APPENDIX 12 (CONTINUED)
Memorandum by Medical Practitioner's Union
4.7 EARTH SHELTERED
What is an earth sheltered building?
4.7.1 An earth sheltered building is a building
which is partially buried in earth. In its perfect form the roof
and walls are hidden beneath earth and only the windows and doors
4.7.2 Partial forms are possible, for example
conventional buildings with roof gardens or buildings that are
covered by earth on only certain aspects. An earth sheltered building
can either be built into an existing earth mound, or can be built
in the normal way then buried.
Is this just a silly idea?
4.7.3 No. Earth sheltered buildings are
common in America and Australia. Roof gardens are required by
planning regulations in parts of Germany. There are some buildings
with roof gardens already in England and one earth sheltered housing
What are the benefits?
4.7.4 1. Reduced Visual intrusion
2. Brings a green
aspect to built up areas
3. Double use of
spaceroofs can be used for gardens or open spaces
4. Potential for
increased housing density due to the double use of space
5. Energy efficiency
Are the technical features fully understood?
So why isn't it widespread?
4.7.6 1. Inertia
2. Doubts about
firms and architects reluctant to learn new skills
4. People haven't
heard of it
5. When they do
hear of it, it is so alien to our current experiences that they
think it is a joke
with the Teletubbies
What are its planning benefits?
4.7.7 1. Can preserve any open space
that it is decided to permit building on
2. Can bring back
open space when new areas are developed
3. Allows combination
of requirements for high housing density with high levels of public
What are its public health benefits?
4.7.8 Open space provides exercise opportunities
and raises the human spirit.
What can be required?
4.7.9 We can reasonably require earth sheltering
in any area where we permit the release of open space for development.
4.7.10 We can reasonably require earth sheltering
on any development that is large enough to provide a self contained
area of useful open space.
4.7.11 Roof gardens and earth sheltered
perimeters in new industrial parks would create large areas of
public open space and introduce the surrounding area to the concept
of earth sheltering and change attitudes towards the relationship
of buildings to greenspace.
4.8 A NEW PUBLIC
4.8.1 In 1997, we submitted to the incoming
Government a draft Public Health Act. At the time, a number of
public health organisations were suggesting that the 150th anniversary
of the first such act, the Public Health Act 1848, would be a
good opportunity for a modern version. We felt it would be eminently
appropriate for a Government which was establishing the first
Minister for Public Health to adopt that approach by passing a
Public Health act in 1998, within its first Parliamentary session.
We suggested the Act should address:
(i) structures for public health;
(ii) specific measures that promote public
(iii) manifesto commitments that could be
seen as health improving.
The third of these points has clearly been overtaken
by events as they have been embodied in separate individual pieces
of legislation. The first two points remain valid even though
the opportunity for symbolism in the date has been lost.
4.6.2 There could be one long Act or a shorter
Act every session, like the Finance Act. An advantage of the latter
is that it would foster an inter-departmental approach as departments
would start to see this as an additional way to get legislative
time for things they want to do and they can demonstrate would
improve health. It would provide a compelling reason to take the
Minister for Public Health seriously.
4.8.3 Recognising the links between public
health and the environment it could be called
the Public Health & Environmental
the Health & Environments
Public Health Structures
4.8.4 On the public health duties of health
authorities and local authorities it could:
(i) create a duty on health authorities to
promote the health of local communities, to define local communities
which suffer social or environmental deprivation and to draw up,
in conjunction with the local authority, plans for addressing
(ii) extend s113 of the Local Government
Act (empowering local authorities to delegate local authority
officer functions to NHS staff) so that it also applies to family
health services contractors and their staff (The Health Act Partnership
process is a mechanism for this, but there may be occasions where
this simpler power is more appropriate);
(iii) for the avoidance of doubt confer a
power on health authorities and Trusts to delegate officer functions
to local authority staff, family health services contractors or
staff of FHS contractors (this is a reciprocal of s113. There
is a question as to whether it is necessary or whether health
authorities or Trusts can do it anyway, since s113 was intended
to overcome some specific restrictions on local authorities. However,
some auditors have argued that in the absence of a reciprocal
provision to s113, this can't be done. The Health Act partnership
process is a mechanism for this but there might be instances where
this power would be simpler).
(iv) empower the Secretary of State to delegate
to a local authority any power that he could delegate to a health
authority (our original proposal also suggested that this power
to delegate should be delegable but the Health Act Partnership
process obviates that need);
(Note points (ii) to (iv) would also be of value
for health care purposes as well as public health);
(v) empower the Secretary of State to constitute
a public health office as a corporation sole and to delegate to
it any power that he could delegate to a health authority;
(vi) require him to use that power so as
to establish as a corporation sole a Borough Medical Officer or
County Medical Officer for the area of each county council, unitary
borough, metropolitan borough or London borough;
(vii) provide that any power delegated to
a local authority or a corporation sole under these provisions
will be subject to the same accountabilities and flows of funds
as if it had been delegated to a health authority;
(viii) provide for the Borough and County
Medical Officers to have a right to appoint a nominee to the Board
of each NHS body established within their area (acting jointly
where a body covers more than one such area);
(ix) establish for Borough and County Medical
Officers a right of access to local authority committees and executive
(x) extend the powers conferred by S4 of
the Health & Medicines Act (trading powers of health authorities),
so that they may be exercised not only (as at present) for the
raising of money for the NHS but also for the improvement of health.
4.8.5 The Act should give a special status
for public health measures in terms of the Deregulation Act by:
(i) excluding health and safety, public health
and environmental protection from the Deregulation Act; and
(ii) provide that existing deregulation provisions
within these areas will cease to have effect 12 months after the
passage of the Act unless renewed by the Minister for Public Health,
the Health & Safety Commission or the Environment Agency (as
4.8.6 To entrench the position of public
health in planning law the Act should:
(i) provide that the public health is
a material consideration for planning law purposes;
(ii) provide that costs may not be awarded
against a local authority in favour of a commercial body on a
planning appeal insofar as it applies to decisions reasonably
taken in good faith upon the advice of the Borough Medical Officer
or County Medical Officer for the protection of the public health
(which should be explicitly stated, for the avoidance of doubt,
as including, the reduction of road traffic, the reduction of
pollution, the promotion of social networks or the protection
of open space);
(iii) power for Borough and County Medical
Officers to object to planning applications, to require preparation
and consideration of health impact assessments, to enter into
s106 agreements as to terms on which their objections will be
withdrawn, and to appeal against a grant of a planning application
to which they had objected;
(iv) restrictions upon the power of planning
inspectors or the Secretary of State to overturn local decisions
to refuse planning applications on the grounds of protection of
open space, reduction of road traffic, or prevention of pollution
of residential areas. Only unreasonable decisions, or decisions
which can be shown to have been primarily taken on other grounds
should be open to reversal on appeal. The same should apply to
calling in and granting an application to which a local authority
(v) power to attach conditions for the improvement
of the nutrition of the population to planning approvals for the
use of premises for the sale of food;
(vi) power on local authorities to require
public roof gardens on appropriate buildings in areas of open
space deficiency (our original proposals also suggested a power
to require public open space in new developments but the High
Court has since ruled that they do have such power);
(vii) duty on local authorities to achieve
by the year 2010 a specified number of trees per hectare across
their area and power for them to require tree planting as a condition
of planning consent if they have not yet achieved their target.
4.8.7 To institutionalise responsibilities
for health improvement policies the Act should:
(i) require each Government Department (including
departments in devolved Executives) to lay before the appropriate
Parliament or Assembly each year a report of its health improvement
policies and the comments thereon of the appropriate Chief Medical
(ii) provide for 20 per cent of the revenue
support grant to a local authority to be paid via the Minister
for Public Health and to be dependent on satisfactory participation
in health improvement programmes. There should be provision that
in exercising this function the Minister should take account of
advice from the Borough or County Medical Officer; and
(iii) provide that any money withheld under
this clause shall be paid to the local Borough or County Medical
Officer and ringfenced for health promotion or public health expenditure
within the local authority area in question.
4.8.8 To establish freedom of information
in the public health field:
(i) there should be a clause defining the
duty of public health practitioners to engage in public health
(ii) there should be protection of freedom
of speech of health workers (non- statutory provisions have been
introduced by this government but we still think they should be
statutory) and a duty on Borough and County Medical Officers to
promote public debate on health matters;
(iii) there should be freedom of information
provisions on public health information applicable to both the
public and the private sector;
(iv) it should be a serious criminal offence
to suppress information about the existence of a serious public
(v) there should be curtailment of the right
of commercial bodies to use libel laws to suppress debate on the
health implications of their businesses;
(vi) there should be protections for the
independence of the Chief Medical Officers; and
(vii) there should be immunity for health
authorities, environmental health authorities and the HSE against
libel actions for health warnings issued in good faith.
4.8.9 To update environmental health legislation
the Act should include:
(i) a review of communicable disease
(ii) a review of the law on nuisances;
(iii) a review of the law on drinking water
control of land contamination that
may pollute water supplies
a timescale for eradication of lead
power for the Drinking Water Inspectorate
to act on the balance of probabilities
(iv) a review of the law relating to air
(v) a declaration that environmental health
services are part of the NHS and provision to include them within
certain NHS systems.
4.8.10 To improve the statutory definition
of public health professions the Act should:
(i) place on a formal statutory footing
the duty on the GMC to maintain a specialist register for public
(ii) place a requirement on the UKCC to maintain
a specialist register of public health nurses and also to provide
a route of entrance to the health visiting profession (and thus
the specialist register) for community development professionals;
(iii) require the GMC, UKCC and Council for
Professions Supplementary to Medicine also to maintain a register
of clinical epidemiologists, practitioners who are qualified to
practise public health to the extent that this is ancillary to
(iv) place a requirement on the Council for
Professions Supplementary to Medicine to register health promotion
advisers, public health scientists, human ecologists, public health
nutritionists, health economists and environmental health officers;
(v) define a "public health professional"
as a person named in any of these registers;
(vi) confer a power on the GMC to grant an
exceptional licence, based on personal skills and qualities, to
a registered member of a health profession (registered either
in this country or overseas) to exercise the functions of a medical
practitioner within a defined specific sphere of practice, and
(without prejudice to the generality of that power) a specific
duty on the GMC to use that power for the following purposes;
facilitate the integration into employment
of refugee doctors;
simplify the training of persons
requiring dual medical and dental qualifications for practice
as maxillofacial surgeons
make provisions for physiotherapists,
occupational therapists and speech therapists to render themselves
eligible for entry to the medical speciality of rehabilitation
make provisions for persons already
qualified in other public health professions to render themselves
eligible for entry to the medical speciality of public health
(The power conferred and the uses proposed for
it are wider than just public health, because we feel it is important
that public health is not the only area where this power is exercised
and for convenience in making some other useful minor provisions
at the same time); and
(vii) provide that from a specified date,
and with protection for existing incumbents and their deputies
(both in their present post and to move) the Chief Executive of
a health authority should be a public health professional and
the Director of Finance should be a health economist in the light
of the central importance of the training and skills of these
groups to the task in hand.
4.8.11 The Act should confer powers on the
Secretary of State, either directly or through a health authority
or public health corporation sole, to exercise any power conferred
by any public health legislation upon any body, if he is satisfied
that that body is failing to exercise it adequately, and to recharge
4.8.12 The Act should empower a Borough
Medical Officer or County Medical Officer to serve upon a local
authority any notice which the local authority is empowered under
public health legislation to serve but is unable or unwilling
to serve upon itself. There should be a duty upon a local authority
to make its inspectorates available to the Medical Officer for
the purposes of this power. (This overcomes the restrictions in
the Cardiff case where a local authority environmental health
department was held not to be empowered to serve an unfit housing
notice on the council's housing department because the authority
can't serve enforcement notices on itself).
Measures to Improve Health
4.8.13 The Act should make provision for
green taxes including:
(i) environmental levies;
(ii) more effective Road Traffic Act charging
procedures for health authorities;
(iii) similar new provisions for industrial
(iv) road traffic generation levies on large
4.8.14 To improve health at work the Act
(i) new corporate manslaughter provisions;
(ii) increased penalties for health and safety
(iii) a clause providing that a local authority,
the Environment Agency and the HSE may, by agreement, exercise
each other's powers, thus giving greater flexibility in boundary
areas or dually inspected premises like food factories;
(iv) power for a police authority and the
HSE jointly to establish a Serious Criminal Negligence & Environmental
Offences Squad, whose members would have the combined powers of
a factory inspector, a pollution inspector, an environmental health
officer and a police constable;
(v) a duty upon an employer to secure at
each workplace an adequate occupational health service, either
by providing a service licensed by the local health authority,
or by providing a national service licensed by the HSE, or by
subscribing to a service commissioned by the local health authority
or by subscribing to a national service licensed by the HSE. There
should also be a duty upon the HSE and health authorities to secure
the involvement of the workforce and the local community in the
management of any service they license or commission. Employers
whose services are licensed by the HSE should still reach agreement
with the local health authority to ensure compatibility with local
(vi) perhaps a clause relaxing the restrictions
on industrial action (eg secondary action, picketing) where the
dispute does not affect pay and is about health and safety or
other issues of relevance to public health; and
(vii) "family friendly" employment.
4.8.15 To improve transport safety the Act
(i) a 20mph universal speed limit on minor
(ii) new drink driving provisions similar
to those in France where there is provision for a fine and penalty
points (but not imprisonment or mandatory disqualification) for
driving with blood alcohol levels of more than 50 but less than
(iii) powers to establish Home Zones;
(iv) legislation requiring Chief Constables
to achieve specified standards of speed limit observance and allowing
them to precept on fines revenue from speed limit enforcement;
(v) a duty on the Strategic Rail Authority
to secure a more extensive and comprehensive rail network, and
on County Councils, the Mayor of London and Passenger Transport
Executives to secure a comprehensive bus network, so that people
have the genuine option of a safer form of transport;
(vi) duty on the Railways Inspectorate to
exercise its powers with regard to the principle that transport
safety is damaged if the access to railway services is diminished
by inflexible or bureaucratic regulation which diminishes the
scope for rail expansion; and
(vii) establishment of a Road Safety Inspectorate
closely linked to the Railways Inspectorate and with a duty to
raise the standards of road safety closer to those on the railways
through improvements in road and vehicle design and traffic regulation.
4.8.16 The Act should require the fluoridation
of water supplies.
4.8.17 To promote walking and cycling the
(i) place a duty on the Highways Agency to
establish and maintain a national cycling network;
(ii) place a duty on local authorities to
establish and maintain safe local cycle networks;
(iii) place a duty on franchised rail operators
to carry bicycles;
(iv) establish, as a Special Health Authority,
a Walking Authority with a duty to ensure protection and maintenance
of the rights of way network, to ensure the creation of adequate
networks of recreational footpaths, to ensure adequate use of
the powers relating to access agreements and the right to roam,
to ensure pedestrian safety, and to ensure the creation in urban
areas of aesthetically attractive pedestrian networks. The authority
should have default powers to assume the responsibilities of local
authorities which are failing to achieve adequate standards, and
to precept to recover the costs of exercising these default powers;
(v) provide that compensation for Creation
Orders should be limited to interference with the use of the land
and not to any general reduction in value. The basis for this
should be that responsible landowners cooperate with the creation
of path networks;
(vi) provide that no compensation should
be payable for a Creation Order where the landowner has unreasonably
refused to negotiate in good faith with a local authority seeking
to establish important concessionary access;
(vii) place a duty on the Highways Agency
to provide a safe crossing where a right of way crosses a road
with more than a 30 mph speed limit;
(viii) establish, as a Special Health Authority,
a National Cycling Authority with a duty to ensure adequate local
cycle networks connecting to the national cycle network (with
default powers similar to those of the National Walking Authority)
and with powers to issue advice concerning cycling to the Highways
Agency and Strategic Rail Authority; and
(ix) abolish the power to close public footpaths
permanently for reasons of the prevention of crime but to replace
it with a power to close footpaths (or to dedicate them subject
to this proviso) during certain hours.
4.8.18 To address the problems of homelessness
and of travellers the Act should:
(i) place a duty on local authorities to
provide, or secure the provision of, an adequate supply of affordable
(ii) establish a Nomadic Citizens Council,
elected by gypsies, travellers and other persons of nomadic lifestyle,
established with the status and powers of a unitary local authority
with the responsibility to make appropriate provisions for persons
of nomadic lifestyle.
4.8.19 The Act should make provision for
better nutritional food labelling.
4.8.20 To address the problems of fuel poverty
the Act should:
(i) prohibit disconnection; and
(ii) place a duty on a fuel supplier to provide
heating to houses on affordable terms. Where a house is hard to
heat it may discharge this duty either by offering improvement
loans to rectify the situation or by putting a ceiling on the
4.8.21 The Act should improve the mechanisms
for control of chemicals.
4.8.22 To prevent the loss of efficacy of
antibiotics due to clinical and agricultural overuse the Act should
provide for the Chief Medical Officer to specify the purposes
for which each antibiotic may be used and it should be a criminal
offence to use it for any other purpose.
4.8.23 To address the health problems of
unemployment the Act should:
(i) establish a levy on businesses which
employ less than their share of the workforce (defined as turnover
of the business divided by the GDP and multiplied by the national
workforce expressed as whole time equivalents) amounting to the
national minimum wage for a 40 hour week multiplied by the shortfall.
The proceeds of that levy should be paid to public authorities
for the creation of socially useful work (the degree to which
such work is temporary or permanent to be a matter of local judgement
based on the local labour market). There should be a right to
be offered such work if genuinely unable to find work on the open
(ii) provide that the refusal of or resignation
from unsafe or health damaging work does not constitute intentional
unemployment or evidence of failure to seek work.
4.8.24 The Act should make the following
provisions relating to public health in Europe:
(i) a duty on British representatives at
the Council of Ministers to pay due regard to public health; and
(ii) a duty on the Foreign Secretary to lay
before Parliament from time to time (as events overtake the most
current statement) a statement of the public health policies which
the United Kingdom will press the European Union to adopt.
5. THE ROLE
5.1 The Two Roles
5.1.1 The Director of Public Health fulfils
two roles and their requirements are coming increasingly to conflict.
5.1.2 For a century and a half this country
has had a group of doctors who analyse the health of communities
and act as advocates for health improvement. This role needs to
be filled by a doctor because of the trust the public places upon
a medical opinion, because of the medical culture of independence
and because of the specific skills and training, including knowledge
of disease processes and treatments. In a century and a half it
has led to the eradication of water borne diseases of cholera
and typhoid, dramatic improvements in child and maternal health,
the eradication by vaccination of smallpox, diptheria and polio,
the clearance of the slums, and the cleaning of the air. This
rate of achievement has not been maintained since it was absorbed
into the cloying defensive corporate managerialism of the post
5.1.3 The other role is as the health authority's
public health manager. This role, not specifically medical, requires
approaches and attitudes which might well be incompatible with
5.1.4 There are many Directors of Public
Health who are exceptionally able at one or other of these roles.
There are very few who are good at both. The temperaments required
may perhaps be incompatible. More importantly the attempt to encapsulate
the two roles in one individual is bound to lead to compromises
at some point in both roles.
5.2 The Doctor to the Town (or County)
5.2.1 We believe that the populations of
each of the 150 top tier local authorities in Englandeach
county, each unitary authority, each metropolitan Borough and
each London borough should have a Borough Medical Officer or County
Medical Officer to take on the role of analysis and advocacy in
direct historical lineage with the former Medical Officers of
5.2.2 It is important that this function
should be independent and professionally honest with moral courage.
These are not qualities currently valued in British public administration.
5.2.3 In this context we view as sinister
the current proposals to widen the professional base from which
Directors of Public Health can be recruited. We are not saying
that only doctors can be independent, professionally honest and
have moral courage. We do, however, say that it will be easier
to eradicate these qualities if the range of people from whom
appointments may be made is broader and includes professional
groups without a strong professional tradition of independence
and without the degree of professional power and public respect
necessary to afford protection.
5.2.4 We develop our ideas about multidisciplinary
public health in section 7 of this evidence. We do not seek to
defend medical hegemony but rather to allow the traditions of
each of the public health professions to develop properly. Once
the professional function of analysis and advocacy has been removed
from the role of Director of Public Health (and only then) that
important managerial function that remains would appropriately
be open to multidisciplinary tenure. Doctors would be required
in the team but not necessarily in the lead.
5.2.5 The office of County and Borough Medical
Officer should be part of the NHS but it should not be part of
any NHS body, since it needs to have access to all agencies. Joint
appointments are a possible mechanism but to emphasise its independence
and to allow statutory functions to be conferred upon it directly
we suggest it should be established as a corporation sole.
5.2.6 The status of a corporation sole should
not mean that complex infrastructures need to be created. A small
office at regional level should be able to cope on an agency basis
with the corporate administration of the public health corporations
sole in the region (such as accounts, convening Advisory Appointments
Committees to fill vacancies, contractual matters for the Borough
and County Medical Officers etc).
5.2.7 Nor should it mean that individuals
should work in professional isolation. There is no reason why
the doctors in question should not work from NHS or local government
premises, draw upon NHS and local government administrative systems,
and work within a Dept. of Public Health Medicine shared with
colleagues working for health authorities and Trusts, thus providing
professional interaction and shared statistical, information,
library and scientific support.
5.2.8 It should be possible for these public
health corporations sole to become part of Health Act partnerships.
5.2.9 The Borough and County Medical Officers
should be entitled to be represented on the Board of all NHS bodies
and of all Health Act partnerships. They should also have a right
of audience at local authority committees and executive bodies.
5.2.10 The Attorney General should establish
mechanisms for supporting Borough or County Medical Officers who
wish to bring legal proceedings for the protection of health,
and they should be acknowledged as entitled to seek judicial review
of decisions if they feel this would benefit health.
5.2.11 Section 4 of the Health & Medicines
Act (the trading power of health authorities) should be extended
to these new corporations sole and should also be extended to
allow trading for the purposes of promoting health rather than
just for the purposes of raising money for the NHS. This would
allow Borough and County Medical Officers to enter into public/private
5.2.12 A new Public Health Act should confer
a variety of powers on Borough and County Medical Officers. We
drew up a draft bill for the incoming Government in 1997 and are
sad that it was not adopted. We have updated it at section 4.8
5.2.13 As an example of the kind of power
we are referring to we suggested that when there is a public health
objection to a planning application a local authority which refuses
the application should be protected from the risk of costs in
the even of an appeal. We also suggested that Directors of Public
Health (and now, our suggested Borough and County Medical Officers)
should have a third party right of appeal against planning application
approvals, a right that could also be conferred upon other bodies
which represent key social values, such as the Environment Agency
or the Countryside Commission. There may also be a case for conferring
this right of appeal upon Parish Councils and equivalent community
5.2.14 Whatever formal statutory powers
are conferred and whatever services are placed within the new
corporation sole, the right of audit and report is fundamental.
Until well into this century the Medical Officers of Health operated
with this power alone, and they did so highly effectively. NHS
bodies and local authorities should have a duty to consider reports
by the Borough or County Medical Officer, including the Annual
Public Health Report.
5.2.15 The independence of this report would
be re-emphasised by our proposal for status as a corporation sole.
If this is not adopted other ways to assert the independence of
such reports need to be found as this is often not understood.
5.2.16 As well as conventional reports the
increasing discussion of health impact assessment is also relevant
Health Impact Assessment
5.2.17 A health impact assessment is carried
out whenever a public health professional systematically recognises
the health implications of a proposal and offers advice.
5.2.18 Techniques for carrying out set piece
health impact assessments are being developed such as the Liverpool
Checklist of matters to consider, the London Quantification Framework
for recognising how they might be quantified and the Manchester
Airport Grid for surveying how useful quantification might be.
The Transport & Health Study Group has recently issued guidance
on health impact assessment of a transport policy. The University
of Liverpool is building up expertise in health impact assessment
5.2.19 Such set piece assessments will always
be the minority of health impact assessments. Resources in public
health and the timescales of decision makers will always ensure
that most health impact assessments are broad brush and are expressed
in a letter of comment.
5.2.20 The underlying duty of public health
professionals to make such comments and the professional body
of knowledge that underpins them needs to be appreciated. They
can be seen simply as a letter of opinion or, because they operate
in a different conceptual framework from the one the decision
maker is used to, they may simply fail to register. For example
Directors of Public Health in the North West of England took considerable
trouble to develop comments on the draft regional planning guidance
addressing the public health implications of the proposals but
were not invited to be participants in the public examination.
5.2.21 Highways engineers and estates professionals
are renowned for the belief that their own system of professional
knowledge is a substitute for intelligent thought and that any
other way of viewing a problem is wrong. They particularly resent
any suggestion that they have any duty to take account of strategic
goals of any kind and will usually argue that coordinated social
policy is illegal.
5.2.22 Training of decision makers in the
health implications of their work is essential both for them to
see the need for public health advice and to value it when they
5.2.23 As a long stop structures should
be put in place for informing DPHs (at present) and (in future)
Borough and County Medical Officers of decisions they may wish
to comment on. But the field is vast and the mail of DPHs already
submerges the important beneath the merely urgent, and both beneath
civil service requirements for Ministerial information.
5.2.24 For example the public health department
in Sandwell, a leading edge department, did not realise until
after the closing date for comments that a planning application
would increase gambling opportunities in an area where they were
convinced this would be damaging to health. They were unaware
of the application and the planners were unaware of the public
5.2.25 Timescales for rapid resolution of
planning decisions, set in the name of efficiency, preclude any
sensible formal health impact assessment.
5.2.26 A commitment to health impact assessment
must be more than a belief that public health professionals, if
asked, will do a calculation that will make a report look nice.
5.2.27 What is needed is a belief that all
decision makers have a duty to improve health and that public
health professionals are there to help with this.
5.2.28 It will be important for Borough
and County Medical Officers to devote time and energy to enthusing
a wide range of local authority staff with the health implications
of their work and their place in the health improvement process.
5.3 Public Health Management in Health Authorities
5.3.1 It seems likely that health authorities
will merge into large remote bureaucratic entities, allegedly
strategic but in fact composed of reformed hackers sitting in
front of large computers monitoring services they do not understand
for populations they have never met. This process was set in motion
by NHS managers under the previous Conservative government and
has continued under the present government with a sustained dynamic
but changed rhetoric.
5.3.2 We do not believe that the system
which destroyed the economy of the Soviet Union will improve the
NHS. For the record we must emphasise that we made this same criticism
in these same words under the previous government.
5.3.3 Centralised target driven top down
planning does not work for two reasons
the mathematics of chaos theory has
demonstrated that some systems are too complex to plan and the
interactions simply cannot be accounted for but become random
organisational theory has shown that
the more performance is monitored the less likely people are to
exceed the minimum required and the more closely activity is targetted
the more neglect affects the things that have not been targeted.
5.3.4 A more sensible approach would be
one which sought to work with the enthusiasm and commitment of
staff whilst developing accountability to consumers and communities.
This should take place within the context of the public health
body of knowledge and the guidance this offers to evidence based
organisation and strategies.
5.3.5 The current government has not departed
anything like as much as it should have done from the over managed
systems introduced by the Conservatives but it has at least put
in place the system of clinical governance, tried to monitor care
rather than meaningless indicators of volume, and launched visionary
programmes of staff development (albeit that its spin doctors
then undermined them by presenting them as punitive so as to appear
5.3.6 It is important that the assessment
of need for health services should be rooted in an understanding
of health care and should not become a technical statistical issue.
We continue to believe that this will be achieved best in a democratised
5.3.7 Public health practitioners need to
have a key role in health authorities and Trusts. It is the public
health approach which is most likely to accentuate the positive
features of managed clinical pathways and needs based plans, use
indicators as information instead of being dominated by them,
and resist the distorting effect of inappropriate targets. All
too often this potential is unrecognised and hence untapped.
5.3.8 Public health doctors have a broad
vision of health and a full range of epidemiological skills combined
with a professional background shared with other doctors. This
makes them particularly well placed to win the support of clinicians
for strategic change.
5.3.9 The skills of public health nurses,
rooted in work with families and communities, could be of immense
value in ensuring that the wishes of consumers are not overlooked.
5.3.10 There is a need for a career structure
for public health scientists who may perhaps be able to tame the
monster of NHS information systems.
5.3.11 Health promotion specialists have
skills in programme management which could be valuable in the
introduction of service frameworks.
5.3.12 Environmental health officers have
an approach to public health which is rooted in legislation and
enforcement. It is unfortunate that the relevance of these skills
to NHS commissioning has been generally overlooked.
5.3.13 The approach of health economists,
with their emphasis on resource optimisation, could almost certainly
make a greater contribution to the planning of NHS commissioning
budgets than the traditional public accountancy approaches which
are more suited to provider budgets.
5.3.14 It is unfortunate that these public
health skills, with their capacity to shape the strategic direction
of health services, have been generally neglected in favour of
skills of operational management, bureaucratic administration
and conventional public accountancy which have much to offer large
provider organisations but are of little relevance to strategic
5.3.15 We suggest that the Chief Executives
of health authorities should in future be drawn from the ranks
of public health professionals.
5.3.16 In 1998 the then Chief Medical Officer,
in his report on strengthening the public health function, said
"the present resource of specialist public health expertise
is already very stretched and there is a need for more dedicated
staff from a number of disciplines to deliver the current agenda."
5.3.17 The scarcity of public health skills
will affect the capacity of authorities to address the agenda
in the way that we advocate. A workforce plan is called for.
6.1.1 We welcome very much the current renewed
interest in inequalities in health. The Government is to be congratulated
on this approach.
6.1.2 Inequalities in health will not be
reduced until the poor cease to be differentially exposed to the
determinants of ill health.
6.1.3 It is not enough simply to address
inequalities in access to health care, although that is important.
We must also, indeed primarily, address the more fundamental causes.
6.1.4 About a third of inequality in health
is work related. We must therefore address the issue of health
at work if we are to address inequality.
6.1.5 Given the powerful association between
social networks and health the stress and powerlessness of social
exclusion must also be addressed. We believe that community development
6.1.6 The material issues of poverty and
the environments in which poor people live provide the rest of
6.2 The Public Health Case for relief of poverty
6.2.1 It is well established that poverty
is the greatest single cause of death. Whenever death rates are
correlated with indices of deprivation, whether in small area
analysis, in large area analysis, in time series or in the comparison
of different social groups, the correlation relentlessly identifies
deprived and oppressed groups.
6.2.2 At the time of the Black Report 70,000
deaths occurred each year in the UK under the age of 65 which
would not occur if the health of the whole population were the
same as that of the professional and managerial classes. By the
publication of "The Health Divide" the figure had increased
to 85,000. It may well have increased further since.
6.2.3 Furthermore both these figures are
diluted by the imprecisions introduced by inadequacies in current
taxonomies of social class. Occupation is not the most precise
indicator of social class and if better indicators were used,
perhaps based on housing type and area of residence, it is likely
that wider differences would be found.
6.2.4 From the work of Fox & Adelstein,
who compared variances between industries with variances within
industries, it can be shown that between a quarter and a third
of these deaths are occupational in cause. This does not only
demonstrate the need for stricter regulation of occupational hazards,
important though that. It also shows the need to think more broadly
of working conditions in terms of their security, psychological
impact, and general pleasantness. Regulation is not enough
-it is also necessary to alter the
balance of power in the labour market. Low paid workers especially
must be better able to demand dignified treatment and acceptable
conditions of work.
6.2.5 Unemployment is also a major cause
of ill health. The ill health of poor quality work and the ill
health of unemployment are not alternatives. Poor working conditions
and insecurity of employment are correlated so these two forms
of health damage have a strong tendency to fall successively on
the same people. There are people who enjoy high levels of job
security in good quality well paid work, people who alternate
between unemployment and poor quality low paid work and people
whose experiences of job security, pay and work quality are, in
various ways, intermediate between these two groups.
6.2.6 Low levels of disposable income impact
adversely on health in a number of ways. Healthy diets are more
expensive than conventional diets if they use simple substitutions
of low fat, low sugar, high fibre versions of conventional diets.
Cheap healthy diets do exist but are distinctly unusual, demanding
much greater lifestyle change to adopt them. Exercise is easier
in rural environments or in leafy suburbs than in inner city environments
and is also easier for those who can afford access to leisure
6.2.7 Transport is an important factor in
health inequality. Car owners find it easier to access a wide
range of health promoting facilities. Access to the countryside
by public transport is increasingly difficult. The price differential
between healthy and unhealthy food is lower at out of town hypermarkets
than at shops accessible without cars. The planning of health
facilities increasingly assumes a mobility which only car owners
6.2.8 The poor are more likely to own old
cheap furniture and equipment which may well be less safe. They
are less able to afford safety equipment such as stair guards
and smoke alarms.
6.2.9 As well as these direct material factors
there is the stress of exclusion from lifestyles regularly presented
as the norm. Also stressful is the powerlessness which goes with
lack of choice, lack of respect from those in power and the dependency
creating models on which the welfare state is organised.
6.2.10 Correlations have been established
between the degree of equality of income in a nation and its health
in relation to its GDP. Countries with high levels of equality
enjoy better health then other countries with the same level of
6.2.11 There has been incomplete investigation
of this correlation and a wide range of possible explanations
can be advanced as possibilities, including the following:
equality of income may occur in the
same countries as social policies which promote health;
there may be a greater health benefit
from money spent on the relief of poverty than the marginal benefits
from the same amount of money made available to the rich;
inequality may itself create ill
health through the stress of relative poverty and failure to achieve
the norm for the given society;
the social cohesion produced by equality
may be health beneficial;
societies which tolerate inequality
may do so only because of inadequate social cohesion (itself health
at least one of the drives for higher
income is a drive to establish a relative position so inequality
of income may itself be economically inefficient. It leads to
the expenditure of excessive sums of money on positional goods
marking social positions that could equally be marked at less
current measures of GDP, which do
not, for example, count the value of economic growth deliberately
foregone for social good, may underestimate the wealth of the
kind of society which opts for more equal incomes;
in societies with greater equality
a greater proportion of the society's entrepreneurial skills may
be devoted to socially beneficial activity rather than the mere
enrichment of the entrepreneur.
6.3 Community development
6.3.1 Community development is an antipoverty
intervention which aims to empower communities to work together
to address their own problems.
6.3.2 It benefits health by
enhancing social networks, itself
a measure that improves health (indeed associations of total mortality
with social networks are as strong as with social class)
increasing the power of communities
to do useful things together and improve their situation.
6.3.3 Since the early initiatives in Parkside
and in Nottingham community development projects in the NHS have
been tried widely but often briefly. The evidence from the Royal
College of Nursing draws attention to the way they have often
been closed down before having a real opportunity to achieve long
6.3.4 Some longer lasting projects such
as those in Salford and Oldham have affected a small area in which
it is difficult to attribute effects specifically to the intervention
because of the small number random variation.
6.3.5 Northern Ireland and Stockport are
the two places where NHS community development has been pursued
for the greatest length of time across relatively large numbers
of small areas.
6.3.6 In Northern Ireland community development
has for many years been a central feature of health strategy.
The interventions have had significant effects on the communities
where they have operated. There is some concern however that they
have worked within, rather than challenged, communal divisions.
6.3.7 In Stockport community development
was introduced in two tranches in 1991 and 1995 to the borough's
most deprived wards. SMRs began to decline in the first tranche
wards taken as a whole after about three years whilst no decline
took place in affluent wards and in deprived wards where no community
development project was introduced. This means that whilst the
health of the borough as a whole was improving only in line with
England as a whole the wards where community development had operated
were improving faster and health inequalities were therefore being
reduced. Overall excess deaths were approximately halved. A downward
movement in the SMRs where community development had been introduced
four years later was noted four years after it was noted in the
first tranche wards. A ward where community development interventions
were reduced part way through the process for a number of reasons,
including the introduction of a large regeneration initiative,
initially improved in line with the other community development
wards but after withdrawal returned to its previous status.
6.3.8 Although the time relationships here
are suggestive it is important to bear in mind that the relationship
between wards and communities is imprecise, the data is crude,
there is considerable scope for small number variation and the
comparison was not randomised.
6.,3.9 We believe the case is however made
out for large scale randomised trials.
6.3.10 Community development projects have
often come to grief because of the failure of local politicians
or health managers to prepare for the prospects of conflict with
a more empowered community. There must be clarity that an empowered
community is the objective and that the workers prime goal is
its creation. Where conflict arises the worker must be able to
take the side of the community.
6.3.11 We believe public health nurses are
well equipped to carry out community development.
6.4 Other measures to address the health effects
6.4.1 Food co-operatives can help overcome
the high cost of healthy food in local shops.
6.4.2 Free bus services funded by the NHS
can take people from deprived areas to swimming pools and leisure
6.4.3 Parks can help overcome the difficulties
of local distance from the countryside.
6.4.4 Community art can affect the drabness
of deprived environments and help raise the human spirit.
6.4.5 The Peckham Health Centre between
the wars undoubtedly had a deep impact on the lives of those who
participated in it and it is to be hoped that healthy living centres
will have a similar effect.
6.4.6 Regeneration initiatives can address
the underlying economic and environmental problems of deprived
6.4.7 Targeted recruitment can help mobilise
the skills present in many poor areas and reduce unemployment.
For example the Manchester Airport Second Runway Health Impact
Assessment noted that economic growth was one of the main health
benefits of the development and so part of the mitigation package
was to ensure that jobs were locally advertised within inner city
6.4.8 LETS schemes can help mobilise local
skills and counter lack of local resources. Problems are sometimes
created by the treatment of such schemes for tax and social security
purposes. We have suggested that transactions on LETS schemes
be disregarded for tax and social security purposes but instead
LETS schemes as a whole be taxed in their own currency for the
benefit of local public agencies, thus creating a useful source
of voluntary work.
6.4.9 Credit unions can help conserve resources
in local areas.
6.4.10 Energy efficiency measures in homes
can directly address both the problem of cold and the cost of
6.4.11 Disability is a cause of poverty
and measures to reduce discrimination against disabled people
can address this and also reduce care costs for the NHS.
6.4.12 Ultimately the solution to the health
problems of poverty is the elimination of poverty. We therefore
develop in a later section of this evidence the case for a citizens'
6.5 Workplace Public Health
6.5.1 A significant part of inequality in
health arises at work so improved working environments (both physical
and social) will help address health inequalities.
6.5.2 We believe there should be an occupational
jointly managed by employers, unions
and local communities;
commissioned by health authorities;
provided either by employers or by
large industry wide arrangements (perhaps set up by the HSE) or
by PCTs or NHS Trusts for group services to small workplaces;
licensed by the HSE for nationally
organised services or by health authorities for local ones;
open to inspection by CHI;
providing a full range of workplace
emergency care, health promotion/information, safety professionals,
biological monitoring, employment rehabilitation and social audit;
complying with a National Service
The Contribution of Work Related Ill Health to
6.5.3 The work of Fox & Adelstein has
demonstrated that about a third of the social class variation
in ill health is caused by work.
6.5.4 This is much more than can be accounted
for by known occupational illnesses or hazards.
6.5.5 The reason for this is that
many occupational hazards are unknown;
it is especially difficult to recognise
occupational causes of common diseases;
the psychological hazards of work
are rarely fully recognised or accounted for.
6.5.6 Psychological hazards of work that
can cause stress and hence physical and mental ill health include;
excessive working hours;
working under pressure to deadlines;
unsatisfactory work situations, ranging
from poor physical conditions to bullying to lack of recognition
and boring work, which the individual sees no way to improve or
lack of control over the work;
responsibilities which the individual
is not trained, resourced and empowered to carry;
the Damocles situation where fear,
whether physical as in dangerous work, or social, as in failing
enterprises carrying redundancy risks, continuously hangs over
somebody without a chance to influence it;
low status damaging self esteem;
frequent life changes such as job
changes or relocation;
conflicts with other aspects of life.
6.5.7 Trends to longer hours and labour
flexibility increase a number of these.
Organising Occupational Health Services
6.5.8 Problems in organisation of public
health at the workplace include:
separation of responsibility for
health at work from health in the general community;
the lack of any coherent form of
organisation of occupational health services;
attitudes of deregulation;
lack of teaching about work hazards
in the education of health professionals even though all health
professionals encounter their consequences;
6.5.9 The debate that was prominent in the
1940s, 50s, 60s and early 70s of whether occupational health should
be part of the NHS has died down following the redefinition of
the NHS in 1974. However there are serious problems in the current
system of unregulated private provision.
6.5.10 Britain and Ireland are the only
countries in Europe where there is no public control of occupational
health services to ensure they pursue the health of the workforce
as their prime goal and maintain a comprehensive service. To counter
this we believe:
occupational health services should
be commissioned by the NHS;
there should be a National Service
Framework for occupational health services;
CHI should enforce this;
Occupational health services should
be jointly managed by employers, trade unions, and the local communities
upon whose environment the enterprise impacts rather than, as
at present, by employers alone.
6.5.11 When the coverage of occupational
health was last assessed only a third of the workforce had access
to a comprehensive service providing a full range of workplace
emergency care, health promotion/information, safety professionals,
biological monitoring, and employment rehabilitation. Social audit
of the enterprise, which should also be a function of occupational
health services, was not included in the study but its inclusion
would undoubtedly have reduced the proportion even further. About
a third of the workforce had access to no service at all. This
study was two decades ago but our impression is that in those
two decades things have got worse not better due to changing employer
attitudes and a trend to smaller workplaces.
6.5.12 We believe there should be a statutory
duty for employers to finance an occupational health service either
by providing it themselves and satisfying the commissioning authority
that it meets the needs or by paying the commissioning authority
to commission it for them.
6.5.13 Only a small proportion of workplaces
(albeit employing a significant proportion of the workforce) are
large enough to support a comprehensive service of their own.
Most will need to associate with other workplaces either vertically
(where workplaces across the country unite in a service provided
for a multisite company or industry) or horizontally (where local
workplaces combine together eg a service for all the shops in
a shopping centre). Both options should be available to employers.
The Health & Safety Executive should sponsor vertical integration,
providing it where this meets the needs of an industry best or
alternatively licensing it for the guidance of commissioners,
although commissioning should still be local in order to ensure
the service fits into local patterns of health promotion, emergency
care etc. Health authorities, NHS Trusts and PCTs have roles in
stimulating, and even supplying, horizontal integration.
6.5.14 Ever since Ernest Bevin fought successfully
to keep occupational health out of the NHS on its creation the
NHS has felt this is an area that lies beyond its remit whilst
those areas of government responsible have seen it as a distraction
from their main goals.
6.5.15 One way or another this must be overcome.
6.5.16 We welcome NHS+ as a cautious step
in the right direction but much more courage by Government, including
a willingness to regulate and to join up thinking across departments,
will be needed to make a real impression on the problem.
6.5.17 We believe our proposal for the NHS
to be the commissioner of occupational health services but not
the funder and not necessarily the provider is a sensible middle
The Cost of Abolishing Poverty in 1991
6.6.1 In 1993, based on 1991 data published
in "The Justice Gap" we calculated the cost of increasing
the income of each household to two thirds of the national average,
a measure which would abolish poverty by any definition accepted
by any substantial body of reasonable opinion.
6.6.2 The calculation was as follows:
||Adjusted household income|
|Number of persons in such households
||Average shorfall of adjusted income per household below national average
||Correction factor back to cash per adult person
||Weekly total income shortfall below national average
|2 adults||£150||1.6 million
|1 adult||£150||1.6 million
|1 adult + children||£150
|2 adults + children||£150
|2 adults||£116||1.6 million
|1 adult||£116||1.8 million
|1 adult + children||£116
|2 adults + children||£116
|2 adults||£83||1.0 million
|1 adult||£83||1.2 million
|1 adult + children||£83
|2 adults + children||£83
|2 adults||£50||0.2 million
|1 adult||£50||0.2 million
|2 adults + children||£50
|2 adults + children||£16
|1 adult||£16||0.1 million
6.6.3 In 1991 to achieve an income of of national average
income, adjusted for household size in the manner described in
"The Justice Gap", would benefit 18.8 million people
and cost £499 million a week, or £25.9 billion a year.
6.6.4 The adjustment to household size which would pay
two people living alone 20 per cent more than two people living
together, although based on valid cost of living data justified
in "The Justice Gap" can be philosophically criticised
as subsidising a voluntary life choice and practically as requiring
a draconian conhabitation rule to enforce. Without this adjustment
the cost would fall to £23.1 billion.
6.6.5 Since the money would be given to the poor it would
therefore be likely to be spent rather than saved. The Government
would raise £4 billion in VAT when the money was first spent,
reducing the net cost to £19 billion.
6.6.6 £19,000,000,000 a year in 1991 was a lot of
money. It was, for example about two thirds as much as the benefits
conferred on the richest 20 per cent of the population by tax
changes during the Thatcher years.
It was indeed slightly greater than the amount by which tax
was increased in the full year effects of Kenneth Clarke's November
6.6.7 It was therefore a large figure but a figure of
the order in which Governments can deal, if the priority be sufficiently
great. The package necessary to fund this measure would not be
beyond the means of a Chancellor of the Exchequer in a government
that was determined to make the abolition of poverty its main
contribution to history.
6.6.8 A Government willing to raise in extra taxation
sums similar to the full year effect of the November 1993 budget
would have needed only to trim £500 million from each of
six lower priority programmes in order to have been able to afford
6.6.9 Indeed even this combination of tax increases and
expenditure cuts may not be necessary as there would be scope
for reductions in public expenditure programmes that are made
necessary by poverty.
The cost of abolishing poverty today
6.6.10 Inflation since 1991 will have altered all the
intermediate figures in the above calculation and proportionately
altered the end result.
6.6.11 On the other hand the substantial fall in unemployment
and the introduction of the national minimum wage will have reduced
the size of the problem.
6.6.12 It would be nice to repeat the calculation but
the basic information has not been produced since.
6.6.13 We suspect however that it may not be greatly
different when the two effects set out at paras 6.6.10 and 6.6.11
are netted off.
The idea of a citizen's income
6.6.14 We believe that the simplest way to abolish poverty
is to give everybody who is willing to contribute meaningfully
to society (or is exempt from doing so by virtue of age or sickness)
a citizen's income of two thirds of the national average income
adjusted for the number of children so as to pay more to parents
and less to those without children using the household income
adjustments used in "The Justice Gap".
6.6.15 The costs of this system are:
(a) the costs of abolishing poverty, which we have calculated
(b) the costs of paying the money to people who do not
need it and then clawing it back in taxes. This is a purely circular
transaction which in reality costs neither the state nor the individual
anything. The mechanism for achieving it, however, need to be
thought about. It cannot, for example, be achieved through general
taxation without creating very high rates of marginal taxation.
We return to this practical issue later in this evidence;
(c) the costs of incomplete clawback resulting both from
restrictions on the proportions of earnings that it is possible
to claw back from low earners and the payment of citizen's income
to low earning members of high earning families.
The costs of incomplete clawback
6.6.16 For the cost not to exceed the shortfalls of income
below the baseline:
people whose income was previously below the level
of the new citizen's income would have to experience a clawback
of the whole of their previous income;
people whose income was previously above that
level would have to experience a clawback of the whole of the
citizen's income they receive. To the extent that this is not
feasible the cost would be greater than that calculated in the
6.6.17 Income derives mainly from four sources:
(i) welfare benefits and other state support to income;
(iii) investment, savings and private pensions;
(iv) internal transfers within households.
6.6.18 Upon the introduction of a citizen's income other
welfare benefits would be replaced by it and income previously
derived from such benefits would therefore clearly be effectively
6.6.19 Problems arise with the other forms of income.
6.6.20 Any form of income support faces the problems
of "earnings rules". It is unacceptable to leave a person
with no gain from income that they earn. However allowing them
to keep other income increases the cost of the benefit by increasing
both the number of people eligible and the amount that each receives.
6.6.21 From the chart in "The Justice Gap"
it is possible to estimate the total income earned by people below
the level proposed for citizen's income and to estimate the cost
of restricting claw back to particular percentages of those earnings.
6.6.22 Claw back from income is also subject to losses
due to tax evasion and tax avoidance but a system of citizen's
income is simpler than other forms of welfare benefit and probably
no more open to fraud or manipulation.
6.6.23 The further area in which clawback will not be
100 per cent effective arises from the citizen's income paid to
non earning members of households in which earnings are on average
above the baseline. It is possible from the chart to count the
total number of such people.
6.6.24 We calculated from the figures in "The Justice
Gap" that in 1991 the cost of incomplete claw back from having
only an 80 per cent earnings rule (more generous than current
welfare benefits) and not having a cohabitation rule would approximately
double the cost of introducing a citizen's income to a total of
6.6.25 Only dual high income households without children
would fail to benefit from the incomplete claw back. Most people
would be left no worse off by tax measures to cover it, and the
exception is a group well able to afford to contribute.
6.6.26 The greater security that people would enjoy with
a citizen's income would reduce the need for them to make provision
for their own old age or sickness and it would be appropriate
therefore to abolish the tax relief on pension contributions.
6.6.27 In 1991 that measure coupled with abolition of
mortgage interest tax relief would have covered the cost of incomplete
6.6.28 Clearly the situation has changed since and would
need to be reassessed. It is important to bear in mind however
that whatever tax changes are necessary to cover this cost they
are, for the population as a whole, circular and for individuals
they represent a redistribution from dual high income families
to low income families and average income families with children.
The Philosophical Case for Citizen's Income
6.6.29 We have asserted above that the ideal method for
the abolition of poverty is a citizen's incomethat is to
say an income paid as of right to every citizen, whether or not
they are considered to need help from the state. The sums paid
to those who do not require help would be recovered through the
tax systemthis recovery is usually called "claw back",
and this is the term we have used in this paper. For reasons which
we will discuss later we believe full payment should be dependent
on a meaningful contribution to society or exemption therefrom
on the grounds of sickness or age.
6.6.30 Having discussed the cost of such a system we
now address the philosophical basis for it.
6.6.31 Philosophically citizen's income can be justified
from right wing, traditional left wing, market socialist or centrist
standpoints. It is in fact one of the few social policy approaches
which can be so justified.
6.6.32 From a traditional socialist standpoint the underlying
concept is "to each according to his needs". In the
field of personal consumption it is difficult to plan to meet
the needs of the individual through a social agency. It is simpler
to allow individuals to judge their own needs within the resources
available. Therefore alongside those fundamental services and
commodities whose provision needs to be arranged by the state
there are other services and commodities which can legitimately
be left to a circumscribed form of market. As planner the state
must determine the extent of each individual's influence on that
market. A citizen's income represents the resources made available
to the individual for that purpose. In a truly communist society,
as described by Marx, this would be the only income the individual
would have and it would vary only with variation in need.
6.6.33 From a free market standpoint the underlying concept
is different. The problem is a conflict between the requirements
of the market in labour and the idea of the market as the hidden
hand for meeting the needs of people. A free labour market requires
that the cost of employing somebody should be the same as the
marginal value of their labour, however high or low that should
be. Allowing that to determine their consumption power is attractive
as a way of making the market entirely a closed system. However
it is unattractive if the market is to be presented as a way of
meeting human needs. There is no reason why the needs of human
beings should relate to the market value of their labour. The
idea that they should has the embarrassing effect that some people
will starve in order that the market be undistorted. It is relatively
simple to overcome this by acknowledging that people's consumer
input into the market is different from other inputs in that it
represents one of the purposes of the market, rather than simply
an intermediate transaction. People's income can therefore be
varied so that it is a transformed function of their market income
rather than their market income alone. The transformation must
be one that is based only on value judgements about the extent
of legitimate variation in consumer power, and not on anything
else. The transformed income is thus a function of human need
and the market value of the individual's labour (and investment
rewards etc). If the transformation involves only these functions
the market has not been distorted.
6.6.34 Thus far a right wing market theorist and a market
socialist would agree (except for the most rabidly fanatical right
wingers) but at this point they would diverge. A market socialist
would argue that since the ideal is "to each according to
his needs" the variation in income to be permitted should
be the minimum variation consistent with the effective operation
of the labour market. A right wing market theorist would argue
that since the ideal is a completely self contained market the
degree of redistribution permitted should be the minimum consistent
with the majority of citizens feeling comfortable that fundamentally
uncivilised states of existence were not being created. Either,
however, would see a citizen's income as the simple way of achieving
the transformation and the one to be preferred because it confines
the state to its legitimate role as redistributor and creates
no distortion beyond that.
6.6.35 From centrist social policy standpoints the philosophical
argument is different yet again. The relief of poverty is taken
for granted as a goal. The welfare state is seen to have as one
of its main problems the fact that it is disempowering. Citizen's
income is a form of relief of poverty which empowers its recipient
and confers no power on agents of the state.
The practical arguments
6.6.36 A citizen's income is the easiest form of welfare
benefit to administer. It requires no process of assessment, since
assessment is replaced by claw back which operates through the
ordinary tax system. For persons in employment payment can be
made through the employer and reclaimed by the employer as a set
off against PAYE, VAT and NI payments. For persons in voluntary
work or education in an organisation which has a payroll system
the organisation can administer payments to them through that
system as if they were employees. It is only necessary therefore
to set up a separate payment system for people who are not in
such a situation. These would mainly be people who would be in
receipt of benefit anyway and the flat rate payment would make
the system easier to administer.
6.6.37 The automatic universal payment without stigma
is much more effective than other benefit systems in ensuring
6.6.38 The system has positive economic effects which
are discussed in a later section.
6.6.39 It is sometimes argued that a citizen's income
will make it possible for employers to offer low wages. However
the main reason that we dislike low wage employment is that it
leaves people living in poverty. If an adequate income has been
provided otherwise low wages can be seen as a benefitmaking
the worker less dependent on his/her job and making job creation
Achievement of Claw Back
6.6.40 Clawback could be achieved by income tax, by national
insurance contributions or by wage adjustments recouped through
taxation of industry.
6.6.41 To achieve it through taxation personal allowances
would be abolished (the citizen's income having replaced them)
and a lower band of income would be introduced equal to the citizen's
income less the cash value of the personal allowance plus X%,
X being the "earnings rule" figure (the proportion of
low incomes not clawed back). We suggest X should be at least
20 per cent. This band would be taxed at (100-X) %.
6.6.42 It would be blatantly unfair to tax the lowest
band of income at a penal rate and then reduce it for higher bands,
but this would only embody the current impact of benefit withdrawals,
so that it would simply make an existing unfairness explicitindeed
if X were 20 per cent it would significantly ameliorate it. In
rendering it explicit and starting the process of amelioration
it may well pave the way for further gradual future resolution
of this injustice.
6.6.43 To achieve it through national insurance contributions
the contribution would be applied to all forms of income and increased
by whichever is the lesser of a flat rate equal to the citizen's
income or (100-X) % of actual income where X is the "earnings
6.6.44 This would be the simplest and least visible of
the options. If citizen's income for employed people were paid
through employers, this option would, for people whose salary
exceeds the citizen's income, appear simply as a book keeping
transaction. Identical sums would be credited to their pay slip
as citizen's income and deducted as a national insurance surcharge.
6.6.45 On the other hand precisely because it would be
so invisible to the majority of the population it might well fail
to capture hearts and minds effectively.
6.6.46 To recoup it through wage adjustments there would
be a once and for all statutory adjustment reducing all wages
by whichever is the lessor of a flat rate equal to the citizen's
(100-X) % of actual income where X is the "earnings rule"
figure. Taxation of industry would be increased to recoup for
the Exchequer the money which industry saves by this adjustment.
Anomalies in the labour market created by the adjustment would
subsequently be resolved over a period of time by collective bargaining.
6.6.47 This, coupled with abolition of the benefits that
a citizen's income replaces, would achieve claw back from people
who either have a single job as their sole income, or who are
dependent entirely on benefit, or who have a single job with a
wage exceeding the citizen's income.
6.6.48 It would not achieve full claw back from those
with pure investment incomes, self employed people, or people
with investment incomes and a wage less than the citizen's income.
6.6.49 It may achieve excessive claw back for those with
more than one job or those who derive their income partly from
a wage and partly from an abolished benefit.
6.6.50 Special provisions would need to be made for these
6.6.51 This would be the most complex of the methods,
the most visible, and the most sensitive.
6.6.52 It would, however, have the following advantages:
(a) by rendering explicit the very low sums which low
paid people retain from their wages it might well stimulate action
on low pay;
(b) by overtly introducing wage reductions and ensuring
that the money is recouped for the Exchequer it would prevent
employers covertly shifting costs to the Exchequer;
(c) by rendering available a large sum of money to be
withdrawn from industry by taxation it would open the way for
a new system of taxation to be introduced, for example one based
on social and environmental audit;
(d) if the taxation of industry were divorced from numbers
of people employed capital intensive industries would have to
make their full contribution to sustaining the standard of living
of the population, and this would benefit labour intensive industries;
(e) by reducing the cost of labour to the employer it
would stimulate job creation;
(f) the reduction in the cost of labour would reduce the
cost of public services. Public services would be treated as part
of industry and the money saved recouped by budgetary reductions
in lieu of taxation. Without in any way affecting real levels
of public spending this would diminish substantially the headline
proportion of GDP spent on public services. However capital intensive
industries are to bear a greater part of the burden of supporting
the population and labour intensive industries are to benefit
correspondingly. The public services would fall in this category
and would therefore retain some of the windfall savings as an
increase in real budgets. Hence real budgets would rise and headline
proportion of GDP spent on public services would fall;
(g) by involving everybody in the process of introducing
the new system it would make very clear that change had occurred;
(h) because this system would alter the way that employers
and employees perceive wage rates, and because its reversal would
be as complex as its introduction, it would be much more difficult
(i) once people had adjusted to the once and for all wage
reduction this system would not entail high rates of visible deductions
from income. It would entail high rates of taxation of industry
but this would be matched by low labour costs. It would also entail
sharp contrasts between British and overseas wage rates but these
would be made up for by the citizen's income.
6.6.53 It would be possible to combine these methods,
each being applied only to the extent necessary to achieve a proportion
of the claw back.
6.6.54 For example if it were thought to be unreasonable
to tax the lowest band of income at more than 40 per cent, or
to increase national insurance contributions by more than five
percentage points, the proportionate contribution of taxation
and national insurance as claw backs could be limited accordingly
and wage adjustments/industrial taxation used to make up the difference.
6.6.55 Whilst this would combine at least part of the
benefits of each method and dilute their disadvantages it would
also be unnecessarily complex, and would, at least partially,
dilute the benefits of each as well as the disadvantages.
The Economic Effects of a Citizen's Income
6.6.56 The introduction of citizen's income is not simply
a social policyit is a significant package of economic
(i) The system itself is a redistribution of income to
(ii) It also represents substantially increased security
which may diminish people's need to save.
(iii) Greater security is likely to alter people's attitude
to work. People would have more freedom to choose to make their
contribution to society through voluntary work or creative activities
rather than through paid work.
(iv) This in turn will shift the balance of the labour
market in low paid work. If the loss of such work represented
a much smaller fall in the standard of living of the individuals
involveda loss of the jam rather than of the butter and
half the breadit would be less likely that people would
accept dangerous or unpleasant working conditions or work systems
which lack dignity.
6.6.57 The above changes are implicit in the system of
citizen's income however it is organised. There are five further
economic effects which might or might not occur dependent upon
the claw back methods used.
(v) If the opportunity is taken to adopt a claw back rate
for low income significantly less than that in current welfare
benefit earnings rules the poverty trap is eliminated and an incentive
to work created.
(vi) If the opportunity is taken, as part of the process
of funding the citizen's income, to abolish certain tax reliefs
which are generally acknowledged to be distorting a simpler tax
system is created.
(vii) If the citizen's income to homemakers without paid
work is paid directly and recovered from general taxation, rather
than clawed back in any specific way, there is a shift in the
balance of economic power within the families affected comparable
to that of a "Wages for Housework" policy.
(viii) If the opportunity is taken to shift labour costs
from wages to taxation and then to divorce that taxation from
numbers of people employed there is also a fall in the marginal
cost of labour. This would benefit labour intensive industries
at the expense of capital intensive industries.
(ix) If the new system of industrial taxation necessary
for the above point is a system which embodies social audit it
will benefit socially responsible industries at the expense of
socially irresponsible industries.
6.6.58 In considering the economic effects of a citizen's
income it is therefore necessary to consider;
(a) the economic effects of redistribution of income to
(b) the impact on the incentive to work;
(c) the creation of incentives to "socially useful"
rather than "wealth producing" activity;
(d) the effect on the competitiveness of British industry;
(e) the effect on the pattern of investment.
6.6.59 Conventional views would hold that;
(a) the redistribution of income to the poor would be
damaging to incentives;
(b) the reduction in the impact of non employment would
produce a disincentive to work and an increase in parasitism;
(c) a shift of labour from the production of goods to
socially useful activity would produce a burden on the wealth
creating sector which ultimately would diminish the power of society
to pursue social goals, thereby more than eliminating the apparent
social gains from socially useful work;
(d) Britain cannot afford a system which imposes on its
employers burdens that its competitors do not impose;
(e) any shift in the pattern of investment produced by
this package of economic adjustments would be a market distortion
and therefore of net disbenefit.
6.6.60 We believe that these conventional views are in
each respect wrong.
6.6.61 We believe that the relief of poverty and the
promotion of greater economic security can be an engine of economic
growth by increasing consumer spending. Consumer confidence will
be increased and the needs of the poor will be expressed as demand
instead of lacking expression on the market.
6.6.62 This is an unashamedly Keynesian position. Keynesian
policies were based on the belief that in a state of recession
the injection of money into the economy would produce growth rather
than inflation. The money would correct an artificial shortage
of demand and thereby stimulate the economy to produce the wealth
necessary to back the money that had been injected. This belief
has been widely abandoned because of its failure in the 1970s.
Implicit in Keynesian theory was the idea that the money injected
would be spent on meeting the real needs of real people. Indeed
the mechanism by which Keynesianism successfully worked for over
a quarter of a century was to pay people to undertake programmes
of public works, or other programmes of social value, thereby
both meeting a social need and also turning into demand the needs
which those people were unable to express as consumers whilst
unemployed. Keynesian theory assumed that money injected into
the economy would be spent. And when it was given to the poor
this was a fair assumption. Unfortunately this assumption was
not made explicit and the idea began to develop that any method
of injecting money into the economy would have the same impact.
Reducing taxes on the rich, or spending money on subsidies to
produce things that nobody wanted were thought to be just as valid
a way of injecting money. All that was necessary was an unbalanced
budget, and since the poor had ceased to be a high political priority
these other methods were, on the whole, preferred. It is hardly
surprising that money given to the rich will be more likely to
be saved than spent. This simple common sense statement is only
rendered inexplicable when it is turned into the language of economists
and called a "shift in the savings ratio", which sounds
like something weird and unpredictable, and can therefore be presented
as some mystical flaw in the Keynesian idea. Since "unpredictable
shifts in the savings ratio" is the explanation given for
the failure of Keynesianism in the 1970s we would advance the
proposition that money given to the poor will be spent not saved,
and that it has always been true that giving more money to those
who cannot afford to express their needs as demand will lead to
increased demand. This is why Keynesianism worked for a quarter
of a century and it was not Keynesianism that failed in the 1970s
but some silly caricature of it.
6.6.63 It should also be borne in mind that greater security
of income will also lead to a greater consumer confidence. There
are many people who can today afford to buy things that they need
but do not do so for fear that they may lose the jobs and need
the money as savings. Greater security will strengthen their willingness
6.6.64 One of the objections to a citizen's income is
that it will diminish the incentive to work if people can live
an acceptable lifestyle without doing so. This principle is as
old as the Speenhamland system. It has been the cause of a great
deal of gratuitous cruelty in British social policy over many
years from the harshness of the workhouse in the 19th century
to the inhuman administration of the income support system today.
6.6.65 The contrary proposition is that on the whole
people will choose to work because work gives rise to social status,
to the structuring of time and to social interaction and because
people have a strong need to be of value to society. Entrepreneurs
and professionals continuing their work long after they have earned
enough to retire, voluntary workers, people working for pay barely
higher than the dole, and women who choose to work even though
the bulk of their income is spent on childcare are all sources
of data for the concept that people will choose to work. Little
data has been advanced to support the proposition that people
are inherently lazy, and the examples of such laziness are usually
isolated examples of individuals who are deeply alienated from
society, often for reasons that are not difficult to understand.
6.6.66 A citizen's income would have little impact upon
the incentives to work of those whose incomes are high since it
would form only a small part of their income. And for those whose
incomes are low the elimination of the poverty trap would in fact
be an increase in work incentives.
6.6.67 In any case it would be desirable to build into
the concept of a citizen's income a system which created an incentive
to engage in a meaningful contribution to society through making
part of the income dependent on such a contribution. Voluntary
work and formal education could be incorporated by treating them
as employment at zero wages. Housework could be incorporated by
allowing excess hours worked by one member of a household to be
transferred to other members of the household and by making allowance
for carers and parents. It would be necessary to work out some
system for incorporating informal education and creative activity.
Unemployed people could qualify for the full payment by engaging
in voluntary work or education. People who are sick or above retirement
age would be exempt from the obligation to contribute to society
and would receive the full payment automatically.
6.6.68 The differential between the level of citizen's
income payable as of right and that payable only to those engaged
in a meaningful contribution to society could be adjusted until
the proportion of the population electing for the lower payment
achieved a fixed figureperhaps 5 per cent, perhaps 1 per
centor until the differential was completely eliminated
without this figure being exceeded. If we are right in our belief
that people would normally choose to contribute to society the
differential would become small or non existent. If we are wrong
this system would automatically accommodate for that situation.
6.6.69 If voluntary work became an acceptable way to
contribute to society and was linked to an acceptable citizen's
income it is likely that it would increase. To the extent that
it substitutes for unemployment this would be an extremely positive
step both for the individuals concerned and for society as a whole
which would benefit from their work. To the extent that it substitutes
for paid employment there might arise the question of whether
this deprives industry of needed workers.
6.6.70 Goods and services produced by industry are not
the only source of well being and the benefits produced for us
all from the increased voluntary work would need to be weighed
in the balance against any lost production.
6.6.71 But in any case the amount of such lost production
is probably exaggerated.
6.6.72 The fact that individuals have the choice of voluntary
work rather than employment would alter the nature of managerial
relationships at the lower end of the labour market. No longer
would workers be compelled to accept undignified, dangerous or
unpleasant work for fear of losing the source of their basic standard
6.6.73 Managers would need to change their approachattracting
workers by paying attention to their needs and creating pleasant
and inspiring working conditions.
6.6.74 For too long British management has been featherbedded
by outdated concepts of managerial authority and by an attitude
that sees safety and quality as unnecessary costs. This attitude
represents a subsidya subsidy paid with our environments,
and with the health of workers. Like all subsidies it drives out
better quality investment.
6.6.75 The shift in attitudes towards investing in people,
in safety and in quality go hand in hand. They will be overwhelmingly
beneficial to British industry and the shoddy unsafe back street
sweat shops that go out of business will not be missed.
6.6.76 It is important to appreciate that the so called
burdens of tax and labour costs upon industry in fact represent
the mechanism by which society draws the benefits of wealth creation
in terms of social improvement and individual living standards.
It is therefore rather irrational to increase wealth creation
by diminishing the enjoyment of that wealth.
6.6.77 Even ignoring that point, however, we challenge
the idea that the package of changes produced by a citizen's income
would in any way diminish the overall competitiveness of British
6.6.78 The competitive position of British industry is
not determined by any particular single burden but by the total
of the burdens upon it. The total tax and labour costs imposed
upon the whole of British industry will alter under our proposals
only by the £19 billion necessary to abolish poverty and
even that only to the extent that this burden is imposed upon
industry rather than achieved by redistribution of wealth, and
even then only to the extent that we are wrong in our belief that
it will be offset by Keynesian growth.
6.6.79 It is true that some of the models we have discussed
would increase the burden on some industries. But if the burden
as a whole is unchanged this means that other industries would
6.6.80 It might even be argued that if the distribution
of burdens in this country differs from that in other countries
there will be more companies in other countries which experience
an incentive to relocate to Britain than there would be companies
in this country experiencing an incentive to relocate out.
6.6.81 A system which:
lowered wages and hence the marginal cost of labour;
correspondingly increased the burden of taxes
on industry so that the overall tax and labour cost burden was
distributed the extra tax burden according to
would benefit socially undamaging labour intensive
industries such as personal services, public works or craft industries;
adversely affect socially damaging capital
intensive industries such as highly automated polluting industries
(nuclear power for example);
have mixed effects on labour intensive socially
damaging industries, such as smokestack industries. Lower wages
would benefit them, social audit would harm them, but there would
be a pressure to realise the benefits by eliminating the source
of the social charges. Improved environmental and social impacts
would replace redundancies as the main way to reduce costs and
gain competitive advantage;
have a neutral effect on capital intensive
socially undamaging industries such as electronics.
6.6.82 We see no reason to suppose that this shift in
the balance of economic activity would adversely affect the standard
of living of the British peoplecertainly any effects would
6.6.83 Whatever marginal impacts there might be on the
standard of living there would be overwhelming positive effects
on the quality of life.
7. MULTIDISCIPLINARY PUBLIC
7.1.1 There is much discussion at present of multidisciplinary
7.1.2 Public health is practised at several levels. Firstly
there are those whose work improves health but who do not need
to perceive the broader public health picture or even to recognise
it. This group ranges from binmen to firefighters to health professionals.
Secondly there are those who carry out a specific health improving
function, and need to know how it fits into the broader picture,
but who do not need to concern themselves with matters outside
their own function. Teachers including health education in their
materials, those who operate a screening programme, or exercise
promotion staff would fit into this category. Thirdly there are
those who concern themselves with the totality of a particular
health problem and fourthly there are those whose job is to maintain
the operation of the entire public health system. The third and
fourth groups are appropriately called public health professionals.
7.1.3 There are a number of different groups of public
health professionals and the relationship between them and the
way they work together needs to be addressed.
7.1.4 This is often presented as bringing all the public
health professions together into a single new profession.
7.1.5 Often however discussion excludes some key professions,
such as public health nursing and environmental health, and seems
to do little to preserve the traditions of any of the professions
or to recognise their different perspectives.
7.1.6 We believe that multidisciplinary public health
should mean a family of professions, each with its role and proud
of its traditions. It should not mean mashing the different professions
together into a soup tasting of the lowest common denominator.
As outlined in section 5.3 each of the professions has distinctive
traditions, strengths and contributions. There are examples of
the functioning of public health as a multidisciplinary family
in some leading edge public health departments.
7.1.7 In this section of our evidence we:
restate our commitment to multidisciplinary public
summarise the traditions of the different public
argue that each of these traditions is important
and that attempting to merge them in a single professional group
is unlikely to enhance them
suggest that there are better ways to improve
the career prospects of non medical public health professionals
outline our belief in a family of public health
suggest that it would be sensible to establish
mechanisms for transfer between these professions
7.2 Our Commitment to Multidisciplinary Public Health
7.2.1 The MPU has a long tradition of support for team
working between the different health professionals. We are the
only medical organisation to be part of a wider trade union representing
a range of health professions. We have long advocated simpler
interchange between health professions including the power of
exceptional licence included in our proposed Public Health Act.
7.2.2 As long ago as 1980, long before it was fashionable,
we advocated improved career structures for non medical public
7.2.3 We remain firmly committed to the belief that a
range of professions have key roles in the public health endeavour.
7.3 The Traditions of the Public Health Professions
Public Health Medicine
7.3.1 Research by the BMA has shown that the majority
of public health doctors perceive themselves as change agents
and entrepreneurs for health and chafe at the restrictions of
7.3.2 Other research has shown that local authorities
value the decisive and authoritative nature of advice from public
7.3.3 Doctors remain one of the most trusted of professions
in opinion polls even after a somewhat unfortunate period. One
of the reasons for this is that doctors have a strong tradition
of independence and honest advice.
7.3.4 Public health doctors are able to discuss health
service issues with other doctors from the basis of a shared professional
7.3.5 The medical profession is at times an assertive
and single minded body of people. Outsiders might even call it
unreasonable. George Bernard Shaw pointed out that reasonable
people accommodate to the world and unreasonable people expect
it to accommodate to them, so all change is brought about by unreasonable
people. Single minded assertiveness is needed in public health
at any time. The very existence of public health medicine has
been under attack for 150 years (as our early quote from "The
Times" about Dr. Snow points out) and it will be under attack
for a further 150 years because it speaks for a social value that
many would wish to ignore.
7.3.6 We believe that public health doctors are, by virtue
of their professional standing, training and traditions, equipped
be the advocates for public health in those settings
where it is important that the individual be trusted as a doctor
rather than as a public official and should have a background
of honest assertiveness
be the advocates for public health within the
be uniquely qualified to carry out needs assessment
as individuals since they bring with them an understanding of
disease and medical practice. Professions without this background
need to work in teams where the clinical background is supplied
be well placed as an honest broker between primary
and secondary care clinicians in implementing the clinical modernisation
which is at the core of the NHS Plan.
Public Health Nursing
7.3.7 Health visitors originated in the local authority
health departments as lady sanitary inspectors. There was for
some time in the early years of the century a debate as to whether
they should be nurses or simply specialist sanitary inspectors,
a debate which nursing won.
7.3.8 For many years health visitors practised as public
health practitioners working within the setting of the home. They
came to have an understanding of the place of families and communities
both as sufferers from ill health and as potential agents for
7.3.9 In the 1980s and early 1990s health visitors were
increasingly forced to conform to concepts of nursing which underplayed
their public health traditions and saw them in many ways as some
kind of specialist children's nurse.
7.3.10 Despite this their representative organisation,
the Health Visitors' Association (now Community Practitioners'
& Health Visitors' Association) continued to be a mainstay
of the public health movement and student health visitors continued
to be taught public health skills. A number of experiments in
the 1990s demonstrated that these skills could still be used in
fields like community development or neighbourhood public health.
7.3.11 This understanding of public health at the grass
roots is the key contribution that public health nursing brings
today to public health.
7.3.12 Their standing in the primary care team and in
the nursing profession is also an important contribution.
Health Promotion Specialists
7.3.13 Health education was a relatively low status activity
in the pre 1974 system and one of the few benefits of the 1974
reorganisation was that the NHS established Health Education Departments
which developed into Health Promotion Departments.
7.3.14 The original professional skill of this professional
group lay in marketing and in lifestyle modification and they
still carry the greatest expertise in this aspect of the public
health body of knowledge.
7.3.15 Ultimately however Health Promotion Departments
grew beyond the original role in health education and came to
be the focus for the organisation of health promotion programmes.
7.3.16 This skill in programme management neatly complements
the predominantly visionary and entrepreneurial skills of the
public health doctors and the practical grass roots professional
skills of the public health nurses.
Environmental Health Officers
7.3.17 We have discussed the history of environmental
health in section 3.5 of this evidence.
7.3.18 In that section we pointed out that environmental
health officers bring a perspective to public health based on
the technical assessment of hazards and the use of enforcement
of legislation to control them.
Public Health Scientists
7.3.19 The academic discipline of social and preventive
medicine was one of the founding disciplines of public health
medicine. It brought with it to public health a world renowned
standing for British epidemiology and British medical sociology.
This has contributed to the academic rigour and analytical skills
of public health medicine.
7.3.20 Social and preventive medicine was a multidisciplinary
speciality comprising public health doctors, other academic disciplines
and clinical specialists who carried out epidemiological research.
Only the first group were found a place in the new medical speciality.
7.3.21 As a result a significant academic tradition has
been left separated from the scope for practical application and
separated from a significant group of its practitioners.
7.3.22 The Faculty of Public Health Medicine is now belatedly
bridging the gap.
7.3.23 Clinical specialists carrying out epidemiological
work were another group affected by the way the 1974 reorganisation
tore apart a British academic success story.
7.3.24 The tradition of all doctors concerning themselves
with public health issues is a valuable distinctive feature of
British medicine. It needs to be built upon.
7.3.25 There is also scope for clinical epidemiology
in other health care professions.
7.3.26 Settings should be established in which clinicians
who have been trained in certain public health skills can apply
that knowledge within fields directly relating to their own clinical
Cardiologists who contribute to control of heart disease
or dieticians who contribute to food policy would be examples.
(In the case of dietetics there is also a need to involve nutritionists
as well as dieticians).
7.3.27 A great deal of work has been done in academic
departments on resource optimisation in health services but it
has had virtually no systematic application within the NHS.
7.3.28 In recent years local authorities have developed
structures for addressing environmental initiatives such as Agenda
21 or sustainability. These initiatives are central to public
health. A new professional group is emerging with considerable
skills in these areas. This group moves beyond the technical enforcement
oriented perspective of environmental health and is more visionary,
long term and policy-oriented. Although a variety of names have
been used we call this group "human ecologists".
7.4 Why Creating a Single Public Health Profession Will
7.4.1 No one person is capable of fully grasping the
full range of perspectives that the above traditions draw together.
If we try to create a single public health profession there is
a danger that all these rich traditions will be impoverished.
7.4.2 More likely some will dominate and some will lose
7.4.3 There is some uncertainty as to whether the Government
has entrusted the creation of a single public health profession
to the Faculty of Public Health Medicine or to the Health Development
Agency. Each can point to clear statements entrusting it with
7.4.4 The HDA, entrusted with a task of developing the
public health workforce, is approaching the task through a process
of skills audit and vocational development which we believe has
a bias that could ultimately base public health practice on the
principles of health programme management. This could disempower
other perspectives and seriously damage independent professional
7.4.5 The Faculty of Public Health Medicine, entrusted
with developing standards for public health specialists, is approaching
the task through a process of professional development which we
fear could ultimately base public health practice upon the underlying
principles of public health medicine. Ultimately therefore it
could peripheralise other perspectives, in which case it would
reinforce medical hegemony by allowing a few non doctors to join
7.4.6 It would be a disaster if either of these projects
were to have the effects that we fear.
7.4.7 It would be even more of a disaster if the fall
out of them coming into conflict, as they inevitably will, were
to embitter relationships between traditions which should complement
7.4.8 We note the concern of the Royal College of Nursing
that public health nurses are being excluded from this process.
They are indeed. In fact they are being generally ignored, or
referred to as support workers.
7.4.9 We resent this. These are valued colleagues of
ours, whose perspective is as important as ours and who are needed
to complement us.
7.4.10 We regret however that the RCN has chosen to enter
the fray by advocating that public health be reshaped along a
grass roots perspective. We wish that instead of entering the
fight they had thrown a bucket of water over it.
7.4.11 Environmental health officers are also being ignored.
7.4.12 We believe that the attempt to create a single
public health profession should be abandoned forthwith and we
should concentrate rather on glorying in the diversity of the
different and complementary traditions.
7.5 The Career Structure for Non Medical Public Health
7.5.1 An important factor in the drive to demedicalise
public health is the poor career structure for non medical public
7.5.2 This needs to be addressed but there are simpler
and better ways which do not involve destroying old traditions
in the process.
7.5.3 We believe that for most public health doctors
the natural pinnacle of their career will be the role of County
Medical Officer or Borough Medical Officer which we have described
in our main evidence as taking over the professional functions
of a Director of Public Health.
7.5.4 We believe that for most public health nurses,
environmental health officers and health promotion specialists
their ambition would be to head their profession within the new
Health Act partnerships that we envisage PCTs and local authorities
forming. These form valuable and important roles heading up key
perspectives of the public health endeavour.
7.5.5 Beyond these uniprofessional posts, custodians
of a key part of the public health heritage, the post of Director
of Public Health of a health authority could, once its specifically
professional medical functions had been transferred to the County
and Borough Medical Officers, be a multidisciplinary post needing
doctors in the team but not necessarily in the lead. And all public
health professionals could legitimately aspire to be Chief Executive
of a health authority.
7.5.6 The post of Professor of Public Health is appropriately
open to medical and non medical public health scientists alike
and so should be the senior research and health analysis posts
in the regional and health authority tiers of the NHS which we
believe to be the natural leadership roles for public health scientists.
Networks need to link these leadership roles with people working
on research and analysis at local level. A clear career path can
be created using the clinical scientist grading structure, the
most senior points on which are generally acknowledged as consultant
7.5.7 This is a much more effective way to overcome the
career structure problems that have led to the demand for a new
7.6 A Family of Public Health Professions
7.6.1 There are two models of multidisciplinary public
health. The model in which all the professional groups are mashed
together into a liquefied traditionless mass we call the public
health soup model. Our model is the model of a family of public
health professions, respecting each other's complementary skills
and glorying in each other's histories, successes and traditions.
7.6.2 We share this model with the BMA, but we may differ
from the BMA when we say that this family should not have a head
profession, but that the different professions are complementary.
7.7 Transfer Between Professions
7.7.1 Although the priority at the moment is to restore
the traditions of each professional group, we have always argued
that there should be flexibility in interprofessional relationships
and there should be scope to transfer between the different health
professions, with appropriate additional training but with recognition
for the knowledge and skills already acquired. This should apply
in all health professional areas, including public health.
7.7.2 Elsewhere in this evidence we have argued for the
GMC to have a power of exceptional licence for individuals who
are able to practice appropriately in a specific field of medicine,
and we have argued for the UKCC to reopen the non nursing route
of entry to health visiting. This would ensure that public health
professionals wishing to retrain in public health medicine or
public health nursing need not return to the very start of medical
and nursing careers. We envisage similar arrangements elsewherefor
example, rehabilitation, so this should become an exceptional
but not abnormal route into professional practice.
7.7.3 If proper career structures are established in
all the public health professions we believe that interprofessional
transfer will be highly exceptional.
7.7.4 It is worrying that non medical public health professionals
prefer to seek access to the work of public health doctors than
to develop their own complementary and equally important and challenging
roles. This is understandable given the different career structures.
However there is no other rationale for it and it should be seen
as the consequence of a failure to develop other professions rather
than as an aspiration that has value in its own right. The solution
is a proper career structure in all areas of public health practice.