had to say but my concern, and the reason why I raise this point about the public health location within government, is that she answered very honestly when I asked specific questions about whether she had been involved in certain initiatives, which I think she should have been involved in, where on a number of developments the Government can claim great credit at a local level which should relate to sport, and she had no involvement whatsoever. How do you, not just with you but in other areas where the Minister has a part to play, ensure they are involved, because in that case clearly she was not and in my view she should have been? (Mr Milburn) I think there are always improvements which can be made, of course there are, but the machinery for cross-government working now in this Government - and certainly that is the view of the people who have been around in previous times - is immeasurably enhanced. I think the commitment to joint working is a big commitment. On the public health front you will remember when we published Our Healthier Nation White Paper, of course it was my Department which was in the lead but there were contributions from other relevant departments, of course there were. Issues like sport obviously would relate to DCMS. On one of the important Our Healthier Nation target areas, the prevention of accidents, we worked closely with colleagues in the DETR, DTI, DfEE, across the piece. The point about this is that in a sense it is rather like a local co-ordination function, wherever you locate it there is still going to have to be co-ordination, and where there are co-ordination issues and where there are boundary problems then inevitably you hit difficulties. But what I believe absolutely fundamentally is that if you take the public health function out of the Department of Health and if you put it in a ministry like the Cabinet Office, what you remove is the Minister of Public Health and all of the officials and all of the machinery and indeed all of the financial leverage which goes with a location in a big spending department. For example, this year I think the Department of Health will be spending between œ40 and œ50 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 œ200 million. In the end, money talks because it provides you with leverage to get things done. There is an argument about whether or not we need to do more within the National Health Service to better focus growing resources on prevention, on tackling inequalities, on intervening sooner rather than later, and that is a perfectly reasonable debate to be had and I think all of us sat around this Committee table would think there is a lot more to do, of course there is, but actually the chances of doing it, it seems to me, are decreased and not increased if you strip out the public health function from the mainstream Health Service delivery functions. 673. In simple terms, how do you avoid treating policy issues in separate boxes? The best example I think we had with the Sports Minister was when I raised the initiative of healthy living centres, which I think is an excellent idea, and I see a very clear connection between the role of sports clubs and healthy living centres, but there had been no connection between your Department on this issue and her Department. What I am trying to say is, how can we ensure structurally that that happens, that, to me, a fairly obvious connection at local level is made nationally and locally in a way which is not being made at the moment? (Mr Milburn) I think two things. First of all, there is a big commitment to do this across the Government and Our Healthier Nation is an expression of that but the truth is it is early days. It is the first time we have had a Public Health Minister, the first Public Health Minister was appointed in 1997, and I think that was the right step to take and it allows us to focus on these issues in a way perhaps politically which has not always been possible in the past. It is a positive step in the right direction but there is a big commitment across the piece to improving the health of the nation. If you take the argument to its logical conclusion I think you are left with some pretty anomalous potential structural arrangements, because most of us would agree that poverty has a bearing on ill health. That is certainly the position in the Black Report, in the Acheson Report, it is the position that many people in the medical and health service field would agree on. The Government has a big commitment to abolish child poverty, I think it will make a huge contribution to improvements in public health and to narrowing health inequalities, but the logic of the argument, with respect, is if we believe that child poverty is going to be a major determinant of improved health then why do we not take the public health function out of the Department of Health altogether and put it in Her Majesty's Treasury? 674. Something we could think about actually! (Mr Milburn) I am not going to give you ideas, Chairman, because I am slightly worried you will recommend that! Dr Brand 675. Is it not already? (Mr Milburn) You can say that, Dr Brand, I cannot comment! Mr Burns 676. We have a Department of Health that has overall responsibility for improving and enhancing patient care and the health of the nation, and it does seem odd to seek to take out public health and give it to the Cabinet Office or the Treasury, or whoever else, because it just becomes diffuse and to my mind ridiculous. Can I ask the Parliamentary Under- Secretary whether the structure of the Department of Health at the moment means that she, as Parliamentary Under-Secretary, is answerable solely to the Secretary of State, as certainly under the last Government the Parliamentary Under-Secretary who was responsible for mental health, children's issues, drug abuse, alcohol abuse, et cetera, had no Minister of State above them, they were answerable directly to the Secretary of State? Is your position answerable solely to the Secretary of State, or do you have a Minister of State above you and below the Secretary of State? (Yvette Cooper) I answer directly to the Secretary of State. 677. I am glad you said that because there is a view held by some people that if you put public health, which is considered to be a very important issue, at Parliamentary Under-Secretary level you have down-graded or minimised the issue. The fact that you, I suspect, and you can correct me if I am wrong, are unique in that presumably other Parliamentary Under- Secretaries at the Department of Health at the moment have a Minister of State above them and under the Secretary of State, surely enhances rather than down- grades the role of public health because without having a Minister of State to go through you have direct access to the Secretary of State, you are working simply with the Secretary of State? So would you agree with me that in fact, presumably, given your line of command and that you are answerable simply to the Secretary of State so it is just the two of your within that narrow ambit, the whole area of public health has not been down-graded simply because it is at Parliamentary Under-Secretary level? (Mr Milburn) Let me answer because it is slightly invidious for Yvette to answer questions about command structures in the Department of Health. I know the argument, Mr Burns, that because the previous Public Health Minister was at Minister of State level and Yvette is not, somehow or other this represents a down-grading. All I say to you is that nothing could be further from the truth. Not only does Yvette answer to me personally but, in addition to that, when Yvette came into the post one of the things I wanted to do was better "mainstream" public health within the Department, and that is why actually we changed some of the functions around within the ministerial team, so that she as Parliamentary Under-Secretary for Public Health has responsibility for the two big areas of public policy where we need to make rapid improvement in terms of mortality and morbidity rates - cancer and coronary heart disease. That was not the way the Department had previously been divvied up. I did that precisely, one, in order to locate responsibility where it should be; two, to ensure the focus was as much on prevention as treatment; but, thirdly, to actually "mainstream" the public health function within the Department of Health, because I do think there is a tendency, if I may say so, with respect, within the public health world, for public health professionals as narrowly defined to believe that they are the only purveyors of public health. If that is the case, if we actually believe that it is the 600 public health consultants and 32 epidemiologists who are going to improve the health of the nation, however good they are, frankly we can all go away and give up now. The people who should be "mainstreaming" and delivering public health are our 30,000 GPs, our 12,000 district nurses, our 14,000 health visitors. They are in the best position to do that and if they are going to do that then actually we have to have a line of command, a line of delivery, all the way from Richmond House down to Wakefield, Darlington and Chelmsford. Mr Burns: Thank you. Mr Hesford 678. In terms of this issue, Secretary of State, in 1997-99 the Chancellor has made it clear for very good reasons that spending was tight in those years in order to stabilise the economy and get rid of the œ28 billion deficit. Those in the public health field will have recognised that between 1997 and 1999 public health had a Minister of State-level occupancy at a time when the money was tight. At a time when others might have felt money was coming on stream, the position was, in some people's terms, down-graded just at the point in time when that person might be expected to spend some money. Can you deal with that point? (Mr Milburn) 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. Rather than being a retrograde step, I think that is a huge step in the right direction of ensuring that we target in a rather more consistent and effective way than perhaps has been done in the past our efforts, the machinery of the Department and, most importantly of all, the resources we have available to us on those areas, those disease groups, those parts of the country, those sections of the population, which need most help. 679. In terms of raising the awareness of public health, which I know the Minister is absolutely keen on and does a very good job of, would it not send out the wrong message to those areas that need support in their job - that very difficult job of raising awareness of public health - to have what others have described as a retrograde step in terms of the exact status of the Minister of Health? (Mr Milburn) If that were the case, it would indeed be a retrograde step, but it is not. 680. Do you accept that there could be a feeling abroad that that is what it looks like? (Mr Milburn) I have no doubt that for various reasons people within particular parts of the National Health Service or particular parts even of the Department of Health may feel that is the case, but believe you me it is not. 681. It is just that quite a number of witnesses we have heard, and no doubt you have seen the transcripts, have made this point time and time again and it is something the Committee will have to deal with. (Mr Milburn) Yes, I can understand that, but one of the pleasures of my job is that I get a broad over-view of all the issues which come before the Department of Health and I am acutely aware of protectionism in many, many parts of the field. It is very, very important that we keep these things in balance. It is very hard for people to argue, when we are investing in the way that we are in improvements in coronary heart disease and cancer and focusing resources as much on prevention and treatment in the way that we are, making, I think, some pretty major - or about to make - improvements as far as the diet of the population is concerned, when we are empowering primary care to get a population focus as well as just a focus on individual lists of patients, that somehow or other public health has been down-graded within the Department of Health. Far from it. What is very, very important for people in the public health field to realise is that the two major policy statements we have had over the course of the last couple of months - Our Healthier Nation and the NHS Plan - together form the basis, if you like, of a health plan for the country, and they are of equal status. Indeed the NHS Plan broadly reflected the aspirations, ambitions and some of the targets within Our Healthier Nation but then it went further and suggested, for example, we are going to roll out more screening programmes, a greater emphasis on prevention and, most important of all, for the first time in this country and I think for the first time in any developed country that I know of, we are going to set a national inequalities target precisely to ensure the whole of the National Health Service, not just one part of it, is focused upon these very, very important public health issues. Chairman 682. Minister, this is a debate about your pay rise, do you wish to comment? (Yvette Cooper) I am really touched that people are so concerned about my status and my pay. I just think this is such a trivial argument. What is the title of the minister in charge of public health, is it a Minister of State or is it a Parliamentary Under-Secretary? I do not think most people in the country know the difference between a Parliamentary Under-Secretary and a Minister of State, and I do not think most people care. In the end, the test is what we are delivering. What are we delivering on public health? The test of what we are delivering I think is showing huge improvements. If the test is money, there are extra resources going into public health, into prevention, into smoking cessation services, into fruit in schools, whatever your test, in terms of the extra boost to public health we have seen, building on the work which was done under the previous Minister, and the extra work we have shown in the NHS Plan, on health inequalities and on tackling some of the key causes of cancer and heart disease, is really significant, and that is really in the end what people will judge our public health commitment on. Mr Burns 683. Secretary of State, can I try and help you? (Mr Milburn) Oh dear! 684. As your Parliamentary Under-Secretary has said, it is trivial, and it is in one way but it is important in another because of misapprehensions which abound in the health area. Can you categorically confirm that my view is right --- (Mr Milburn) You are making me very nervous! 685. I am trying to be helpful, keep cool! If you have an area which the Government of the day has prioritised as an important area where you want action and achievement, if you have a Parliamentary Under-Secretary rather than a Minister of State with no Minister of State above her, where the Parliamentary Under-Secretary is directly answerable to the Secretary of State and they are working in tandem, it is totally irrelevant whether the person is a Parliamentary Under-Secretary or a Minister of State, providing the commitment is there and the objectives are vigorously pursued by that Government, and that the whole argument is actually time-wasting and fallacious? (Mr Milburn) I think that is broadly right and frankly I think people would be bemused - there will be some people who are not bemused and who find this all incredibly interesting and revealing - the vast majority of people working in the National Health Service, working in local government, working in any arena which has any bearing on public health, let alone the public, would find this whole debate a rather bizarre one. Chairman: I have just had a note passed to me asking me which position Mr Burns had in the Department of Health. Mr Burns: I did not have a Minister of State over me either! Mr Austin 686. I think you have both made a very cogent and convincing argument for the location of the public health function departmentally in the Department of Health, but can I ask you whether you feel the Minister for Public Health within the DoH can really affect the main determinants of health - housing, employment, poverty, et cetera? (Yvette Cooper) 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. But it is absolutely true that all of the determinants are widespread across all the different departments and we will only do this if we have all the departments working together. But we cannot just say that the NHS should play no role in that, the NHS should play a huge role in it both nationally and locally. (Mr Milburn) Let me add to that very briefly. When Sir Donald Acheson produced his report for us in 1998, he came up I think with 39 recommendations, something like that, three of which pertained particularly to the Department of Health, the rest pertained to the wider governmental agenda, and that is right because we all know from our own constituents that poor people tend to be iller and certainly they tend to die sooner than people who are rather more affluent, so there is a broad cross-Government agenda here. Sometimes though I think that people in the National Health Service, faced with this point about the determinants of ill health being so big and so deep-rooted, throw up their hands in horror and almost adopt a counsel of despair that nothing can be done until you abolish poverty, until you ensure nobody lives in a damp house, until you ensure that every person is eating five pieces of fruit and vegetables a day. All of those things need to happen but actually it is very, very important that the NHS better focuses on what it can do to contribute to improvements in public health. Of course, some of those will be very deep-seated issues and will take time to deliver, but some will not. Providing the will is there and the commitment is there and the resources are there, actually we can begin to make a difference quite quickly. I think a good example of that, frankly, is when we decided, when Frank Dobson decided, to invest very, very early in the meningitis C vaccine. As I said in the debate in the House the other day, being the first in the field is always a risky place to be, because when you are out in front it can all go horribly wrong. It did not go horribly wrong, despite some of the adverse comments at the time in the newspapers about the dangers of the vaccine and so on. We invested quite a lot of money in it, we concluded a deal very early on with the company concerned, in order to ensure that people in this country were the first people in the world to get access to a vaccination programme which has already saved lives. I want to see more of that happening and to do that we have got to have a proper focus and a co-ordinated focus through the Minister, and through her line to me, on public health in a way that has not always happened in the past. That is why I believe that the arrangements that we have - and they are not perfect arrangements and they will never be perfect arrangements - are the best arrangements that we are going to get. 687. Can I take you back to the original question that the chair put. Let us say that you have convinced us of the departmental responsibility of location for the public health function but in terms of the local delivery of public health, several government departments relate to local government, including your own, and you are responsible for social services, child protection, all of those areas of delivery by the local authority. The DfEE is involved with the local authority, the DTI, a whole range of public departments. Since I am a dinosaur with the chair and remember the 1970s, all of that comprehensive range of functions is delivered by local authorities. You mentioned anti-poverty and local authorities are key players in developing anti-poverty strategies. Does that not therefore suggest that wherever the departmental responsibility for public health lies, and particularly now local authorities also will be given the scrutiny role of health services, that public health should be located at local authority level? (Mr Milburn) No, I do not believe that for the reasons we discussed earlier in answer to the Chairman's questions. What I do believe is that the local authorities have a very, very important co-ordinating role at a local level and indeed we as a Government have given them certain statutory obligations to promote the well-being of their local communities and personally what I want to see is much better co-ordination at a local level. As Yvette was suggesting, I think the local strategic partnerships that are beginning to roll out across country will provide a very, very important vehicle for the Health Service, for local government and, indeed, for the contribution of the voluntary sector and the private sector to make a big contribution to improvements in the well-being of the local community and specifically the health of the local community. That begs some important questions about how best we are going to co-ordinate public health functions as widely defined at a local level. Some parts of the country, Somerset and Wolverhampton are two for example, do have joint appointments of directors of public health between the local authority and health authority. That is a welcome development. I think we should assess it but if it makes sense we would want to see more of it. There are issues about the future of health action zones and employment action zones, and so on and so forth. For my part, as far as this is concerned, I am completely unterritorial about this. If in some parts of the country we are great closer collaboration, as we are for instance in the Chairman's constituency in Wakefield, of the health action zones and some of the other partnerships and that makes sense, then we should encourage it. I do not have a problem with that at all. I think it makes absolute sense to do it. 688. I am not wanting to challenge your territorial integrity or sovereignty --- (Mr Milburn) You are welcome to. 689. What you are saying is that the director of public health is a key figure in terms of the local authority for fulfilling its public health role? (Mr Milburn) Yes, I think that is right. All I would say about that is that in terms of the role of the director of public health we want to be a bit careful about being overly prescriptive about this. In some parts of the country, particularly where there are coterminous local authority and health authority boundaries, it is fairly simple, frankly, to have a joint director of public health. In my part of the world that does not happen to be the case. There is a unitary authority in Darlington and there is a huge County Durham and Darlington Health Authority so there is not the coterminousity issue. What we have to ensure, regardless of the organisational structure that is put in place, is that the director of public health has a close and growing relationship with the local authority precisely because of its wider statutory duties but also because of the wider contribution it can make to public health improvement. Chairman: Before we move off this important area, you mentioned health action zones in my area - and I have taken a close interest in it as the constituency MP - and what strikes me about that and a number of other initiatives I have looked at is so much of the work and operation of these action zones is recreating relationships that I saw in existence in practical terms pre-1974. We were in Scotland looking at a scheme in Glasgow and my colleagues who were there will bear witness to the fact that there was a health visitor --- Siobhain McDonagh: As old as him! Chairman: Who was as old as me who had worked pre-1974 and was looking at this brilliant new scheme that they had got in this particular part of Glasgow, the Gorbals area, and she said - and my colleagues will bear out that this is correct - it was basically back to what she did pre-1974 restructuring. It is not simply abstract debates in this place about where we place the function, it is about people at grass roots level having sensible structures that enable them to work together. The worry I have got is all the good work we are doing on these initiatives is simply recreating the relationships that I saw in existence pre-1974 at a local level. It will certainly not come as a surprise to the Minister. If you want to come back on that one, fine, otherwise I will move to Marion. Marion? Mrs Roe 690. Secretary of State, can I first of all apologise to you and the Minister that I shall not be able to stay for the full session and therefore the questions I am going to put to you will be disjointed groupings, if I can put it that way. First of all, it is claimed that one way to influence the wider determinants of our health is through health impact assessments. Could you suggest any ways for their effectiveness to be scrutinised? (Mr Milburn) I think that is true. I think that health impact assessments have potentially an important role to play in determining whether policies, not just in the Department of Health but in the DfEE or the Treasury, across government and indeed local government and other organisations whether they contribute to improvements in health, one, and, two, contribute to the wider governmental agenda which is not just to get improvements of health overall for the population but is also to bring about improvements for health in the poorest people at a faster rate than the average. I think there is a potential role. We are looking quite carefully at health impact assessments. There are various tools and frameworks around, within government and outside. Potentially they have an important role to play, but they only will have an important role to play, in my own view, because they provide a methodology and that is all. In the end what we have got to do across government and within the Department is get the commitment and the focus and the resources on improvements in public health, and health impact assessments potentially are an end to that means. 691. What would be your view on a Health Audit Committee on similar lines to the Environmental Audit Committee? (Mr Milburn) It is the first time I have heard that suggestion made but in many ways I guess that is the role of this Committee and certainly if you have had witnesses from DCMS and from other departments that seems to me to be a perfectly sensible and reasonable thing to do, if we all accept that it is not just what Yvette and I do, it is not just what the GP does, but it is what the local employer does and the local charity and the local council and, of course, individuals themselves that will have an impact upon the health of the nation. (Yvette Cooper) There has been a lot of work going on on developing health impact assessment methodologies and how you would assess them. One of the things we are interested in is whether the Health Development Agency could play a role in standardising or evaluating health impact assessments and how effective they are. That is one of the things that we are looking at at the moment. 692. Thank you very much indeed. Can I put it to you, Secretary of State, that there are serious concerns that local health improvement programmes are losing significance to a multitude of national priorities which are passed down increasingly from a centralist health agenda, as a consequence of which the public health needs of local populations are being ignored in favour of the rush to meet national targets. Secretary of State, could you reassure us that local community specific health agendas will not be squeezed out at the expense of what your own Permanent Secretary and also the NHS Chief Executive Nigel Crisp terms as the "must dos". (Mr Milburn) It is very, very important that local services, whether they are health services or local government services, whether that be education or transport functions, are sensitive to the particular needs of the local community. I guess your constituency and mine may be quite different constituencies and I guess the communities are pretty different too and they will have different needs and it is therefore important that local services are attuned to those needs because otherwise they do not enjoy public confidence and, frankly, they do not reach the people they need to reach. However, sometimes when this sort of question is asked I do think the people rather want to have their cake and eat it because they also want to see a proper and strong focus upon some of the big determinants of public health, about whether people are getting a decent diet, about whether people are getting access to cancer screening services, about whether people are getting access to heart operations, and so on and so forth, in a way that brings about improvements in health. You know as well as I do that unfortunately one of the things that most characterises the NHS is the fact that there are such enormous variations both in performance and access to those services and that is why we have got to get the balance right, which is what we are seeking to do, between establishing very clear national standards and, if you like, a very clear national framework of what must be done. What must be done is to invest in cancer services and heart services, on the prevention side, the screening side, as well as the treatment side, not just in some parts of the country but in every part of the country. That is what must happen, but then of course it is for the local service to determine how best to deliver that national framework. What we cannot have is, frankly, sometimes the lottery of services that we have seen in the past. Let me finish on the health improvement programme because I think it is extremely important. For me it is a very, very important co-ordinating device to try to ensure that the national priorities are translated sensitively into local priorities, that if there are specific developments that need to take place in local services that are required by the local community they are reflected in the health improvement programme, one, but, two, that the health improvement programme, if you like, should become a focus, just for the local health service (whether that be the trusts, PCTs or the health authorities) but also for local government input or for employer side input or for voluntary sector side input. For the first time at a very local level what you have is an agreed local health plan. That is what the health improvement programme should be about. If people think that is not happening I would be interested to know why. 693. Could I take you a little bit further down the path on access and talk about inequalities of access to medicines. I wonder if you could comment on the National Institute for Clinical Excellence's ability to in the words of your own Minister of State for Health, Mr John Hutton "mark the end of an era of postcode prescribing in the treatment of Alzheimer's" when in fact Wiltshire Health Authority states it cannot afford to provide the very Alzheimer's drugs recently recommended by that body? (Mr Milburn) With respect, I do not think that is Wiltshire Health Authority's position. 694. That is what I would understood but I would be very pleased to hear you correct it. (Mr Milburn) I try not to believe everything that I read in the newspapers because otherwise, frankly, I would not get up in the morning - and I quite like getting up in the morning. I saw that in one of the papers and I think it was one doctor of the health authority but that is not the health authority's position, as I understand it. I am very happy to send you a note on that. 695. I would be grateful. (Mr Milburn) There is a broader point. We set up the in National Institute of Clinical Excellence - and I know it was a controversial thing to do but I think it was the right thing to do - precisely in the face of the lottery in care and prescribing regimes that you describe. Under the old order it was up to the individual GP practice and the individual health authority, too, to decide which drugs and treatments were available to which patients and inevitably in that situation you ended up with the rather absurd, and I think unfair, proposition whereby different people with very similar conditions sometimes living in neighbouring streets were getting different access to the same health treatments. That cannot be right and certainly does not fit with the principles and values and philosophy of the National Health Service, and that is why we have an Institute that can produce clear guidance and authoritative guidance to the National Health Service. From our position as Ministers we have made it absolutely clear that it is very, very important that when NICE produces its authoritative guidance that that should be taken full account of by each and every health authority in the land and there should be not opt-outs of taking full account of each and every piece of NICE guidance. As far as Alzheimer's is concerned, as you are aware, the National Institute recently produced authoritative guidance on Aricept and two other drugs largely found in their favour. I think that has been broadly welcomed. It will help ensure that these cost-effective and clinically effective drugs are available to more people. 696. Thank you very much. If you could send me a note on whether that is accurate or not I would be very grateful. (Mr Milburn) I will send you a note on Wiltshire. Mrs Gordon 697. The Committee visited Cuba last year and I think we were all impressed by how they do so much with so little and how good their health outcomes are given that their health budget is only one per cent of ours. I think this is partly due to the fact that their national health service started some ten years after ours but they went off in a completely different direction. Ours is basically a sick health service in that most of our resources go into the acute sector whereas they went down the road of trying to stop people becoming ill simply because they have not got the resources to provide for the acute services. We found going round that this idea of public health, health promotion, is deeply entrenched in their culture. Everybody that we have come across in the organisations we have met has given this Government credit for taking up the public health agenda and trying to widen it and run with it, but it is this cultural thing which is not engrained, I do not think, in the same way in our culture. I would be interested to know if you feel we can achieve this cultural shift and how we can improve the health structures that we have to bring that about given the pressure on GPs, the health visitors who will deliver that service. (Mr Milburn) I think the points that you make are very, very important ones and I think it is something we have got to get engrained first of all within the culture of the National Health Service to realise it is not just a service to treat sick people, although of course that is hugely important, but it is also a service that can do much more to prevent sickness in the first place. I hope that we are beginning to shift the balance in the way that, for example, we are developing more prevention and more screening programmes over the course of the next few years. I am hopeful that we will have more screening programmes for everything from chlamydia to colon/rectal cancer when we have got an appropriate test available for people. We have made commitments similarly that when we can get to a position where there is an effective and safe test for prostate cancer then we would want to roll that out. We have got to do something more than that as well. We have got to get into the business more actively not just of primary prevention but secondary prevention. Here I think primary care, as Yvette was suggesting earlier, has a hugely important role to play. I think you are beginning to see some of this now beginning to happen on the ground. Traditionally the view has been that the GPs' function is effectively to act as gate-keeper into the Service, to wait for patients to come through the door and then to deal with them, and that produces a lot pressure on GPs and other staff too. There is another very, very important role, it seems to me, and that is the role of getting into some of these areas of secondary prevention. For example, when I visited Bradford several months ago I was very, very impressed to see the work that they were doing in relation to diabetes, and they have got a large Asian population, a high prevalence of coronary heart disease and diabetes. They are now establishing registers of people who are at most risk of those two diseases and they are actively intervening at an early stage. In Northumberland the health action zone is doing something very, very similar, setting up a register of people who are vulnerable to or have had heart disease and GPs and people working in primary care are doing everything that they can to get cholesterol levels down. Their estimates of what they will be able to achieve within the next five years - not just in the long and distant future but in the immediate future - are very, very impressive. They are saying they expect to save between 150 and 200 lives alone in that one county precisely because they are getting into that very active interventional business. That is where the National Health Service, it seems to me, has to go. We have to see a lot more of that. As I think I have said at this Committee before, it has got to get into the provision of more information to people. I do think it is important on public health that we recognise that the Service has got a big part to play, but in the end individuals have got a big part to play. Somebody with heart disease or who is prone to heart disease might need an operation, they might need a drug, but they will almost certainly need a balanced diet and regular exercise and in end that becomes their responsibility and we in the National Health Service have got a lot more to do to help people through that. 698. Some of the organisations, the community projects that we saw bottom-up coming from the community, although in some of them the GPs were very involved in others they found it almost impossible to get the GP involved. They have had trouble doing that, partly because the GP felt overwhelmed already by the workload. Back to Cuba, the family doctor there deals with something like 800 people whereas obviously our lists are 1,000 or almost 2,000 for a GP. Are there any practical measures that the Government can take to lift some of that workload? (Mr Milburn) I think there are several things. First of all, you have got to expand the workforce. The truth is that we need more GPs, we need more doctors, we need more nurses, we need more scientists and technicians working in the National Health Service and we will get there in the medium term. I think we have got fairly ambitious plans to expand the number of doctors working in the Service and certainly the NHS Plan says they want to see an extra 2,000 GPs working in the National Health Service over the next three or four years. That should be a minimum. If we can go faster we should go faster. The more the merrier, as far as I am concerned, because we need more family doctors. That is the first thing. The second thing is to recognise that there has to be a better division of labour within primary care. A lot of people do not need to be seen immediately by the GP but can be seen by the nurse. That is happening in a lot of GP practices already and it should be happening in more; I hope that it will. Thirdly, I think we have got to change the terms of this debate actually because in many, many ways intervening later rather than intervening sooner increases workload rather than diminishes it. If you have people presenting with more acute problems precisely because the NHS, local services, primary care services have not been able to establish the registers of those at risk, it is more of a problem. I know all that is easy to say and it is not so easy when you are sitting at a GP's desk having to see lots and lots of patients, but that is the big shift we have got to bring about and that is about, if you like, changing the culture of the Service so that it recognises that this whole focus now on prevention is at the top of the agenda rather than way down the agenda. (Yvette Cooper) There are some amazing things going on already in the NHS. I think the Committee has been to the Beacon Project in Cornwall, Hazel Stutely's project with health visitors working in the local community, working with the tenants' and residents' associations, making a huge difference not simply on levels of breast-feeding but also teenage conceptions, levels of crime, a huge impact that people working in the National Health Service can have working in the community as well. There are other examples. There are examples of the NHS and primary care working with housing organisations to make sure that the people who are prioritised for central heating or insulation are families of children with asthma or families with young children and so there are all those kinds of examples. There is work going on around teenage pregnancy. There are GPs and primary care teams playing a huge role now in starting to work to prevent teenage pregnancies, mainly working with local schools. It is that point that I think would reinforce our previous point. It is because there is so much starting to happen and really starting to spread throughout the NHS, whether it is smoking cessation, whether it is working on teenage pregnancy, whether it is work on housing, whatever it might be, that now would be the worst possible time to take public health out of the NHS at exactly the time we could be driving more and more public health work and prevention through the NHS and getting the NHS, particularly in primary care to play a much greater role in prevention than it ever did, than it ever did before 1974, than it ever has done ever in its history. John Austin 699. Can I come in on the point made about the Beacon Project. All of us were greatly impressed by the work Hazel Stutely and others have done there but up and down the country in the projects we have been to one of the key players has been the health visitor, as you recognise, and also the role of school nurses as well. I know that the Government has done a great deal to redress the rundown in recruitment and training of nurses but in the specialist area of health visiting, in our previous inquiry on the staffing requirements of the NHS, one of the most alarming statistics we saw was in the reports that came from the CPH, BMA and others about the likely age range and the retirement and drop-out rate of health visitors. Are you confident that within the general desire to get more nurses into the specialist areas like health visiting that the training is being expanded sufficiently, and what are the implications for the training of health visitors, not just the quantity but the content in terms of the new public health agenda? (Yvette Cooper) We really see a lot of the work around community nurses as part of all of the work of nurses and the expansion in the size of the nursing population working for the NHS is something that has to happen in terms of the community-based nurses as well. There is a lot of work that has been going on to develop leadership functions and training through the health visitors' and school nurses' development fund, trying to improve the training and support for health visitors and school nurses across the country. I think we should not under-estimate quite how vital they are. School nurses were absolutely vital to delivering the Meningitis C vaccine. We would never have got the entire under 18 population of this country offered the Meningitis C vaccine in the space of around 15 months if it had not been for the role of school nurses. We just could not do it. We do very much see the commitment in terms of expanding nurses as one which applies to community-based and district nurses as well. 700. Can I come on to the general initiatives that the Government has undertaken. No-one welcomes more than I do the very high priority that your Department gave at very early stages to public health. The commissioning of the Acheson Report very shortly after the Election, the creation of the post of Minister of Health are initiatives that all of us around this Committee would very much welcome. Indeed, when Professor Acheson came here he commented on the very positive steps which the Government had taken in the light of his report. We have got the policy initiatives of health action zones, health improvement programmes that have been mentioned earlier. But now we have the new NHS Plan. Has the new NHS Plan eclipsed those initiatives in any way and placed new priorities on the National Health Service? (Mr Milburn) I do not think it has. I think the sovereign role of public health and the job of tackling health inequalities and the bigger focus on prevention is very much at the heart of the Plan and what we have now got to do --- in the end writing plans is easy and devising policy is easy, delivering it is sometimes more difficult. What we have got to do is make sure that the Government's intentions to improve public health and tackle health inequality are embedded within the Health Service at every level and there too we have tried to change the institutions in such a way that they will deliver what we all want to see delivered - improvements in public health and the health of poorer people, getting better health opportunities. So, for example, as you are aware, for the first time now we are measuring and indeed rewarding the performance of local health services, recording not just how well they do on waiting times and the traditional acute sector agenda but how well they do, too, in improving health outcomes, ensuring there is fair access to services (the point that was raised earlier) and the performance assessment framework that we have includes these two vital measures about health outcomes and fair access. I think it is fair to say that as a consequence of doing that not only does it hold the local health service to account against our broad objectives but it provides some very positive incentives for the local health service in every part of the country to take seriously precisely these two issues, how you ensure fair access, for example screening services where we know that although in this country we have done incredibly well in screening services, cervical cancer and so on and so forth nonetheless it is true that poorer women tend to use those services less than others and there are big differences according to ethnic minority background too. If we are going to make the big improvements that we want to see in cancer survival rates and we want to save the number of lives that we do and people suffering from and dying from cancer, then we have got to get into these difficult areas and make sure that there is genuinely fair access. One of the ways you do that within the National Health Service is to measure the performance of every local service and to hold people to account against the objectives that we have set. It is not just a question of writing a plan or embedding prevention in a plan, it is also saying to the service this has got to happen and these are the ways that you have got to account for it happening. Chairman: Have we politicians not got some responsibility to broaden out the debate to include in the political mainstream issues of public health in a way that certainly was not case from our point of view at the last General Election where our pledge related to one issue on health which was waiting lists. You can ask anybody in the Health Service if you want to evaluate how effective the Health Service is there are a number of measurements and that is not one that I would have in mind. Looking at how we broaden out the debate in ways you are describing and looking at targets way beyond the immediate waiting list initiatives, etcetera, are you optimistic that in the next Election we might have a somewhat more mature debate on health --- Mr Amess: No chance. John Austin: No chance if you are involved. Mr Amess: I am replying to all the rubbish we have to listen to. Chairman 701. Do you understand the point I am making? I think we have a responsibility to get the debate widened to include the very important areas you are talking about. In a sense, certainly at the last Election, I do not think that my Party did that in a meaningful way. (Mr Milburn) I think your Party, my Party, our Party --- Mr Burns 702. Different wings. (Mr Milburn) There are no different wings in the Labour Party, unlike others I could mention! I think our Party and our Manifesto did have a focus on issues like cancer and heart disease and so on and so forth. Chairman 703. But key issues --- (Mr Milburn) Let me finish the point. I think it is very, very important that there is a proper and mature debate about these issues and, of course, improvements in health and improvements in health services are not just about improving waiting times for hospital treatment but improvements in waiting times for hospital treatment have an enormous bearing on the health of the population because, as we all know, people are waiting too long for heart operations. That is a fact of life. Thankfully because for the first time the Government has had the courage to earmark funding for coronary heart disease in a way that perhaps should have happened in the past, I am confident that we will get those waiting times down. We will grow the number of staff, we will invest in the treatments, and we will invest in the secondary prevention too. So there is not a contradiction I do not think --- 704. I am not saying there is a contradiction. (Mr Milburn) Nor do I think there is a conflict. If the argument becomes treatment versus prevention, that is the wrong debate. It is about how we ensure that the Health Service is both focused on treatment and prevention. Coronary heart disease is a good example, if I may say so, because when we pushed our coronary heart disease National Service Framework, our blueprint for tackling the appalling incidence of heart disease we have in our country, which incidentally is more concentrated in deprived parts of the country than others, the focus was as much on prevention as it was on treatment. That is the first time we have done that, sadly, where policy has been rounded enough and, in your word, "mature" enough to recognise that if you are going to bring about big improvements in public health let alone tackle these appalling health inequalities you have got to do the two things at the same time rather than assuming that inevitably it either/or. It is not either prevention or treatment; it has got to be both prevention and treatment. Mr Hesford 705. Can I pick up on something Mr Austin was dealing with a few moments ago. One of the strongest statements you made today was your support for the health improvement programmes. I personally welcome that. There is evidence that within local authorities, health authorities, PCGs/PCTs, the priority of HImPs is slipping down the agenda. You also said in terms of public health delivery that you are not territorial - partnership working, all that sort of thing. In terms of tangible benefits could you say something about the suggestion which we have heard quite a lot of merging the HImP programme with community plans? (Mr Milburn) I think in some parts of the country already what you are seeing is the health improvement programme where the health authority is in the lead (because somebody has got to be in the lead) and the community plan where the local authority is in the lead and because many of the contributors are the self same contributors - local government, the Health Service, the private sector, the voluntary sector and so on and so forth - in some parts of the country already there are shared objectives and common values that underpin the community plan and the health improvement programme. That seems to me to be a perfectly sensible thing to do. I do not have a problem with that. One of my own objectives for local government is to cut down on the number of plans that they have to prepare. We impose all sorts of bizarre statutory obligations on local government to prepare plans until they are blue in the face. In the end I am not interested in plans, I am interested in delivery. I would rather have people working in local government on delivering services rather than writing plans about delivering services. I know one is easier than the other, but actually we pay people to deliver rather than simply to plan. We have to see a reduction in the number of plans that we ask for in central government, we have some responsibilities in that regard. If we can see a closer relationship between health improvement programmes and community plans that seems to me to be a perfectly reasonable thing to do. What we should do is assess in those areas, I think, again, in I think in Wakefield, the community plan process and the health improvement programme process do have some share objectives and common values and so on and so forth. We should assess what gains are made for precisely that level of cooperation. If we think that that is beneficial then surely we should learn a lesson from it. Mr Amess 706. I certainly applaud the role of nurses in schools. I have to say to our minister for the Department of Health we have a desperate shortage of school nurses in Essex, and if there is anything that can be done to help I would be grateful. This is a subject that people laugh about but that for parents it is a big problem, that is the problem of head lice, which one of your colleagues has raised before. It is the sort of thing we do not like to talk about. There clearly is a very real and serious problem. It does appear that all the products which are available at the moment do not seem to be working. They are very expensive. There are new sprays and all sorts of things coming on to the market. Unless every child is done - because with the little ones their heads get together - it will go on and on and on. As a constituency Member of Parliament I keep getting letters about this, does the Government have any strategy to try and do something about this problem? (Yvette Cooper) It is something that I certainly answer quite a few letters from MPs on, including correspondence from constituents. There is an approach that is taken, that is supported locally, through the whole schools approach. You are right, the difficulty is finding it and catching it and supporting the whole school. What I can certainly do is send the Committee the details of that. It is something where we have cross working between the Department of Health and the DfEE on that. It obviously something where the whole school becomes involved, it is not simply an issue for the school nurses. On the issue of the school nurses, it is true that there are recruitment pressures and it is something that we are very aware of and it is something that applies to a lot of sectors. Certainly our commitment right across the NHS and right across the nursing staff is that we want to see expansion, although we do recognise that that is not always as easy as our intention might be. 707. Thank you for sending us the document. I would like to persuade our local authority do something about it. They will probably say, "Where would the money come from". What is the Government's position at the moment concerning the MMR vaccine? (Yvette Cooper) There have been a lot of concerns raised about the MMR vaccine. We take the approach that whenever there are any concerns raised about any medicine or any vaccine we always refer it to the expert committees that advise the Government on these issues, particularly the Committee on the Safety of Medicines also the Joint Committee on Vaccination and Immunisation and we seek the advice of the Chief Medical Officer. That is what we have done on this issue. We have referred all of the research, all of the publications, all of the claims that have been made by Dr Wakefield, all of the claims that have been reported in the papers to those expert bodies for them to examine them in great detail and examine them thoroughly. Their advice to us has been that there is no evidence of a link between the MMR vaccination with autism. Secondly, MMR remains the safest way to immunise children against what are quite deadly diseases. We think it is important on an issue like this to follow the advice of the experts and to make that advice available to the public. We should not be in a position of hiding information from the public. All of the information that we have been given from the CSM, from the expert committees and from the Chief Medical Officer on this subject we have made public and we need to continue to do so. 708. I know on 8th January you answered a question about the TB programme. Do we have an update as to when the schools can expect to have this vaccination programme resumed? (Yvette Cooper) We do hope to be able to make an announcement on that shortly. You will be aware that the vaccination programme has already resumed in London. We are also very conscious of the need to make sure that children do not reach the point of leaving school without a catch-up programme reaching them in time. We are very conscious of that. We have held discussions with companies all over the world to try and make sure we can get a secure supply of the BCG vaccination. There were problems with the sole supplier that persisted over some time that lead to the suspension of the programme. There is certainly a lot of work going on that and we do hope to be able to make an announcement. 709. When can we expect the sexual health strategy from the Government? (Mr Milburn) Hopefully within the next couple of months. 710. Do you have any concerns about the way the morning after pill will be administered? (Yvette Cooper) Are you referring to the morning after pill available in pharmacists? 711. Yes. (Yvette Cooper) This is something which has gone through the proper procedures, through the Committee on the Safety of Medicines and the Medical Control Agency. The company applied for a licence to use this to be able to deliver this product in pharmacies for over 16s. All of the expert committees who assessed it said this was a very safe product and this was something that could be give in pharmacies. The Royal Pharmaceutical Society has provided very detailed support and guidance for pharmacists to ensure that it is done in the proper context, the right kind of questions are asked and the right kind of advice is given. My view is that this is an extremely positive move, it is about giving women more access and choice to a product that all of the experts say is safe. It could also make a big difference in terms of bringing down the number of abortions and unwanted pregnancies, which are highest amongst women in their 20s. 712. Two final questions, you and I have been in correspondence about the palpatia(?). For the record, could you say why your expert group, I am not challenging it, decided that palpatia(?) should stop in terms of breast screening? (Yvette Cooper) Perhaps I should write to you or the Committee with the detail on that. 713. I would be grateful for that. I understand that you will be visiting the Lupus Centre later this month, which I am very pleased about, because we know this effects women between 20 and 40. The Secretary of State spoke earlier about why in the discussion and knowledge it is quite clear that the number of general practitioners do not - I know we have two on the Committee - seem to know about sticky blood, and all of that. Is there something that the Government might do if they are persuaded that this is a problem that we should address? (Yvette Cooper) We will certainly always look at any new area or any particular condition where there might be improvements that could be made. We have to take an evidence-based approach. We have to look at what works, what is properly evaluated and what will make a difference. Our approach right across the NHS is as new techniques become available, as new technologies become available we will also find areas that need research. We always need to take all of those seriously. Mr Amess: They do not get any money at all to help with their research. Dr Brand: Can I pick up one of the relevant questions that David Amess asked? Chairman: I thought they were all very relevant. Dr Brand 714. The issue of sexual health, when the Government reduced the public health targets, which were set in Health for the Nation, two to four main targets that we got in Saving Lives and Our Healthier Nation, I was given an undertaking by the Secretary of State's predecessor that we would not lose sight of the other targets. Although targets would be local for some of the other issue, like sexual health, they would be collated in some form so that we could see whether as a nation we were actually delivering the agenda that needs to be delivered. Sexual health is a very good example of that, teenage pregnancy, etc. I have asked this question annually for the last three years and I have been told that it will emerge from the system eventually. Can the Secretary of State or the Minister tell me when it will be available? (Yvette Cooper) What specifically are you asking for? 715. The previous targets that existed are no longer national targets they are now local targets. (Mr Milburn) You mean Health of the Nation targets. 716. When will we be able to see how we are getting on as a nation in reducing the issues like genitalia infections, teenage pregnancies, etc? (Yvette Cooper) Most of the figures you are talking about, like sexually transmitted infections are in the public domain. The Public Health Laboratory Service publishes a lot of information about communicable disease. There is a lot of information in the public domain already. We have a commitment to demonstrating progress against the targets we have set on sexual health. You are right, one of key areas there is teenage pregnancies, where we have set quite clear targets over the next ten years on teenage pregnancies. We are also looking at publishing a text supplement to the work that went you on through our Healthier Nation but also which is updated in the NHS plan that might also provide more of the kind of information you are talking about. I think our approach with a lot of these things is the information is out in the public domain. 717. I am not denying there is not a lot of information. What I think is difficult is to get the information in a form that you can track what is happening. Where we had 22 targets before we could follow what was happening to them, I was given assurance by the previous secretary of state that there would be some way of seeing how we were getting on. That would be helpful. (Mr Milburn) Can I take that away. I am sorry I do not have an answer for you today. I will take it away gladly. 718. While we are on targets and priorities, it is a bit alarming to hear from some of our witnesses that during regional reviews directors of public health would not necessarily be invited to take part in a review. Health authorities, on the whole, were questioned about the acute delivery of services, waiting lists, and that sort of thing but the public health targets, if they existed, were never discussed. Have we got the right mechanism of delivering the public health agenda you talked about so eloquently this afternoon? (Mr Milburn) I hope we have. It is very, very important. This is one of the changes that we have to achieve. If you like, we have to take public health out of its ghetto within the National Health Service. It not just a function and it is not just a responsibility that belongs to one part of the Service or to one group of professionals. It is a responsibility for the whole service, particularly in primary care it is the responsibility of all professionals. We have to, as I was indicating earlier in answers, have a means of imbedding it within the Service. My guess is you share this view, it is reflected in your question, that for too long these public health issues have somehow been second order rather than at the top of the agenda. The way that we have sought to do that is precisely by making health outcomes and fair access to services as important as the patient's experience in a hospital in determining how well their local health service is doing and, therefore, being able to hold a local health service to account. As you are aware, in future being better able to reward good performance across a whole range of quite complex health service responsibilities according to performance of the individual health service, not just on the waiting time issue, but on health outcomes and health improvement too. Within a managed service that is the way it seems to me that you stand a better chance of locating responsibility for improvements in public health within the mainstream of the NHS, rather than simply having it parked to one side, which I think has been the position in the past. That is quite a big change. I do not pretend that it will be easy. I think there is not a chief executive in the country that does not realise that there are certain important priorities for the NHS. Certain priorities, in Mr Hesford's phrase, are "must dos". In the future "must dos" will not just be about what happens in hospitals, they will also be about what happens in primary care, what happens to improve preventive screening services and what happens to bring about what we are all in the business of, which is improving health. Dr Brand: You are still talking about the medical model of public health rather than the broader model of public health -- Chairman: This is coming from a doctor! Dr Brand 719. -- which is something that saddens me actually. We have been talking about screening, prevention and some very good things have been done, I am not denying that, but that really is improving things very significantly for a relatively small number of people at risk. The broader population benefits from the broader issues of the environment, housing, nutrition, which have been touched on, but they are not actually delivered through the Health Service. (Mr Milburn) Hold on. With respect, and nor could they ever be. Unless you want to have a rather Stalinist approach to government - I know that is my reputation, Dr Brand, but as you know I am much more amenable and flexible than he ever was. 720. I am still alive, I am very grateful for that. (Mr Milburn) One of these days I will convince you of that. Unless you are going to have one supremo who is responsible for every governmental function then, of course, there are going to be different departments with different responsibilities, absolutely right, but with one big objective. If you ask me to define what the Government's big objective is overall, it is to ensure that there is genuine opportunities for every section of society in every part of our country, that is what we are about. The Health Service happens to encapsulate that but so do our ambitions to abolish child poverty or to create full employment or to ensure that everybody has a decent home and a decent environment and good public transport services and less crime on our streets. Those are the Government's broad objectives. All of these have a direct bearing on the health of the population and on people's health opportunities. 721. I agree entirely that the health outcomes will probably be the best measurement of how successful the Government is at actually creating an enabling society. Can I ask a specific question about the role of health authorities versus health trusts. I do get a bit confused as to whether we still have a commissioner/provider split when I look at the Health Bill that going through at the moment, where delivery trusts are going to be directly influenceable and rewarded by the secretary of state as with the influence of health authorities. We also see that each trust by statute has to have a Patients' Forum to influence its delivery. The minister of state quite specifically said that this was a Patients' Forum and not a Community Forum. That worries me slightly because trusts are actually very good at influencing ex patients of their brilliance and how wonderful they are. They tend to be fixed on the medical delivery of acute services, whereas the health authorities are allowed to have an ad hoc arrangement of public involvement. If health authorities have to deliver the public health agenda, which is not always the most popular in the short-term, how are they going to be able to have enough influence over the trusts, given that the trusts are going to have very powerful advocates in the statutory Patients' Forum? (Mr Milburn) I do not think the premise of your question is quite right. I do not believe it is purely the responsibility of the health authority to deliver improvements in public health. Perhaps we will not get as far as we need to get. It is the responsibility of the whole service, of community trusts, mental health trusts and most importantly of all primary care trusts, all of these organisations have a huge part to play. Within the primary care sphere I believe that - I was talking earlier about the role of GPs and other primary care professionals will play - the advent of primary care groups and now primary care trusts, for the first time, give primary care professionals the opportunity to have a proper population-based focus, to focus on the needs of its overall population, of 100,000 people or 70,000 people or 150,000 people. That allows, in my view, at least the potential for primary care professionals to get into another arena of activity that is hugely important in determining the health care and the Health Services on behalf of its local population. If GPs or as other primary care professionals you find there are particular problems amongst their patients, for example with poor housing, lack of central heating or damp homes, whatever, for the first time through the primary care trust group have you the opportunity of doing something about it, not least in relation to the roles that PCTs will play with local government. I think all of these organisations within the health service, not just the health authorities, have a responsibility to play on the Patients' Forum. I am completely unapologetic about that. As recent events have rather demonstrated all too graphically, the lack of direct patient influence, of patients being on the outside rather than the inside of the National Health Service have not always got their families, their relatives the right sort of results from an NHS that is supposed to about, primarily, serving the interests of patients. 722. I thought the NHS was there to serve the interests of the community from which its patients came. It is the concentration on the narrow user group rather than the broader community that gives me some concern when we are talking about the delivery of public health. (Mr Milburn) On the Patients' Forum side they will be comprised of two groups, although I do not think they are particularly distinct. People who use the Health Service, and use it on a regular basis, they have some insight into it. Actually, listening to what patients have had to say and listening to their concerns and complaints and, more importantly, imbedding the patient's voice within the National Health Service at a local level will make a real difference. That is one group. The second group are patient organisations within the local community, the local MS Society, the local Alzheimer's Disease Society. These local groups are drawn from the local community but have a particular interest and have a particular expertise which we ought to bring to bear for the benefit of the local community and patients in general. 723. I have no doubt they will be formidable advocates for the particular delivery of a medical treatment service. Can I turn to the local delivery of public health. I was very pleased to hear you say that you recognise that there are far too many initiatives, and too many plans are having to be drawn up. I hope that the Department will consolidate some of that. Can I ask whether the plan is to base the joint working predominantly on health geography or local authority geography? It is easy for me, I am as coterminous as one could possibly be. (Mr Milburn) You are at ease with yourself, are you? 724. I am totally at ease with myself. The health improvement programme clearly may have a different area from the community plan. I also find that the health improvement programme, because it cuts across a number of local authorities, is not the ideal unit to be looking at a local community. I think we should be starting to talk about sub HImPS and a smaller population that should create HImPs based on a district or unitary authority. (Mr Milburn) Some of that is happening on an ad hoc basis, the so-called HImP-lets. One of the amazing things about the National Health Service is it does manage to engender all sorts of interesting language which has a passing acquaintance with the English language on occasions. 725. Almost as good as politicians. (Mr Milburn) Some of that is beginning to happen, and why not? Certainly within my own area, Darlington, it is a very different place from the Teesdale and the East End of Durham, the old mining communities, and they have very different health problems. We have to have some ability and some flexibility to plan for the needs of the specific local population. I do not have a problem with that. As far as this issue of coterminousity is concerned, I think this is quite a difficult issue for all of us. The truth is there will never be a perfect set of boundaries. You are the dealing with different organisations of different traditions, different cultures, different representatives and accountability structures. That is bound to be the case. All that I say to people in the NHS, whenever they come to talk to me about this, because the NHS likes nothing better than a really good reorganisation, and it has had lots of them. It has lots of experience in doing it. All that happens, or what tends to happen whenever you have a reorganisation is that by and large people's eye is taken off the ball and in the end what happens is that rather than concentrating on getting the services delivered or the services improved or the health of the local population improved people start jumping into a position and wondering which job they are going to get. Sometimes we need to reorganise and we need to change things in terms of structures and institutions within the local service. Sometimes it is better to take your foot off the accelerator rather than always pressing it down. Dr Stoate 726. Minister, one of big public health issues I am interested in is men's health. Can I say I am pleased you have been helpful and very useful in the Men's Health Forum, working inside and outside this place, to tackle the big inequality facing men at the moment. One of the issues I really want to talk about is how as a GP we can try and improve health across different groups. We were told recently that the Health Education Authority carried out a survey and only 11 per cent of GPs understood what the New Age targets were for exercise. What that really means for me is that perhaps GPs are not as focused on the side the public health agendas as they might be. How do you think we can get GPs more on board with the Government's target for delivering public health. I do not think at the moment they understand what you are trying to achieve. (Yvette Cooper) There are some GPs in some parts of the country who are doing quite amazing work around public health and who are leading the way in showing what can be done, whether it is around coronary heart disease prevention or whether it is around teenage pregnancy. It is interesting on the issue that you mentioned, on exercise, the programme called Health Walks that has been funded by the New Opportunities fund quite recently as part of the Healthy Living Centres programme is all about improving access to exercise and working through primary care to do that. That has been driven by a GP. That has been driven by primary care. There are some very goods examples. The question is how you spread those examples across the country. Primary care does now have a duty and responsibilities for public health and health improvement. What we need to do is to build on that over time. It will take time. We should not have any illusions about the fact there are no swift solutions. There is a huge amount going on in primary care, with the shift of primary care trusts in many areas. I think there is a huge amount that can be done. Perhaps most will be done if we see primary care as a team and not simply as the role of GPs, so the work that nurses in primary care do, the work that health visitors do, the work, increasingly, that community midwives may be doing if they are linked in, and so on and so forth. There is a broad programme of work, it will take us some time. The more that we have targets, for example, health inequalities target, for example, the work on smoking cessation and, for example, the implementation of the national service framework for coronary heart disease, which requires a lot of work at local level and through primary care, the more progress we will see in this area. 727. That is fine. As you said, there are extremely good examples of where GPs and primary care teams have been extremely innovative with excellent results. My worry is there is a vast bulk of GPs who are struggling day-to-day to see 50 patients a day, sometimes more, plus on call. I find it quite difficult to grasp the actual concept of public health and how it is that we are trying to make any real difference. They feel swamped and overwhelmed and they wonder what it that they can reasonably achieve. (Yvette Cooper) Primary care groups and primary care trusts will be the mechanism for doing that. They will have responsibilities on public health and on health improvement. As a trust or as a primary care group they will need to show progress and to make progress and to be involved in the partnerships with other organisations at the local level. That does not necessary mean that all GPs within a primary care trust will instantly change the work they are doing, or anything like that, it does mean that as a whole the primary care trust is the mechanism. Obviously it is going to involve more training and support for people in the new kinds of functions. It may also be very much about the kind of teamwork, or it may be that particular GPs specialise in particular areas around public health. The honest truth of this is that I think it is an area with huge potential. We have not worked out the way in which it is going to work and a lot of it will be about the way it develops at a local level. You can just see some of the ways that some primary care trusts in some areas picked up smoking cessation and are doing a lot of work there. There is huge potential. What we need to do is follow what is working in different areas and make sure that other areas can learn from it. 728. Are you convinced that PCTs are the right vehicle to deliver this programme? (Yvette Cooper) They are such a massive resource. GPs are seeing people on a day-to-day basis. People come into their surgeries with health problems that are often linked to all kind of different social problems or economic problems locally. You have health visitors who are working with families with young children at a critical stage of a child's development. What happens in the first year of a child's life can have a huge impact not simply on their health later on, but also on their education opportunities and how they develop. Community nurses, people who are working in the local community at a very tangible level. It could be something as simple as identifying who it is that is suffering from fuel poverty by just a simple question to them when they come to have a flu jab, the primary care nurse asks. The potential for all of these health professionals, who have huge contacts with the community, and also with other organisations in the community, the potential for them to deliver improvements in public health I think is massive. It will take us a lot of time and we have to be very realistic about the capacity of the NHS. It is a time of great change and resources will only come on stream over time. The potential is huge. 729. It is interesting what you said about very young children and the contact they can have with health professionals. It might interest you to know that in Cuba the GP visits every child under one personally every day until they are one. (Mr Milburn) Are you advocating that? 730. No, I think my colleagues would lynch me. You said it was easy for a GP, a health professional, a health visitor or a practice nurse to pick up poverty or housing problems. That is fine and they do. What do they do about it? I still do some medical work, if I see somebody in that position now what I say is, "Go and see your MP", and they come and see me again. That is the matter, Secretary of State, to pick up. You can pick up these issues of poverty, GPs know about these things, but what can a GP do about them? (Mr Milburn) There are things that can be done for the individual patient, a referral to the local authority, and so on and so forth. That is not the trick we have to pull off. What we have to pull off is a means of harnessing the expertise of people in primary care with the knowledge that they gain from their contact with people in the community in order to formulate locally based approaches and strategies to deal with particular problems that you and Dr Brand see in your surgeries. There will be particular pockets of problems in particular areas, as there are in my own constituency. Some parts of the constituency are relatively affluent, some are pretty poor and they have specific needs. I think based on that knowledge what we need to do through the PCT structure, because it is operating at the level of the general population rather than a specific group of patients on a doctor's list, at that level what we to have to do is get the PCT working together with the local authorities and the other players in the community to formulate answers to the specific problems that walk through the doors of GPs surgeries either to see the family doctor or the local nurse. That is not easy to do - of course it is not - but the point about this is that there is a bank of knowledge, both in terms of expertise about solving problems and indeed about the nature of problems themselves, that is located absolutely in the heart of primary care. I do think this is an important issue in terms of how we frame this whole debate around public health. I said earlier that if we think that public health is just about certain professionals within the National Health Service delivering certain services we will not get anywhere. Public health is about how you mainstream these issues right into the heart of the Health Service onto the front-line of the Health Service and I think the PCT structure offers the potential of doing that precisely because over time you will see - and I am convinced of this and in the best places it is already happening - greater co-operation and greater collaboration with local government services, not just social services but environmental health services, transport services, education services too. Dr Brand 731. I think it is very ironic that we are having this discussion whilst the local government settlement is being announced because one of the reasons why I went into politics was because one got very frustrated because one recognised there was a problem but there were no delivery mechanisms. I think the only way you are going to get primary team members to reach their potential and start doing the work is to show that when they do the work there is a result. When I refer people to me as an MP I am almost as frustrated as a GP because fuel poverty and damp housing is not something I can change there and then and that is extraordinarily frustrating. (Yvette Cooper) But it is something where there are some local delivery mechanisms in some places being set up. 732. You need funding. (Yvette Cooper) In some places they have set up partnerships where the local authority has got a programme of improving insulation, central heating and so on so they build a partnership with the local health service on how are we going to prioritise, who is going to get the heating first, who is going to get the help. There is all kinds of work going on on home energy efficiency schemes and support to tackle damp housing. Those problems exist. The problem is matching them with the people who need them most and the Health Service is actually a brilliant way to match people but only if the co-ordination mechanisms are in place, and they are in some places and they could be in many more. Chairman: Can I say we will adjourn for ten minutes. The Committee was adjourned from 18.02 to 18.12 for a division in the House Chairman 733. Colleagues, could we recommence. I hope we can conclude in just over 15 minutes. Before we move away from the point Howard raised, he mentioned men's health and certainly one of the issues that has come out as a concern in this inquiry is the extent to which we have a lot of work to do in that area. As a Committee we feel quite strongly we need to look at that very closely. One of the issues that struck me in some of the visits we did was the fact that the front-line workers who were addressing this were primarily female and I wondered whether if any of the initiatives looked at the way in which you may involve more men in advising men on male health and looked at possible alternative models. I am involved in something you may be aware of on testicular cancer. I will not go into the rather laddish messages we put across but it is an important health message targeted at male spectators of sport. Have you any examples of how you are addressing this as an issue and the staff involved in front-line advice giving? (Mr Milburn) The best one that springs to mind is again in Bradford. Certainly on my visit there I had an opportunity to meet some of the male primary care staff, community staff, who were providing health promotion services but in a rather different way than perhaps they had been provided in the past. They were doing lots of "surgeries" in pubs and clubs and getting an incredibly good response, it has to be said. There is quite a bit of that in various places and some of the health action zones (not all but some of them) have helped to pioneer some of that work. I think there are some quite important lessons that are to be learned. It is true that basically men are not as forthcoming as women are about some of these health problems and actually it is important that we therefore have the debate with men on terms that they relate to and understand and in some of the venues that they feel comfortable in. That struck me as a very good example but I am sure there are very many others. The issue is, as always in the NHS, how you generalise from the particular and make sure those examples of good practice become more generalised across the piece. I am optimistic about this because I think that both for women and more men there is such an obvious and growing interest in their own health. You can see that whether it is in types of magazines that have been sold, the growth of gyms and fitness studios or whether it is the number of sports shops on the high street. People are more and more interested, quite rightly, in health issues that affect them, not necessarily Health Service issues either, about their own health. The issue is how best the National Health Service, which has tended to give a fairly passive response to demand, can relate to quite a different order of interest in the population about people's own health. (Yvette Cooper) I was going to say that it is not even just about the services, it is also the health information that we provide. I think the traditional approach of the health information campaigns has been to target women. It has been the traditional approach. You think about women as the guardians of family health so health messages go to women rather than to men. That perpetuates a situation in which men feel less empowered when it comes to talking about health, that health is not something to do with them. It is something we have made a conscious effort to address with new campaigns. So, for example, the teenage pregnancy campaign is very explicitly as much about boys as it is about girls, and is very conscious of the different approaches that boys and girls might take or different things that might resonate and it is very clearly about teenage boys as much as it is about teenage girls. Equally, the flu jab campaign we did involved Henry Cooper. We have been very conscious of trying to make sure that the campaigns that we run are as much about men as about women. Another interesting point I would make is that health inequalities issues between low and high income become very clear here as well because what you see over time is high income men catching up with women when it comes to life expectancy but low income men falling further and further behind. You also have to look at inequalities in terms of income as well as the differences between men and women. Dr Stoate 734. If I could ask a couple of specific questions, Secretary of State. A bit of a booby for you really: why has it taken so long to publish Sir Kenneth Calman's Report on public health function, which has been promised for some time now? Is there a particular reason it has not been published? Do you intend to publish it quickly and, if not, why not? (Mr Milburn) I hope we can publish it quickly. I hoped we might have been able to publish it this week but for various obvious events we have not. It is literally on the stocks and it has been with Ministers and it will be published, I hope, within the next few weeks. The major reason is that we had a change of Chief Medical Officer and it was important that Liam Donaldson had an opportunity to put input into it. 735. My next question is about the fluoridation of water. When we took evidence from the Sandwell Authority, which is a most deprived area, when they fluoridated the water 13 years ago they found dramatic improvements in the health of kids under 14 in their oral health, particularly in fillings. What is your Department doing about the fluoridation of water? Why is it not being rolled out across the country, do you have any plans to do so? (Mr Milburn) As you know we commissioned a study from the University of York which was published in October last year. It was an important study, yet in some ways it was disappointing in that it did not in the end make clear any firm recommendations for action. What it concluded, as you remember, is that overall the fluoridation of water had a positive oral health impact. If the people from Sandwell have told you that then their evidence bears that out to you. As far as they could see from the evidence there were not adverse health risks associated with the fluoridation of water but nonetheless they went on to say that there was not as much primary research around, and the primary research that was around was pretty dated. They recommend that we needed more research and, indeed, that is what we are doing. We are talking to the Medical Research Council about how we can go about getting more primary research. The problem of doing that is that it takes time. If you are going to have a whole series of population studies it is going to take some time to get. There are very different views about this, as you know. My post bag is full of very different views on this issue. I suspect that members around this table have different views. My own view is there are probably big benefits in fluoridation. As with all things, we have to make the policy decisions on the basis of the best evidence. Indeed, I think it is true of public health policy generally that we think we know what works very often but sometimes there is just not an evidence base for it. If we are going to invest public money and we are going to develop new strategies and new interventions then, above all else, we have to be pretty sure they are going to work. 736. I am disappointed more is not being done. The Americans have done it now for the last 20 years. They have a wealth of evidence and, as far as I am aware, very little adverse evidence. If a country like America can accept it wholeheartedly, virtually all American states are fluoridating their water--- (Mr Milburn) I am happy to send you a copy of the report. We commissioned the report precisely because there are so many different views about this and to try to get a clear evidence base for any policy decision we took. As I say, the conclusions of the report were clear in one regard but were not in another and, therefore, we have to act appropriately. However, that does not mean that in the meantime there will not be discussions, particularly in those parts of the country where we know there is poor oral health, deprived areas in particular, with the water companies about pressing forward the fluoridation schemes. Siobhain McDonagh 737. We have already heard earlier on about how you feel that the target for reducing child poverty is probably the biggest single commitment the Government has made and is going to have an impact on public health. Can you tell me what other Government measures have had an impact on public health? (Mr Milburn) The measures that will have an impact, a lot of these things are for the long-term 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 property 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. I think these measures are very, very important, reflecting Dr Brand's earlier point, they are very, very important measures in their own right, but they are also very important public health measures too. Over time they will pay dividends. There is little doubt about that. If Black is right, if Acheson is right, if Donaldson is right, 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. 738. How can performance in tackling health inequality be better managed? How can you enforce targets and monitor progress, given than the rest of the health service is run like that? (Mr Milburn) It is very, very important the development we announced in the NHS plan. There was a lot of to-ing and fro-ing about this. There were very mixed views about this. In our Healthier Nation we said that we would press ahead with a policy of local health inequality reduction targets and some of that has been happening through the health improvement programmes, and so on and so forth. There was a debate inside the Department and in the Modernisation Action Teams about whether we should press ahead with national inequality targets. My own view, and Yvette Cooper's too, was that that was the right thing to do. In the end you have to believe that what we have been talking about in terms of child poverty reduction and the interventions that we can better make in health are going to produce the right results. One thing that is crystal clear about the NHS as a managed service is that if you set a target that influences behaviour. It influences behaviour amongst clinicians and amongst managers. The fact that we are going to have, for the first time, a health inequality target, I hope we well be announcing before too long, I think will gear the Service to better recognising that this is a very important arena of activity for us in a way that has, perhaps, been neglected in the past. We have brought in new expertise to help us do that. We have brought in Don Nutbeam, who is a professor of public health of the University Sydney, to lead our public health effort and specifically to help us with the devising of an effective but also a challenging health and equality target. 739. I am only a very new member of the Health Select Committee and I have really enjoyed my time on it, particularly hearing about the local schemes and the really imaginative ideas that people have about regenerating their areas and improving health. All our discussions show they go hand in hand. One of the things that has come up as a minor issue is that the NHS can often be the biggest employer, the most well resourced organisation in any constituency or any borough. Do you think the NHS understands its role as employer, as an owner of property, as an owner of land, as a planner, in relation to what it could do to be involved in these particular regeneration schemes. Do you think the Department and NHS Executive actually understand it? (Mr Milburn) I think the frank answer to that is probably, no, we do not or the NHS does not. There is real work to do there. It is absolutely the case, in my constituency, and I guess in most others, if it is the true that the NHS employs one in five of the public sector work force and one in 20 of the whole country's work force, and it is going to be a growing work force, that must be reflected in most constituencies in the land. The NHS has some broad responsibilities, as Dr Brand was indicating earlier, not just to the patients that it serves but also to the wider community that it serves. It is a very important local employer generally. We try to encourage it to get involved at a local level with the New Deal to provide employment opportunities for the long-term unemployed and for the youth unemployed. Although there has been some success there I think a lot more can be done. As far as regeneration efforts are concerned I think probably the most significant thing we have done to date, and I think we need to do more, is the announcement we made in the NHS plan that we would have joint public health groups jointly reporting to the regional offices of the NHS through the NHS Executive and to the regional offices of government. That will, I think, allow something to happen that has happened sufficiently to date, which is that in all of these big regeneration schemes, whether they are New Deal for Communities or the Single Regeneration Budget or whatever for the health benefits and the health impact of those schemes to be better recognised from the outset. What I want to see is a lot more NHS input into regenerated activity both at a regional level, but at a local level as well. John Austin 740. Could I just follow on on that because you talk about input there but you are talking about input on the basis of ensuring there are good health outcomes from regeneration schemes. I think clearly in the ones I have looked at there have been measurable or potentially measurable health benefits, but there have been very few regeneration schemes which have been health-led rather than health being a positive good coming out of the economic and education schemes, or whatever it is. Do you think there is much more scope for looking at health becoming a driver and health being a regenerative engine itself? (Mr Milburn) Yes, I think there is scope for some of that and, indeed, I am considering at the moment the next wave of major capital developments within the NHS following from the first and second wave of PFI and other schemes, including the one in your own area. Of course, you always have an eye on the potential broader impact that a major scheme of this sort can have in the local community. If you are going to spend œ100 million, let alone œ200 million or œ300 million, and we have got some very, very big initiatives now coming through in terms of hospital developments in particular, they can not only provide the local community with a better local health service but potentially they can also have a very big knock-on effect into regenerative and economic development activity in a local community too. We try to do that at a national level, but I think the point that was being made earlier was that that needs to be replicated right down the command chain to both regional and local level, and I am convinced there is a lot more that can be done in that regard. Chairman 741. Are there any urgent final points Members want to raise or any points either of the ministerial team want to make? If not, can I thank you both for coming along today. We are most grateful to you and I hope our report will be of some help. (Mr Milburn) I am sure it will. 742. Thank you. (Mr Milburn) Thank you.