1.  EXECUTIVE SUMMARY

  1.1  Gateshead Council is set in the bustling conurbation of Tyneside and provides a comprehensive range of services to a population of 200,000. Gateshead is one of the five local authorities delivering the Tyne and Wear Health Action Zone in alliance with local health services and the voluntary sector.

  1.2  This submission will focus on the Council's experience of the Health Action Zone, the development of the Health Improvement Programme and local partnership working.

  1.3  The most important organisational achievement under the Health Action Zone has been the establishment of multi-agency Local Health Partnerships in each of the local authority areas. The Gateshead Health Partnership sees its main role as facilitating joint working between all of the agencies and ensuring a focus on the needs and views of local people. There is a genuine commitment to change and the need for a more client focused approach working across organisational boundaries. This level of co-operation is now embedded and will be sustained beyond the life of the Health Action Zone.

  1.4  Substantial work has been undertaken to try to ensure the Health Improvement Programme develops into a comprehensive planning process for the whole spectrum of health, from prevention through to rehabilitation. The White Paper Saving Lives: Our Healthier Nation recognised the broad socio-economic and environmental determinants of health, many of which local authorities are best placed to influence. It therefore appears more appropriate for local authorities to have the lead role in developing the Health Improvement Programme in line with their new role of Community Planning.

  1.5  The Council has led in the creation of a Strategic Partnership for Gateshead to oversee the preparation of the Community Plan. The Gateshead Health Partnership is represented in the strategic partnership at a very senior level reflecting the importance of health and the need to integrate the objectives of the Health Improvement Programme with the community plan.

  1.6  It is recommended that the structure and membership of PCG and PCT boards be reviewed. The review should aim to minimise the pressure on local GPs and give increased accountability through the appointment of locally elected Councillors to Governing and Executive Boards.

  1.7  It is recommended that clear national guidance be produced on the respective roles and responsibilities of the Director of Public Health and the Consultant in Communicable Disease Control/Proper Officer. In particular this should cover the support they give to local government in carrying out their public health functions.

2.  INTRODUCTION

  2.1  Gateshead Metropolitan Borough Council is set in the bustling conurbation of Tyneside, stretching almost 13 miles along the south bank of the River Tyne and covering an area of 55 square miles. The Council provides a comprehensive range of services to a population of 200,000. Gateshead is a mix of urban, busy commercial and industrial and rural areas.

  2.2  The local health authority covers Gateshead and the neighbouring South Tyneside borough. Within Gateshead there is one acute Health Care Trust and two "Level Two" Primary Care Groups which are coterminous with the borough boundaries.

  2.3  Gateshead is one of the five local authorities delivering the Tyne and Wear Health Action Zone in alliance with local health services and the voluntary sector. This is a first wave HAZ with a focus on reducing health inequalities and modernising services around the issues of cancer, mental health, heart disease and children and young people.

  2.4  This submission will focus on the Council's experience of a Health Action Zone, the development of the Health Improvement Programme and local partnership working.

  2.5  Gateshead is home to one of Europe's largest out-of-town retail and leisure complexes, the MetroCentre, which attracts millions of visitors from this country and overseas. The riverside south of the Tyne Bridge is being transformed into the Gateshead Quays, a major leisure and cultural area. Major new attractions now being built on Gateshead Quays include the Gateshead Millennium Bridge (open early 2001), a striking and innovative opening foot and cycle bridge which will link Gateshead Quays to Newcastle's Quayside. This will provide access to the Baltic Centre for Contemporary Art (open Autumn 2001), Britain's newest national gallery and the largest displaying contemporary art outside London. The Music Centre Gateshead (opening in 2002) is a new concert hall and music complex which will stage performances catering for all musical tastes.

3.  THE INTER-OPERATION OF HEALTH ACTION ZONES, HEALTHY LIVING CENTRES, HEALTH IMPROVEMENT PROGRAMMES AND COMMUNITY PLANS

  3.1  Tyne and Wear has a history of coal mining, ship building and heavy industry and a legacy from their decline. Unemployment is higher than average and many people in work are on a low income. The population is slowly declining and there is an increasing percentage of older people. Against this, the area has seen massive investment in regeneration, culture and the arts. Local employment opportunities have diversified, there is a vibrant social scene and a strong sense of identity.

  3.2  The Tyne and Wear bid "A Fair Chance in Life" was one of the first 11 successful Health Action Zones to be announced in March 1998. The opportunities presented by the Health Action Zone to make a real difference to inequalities in health and access to services in an area of real health need fired tremendous enthusiasm to make a difference.

  3.3  The greatest organisational challenge faced by the Tyne and Wear Health Action Zone was its complexity. The bid was made on behalf of three health authorities, five local authorities, and 10 NHS trusts. In total more than 100 organisations were involved in its production. This was against a legacy of fragmentation caused by the NHS internal market and a history of competition between authorities in bidding rounds for additional funds.

  3.4  The most important organisational achievement under the Health Action Zone has been the establishment of Local Health Partnerships in each of the local authority areas. In Gateshead this brought together elected Councillors, Chairmen and Non-Executive Directors of the Health Authority, Trust and PCGs; the police and representatives of the local minority ethnic communities, business and voluntary sector. This Partnership has given high-level, visible leadership to all agencies in seeking to work closer together in improving the health of the people of Gateshead. The Partnership has the role of approving all expenditure under the Health Action Zone and the former Joint Finance Fund. It also leads in approval of the Health Improvement Programme, joint charters and Healthy Living Centre proposals.

  3.5  The Partnership sees its main role as facilitating joint working between all of the agencies and ensuring a focus on the needs and views of local people. In addition to business meetings, a number of less formal half-day meetings have been held to discuss issues such as partnership working and "whole-systems" approaches. There is a genuine commitment to change and the need for a more client focused approach working across organisational boundaries. This level of co-operation is now embedded and will be sustained beyond the life of the Health Action Zone.

  3.6  Substantial work has been undertaken to try to ensure the Health Improvement Programme develops into a comprehensive planning process for the whole spectrum of health from prevention through to rehabilitation. Considerable time has been spent tackling difficult issues in the hope of providing lasting agreements. The emphasis on the need for the NHS to work closely with local government and local communities set out in the Government's White Paper—Saving Lives: Our Healthier Nation was welcomed. However, the Government has indicated that Health Authorities are to continue to act as co-ordinators of Health Improvement Programmes. The Government's modernisation programme emphasises the community leadership role of local Councils, in part through the duty to produce local community plans. With the analysis of the White Paper as to the determinants of health it continues to appear more appropriate for local authorities to have this role. An NHS lead inevitably gives precedence to issues of acute care with a risk of public health concerns not being fully considered.

  3.7  A co-ordinated approach has been taken to applications for Healthy Living Centres. As part of the HAZ, the areas of the borough suffering the worst health outcomes and most marked health inequalities have been identified as "areas for special action". A comprehensive Health Needs Assessment is being carried out in each of these areas. Much is already known about the distribution of ill-health and its causes. This new work will inform the Partnership by focusing on what action is needed to tackle these issues to meet the expressed needs of local people. The Partnership has agreed three priority areas that will be the first to make bids for healthy living centres based on this research. A multi-agency group is working on detailed proposals and linking very strongly into the local communities through existing routes established as part of Single Regeneration Budget activities and other community based initiatives.

  3.8  The Council has led in the creation of a Strategic Partnership for Gateshead to oversee the preparation of the Community Plan. The Gateshead Health Partnership is represented in the strategic partnership at a very senior level reflecting the importance of health and the need to integrate the objectives of the Health Improvement Programme with the community plan.

4.  THE ROLE OF THE HEALTH DEVELOPMENT AGENCY

  4.1  It is hoped that the Health Development Agency will take the lead in producing an evidence base for effective health promotion interventions. This would assist in establishing a "level playing field" in comparing the benefits of funding preventative interventions against those of treatment. In a similar role to that of the National Institute for Clinical Excellence for treatment there is a clear role for a national lead on promoting what works and stopping what does not. It is too early to make a judgement on how effective the new Health Development Agency will prove to be.

5.  THE ROLE OF PCGS AND PCTS

  5.1  Two primary care groups exist in Gateshead. They moved to level 2 status, as sub-committees of the Health Authority with delegated authority for significant budgets, from 1 April 2000. There is a proposal that they will merge to form a level 4 Primary Care Trust from 1 April 2002.

  5.2  The advantages of PCGs have been a demonstration of fresh thinking, openness to change and closer link with local people due to their locality basis. Each has invited the Council to send an official observer to board meetings and they have attempted to be fully involved in all health partnership activities. There are clear benefits in having health service organisations that are coterminous with the Council boundaries.

  5.3  There are however a number of difficulties which arise for the current structure of the PCGs and in particular their board. The Chairmen and a majority of members of the PCG board must be GPs. Difficulties have arisen due to the amount of time GPs have to spend on PCG business which is taking them away from the delivery of care. This can lead to a reluctance of GPs to stand for the Board. This problem will increase with a move to Primary Care Trust Status, with additional responsibilities and additional governance arrangements.

  5.4  The constitution of PCG boards also prevents locally elected Councillors from being appointed to them, other than as lay members. Local accountability of NHS services is considered both important and beneficial in terms of the health of the local population and sensitivity to patient needs over service provision. A make up of PCG boards can lead to a focus on clinical and client based issues, to the neglect of the wider health improvement role.

  5.5  Regular organisational change is a feature of the Health Service that creates significant uncertainty and militates against partnership working. Currently local health authorities are changing to take on a more strategic, leadership role. Key staff are leaving with a likelihood of fewer, smaller organisations covering larger geographical areas. At the same time, Primary Care Groups are taking on ever-greater responsibilities and resources. Many are merging to form Trusts. It would be of benefit if the future structure of the NHS could be resolved quickly so that the focus could shift from organisational change to health improvement and the delivery of services.

  5.6  It is recommended that the structure and membership of PCG and PCT boards be reviewed to minimise the pressure on local GPs and give increased accountability through the appointment of locally elected Councillors.

6.  THE ROLE AND STATUS OF THE MINISTER FOR PUBLIC HEALTH

  6.1  The appointment of a Minister for Public Health was welcomed as an important signal that Government recognised its responsibilities in this area. However, real improvements in public health require action across central and local government. A substantial number of Government initiatives affect health as indicated in the Committee's Terms of Reference. There is a concern that these are often promoted by individual Ministries and are not sufficiently "joined-up" at a national level. This can translate into local difficulties in implementation. The Minister for Public Health could assist in this process.

7.  THE ROLE OF THE DIRECTOR OF PUBLIC HEALTH

  7.1  A feature of the local Health Authority is the high turnover of senior staff. This certainly applies to the local post of Director of Public Health. Relationships and understanding take time to develop. Frequent changes of personnel militate against effective joint working. This is compounded by organisational changes within the NHS. Clear national guidance on the responsibilities the public health function has to local government would help to reduce the disruption caused by such changes.

  7.2  It is recommended that clear national guidance be produced on the respective roles and responsibilities of the Director of Public Health and the Consultant in Communicable Disease Control/Proper Officer. In particular this should cover the support they should give to local government in carrying out their public health functions.

8.  THE EXTENT TO WHICH CURRENT PUBLIC HEALTH POLICY IS REDUCING HEALTH INEQUALITIES

  8.1  The Government has recognised that health inequalities are entrenched and the product of a whole range of socio-economic and environmental factors in addition to personal lifestyle behaviour. When Health Action Zones were first established there was an understanding that measuring changes in inequality brought about by individuals would be difficult to measure and in any event take a considerable time to have an effect. More recently there have been calls to demonstrate early progress. This is possible, but generally only in terms of inputs and outputs of activity, rather than outcomes. A positive change however has been the recognition of the need for positive action to tackle inequalities and the need to integrate consideration of these issues with the broad range of policy development. For example, the Tyne and Wear Health Action Zone has identified those areas with the worst health inequalities for targeted action. The development of regional Public Health Observatories may be a useful development in taking this work forward, but this remains to be seen.

9.  THE COMMITTEE WILL ALSO STUDY ALTERNATIVE MODELS OF PUBLIC HEALTH PROVISION

  The NHS is undergoing a major re-organisation. The location of the Public Health Function will need to be considered as part of this process. However, as with other issues mentioned above, it is important that organisational issues to not cloud lines of responsibility and effectiveness. Partnership working is seen as the key, not organisational merger.