THURSDAY 23 NOVEMBER 2000

DR PETER DONNELLY, DR ROSEMARY GELLER, PROFESSOR JAMES MCEWEN, PROFESSOR SIAN GRIFFITHS, MR JOHN NICHOLSON and MR GEOF RAYNER

  240. The second bit?
  (Dr Donnelly) The second bit, I do not pretend it is easy to come up with a fair set of measurements which would allow you to judge the performance of the public health system in an area but there are a bundle of measures that you can begin to put together which are focused on outputs rather than inputs which do look at things which predicate ill-health in the future, like smoking rates, like diet, like exercise rates, and that would be a start. I think the premise you should move from inputs to outcomes is absolutely right.

  241. Can I pick up on that because we used to have about 22 national targets and they were contracted to four. When we challenged the then Secretary of State he said of course there will be very strict local targets and those targets will be published and they will be aggregated so we can still see how we do nationally. We have not seen any of that since he made the announcement. I have asked questions and been told "they are still in the process". Now I am very surprised to hear Dr Donnelly say that your local targets are not even validated by your reviews. How far up the line do you think they get? If the region is not interested, how can the Secretary of State give an answer about what is happening nationally on some of these issues?
  (Dr Donnelly) The picture is not the same all around the UK. The Association of DPH is a UK organisation, so that may explain why we can see it is not the same around the UK. In Wales, when I worked there, the Director of Public Health always went to the annual review. The first item on the annual review meeting was the health status of the population for which that health authority was responsible. During a three hour review that would take on average the first hour of that three hour review. It was very skewed towards health rather than simply health care. In Scotland the position is somewhat similar, but in many English regions the DPHs do not even routinely attend the annual review. The health status of the population is not universally something which is discussed at those annual reviews which instead tend to focus upon input measures relating to health service rather than health. That was the point I was trying to make.

  242. Before I bring in Eileen, who wants to pursue a different direction slightly, can I come back to you on the point you made about politicians which I thought was a very fair point. I would seek your indulgence on the problems we as politicians have when we face the electorate. If I went out in May or whenever with a pledge about smoking, about reduction in suicides, about the various other targets we have got nationally, and what we will have in 20 years' time, I do not think it would mean a lot to a lot of people. I think you probably understand the point I am making. I certainly do not defend slimming down such hugely complex issues into waiting lists etc, but we all understand that is sadly the nature of modern politics. It is not just my party, it is the other parties which are slimming down their pledges to half a dozen and it over-simplifies some complex issues. How do you see politicians, perhaps, with the reality of politics, the reality of going out and talking to people about voting for us, what we will do, bringing about the kind of debate that you want to see of a more responsible attitude to health, to broadening health out beyond simply a new hospital or a new this or a new that to the real issues in health in a way that clearly you want to see? How can that happen? How can we bring it about?
  (Dr Donnelly) I have very considerable sympathy. Having been an elected politician myself I have got considerable sympathy with what you are saying. The first point to make is that, in fact, there are places in the world where elections are won or lost on the basis of health rather than health care. It is not in this country.

  243. Yes.
  (Dr Donnelly) It happened last month in the Western Cape in South Africa where the principal issue in the election was actually around HIV and Aids. The first thing to say would be, in a sense, thank God we do not have such hugely overwhelming public health problems that elections in this country are fought and won and lost on the basis purely of an overwhelming public health problem. That is the first thing to say. The second thing to say is just as we cannot do it on our own, and that is the point I was making earlier, I actually do not think you as elected representatives can do it on your own. It is something which is going to have to happen over a protracted period of time and it simply is about chipping away all the time with the public and with the media, convincing them that health is about a lot more than medicine and that health is about a lot more than health care provision. The single most important thing that in my personal view we have got to achieve is that we have to start returning to individuals some kind of feeling of autonomy over their own health. The feeling that, yes, there are all sorts of things which we can effect which happen to us which affect our health but this idea that medicine will always have the magic cure, the magic bullet, the potion for every ill, is ultimately not sustainable. You have to try and encourage people to take responsibility for their own health.

  244. Some people, certainly looking at communities in my area, do not feel empowered in any way.
  (Dr Donnelly) Sure.

  245. The example we saw in Cornwall was an estate where people had become empowered, people who were not empowered had become empowered. How we ensure that kind of model is applied elsewhere is a difficult task for this Committee. I do not see it coming through in some very learned reports I have seen from Directors of Public Health. We have a lot of answers but we have not got the answer to how you can empower those people, people who are not medically qualified or qualified in any way, uneducated power but who have been engaged in the process of change in the way that I think us, as politicians, certainly speaking for myself, I was very surprised to see and encouraged to have seen.
  (Dr Geller) Just a very brief point to add to that. I think one starting point would be to convert the public health language which has a jargon of its own and can be a bit sort of ethereal into some sound bites that you can sell to your electorate.

  246. Six words.
  (Professor McEwen) Going back to the question of targets, the national targets are, of course, of some value but they are often seen as meaningless at a local level. I think this is where you can take the project like the Cornwall one and you can look at outcomes, you can see what has been achieved. Hazel Stuteley has identified her various parameters in evidence. I think this is the sort of thing, if we can actually get locally owned and devised targets that is much more relevant.

  247. Can I just stop you there and ask are you all medically qualified?
  (Dr Geller) Yes.

  248. Several doctors and two who are not medically qualified. One of the interesting points that appealed to me in that particular project, obviously you are familiar with it, was there were no doctors anywhere near it.
  (Professor McEwen) I do not think any of us who are doctors would be worried by that.

  249. Or even surprised.
  (Professor McEwen) Possibly surprised.
  (Professor Griffiths) Does that not go back to the whole emphasis on communities, community development, things like area forums which are being set up and the whole way of engaging communities in these issues which is not a medical model and it is about health, it is about what other people do.

  Chairman: We are dominated by doctors on this Committee, that is my problem.

  Dr Brand: It is the social workers who create the difficulties.

  250. I just wanted to ask you actually about your own joined up working and thinking, perhaps if I could ask Mr Rayner and Mr Nicholson. As you said, your own organisation is very new. Can I just ask what was the imperative to form your Association? What are your aims? How do you see yourself within the spectrum of public health bodies, including the two other organisations here this morning?
  (Mr Rayner) There are about three or four points in that question but I will start off by answering the last question in a sense because it leads to it. The problem is that opinion polls say that health is people's number one social concern, continually shows that. Yet we have a million and a quarter members in the Royal Society for the Protection of Birds, we do not have any analogous activity for protecting people's health. We actually put our faith in a particular model of the world which is we go to see a doctor and the media is obsessed about waiting lists. How do we change that position to a different position which we are all here, I think, talking about, which is health at a wider terrain. It is about our environment, it is about our housing, it is about what we eat, it is about the food we choose. To come to the answer about what our job is, our job is actually to have that sort of vision but to sign up not just professions, not just organisations, local authorities, health authorities, people in the street and so on, to act on the wider issue of health and actually to think of practical ways for carrying it out and for them to join in and create a movement. We have a consumer movement, we have an environmental movement, but actually we have had a very, very weak public health movement. Our job is stimulate that kind of movement and lever in professions, individuals, ministers of religion, whatever, politicians, to take a role in that movement. We are an organisation of individuals and organisations with that point.

  251. Do you think it would be desirable to have a single voice, just as we are talking about working across multi-agencies, if you had a single voice?
  (Mr Rayner) Our logo is the voice of the public health movement. It is not a voice of professions, we are different professional groups and we welcome professional groups being part of that picture. It is a voice of a movement trying to establish a new basis for thinking about public health.
  (Professor McEwen) We would very much support this. A number of our organisations, and there are more than are represented here today, have arisen for different purposes. Our Faculty has had a special responsibility over many years for standards in education and training in professionalism in public health, originally in public health medicine, increasingly moving over to the wider public health responsibilities. But, we recognise that we have limitations in our organisation and we collaborate very closely with UKPHA, for example, on policy where they are better geared than we are. It is ridiculous to have two networks doing two things less efficiently so we work very closely. We are individual and collective members of UKPHA and obviously the same links apply with the Directors of Public Health. I think, of course, we would want to see a co-ordinated voice in many things and we are moving in that direction increasingly. I think at the moment it is saying "We have different tasks, we will collaborate to ensure that there is a co-ordinated voice on policy". We would not want to put out two different statements on some policy issue between us, we will do it jointly.

  252. Dr Donnelly, do you want to contribute anything?
  (Dr Donnelly) Yes. I think the point is that there is a very considerable cross membership. Like many, many people I am a member of all three organisations which are sitting along this table. The organisations were created for slightly different purposes and that is why there are three organisations. There is no turf war.

  253. Dr Donnelly, in answer to one of the questions from the Chairman you made what I thought was an extremely interesting but also very important point which was that you believed there should be more autonomy to the individual for their health care. I do think that is very important. I was wondering if you could briefly elaborate a little more on exactly how you saw that moving forward and how as a Committee we might be able to help aid and abet that process?
  (Dr Donnelly) I am happy to do so. The point I was making was that I think over the last few decades in developed countries medicine has been seen as synonymous with health and within medicine high tech medical care has come to be seen as some desirable end point. People have falsely come to believe that whatever befalls you there will always be, ultimately, a high tech cure for the ailment from which you suffer. There are, therefore, whole groups of people who for different reasons feel disempowered. There is a group of people in society who feel disempowered because they have had life experiences and live in areas where they do not feel they have a lot of opportunity. They, therefore, understandably, find it very difficult to take personal responsibility for their own health. If you are a single mum living in one of our run down areas of Edinburgh you really do not need me banging on the door telling you to stop smoking. Whether they smoke or not is one of the very few things in life over which they exercise autonomy.

  254. You are preaching to the converted here.
  (Dr Donnelly) Well, no, with respect, it is not the converted, I am trying to point out—

  255. No, I am talking about us, I am talking about in terms of smoking, Mr Burns. Forgive me for intervening.
  (Dr Donnelly) There are two different groups of people who are disempowered. There are these groups of people who are marginalised in society who feel disempowered because of the reasons that we were talking about earlier. There is also a group of people who actually, bizarrely, are disempowered because they have given up on looking after themselves. They have all the social skills they need to do it, they have the opportunity financially and other ways to do it but they have given up on doing it because they have come to see that as something which is ceded entirely to the medical profession. Very quickly, one very good example is to take something which is in secondary prevention rather than in primary prevention. Following a heart attack the model in this country is that you will get a high tech intervention if you require it, in terms of coronary artery bypass grafting and some other high tech stenting procedure. You may or may not get a very simple but proven and effective intervention of cardiac rehabilitation. If you do get it, it will be very, very medicalised. It will be supervised by doctors, nurses and physiotherapists. Go elsewhere in the world and I can point, for example in Australia, to very effective cardiac rehabilitation programmes which are run by staff who work in local leisure centres, quite safely, very effectively, very cheaply. This is what I mean about people at both ends of the spectrum actually feeling disempowered by this kind of obsessive view that clinical medicine has the solution to everything because it does not. People have to start taking responsibility for their own health.

  Mr Austin: That is a good lead in. Yesterday we did visit a centre in the East End where there was a great deal of emphasis on leisure and exercise and other aspects. What I want to say, as a balance to the medical presence on the Committee, as part of the social work—

  Chairman: A minority.

  256. We have been talking about empowerment. All the evidence we have been getting suggests that people's sense of control of their own lives is a determinant of health. We are talking about empowerment. I would like to add for the record that there was talk of that in the late 1960s and 1970s. Dennis Howell when he was the Minister for Youth and Sport located in the Department of Education did commission a report about community development, the Wilson-Fairburn Report, which the incoming Secretary of State for Education, Mrs Thatcher, put in the waste paperbin. It seems we are now talking again about the developments of community development empowerment but coming at it from a different angle from health. I would just like to ask whether you feel, any of you, that perhaps public health doctors may be a barrier to empowerment? What we may need is more development workers, lay health advocates, workers, on the ground level working with the community and acting as a link with the services which the NHS provides?
  (Professor Griffiths) Can I just pick up on that. I would just like to reflect on the healthy living centre programme which is currently being developed which again demonstrates the need for partnership. I do not think it is either/or at any of these levels, it is about individuals feeling empowered by the circumstances in which they live and the money which they have available to them to make a difference and then having people play the right role at the right level. I think that public health doctors are the wrong people to be doing community development, they are the right people to help get the bid through at a strategic level. It is about the right skills at the right point. The other key role for public health professionals may be evaluation of the impact of community development. If we are going to do that we have to see it at that spectrum and see community development as important within health authorities. I think it is about actually thinking about health in the round within the health sector, just as you need local government to think about health. Every local government organisation has been organised differently but health is a responsibility, both at local government and health authority level, you have people working in the community on behalf of both sides. It is about seeing the right skills at the right place with some concept of co-ordination within that population, which is appropriate to that population, particularly if you have black and ethnic minority groups making sure that you do not have any language barriers. I would not say it was public health doctors that are the barrier, I think there are many other things about the social structure in which people live which are the proper barriers to that health. It is about how we all work together at our appropriate level to address that. Public health doctors think outside their medical box.
  (Mr Nicholson) I think I would back that up because I think it is not just about individual autonomy, it is also about community autonomy. It is trying to bring that concept back into the thinking. Secondly, if I could say, I think there is a danger though in thinking that, in a sense, health visitors can do everything. In order to correct the model that is the domination of doctors, which seems to have been the language of the last few contributions, there is a danger in thinking that people with different skills can then do all the other things. It is the right skills in the right place at the right time. I think what we have seen on community projects is that people can make significant contributions to health who have not necessarily got medical qualifications. Equally, at the other end of the spectrum, training is not valueless, there are skills within medicine and within other disciplines which we need to incorporate. That combination should not mean competition, it should not mean a value judgment which says one is a better person than another or vice versa, it has to be a combination of those skills.
  (Dr Geller) I just want to add a few points. I think we need both. I think we need public health doctors and other public health professionals, that is one point. Maybe from all the discussions we have been having this morning there may be a misunderstanding of what public health medicine is in the training we have. Although we start off at the beginning as pure doctors, the actual training that we have is in all these other models. We do use the medical model when we need to and when it is appropriate, particularly when dealing with our medical colleagues on NHS issues. We also have access to a lot of other models and training. Although we do not do, for instance, extremely detailed training on community development or whatever, we understand what it is, we understand how it works and we understand its value. I think public health doctors do bring a wide range of skills, as well as their medical skills. I have not met many, I have not met any, in fact, who think in a medical model for the majority of their working day.

  257. Can I just go back, Chairman, to Mr Nicholson's point. I share his view that you cannot just address a problem by throwing a health visitor at it. I take the view that health visitors have a crucial role to play.
  (Mr Nicholson) Yes.

  258. I think we have seen a number of projects where the health visitor has been the key driver in the community empowerment that has been going on.
  (Mr Nicholson) Yes.

  259. Do you think, however, that we do use generally our health visitors most effectively?
  (Professor Griffiths) No.