Examination of Witnesses (Questions 1-19)
23 FEBRUARY 2005
RT HON
JOHN REID,
MP, MISS MELANIE
JOHNSON, MP AND
DR FIONA
ADSHEAD
Q1 Chairman: Colleagues, could I welcome
you to this session of the Committee on the Government's Public
Health White Paper (Cm 6374) and a particular welcome, Secretary
of State, to yourself and your colleagues. We are very pleased
to see you here again. Would you like to each briefly introduce
yourselves to the Committee and then I know, Secretary of State,
you want to make a brief opening statement.
Dr Reid: Perhaps I could do the
introductions then. This is Dr Fiona Adshead, who is the Deputy
Chief Medical Officer, and Melanie Johnson, who is a Minister
in the Department, Chairman, both of whom, I have to say, were
central (I think more central than myself) to the publication
and the work behind the White Paper. You rightly said that any
introduction content should be very brief indeed, and I will be.
Basically I just want to say that for many, many years we had
had discussions about the outcomes we wanted to see in public
health, so the consultation and the White Paper is not about the
outcomes we want to see. We know that we want people to do a little
more exercise, to give up smoking, to avoid obesity, and so on.
It was more about how we achieve it, and in particular how we
get the balance between encouraging people to live healthy lives
and get healthy outcomes and the balance of freedoms that people
have to live their own lives. That really was a large part of
the consultation. I think that the White Paper consultation we
carried out showed a couple of things very, very clearly indeed.
The first was that people did not want us dictating to them how
they lived their lives and that came through very strongly. On
the other hand, they did want three things, I think. First of
all, they wanted advice and support to help them make their own
decisions, particularly in terms of information. Secondly, they
wanted where possible the resources to back them up in implementing
the healthy decisions that they made. Thirdly, they wanted protection
from the unhealthy decisions of other people, if you like, in
the case of smoking for example, and in particular for children.
So that is the context in which we published the White Paper and
that, as briefly as I can, sets the balance we tried to achieve
in the White Paper, Chairman.
Q2 Chairman: Thank you very much. I think
it is appropriate to place on record, as I did in the obesity
debate two weeks ago, our appreciation as a Committee that the
Government has listened to a number of the points that we have
made on public health and we appreciate that. Can I begin by asking
a question basically about the overall period that the current
Government has been in power and my impression very early on was
that we, for the first time in many years, as a government took
public health seriously. We saw a range of initiatives which were
very welcome. Health Action Zones, for example, impacted on areas
such as my own in a very positive way. Then I gained the impression
that somehow the public health agenda went off the boil, probably
towards the end of the last Parliament. Early on in this Parliament
we got into debates around targets and waiting lists. There is
nothing wrong with that, but it took us away from mainstream public
health. We got into debates around Foundation Trusts and we got
into debates around choice, basically looking at the acute sector
and how people use the acute sector. What guarantees have we got
now that public health arising from the White Paper will remain
in the mainstream, in the engine room of your health policy?
Dr Reid: I do not think that is
an unfair characterisation of the chronology as it happened, because
there was a White Paper. Tessa Jowell was heavily involved in
it, for instance. But I think certainly when I came in, just less
than two years ago, I saw a sequence of things as being necessary
to be done. The first was to build up and to continue to build
up a huge capacity in the NHS to make up for the years of under-investment.
Then it was to introduce the degree of not quantity but quality,
and that is where we got into the controversial areas, Foundation
Trusts, and so on. But once we had caught up with where we ought
to be, or got nearly to where we ought to be, we then had to look
forward and to prevent so many people becoming ill and putting
such a drain on the health service. So it was not just a good
thing to do, it was a timely thing to do and in fact a necessitous
thing to do. That is the first reason why public health will stay
in the agenda because we are putting in the biggest ever increases
in health in the history of the NHS over the longest period and
quite frankly I do not think anyone can reasonably expect that
to go on after 2008. There may be increases but they will not
be to this extent. Therefore, as Wanless (among others) has pointed
out, it is necessary for us to pay more attention to public health,
to reducing the need to treat sickness through the public health
work. The second reason why I think it will stay in the agenda—provided
always that this Government is re-elected, Chairman—is that
we are now committed publicly not only to a whole range of general
aspirations but to very specific 170 recommendations and very
soon the delivery plan, which we will publish, and that will be
a public commitment by the Government. That will be impossible,
even if the Government wanted to, to withdraw from. So there are
good pressures both in terms of circumstance and in terms of our
commitment.
Q3 Chairman: One of the problems in politics
is that we politicians tend to have short-term goals, inevitably,
because we are tied to a four or five year parliamentary cycle
and the General Election. How do you see it being possible within
the political environment that we all operate in to ensure that
public health becomes as big a player in the political ball game
as hospitals, doctors, nurses, or waiting lists, because clearly
any public health measure which you are taking now may impact
in a minimum of 10, 20 or 30 years' time in a way which could
possibly (but may not) reflect better on a government of a different
party? I have always found this a major dilemma politically, in
that public health does not have any real immediate short-terms
gains, it is the long-term gain, and us politicians tend to work
primarily in the short-term. What can we do about shifting that
point?
Dr Reid: First of all, I think
in terms of importance health consistently is the most important
issue in all opinion polls. Occasionally the economy goes above
it or drops below it, occasionally law and order goes above it
or comes below, but if you look at the last couple of years health
is always at the top. So it is top of people's agenda and it is
changing in the nature of concerns about health. You only need
to look at magazines, newspapers, and so on. There is far more
discussion on what we call public health issues now—exercise,
diet, and so on—than there ever was before. So it is there
in the public's agenda. The second thing is that I do think, and
perhaps this is immodest, that this Government has taken a longer
term view of certain important issues than perhaps previous governments.
The truth is that we would not be able to put money into the health
service, for instance, unless we had taken a long-term view of
the economy because for the first two or three years we reduced
debt and we reduced unemployment and people were saying, "Spend
the money now." We said, "No, we will spend it on reducing
debt and reducing unemployment because thereafter in the long-term
we will be able to sustain big increases on the health side."
I think exactly the same is true of health, and Wanless points
that out. If we want to maintain a health service at a good, high
level of quality and fast access to people in this country we
will have to do two things apart from investing in the health
service. The first thing is to shift as much as possible from
secondary acute care through to primary and do it in the community,
and even before that to stop people having to go to primary or
secondary through good public health programmes. So the seed corn
of the future of having an effective NHS and funding it is to
have an effective public health policy where we lay the seeds
now and we will get the benefits, hopefully, in five, 10, 15,
20 years' time. That is why, for instance, we bring in fresh fruit
for kids at school. That is not going to yield any benefits for
the country, though it will for those children in the next three
or four years. But over five, ten, fifteen, twenty years kids
who are used to eating fruit rather than chocolate all the time
will be a huge boon for the country.
Q4 Chairman: In a couple of months' time,
possibly, I may be sitting at home with my feet up watching you
guys racing around like idiots fighting a General Election! What
guarantee are you going to give me today, without betraying any
secrets, that when I am watching the television and the debates
between you and whoever from the other parties on health the real
issues you are going to be talking about are public health and
not solely hospital waiting lists or hospital building programmes?
They are very important, I accept that, but what I am saying to
you is, are you going to shift this agenda in a way in which in
a General Election public health is going to become a sexy political
issue in a way in which it has not been for a long, long time?
Dr Reid: I think we have already
done that. I cannot remember in my lifetime so many debates and
discussions on, say, exercise, fitness, obesity, smoking, drinking,
as we have had in the past three or four years in this country.
I genuinely think it is at the top of the agenda and I think it
will continue there. Even if you were sitting at home with your
feet up—which I doubt very much, knowing your proclivities
and your energies, Chairman—I will bet that you will have
a pedometer on your belt to remind you to go out and do a bit
of walking. Even if you do not have that, you will recall that
on the television set you are watching there will be an NHS digital
programme which will be largely dedicated to advice on health,
and next to you will be a telephone where you will think of calling
up Health Direct, which we are bringing in, other than NHS Direct.
You will then get a whole series of magazines which we are producing,
which are largely (though not exclusively) targeted on public
health issues, at younger men, at younger women, and so on. So
the agenda that we are setting even at this early stage, I think,
is to ingrain a recognition of the need to have instruments which
constantly bring to people's attention the benefits of healthy
living—without nannying people—protecting those who
have to be protected against the irresponsible healthy attitudes
(as some would regard them) of others, protecting children in
particular, but making sure through the telephone, through the
health trainers which we are bringing in in the community and
the education programme—which we can speak about because
we want to turn all 1.3 million people in the health service into
people who recognise public health rather than just treat the
sickness. So if you come in, for instance, to accident and emergency
they will not just treat your broken leg but if they know it is
the third time you have been in in the last year and you have
got drink on your breath, without being over-intrusive people
may be able to say, "Do you need any help in another direction
apart from your broken leg?" So I think we are going to ingrain
that sort of thing.
Q5 Chairman: So there is hope for all
of us?
Dr Reid: Yes, and one other subject
which I was making our views known on this morning in one newspaper
is food labelling. We are all very busy people now and when you
get off the couch and rush off to buy your food at the supermarket,
at the moment unless you have got a PhD in biochemistry and all
day, and 20/20 eyesight, you have no idea of the nutritional value
of your food. I want to make absolutely certain that busy mums
and dads, and even retired politicians, will be able to go to
the supermarket and get a simplified form, easily available to
them, which indicates the nutritional value of the food they are
getting. I have read in certain quarters that we are backing off
that. I have to disappoint whatever lobby thinks we are; we are
not. I am open about the format. I do not care whether it is 1,
2, 3, or A, B, C, or the colours of the rainbow, but we are going
to have food labelling for the people of this country and if we
cannot get it voluntarily here then I have already opened discussions
with the European Commissioner on it and we will be pursuing a
European-wide measure on that. So public health is here to stay.
Chairman: We will probably touch on that
particular issue in a few moments. Jon.
Q6 Mr Jones: Thank you, Chairman, and
you are welcome to come down to Cardiff with your pedometer—as
you are, Minister. I want to refer to the Wanless Report. Wanless
asserts, Minister and Secretary of State, that better public health
will save the National Health Service money. Do you agree with
that assertion and do you agree with the spending projections,
the different projections of potential savings which could be
made according to Wanless?
Dr Reid: I agree with the general
point and I met, obviously, with Derek Wanless on this and as
I indicated at the beginning, I do not think this is an add-on
in terms of the future economies of health care in this country;
it is an essential ingredient in making sure that we have got
a sustainable long-term health care system. I would make one qualification
for that: whatever we do in health, if we are successful it brings
us bigger challenges because if we are successful people live
longer in greater numbers and therefore have to be taken care
of longer. Having said that, I do agree with Derek Wanless. The
real question becomes, I suppose, to what extent you are willing
to curtail people's freedom to have their own choices in life
in order to reach the outcomes which give you not only the maximum
health benefits but the maximum economic efficiency in the provision
of health care. That is why I said at the beginning, Mr Owen Jones,
that there is a balance between the two. But in general I agree
with Derek Wanless.
Q7 Mr Jones: You anticipate the next
question. My next question is, in the scenarios that Sir Derek
describes he describes the fully engaged scenario. A fully engaged
scenario has a target, according to Sir Derek Wanless, of 17%
of the general population smoking by 2010, which is the current
level in California. You have rejected this target in favour of
a less ambitious one. Other than enabling more choice, do you
have any other reason for that?
Dr Reid: The first thing to say
is that some of the targets that we have put out Derek Wanless
regarded as over-ambitious and some of the targets he thought
were less ambitious than they ought to be, though more ambitious
than the ones be criticised four or five years ago, particularly
in the case of smoking. The fact of the matter is that I doubled
the target reduction for smoking because we were going to reduce
it originally down to 23%. I doubled that, and secondly I put
a very important proviso in it which I think is as important as
anything, and that is that reduction should apply to all social
classes. That, to me, was as important as achieving a reduction,
which was basically middle-class people giving up smoking. So
contrary to what you may have read in the press, I want to make
sure that right across social classes we get that reduction. Now,
when you reach a decision as to how far you can go the important
assumption which is built into the White Paper on all sorts of
issues is that you cannot achieve and get towards what Derek Wanless
in this country by direction. It is not acceptable to do it by
direction because if you are going to achieve all of these targets
by direction then you would not get to the stage where it was
compatible with the sort of mature adult lifestyle and life choices
which people in this country want. So where we introduced the
target in smoking, it was what I thought was realistic to get
it down to around 20%, which will have reduced from 48%. Other
countries have taken a more stringent view on, if you like, the
prohibitive side of things. In Scotland, for instance, they have
decided to go for a complete ban on smoking. I came to the conclusion
that that was not a good thing on health grounds, apart from anything
else, because you get a displacement of smoking from some pubic
areas to the home—and most of the evidence about passive
smoking is about the home—but in any case if you look at
the reduction we have had in England in smoking in recent years,
the figure we are at now is higher than the reduction in Scotland.
So it is a matter of getting a balance between what we felt was
reasonably achievable—and not just in smoking but across
a whole range of areas. The fully engaged scenario of Wanless
would in some cases require a degree of government dictation to
you about your life which is not acceptable in modern Britain,
in my view.
Q8 Chairman: Can I just intervene? We
are going to talk about smoking in some detail later on, but just
to clarify, you made the point that in Scotland you were concerned
that banning smoking in pubs would displace it to the home. Have
you got some substantial evidence to prove that, because certainly
there are people who have put to us the alternative argument that
many people who smoke do so only when they have a drink and if
they did not smoke when they were drinking in a pub they would
not smoke at home?
Dr Reid: That is anecdotal when
people tell you that, I am sure, because I speak with some considerable
experience of smoking and drinking, if you do not mind me saying
so. There are not that many people who endanger their lives hugely
by smoking only when they go out to a pub and the truth of the
matter is that we do not have a great deal of evidence on that
because there are not that many places where we have had long-term
prohibition of all smoking outside the home, but what we do know,
for instance in Ireland and we would anticipate in Scotland, is
that a %age of people who previously went to the pub to smoke
will now get a carry-out and take it home. I think the %age in
Ireland is about 15%. That is not the primary reason for reaching
the decision I reached, Chairman. I reached my decision on smoking
because I felt that we had achieved a balance between protecting
the public who did not smoke and who wanted a smoke-free atmosphere—and
the legislation was introduced to protect the public, not to force
you to live a certain lifestyle because if we do that and force
you to do that which remains legal we start on a whole series
of questions like why should we allow you to box, or drink, or
whatever and then still be treated on the health service. So the
primary purpose for which I brought in the legislation was to
protect people from the smoking of others, that is passive smoking,
but in addition to that I am saying as an observation (it was
not the primary reason why we did it) it is also my view that
there will be a displacement if you allowed no smoking in any
public place whatsoever. In our case we have got 90% of pubs and
restaurants which will be non-smoking, but there will be some
areas. So if you allow none whatsoever there will be a displacement
(as in Ireland) from people who previously went to the pub who
will take drink home. Now, I assume they will smoke at home and
most of the passive evidence we have got on smoking is based on
people who live with smokers. So that is a secondary point.
Q9 Mr Jones: Can I come back, because
this conversation you have just had with the Chairman illustrates
one of the most important parts of the Wanless Report, which was
not about specifying what we should do but specifying how we should
do things and how we should make choices about what we do. Sir
Derek Wanless stated that measures to improve public health should
be based on considerations of evidence and cost-efficiency. In
that discussion you were assuming that evidence from Scotland
would show something—
Dr Reid: But I think there is
something missing from that quote. The decision about how you
dictate to people about how they live their lives has to be based
on more things than just evidence and efficiency, it has to be
based—
Q10 Mr Jones: If you will allow me, I
am accepting the argument that we have to make this balance. I
am only trying to explore a different argument about when you
are balancing what works and what does not work you can take into
account whether you should or should not do it for reasons of
choice but you still need to have a sound evidential basis for
deciding, does this work anyway? He expressed a dearth of evidence
on the cost-effectiveness of many, many programmes. Do you accept
that there is an argument that there often is not evidence?
Dr Reid: I do not accept it on
the main one because my memory is that, ironically the main one
is that he did not think smoking cessation services—
Q11 Mr Jones: No, no, forget smoking.
I am not talking particularly about smoking.
Dr Reid: That was his main one,
as I remember. I will stand corrected. But on smoking cessation
services, I believe they are very effective. I think we have got
another 240,000 people in the last year who gave up smoking.
Q12 Mr Jones: We will ask questions about
smoking again, but I am just trying to ask you about the methodology,
not—
Dr Reid: I am giving you an answer.
No, I do not accept his view that in some of these major areas
on which we have based our proposals in the White Paper, including
in areas where he thought there was insufficient evidence, we
have not had the evidence. I do accept in the question the Chairman
asked me about the future that I do not have the evidence on that,
and that is why I made it plain it was not my primary purpose.
I do think we should base it on evidence, that contention I agree
with, but some of the conclusions he then reached about some of
the services which were directed towards public health not being
evidentially based I do not accept.
Mr Jones: Let me give some specific examples,
and I am going to move away from smoking. I am sure others will
raise smoking questions later on. The Chairman quoted approval
for Health Action Zones. I am not aware of the evidential basis
or the cost-effective basis for Health Action Zones, and if there
is a good evidential base and a cost-effective base then obviously
we should be continuing with that.
Chairman: Jon, can I just say I quoted
the example of one constituency where I saw some very positive
developments.
Mr Jones: Anecdotal information.
Chairman: Anecdotal, what I saw up in
the schools. That is what made me feel that it was a positive
initiative at the time.
Q13 Mr Jones: Nevertheless, the point
is there was an initiative, Health Action Zones, which does not
exist any longer. I am not saying whether that was a good initiative
or a bad initiative, but has the Department conducted any work
to establish an evidential base and a cost-effective base for
this? Did it work cost-effectively or did it not work cost-effectively?
Dr Reid: The answer to that is—and
I will try and wrap it all together—I agree with the challenge
that these should be evidentially based. I disagree with some
of the comments you made about specific areas. There are some
areas on which we do not have evidence, and if you look at the
White Paper what we propose, and certainly what we are doing,
is evaluating evidence now. For instance, on drinking we are doing
an audit of both treatment and identification of drinking. I would
have liked to have gone further but in some areas there was not
the evidence that we needed. In the case of Health Action Zones,
which you mentioned, we are now carrying out an evaluation of
the cost benefits of Health Action Zones.
Q14 Mr Jones: Will the Committee be able
to see that?
Dr Reid: If I could take advice
on when we would expect that.
Miss Johnson: Ken Judge has carried
out an evaluation of Health Action Zones for us and we could give
you the information and the evaluation report within the next
couple of weeks, I am sure.
Q15 Mr Jones: Excellent! Can I turn to
another initiative which, Secretary of State, you mentioned earlier,
health trainers. Is there any evidence for the cost-effectiveness
of health trainers?
Dr Reid: Yes, the fact that lots
of people spend lots of money on it.
Q16 Mr Jones: That is not evidence for
the cost-effectiveness.
Dr Reid: Is it not?
Q17 Mr Jones: It is evidence that people
can be persuaded to spend a lot of money. There is a lot of things
in the market that people spend a lot of money on which are not
necessarily effective.
Dr Reid: In health terms?
Q18 Mr Jones: In health terms, yes.
Dr Reid: Like what, for instance?
Q19 Chairman: Cosmetic surgery?
Dr Reid: That is not really down
to health and we do not provide that on the NHS precisely for
that reason. I say this in half-jest, Mr Owen Jones: most of the
times that people pay money for in health is access to gyms, sports
equipment, involvement in various sports (skiing, running, and
so on) and in cases where they have sufficient money personal
trainers to give them advice on training routines, and so on.
Most of these things appear—and I do not have the statistical
evidence in front of me to illustrate that this is intrinsically
a good thing, but most of this seems to me a good thing. The evidence
is being supplied to me from left stage even as we speak and if
I was sufficiently educated to read very good writing I would
be able to tell you. "Peer education works," it says
here. So if you have a trainer it helps. Now, look, this is based
on a very simple hypothesis which I think there are generations
of evidence for, and that is if you want to live a healthy life
and you have access to support, encouragement and information,
you are more likely to sustain that healthy life than if you do
not.
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