Examination of Witnesses (Questions 460
THURSDAY 14 DECEMBER 2000
HEATH, CBE, DR
DRINKWATER, CBE, DR
460. You spoke about the pressure that you are
under personally, Dr Archard, and I sympathise with that; your
comments that your colleagues see that you ought to be there,
doing what you call proper work. I was interested in the outline
comments in your evidence that general practice is and always
has been based on the concept of personal doctoring which they
would regard as proper work. What I am interested in exploring
is whether we need to be much more radical about how we use our
GPs, how we train our GPs, how we place our GPs. I say this on
the basis that this Committee a while ago went to another countryI
will not mention wherein which the role of the GP is fundamentally
geared to public health. They are in a position to influence the
direction of decisions on local issues in a way that certainly
you are not in any way in your work here. The training of hospital
doctors requires them, when they are qualified, to have spent
at least two or three years working as a community based family
doctor. The family doctor lives in the community where they serve,
along with the local community nurse. They are from the community,
quite frequently. They are very different people to the kind of
GPs I know. The last thing they would want to do is live in the
community in which they work and I understand why. I worked in
social services. I would not particularly want to volunteer to
live in the area where I was doing child protection and mental
health work. Do we not need a cultural shift here somewhere and
look much more radically than we are doing at issues such as training,
how we recruit our GPs, where they come from and how we do enable
you to be seen to be doing proper work when it is not necessarily
personal, face to face doctoring?
(Dr Archard) I absolutely agree with you, 100 per
cent. It is our colleagues who need to recognise that proper work
is also not necessarily face to face medicine. The other thing
is that people evolve and if you had suggested to me, when I was
a medical student, that I would be addressing this Committee today
I would have laughed at you. Indeed, it was exactly the same when
I became a general practitioner. People evolve; people become
interested in different things and this is why I am here today
perhaps. This has to be addressed because if you go into the current
partnership model, by and large that is where you will be for
the next 25 or 30 years until you retire. Your job is set out
in front of you; there is no career structure. You become a partner
and there you stay. That is it. Until recently it has been quite
difficult even to move partnerships. If you try to change your
career structure, the only way you can do it is to take the sorts
of risks which I have implied. Because that is not recognised
I believe either generally by colleagues or the government, it
is an extremely difficult step to take. This does put the brakes
on the sorts of projects and priorities which we feel should be
undertaken and public health is one of them.
461. You talk about career structure. Do you
see any opportunities within the move towards PCTs, where I see
in my area individual GPs within those PCTs specialising in certain
areas? Do you see a possibility that that might offer some sort
of career structure and within that career structure the possibility
that some of the public health specialism within that PCT may
be on offer?
(Dr Archard) What do you mean by "specialism"?
462. What I am seeing in my area is that within
PCGs you have a lead GP for such and such an area or such and
such a specialty.
(Dr Archard) Do you mean a clinical specialism?
463. Indeed, yes. Is there a way in which we
may look at addressing the issue of the career structure point,
which I think is a very valuable point that you have made; I am
on board with that completely and I am sure our two GPs who are
not here today would be. Is there not a way of building in a public
health function within that? Can we explore that? Is it something
you have looked at?
(Dr Archard) The model that I have written about would
suggest a third, a third and a third, in which one third is in
face to face clinical practice so you do not lose touch. One third
would be involved in local priorities such as PCGs, PCTs or whatever,
appraisals and education. One third would be on national agendas
such as college agendas or the GMC or whatever. That is the way
I would see it, but these career structures would be agreed on
an annual basis such that people would know what they would be
doing. If we did this, it would give general practitioners and
the public protected time. These sorts of areas could be addressed
properly. They would therefore, by implication, be resourced.
For example, they would not be tacked on to the end of a busy
464. And it will be seen as proper work.
(Dr Archard) Yes.
(Dr Heath) The idea of GPs with a special interest
in public health is a very constructive one, but the problem about
the wider proposal that GPs should develop clinical special interests,
is that it has the potential to make the whole public health problem
much more difficult.
465. Can I come to the issue of health visiting.
Since the Acheson Report, there has been quite a lot said about
the positive role of health visitors. Yet, it appears to be a
diminishing resource in many areas. What do you think the role
or the potential role is for health visitors?
(Ms Amadi) We need to recognise that there are a lot
of other community practitioners out there working and complementing
GP services, one of them being health visiting. Looking at the
roles that they are involved in, often times you can see that
they are not given the authority to optimise the services that
they can bring.
466. What do you mean by that? Can you be more
(Ms Amadi) A health visitor working in a particular
community may see a range of health problems that she can address,
but without resources she has no control over budgets. It is very
limited in terms of who she can work with. Often, you will find
examples where really good health initiatives have been produced
and the health visitor has gone through the process to create
resources and to provide services and that is a real problem because
health visitors are very well qualified to perform a large amount
of functions, but because of the way that health authorities,
PCGs and PCTs have functioned to date, they have been prevented
from carrying out that role.
(Professor Drinkwater) From the Alliance perspective,
there are some issues here around capacity and who does what within
the patch. There are some issues around career structure for community
nurses. What we have at the moment by and large is a system whereby
people become district nurses or health visitors and they stop
at that point and that is their career. For a number of people
that may be fine but it does create some problems within the system,
particularly if you are looking at our own PCG where you have
a number of G grade nurses who have been getting pay increases
so that the system is loaded towards the top end; and a number
of people who have been there for a number of years who are going
to be retiring. Where do you recruit behind that and how do you
get people into the system? There are some issues about the skill
mix that is required to deliver the services that are required
to meet the needs of that community and it is about having a broader
range of skills than a single health visitor, for instance. Phillip
has already talked about the Families First project which is local
people as a resource to support the health visitors who are trained.
There are then nursery nurses who should be part of that system
linked to health visitors and linked to school nurses. There are
some issues about how you build that career structure and equally
at the top end, in terms of the way that system is moving, if
we are going to retain people within the system and hang on to
them, they need the opportunity to develop their skills and careers.
That is around the notion of nurse consultant posts. Again in
our own patch, we have a specialist nurse, child and adolescent
mental health who was a school nurse, a specialist nurse, drugs,
alcohol and young people, who was a health visitor and a specialist
nurse, community, coronary, rehabilitation, who was a health visitor.
There are opportunities there and there are roles there. Those
roles need to be managed and need to fit within a system. You
also need to back-fill that and the major problem at the moment
is getting people into posts behind that because there are some
issues about recruitment of nurses into the system and the need
for more nurses within the system.
(Ms Jackson) We believe there should be a major overhaul
of post registration training for community nurses. At the moment,
there are eight specialist practice pathways. That puts practitioners
in little boxes. What we would like to see is a breakdown of those
boxes which breaks down the barriers. Health visitors and school
nurses have been recognised as having a public health function,
as have other community nurses. We would like to see exploration
of a common public health nurse, public health practitioner, public
health visitor, whatever title you want to put on that, where
there is a common core, but we are not advocating for a generic
nursing role here. What we would be advocating for is a common
public health practitioner who would have a focus perhaps on the
elderly or the under fives or adolescents. That would then fit
in with what is coming out in terms of Higher Level Practice from
the UKCC and nurse consultants because there could be a career
pathway developed for these particular nurses. We do need to start
quite quickly with the post registration training for nurses.
At the moment, we are trying to fit our current practitioners
into the new roles and the training, as it currently stands, does
not equip practitioners to take that forward.
467. One of the criticisms of the training of
health visitors is it is too short; it is too clinically focused
and does not specifically address public health skills. It also
raises a more controversial question: why does a health visitor
have to be a qualified nurse? Some people would argue that the
career of a health visitor is one which should be a separate,
independent career and is not an extension of nursing. How does
the CPHVA react to that?
(Ms Jackson) The CPHVA would take the view that a
health visitor should be a qualified nurse. It is the nurse education,
pre-registration education, which gives you a set of skills and
knowledge to enable you to take a more holistic view within health
(Ms Amadi) I would agree with that, rather than risk
developing very skilled community health workers withoutit
is almost one of those things that are intangible that you have
with the general nurse training.
468. I am very interested in this area because
on the Committee years ago, when I was first a member of the Health
Committee, we looked at midwifery. It was the report into community
childbirth, you will recall, when the chairman was Nick Winterton.
We went to Holland and we saw the professional role there that
was coming across between the GP and the midwife, and we were
very impressed by the function that was occupied by this particular
individual. Do we not need to think more radically about how we
train people for public health work? We tend to think in chunks
and a lot of the concerns we have had expressed to us with regard
to public health relate to the fact that we are bogged down by
the medical model. Is there not an argument that we ought to bepicking
up John's pointdoing that not just in relation to your
function but other professional functions as well, because certainly
when we looked at the relationship between health and social services
in the Committee we saw no arguments against blending, for example,
the role of CPNs with social workers on the mental health front.
Should we not be exploring these areas to pick up the point that
public health is not just about medicine, it is about much much
bigger issues that perhaps we are trained to miss because we are
so blinkered in our professional roles? Do you accept that point
and, if so, what do we do?
(Ms Amadi) I think you made a good point that we need
to explore alternative ways of providing the service. In terms
of a health visiting service we need to be thinking of that as
a service with the health visitor working as part of a team and
that team being from a variety of different sources where different
professionals from different backgrounds and statutory and non-statutory
organisations are all working together. That is one way of working
things through. I cannot say I have the absolute answer on that.
It is something that needs to be tried and tested and experimented
with, sure, but there is a public health role that health visitors
are very well equipped to provide.
469. A very local viewI am always struck
by the isolation of health visitors and by their isolation from
the whole political and public processes. I have seen people at
my advice surgery who have had letters from health visitors about
their housing and I think, "This is clearly written by somebody
who knows nothing about public casing and does not know how to
assist their particular client or patient." I have offered
to go and talk to health visitors about how the council does the
housing and how it works, in an attempt to empower them, but do
you think that GPs and health visitors have very little connection
with local authority services or how to best assist?
(Ms Amadi) I would hope not. That be the situation
in particular areasbecause there will be a variety of quality
of service that clients would getwhere the health visitor
may well be over-worked and over-loaded and where there is a high
volume of clients with the same problems and the same issues.
It may well be that there could be times when the health visitor
is slightly out of step with what is going on, but I do not think
the health visitors would not know.
(Ms Jackson) I would hope your experience is not a
general experience. There are varying degrees of service, if you
like, across the country. Can I pick up on the public health training
issue that you were raising. There is a tripartite advisory group
that is meeting and we are part of that, along with the Faculty
and the Royal College of Public Health and Hygiene. That is looking
at public health specialist practice but at a very senior level
and that would be multi professional. So it is doctors, nurses,
environmental health officers, everybody that would have public
health as part of their remit. A consultation paper is coming
out from the Steering Group in January. Maybe there is a need
to look at that, not at that senior level at which the qualification
is going to be but perhaps at a more basic level. There are lots
of questions there and I think it would be worth exploring.
(Dr Crowley) I think the key to tackling the major
public health issues affecting disadvantaged areas around inequalities
is everybody seeing their role in it and also seeing the role
of local people in that. The Families First model is only one
example of how there is a certain power in training and supporting
local people to provide peer support and peer advice to people
experiencing social exclusion. Sometimes professionals will struggle
to overcome the barriers there and working in partnership with
trained local people who have not gone through professional training
previously could be an additional arm, if you like, to what we
470. I want to go back to the training and qualifications.
We have had a similar discussion about directors of public health
and whether they need to be doctors or not. On the issue of the
health visitor, I think Ms Amadi said that the pre-registration
training for nurses provides the body of knowledge that is needed
for the health visitor. No doubt you saw the article in the Nursing
Times last month where Sarah Crowley, Professor of Clinical
Practice, was saying the reverse, that we could easily design
a three-year degree programme for health visitors with any necessary
elements of nursing included in it. "There are many health
visitors who work closely with nursery nurses, family welfare
and community development workers, who have the potential to become
expert health visitors and who could take advantage of such an
option." Would you fundamentally disagree with that view?
(Ms Amadi) I would tend to say that I would like to
see that be tested and the results evaluated.
471. The phrase came up a couple of times earlier
about the "public health nurse". Could any of you define
what you mean by "public health nurse" and how that
differs from a health visitor?
(Professor Drinkwater) Essentially that came in the
paper around Newcastle West's Primary Care Group where we have
a public health nurse within the patch who is, by training, an
occupational health nurse. She comes by a somewhat different route
and that has some interest and advantages in terms of helping
to retain people in jobs, looking at long-term sickness absence
and a whole bundle of issues around employment. In terms of a
more generic role at the level of PCG/PCT there is an issue. The
housing bit is quite a good example in that at the moment you
have across the patch health visitors or GPs each writing notes
on patients' behalf looking at housing.
(Professor Drinkwater) If they can be persuaded. The
bottom line is that that system does not work. It is a crazy system.
Where we have moved that to in Newcastle is there is now a nurse
within the housing department who is funded through the PCGs.
To an extent it is about how do you put in place systems that
support individuals rather than leave it all to individuals, and
I think that is the role of the public health nurse within the
patch. The individual health visitors cannot do it on their own.
They have to operate within a system that is agreed by the primary
care group or trust and somebody has to be responsible for ensuring
that that is delivered and that is why you need somebody who takes
a lead. It is a lead role in terms of the public health agenda
within the PCG and the PCT. I think that is then all about using
health visitors and the knowledge of health visitors and community
nurses around needs assessment and what is going on within their
patch. Community nurses visit a lot of old people at home. Very
often they live in damp, sub-standard housing which is cold and
poorly insulated. It would not be beyond the wit of man to say
why do they not take in a thermometer with them which they stick
on the wall and as part of what they do in terms of nursing assessment,
they could record the temperature and humidity within the house
if it is damp and then refer it on to the housing department.
That is not going to work unless you put it within a system and
make it everybody's responsibility in which case somebody has
to collect the data and ensure that is being done systematically.
473. I wanted to pick up a point. You were talking
about GPs writing letters to housing departments to help on housing.
Would you not agree, though, that that system is in a large proportion
of cases totally discredited because the housing departments tend
to look at them as pro forma letters and disregard them because
due to the pressures of work on GPs they will write those letters
to get the person out of the surgery. It is a ludicrous situation.
(Professor Drinkwater) I entirely agree, they are
totally owe discredited and not worth the paper they are written
474. But GPs still find their arms twisted up
their backs by patients and it is easier to send a letter than
put your foot down and say
(Professor Drinkwater) That is why you need a system
that is agreed across the patch and there must be a route and
a signpost in terms of how that operates.
Chairman: MPs have not dissimilar practices
in my opinion.
Mr Burns: Speak for yourself, Chairman. You
are a braver man than I am!
John Austin: I do not want to suggest that there
was once upon a time a golden age of pre-1974 local government,
but in my local authority we had in the health and welfare department
an army of health visitorsperhaps a little army of health
visitorsand some of them were specialist health visitors
who were only working with the elderly. Increasingly health visiting
is seen almost exclusively in my area as being concerned with
young children and that may be the right decision. When the health
visitors were within the health authority it is my view that there
was a much more co-ordinated approach in terms of relationships
with housing. I was interested to hear you say you have a nurse
within the housing team.
Chairman: Is it not tokenistic compared to what
we had pre-1974, which was basically the local authority anyway?
We are gradually going back to pre-1974, this golden age that
John and I remember!
475. It does strike me that we do now have this
fragmentation, whether we are looking at the planning process,
community plans, or HImPS not coming together, or whether it is
where people work and how it is structured.
(Professor Drinkwater) I agree for all sorts of reasons
that there has been fragmentation not least around health visitors,
and why they are focused around children is there is a whole bundle
of agendas around child protection and risk and issues to do with
community trusts having to focus health advisers in that area.
How we move away from that and begin to take a broader view and
look at more effective systems, I do not know. I do not think
we are going to go back to re-inventing pre-1974 local authorities
but the next best thing might be primary care trusts where there
is real partnership with local authorities.
(Dr Heath) Can I support the point that Chris making
about skill-mix. I often think it is good to use a real example
where the system is not working. In my particular practice we
are seeing an exponential growth in the number of young families
where one or both parents either have a psychotic mental illness
or have a serious drug problem and you just see these children
going down the pan and there is no way to salvage these families
at the moment. Maybe it is Families First sort of initiatives
but our practice used to have six health visitors one of whom
specialised in the elderly and it now has one just out of training.
There is no way that she can offer any sort of agenda let alone
the public health agenda. Meanwhile, the universal service is
failing the most vulnerable part of the next generation. I think
that sort of example is a good test of what needs to be in place
and what is not in place.
476. You raise an issue there about the supply
of qualified health visitors and I think perhaps the Committee
does need to take some evidence in looking at nursing shortages
to identify the particular position with health visitors. Even
if you were adequately staffed with your health visitors
(Dr Heath) They have said we do not need them.
477. Who is "they"?
(Dr Heath) The community trust.
Chairman: They allocate the numbers within your
area and you do not need them according to the community trust?
478. If you had available to you the number
of health visitors you felt you needed to operate reasonably,
there is still this conflict, is there not, between the universal
role of the health visitor and the issue that you are raising
(Dr Heath) Yes.
479. Even if we had more resources there would
still be an issue as to whether the resources would be adequate.
(Dr Heath) Yes, and I think, reiterating what Chris
said earlier, we are never going to do anything about health inequalities
unless we target in a very systematic way. Yes, you have to ensure
a certain minimum level of provision for everybody but after that
you have got to target the people with the greatest problems.