THURSDAY 23 NOVEMBER 2000

MS YVE BUCKLAND, PROFESSOR RICHARD PARISH, MR ANTONY MORGAN and MS PATTI WHITE

  300. You have divided it into three areas, roughly how many more staff would we be talking about?
  (Professor Parish) Could I put it into financial terms because that is the way I have actually done the calculation, although I am very conscious of my miscalculation earlier on. I think we are hoping that we would have a resource of something in the order of £20 million, of which about one and three-quarter million is needed to provide the extra resource at the centre in terms of the additional staff. The balance would be used partly to pump prime and support local initiatives, to translate the evidence into practice, and partly to commission the research that would be needed to fill in the gaps in the evidence base. In all probability we would not do the research ourselves, in the main we would commission others to do the research for us.

  301. You have got a cross-government role and you are committed to working with local government and the voluntary sector as well as the NHS. Yet you are firmly branded as an NHS organisation, and largely funded by the Department of Health. Does this pose a problem for you in the public's perception or the perception outside the NHS?
  (Ms Buckland) The short answer is no, it has not. When it was first proposed we did ourselves raise some concerns about whether it might be a problem given that this is about a multi-disciplinary approach and the Health Development Agency does have a multi-disciplinary focus. The argument was put to us squarely that people are constantly saying the NHS is not interested in public health and that a new public health agency should wear the brand NHS. I think that was a fairly compelling argument and, if anything, it has helped with our partnerships. I think there is a difference between the HDA and the HEA. The HEA was aiming its campaigns at the public and had done a lot of research to show that the public trusted the HEA brand image and it may not have been enhanced by an NHS image, but the HDA has a different remit.

  302. Do you want to say anything, Professor Parish?
  (Professor Parish) No, I always agree absolutely with my Chair.

  303. Contrasting HDA and HEA, Mr Amess mentioned things that were in your Business Plan but could I mention something that is not and that is Health Promotion England, which was incorporated into the work of the HEA. We know that the Minister has said that we should get away from nannyish nagging, but if the HDA is not doing that public education campaigning because it is too nagging or nannyish, or because it has not proven effective, what is going to be done instead? Who should take the responsibility for bringing about changes in behaviour and lifestyle, especially amongst the communities which are socially excluded and disadvantaged?
  (Ms Buckland) If I can start. I think you probably need to put the question to Health Promotion England about their role and remit. We have retained close links but they are a separate body. The general point, and the point that sits in my mind about some of the earlier questions about how does all this evidence get into practice, is the stark reality is the lives of people on some of the outer estates for whom, as Sir Michael Marmot was saying the other day, smoking is their only pleasure. Who is going to do those sorts of campaigns? It is now accepted there is an overall model and there needs to be a national framework and national campaigns to raise awareness but those need to be backed up with a whole set of interventions, including locally targeted campaigns. The role of the Health Development Agency will not be to do those campaigns but to provide the evidence base for those doing them in terms of what is effective and to help evaluate certainly at national and regional level the effectiveness of the campaigns.

  304. Does that mean that the HDA becomes just a monitoring and evaluation body and is not really developing anything?
  (Ms Buckland) No. In evaluating the effectiveness of the campaign we will be looking at why it worked or did not, what the skills issues might have been, the knowledge, the access to evidence. That is part of our development role. Then we might be working with people at the local level to look at how they might develop those skills. What we will not be doing is the campaigns. It is now absolutely apparent that if we had been doing public education campaigns like the HEA, if we had kept those as part of the HDA remit, there could have been a real conflict of interest if we had to comment on the effectiveness of the campaigns when we were also trying to do them ourselves.
  (Professor Parish) The other point I would just add, if I may, is that mass media public education campaigns by themselves are not particularly effective at changing a complex health related lifestyle. They can be effective where one is dealing with what is sometimes referred to as single action health behaviour with things like immunisation programmes, but not specifically when one comes to the more complex aspects of health related behaviour. The HDA's role is, in a sense, not only to provide the evidence and perhaps the evaluation for the public education initiatives but to actually provide all of the other on the ground support that is needed to ensure that we get the best return for the investment in the public education activity.

  305. Can I go back to the point that was made by Peter Donnelly in the previous session. You heard the dialogue we had about politicians and how we can move beyond targets and waiting lists to realistically look at what health is all about. I wonder what your thoughts are on how we can generate a wider debate about the whole issue of public health? It struck me, and I mentioned to my Clerk a moment ago, that normally within our Committee meetings we may have television, we have radio regularly, but today there is no television or radio and there is no press presence because public health is not a sexy issue. How do we make it a sexy issue in a way that will ensure that we politicians have public health issues raised with us and that we respond in a meaningful way rather than having limited pledges that, frankly, do not mean a great deal? It is a fairly wide ranging question, I appreciate that, but I am sure it is something you have thought about.
  (Professor Parish) Indeed it is and, in a sense, it is closely related to the previous question as well. The main effect quite often of public education campaigns is not to directly bring about a change in health related behaviour but to create a climate of opinion within which politicians are more likely to stand up and indicate their support, within which one is more likely to achieve the sort of organisational change on the ground that one might be looking for. There are some very good examples in Europe going back some way, particularly in the areas of heart disease prevention and heart health initiatives. If I go back to the early 1970s in Finland, for example, at that point in time Finland had the highest heart disease incidence in the whole of Europe. Some of the public health activists made this publicly known, making use of the mass media, and politicians then felt more inclined to pick it up as a political issue and it led to, at that point in time, what became the world's leading heart disease prevention initiative. Within the UK there was a similar situation and I was directly involved myself in the 1980s with what was called the Heartbeat Wales Programme. There we ended up with a huge amount of publicity. The omnibus surveys that we carried out indicated that 97 per cent of the population knew what the Heartbeat Wales Programme was about and what it stood for, and as a consequence this was an issue that politicians from all parties felt most inclined to support. I think there is an issue here for the public health movement as well and I think I am supporting the earlier statements. Part of our responsibility is to provide politicians with the necessary information and advice to help create that climate of opinion within which it is more likely, if I may say so, that you will feel more inclined to stake your colours to the mast.
  (Ms Buckland) Can I just come at this from the other end, so to speak. I know your background is local government and so is mine. It is not difficult for a politician to go out and get worked up and be concerned about housing, education, transport, leisure and employment, and some of the inequity that might exist at the local levels. Think about how Hazel Stuteley got people to engage on the Beacon Estate. It was not actually to engage about improving their health, it was because of crime, drugs and their concerns locally about children's educational attainment. I think we need to create a better understanding of the links between public health and those wider determinants, both within local authorities and in health authorities. Those are big political issues.

  306. The message we have had so far, and certainly last week's session was very significant in terms of the message we got, is that it is about the redistribution of wealth. I am not so sure that we have got every political party on board on that one at this stage. I wonder how we move on to relating fiscal policies to health policies in a way that is not happening at the present time? Clearly you have got a key role to play in this area in ensuring that politicians are informed on the key policy determinants that will impact on public health. Are you optimistic, as our witnesses last week were optimistic, that the current Government is moving, moving rather slowly but generally in the right direction, in respect of the bigger picture?
  (Ms Buckland) I can only echo the point that Donald Acheson made last week and he has made elsewhere, that he sees a gradual but increasing shift in terms of some of those big fiscal issues. The HDA will have a role in informing on those macro policy, macro fiscal issues and looking in the longer term at effectiveness. I think the other important point, and perhaps where less is going on, is looking at the local strategies, local strategies for economic and social development, and the impact that they are having on public health. Certainly perhaps, within our first few years we see ourselves having a role alongside local authorities and working at the local and regional levels and looking at how we might get a better public health output from the monies that are going in there.
  (Professor Parish) I think if I might just add to that. One of the things that, of course, we frequently tend to do in the public health field is we talk about the need to invest across the broad range of policy areas to improve health. The converse is also true in that if you improve health you improve, for example, educational attainment. Health is also an economic resource and there is quite a bit of evidence around to demonstrate improvements in productivity. When I worked in Wales, because the work we were doing in the health field turned out to be very good for Welsh agriculture, I found myself a member of the Meat and Livestock Commission for Wales. I think we need to just point out that there are these benefits working in the other direction and, as Yve was quite rightly saying, sometimes these are actually more attractive from a politician's point of view.

  307. I am very interested in your Business Plan. You have got two sections talking about target setting, one is advice to HImPs and setting local inequalities targets and the other one is a report on local indicators which could be used for performance management. Is your role going to be to identify those targets? Will you also have a role in making sure that outcomes as a result of targets are evaluated? I am not sure whether you were in the room when Dr Donnelly gave his evidence but it is really quite frightening that there are some English regions that do not take the slightest interest in the wider public health of their regions or districts within their regions.
  (Professor Parish) Would it be helpful if I kicked off and maybe, Antony, if you fill in any gaps in what I have to say. If I can just endorse the view that one needs to build these issues into the performance management and accountability frameworks. At the end of the day if one does do that then it does not actually feature as a top priority. When it comes to target setting, our role will be to advise on the types of targets that might be set, to advise on the processes and the mechanisms for target setting, but those targets will have to reflect local circumstances and local needs. Apart from anything else, the base line against which one measures progress towards a target will vary from one part of the country to another.

  308. I accept that, that is why we accepted the move away from national targets in some areas to local targets. One can have such a flexible system that nobody knows what the targets are and what the trend towards the target is, which I think is the current state of affairs, that we really do not have access in an easy way to what is happening in areas of responsibility of the Secretary of State for Health because the data is just not available in a form that we can look at.
  (Professor Parish) I think our role will be very much in helping people to set those targets, defining the sorts of measurement arrangement that one might put in place and to ensure that targets are actually included in the local Health Improvement Programme Plans. We have had a role at the HDA in assessing the first year of HImPs. We hope and expect that we will be in a position to review the second wave of three year rolling Health Improvement Programmes and one of the things that we would no doubt want to do would be to comment on whether or not appropriate targets are being set that are capable of being measured locally to inform the whole process of performance management and accountability.

  309. Will you have a regular reporting system on this? Will this be in the annual report or will you be producing a HImP progress report on the targets?
  (Professor Parish) We have done that for the first year already. We have produced a report on the first year HImPs and that has been made very widely available. It was published about five or six weeks ago. I have no doubt that we would expect to do the same on a roughly annual basis.
  (Ms Buckland) Could I just add a point there which is a very personal view and I think it echoes some of the points Peter Donnelly was making. I think it would be wrong to have a separate monitoring mechanism around public health and health inequalities. I think the key here is to get those targets mainstreamed into the main performance measurement, performance assessment frameworks that are being put into place at the local level. It picks up the point about local authority chief executives will not really take these things seriously unless they are targets which are clearly within their performance assessment frameworks, and the same within local authorities. One of the things that we have been working very actively with the Audit Commission and the Improvement and Development Agency and the Commission for Health Improvement on is to look at the opportunities for mainstreaming these kinds of targets into performance assessment frameworks at the local level.

  310. But who will be monitoring the activity of the mainstream? I am surprised that there clearly is not a monitoring mechanism for regions because otherwise this would be picked up if they do not do much about the local targets. Will that be your role or will that be the role of the NHS Executive?
  (Ms Buckland) If you look at Audit Commission targets at the moment, they are produced locally and they are published nationally.

  311. With all due respect, the Audit Commission is a post event and they are not part of the management of the Health Service. They are very helpful but one would hope that the management of the Health Service would be aware of the problems before the Audit Commission gets to them. If we are going to rely on the Audit Commission to do our target monitoring, I think we are lacking in management somehow.
  (Ms Buckland) The point I am trying to make is if we end up with a separate set of targets that are monitored by a body in London and they are not part of the mainstream, I am not sure they are going to be taken that seriously because of the pressure of priorities at the local level.

  312. Whose responsibility is it to make sure that targets, no matter where they are set or who they are set by, are actually monitored?
  (Ms Buckland) It is no one person's responsibility, is it? There would be responsibilities within the health authority, at regional level and at national level.

  313. Clearly the responsibility eventually is at national level.
  (Ms Buckland) Yes, but equally—

  314. Who at national level is responsible, other than the Secretary of State, of course, who is responsible for the weather and everything else? Which agency at national level acts on behalf of the Secretary of State? Is it you?
  (Ms Buckland) It certainly would not be part of our role. There is a suggestion for a Health Surveillance Monitoring Unit in the National Plan which may indeed take this role on in terms of national monitoring. At the moment I presume it is the Department of Health.

  315. So we have got a system where you are responsible for the targets actually being set, or you can influence. I am sure you report on measurable indicators or you advise on them, that could be nothing or everything, these are very weaselly words. You do not take responsibility for them but you will report on them, you will advise on them. At the end of the day who can I go to and say "what is happening there?"?
  (Professor Parish) I think the key role in all of this will actually be the regional offices and the performance management arrangements that they have in place. The trick that we have not been able to achieve thus far is that we have never made it a priority within what are fairly robust performance management arrangements already in existence within the NHS. There will be other mechanisms increasingly through local authorities, but if I stick to the NHS for a moment, I think it will be the ROs—the regional offices—that have that key role and we have got to make sure that public health targets form a priority in that performance management arrangement.

  316. In every other sphere of health performance indicators the regional offices do not actually set the targets, the targets tend to be national targets influenced by regional and local events. They are a mechanism through which targets are disseminated and checked on, but that is not what we are talking about here, we are talking about the strategic input in actually what the targets ought to be.
  (Professor Parish) I was not suggesting that the ROs would set the target.

  317. So who does?
  (Professor Parish) I think the targets should be set locally by those involved in planning the Health Improvement Programmes.

  318. But surely someone is either approving or disapproving of the targets? As Frank Dobson said, these local targets are not just going to be soft and woolly ones, they are going to be hard and firm. Someone has to evaluate whether they are hard and firm.
  (Professor Parish) I am sure that is the case but—

  319. Who does that?
  (Professor Parish) There are several vehicles for doing this. I am sorry if it sounds a little bit vague and woolly. Part of the role of the HDA is to provide advice to those working locally about the appropriate monitoring and evaluation mechanisms that can be employed. They will no doubt then be assessed by the regional offices to see whether or not they have applied the guidelines that have been produced nationally by organisations like the HDA. Just to try to make this as clear as I can, and it is an evolving science and I suppose to a certain extent art as well, the targets would be set locally by people aware of local circumstances informed by an understanding of local characteristics, service provision, etc. They would then be expected to apply the appropriate monitoring and evaluation mechanisms and the HDA—