Interview

Frank talking on health inequality

After the storm over the possibility of patient charges, what else does Labour’s health team have in store? Secretary of State Frank Dobson spoke exclusively to healthmatters on the new emphasis in government health policy

exclusive interview

Health inequalities are now high on the political agenda and the promotion of public health has moved centre-stage in Department of Health thinking. In a decisive break with the past, the new Labour government clearly recognises the importance of reducing inequalities in income, housing, employment and education in improving the nation’s health, secretary of state for health Frank Dobson told healthmatters.

The health secretary also signalled his desire for closer working on health and social care, as well as on public health, between health authorities and local councils. And, in continuity with the Primary Care Act passed in the last days of the previous government, he expressed strong support for new multi-professional pilot schemes in primary care.

Mr Dobson was Labour’s surprise choice for the health portfolio. With his only shadow experience in the role back in 1982-87, some doubted his suitability for the job. But there are signs that his extensive opposition experience in education, transport and the environment will give a radical edge to public health policy which may yet confound his critics.

‘The Tories complained about the concept of “political correctness”, but no officials here were allowed to use the words “inequalities in health” – they were to be called “variations”,’ he told healthmatters.

Coming from Yorkshire, the new health secretary is clearly a man who calls an inequality an inequality – and in future, so will the Department of Health.

‘For the first time there will be a minister in this department whose responsibility is exclusively public health’, he says. ‘We’ve got to get it into the heads of people in the department that public health, and dealing with inequalities in health, are part of the mainstream functions of the Department of Health.’

‘It’s an absolutely central function of the Department of Health – and it’s going to be an important function of every other government department – to try to make sure that people live healthier lives, work in healthier workplaces, walk down healthier streets.’

With only two months in the post, it is still too soon to say how much influence the new minister of state for public health, Tessa Jowell, will actually be allowed to exert across Whitehall on, for example, policies on public transport or social security. But Mr Dobson is optimistic about the possibilities.

‘The most significant thing is that the prime minister is very, very, very keen on making sure that we do promote public health and we do put a big effort into reducing inequalities in health,’ he emphasises. ‘So other departments know it would be wise for them to respond when we are raising things with them.’

One of Labour’s pre-election commitments was to launch a revised Health of the Nation strategy to coincide with the fiftieth birthday of the NHS in 1998. But this time, the strategy will recognise the significance of poverty and inequality in producing ill health. In contrast with the previous regime, the new health secretary has a broad view of how government can help to improve health, which goes well beyond exhortations to eat well, take exercise and stop smoking.

‘We are committed to allowing councils to, in effect, invest the takings from the sale of council houses in building new homes. That will undoubtedly result in substantial improvements in the health of the people concerned.’

‘The commitment to a national minimum wage should improve the health of those people whose pay will increase as a result.’

‘My understanding is that one of the few groups where the death rate has increased in recent times is young males and that is, in part, associated with unemployment. When we get those young people into work, then we need to be testing what’s happening to their health as a result.’

After 18 years during which the idea of any relationship between income and health was constantly downplayed, New Labour’s new honesty is a palpable and refreshing break with the past.

But when it comes to how the Department of Health can take a lead in promoting better health, a clear policy direction has not yet emerged. What, for example, should be the role of the Health Education Authority?

‘My impression of the HEA is that since it became the HEA it’s not been as effective as it was before,’ says Mr Dobson. Ironically the forerunner to the HEA, the Health Education Council, was abolished in 1987 by the Conservatives after the publication, by then director David Player, of The Health Divide, a highly critical report on widening health inequalities in Britain.

‘We can’t farm out improvements in public health to the HEA. The HEA, or some body like it, has clearly got a function as a centre for pushing out the word, as a focus for promoting health.’ Yet Mr Dobson clearly regards the HEA’s public health role as a limited one.

Many would see local government, with its responsibilities for housing, economic regeneration, environmental health, local transport policy and education, as potentially a key player in effective action for public health. And the government also now seems to agree. ‘We are proposing that local authorities, eventually, will be given a basic responsibility for promoting the economic, social and environmental well-being of their areas – and clearly health comes into that.’

But, historically, the public health role of local government has dwindled and relationships between the health service and councils at local level have been fraught with difficulties. Is change on the cards?

‘I start off on the assumption that we do need to change the relationship,’ he says. ‘I do think local councils need a bigger role in this.’ But the old model of simply reserving a few places on the health authority for interested councillors was never much of a success. ‘Technical liaison was never a function for councillors. We’ve got to make it work at officer level.’

And Labour seems receptive to ideas about how the health-local government axis could be strengthened. What about the idea of joint public health/health promotion commissions? ‘We are open to suggestions’, Mr Dobson says.

He also feels there needs to be a new look at the troubled interface between health care and social care, which has caused so many problems for providers – and users – in the past. ‘We need to address the problem of the artificial boundaries, particularly for people receiving care rather than treatment. There isn’t much of a logic to the boundary between what the NHS provides, what local councils provide and what, in some cases, the voluntary sector is providing.’

Pooled health and social care budgets have been suggested as one way forward, and Labour’s preferred model of locality commissioning as a replacement for fundholding might allow such a development.

‘We expect that commissioning will replace fundholding. It will also replace non-fundholding,’ he says, emphasising that all GPs will be involved, and that locality commissioning will be multi-disciplinary, and not necessarily doctor-led. Labour’s moves to defer the next wave of fundholders for a year, and to increase the financial risks of fundholding for individual practices, suggest a careful strategy to take the political heat out of the fundholding battle and allow it to wither of its own accord.

Yet the future organisation of primary care itself, as distinct from the commissioning of secondary care, remains hazy with no grand plan in evidence. Apart from fundholding, Labour seems happy to follow the direction set by the 1997 Primary Care Act.

Mr Dobson is a pragmatist when it comes to primary care development: ‘I don’t believe there is one formula, one model, which will succeed in every part of the country,’ he says. ‘What we need to be looking at is the quality and the outcomes, and the method of delivering it is much less significant.’

He welcomes the emphasis on innovation and experimentation in the organisation of primary care, and general practice in particular, ushered in by last autumn’s white paper Choice and Opportunity, but warns that he will not be encouraging ‘wholesale, untried change’ which is ‘the last thing the health service wants’.

Mr Dobson also accepts the inheritance – for the time being – of another aspect of Tory policy in the NHS, the Private Finance Initiative.

‘We’ve inherited more than 60 allegedly PFI schemes, some of which are clearly not a priority from the health service’s point of view, or “do-able” by the PFI approach. And so what we’ve decided to do is to try to prioritise things and to standardise the process.’

Though Labour policy unambiguously accepts the PFI in general, its application to the NHS remains fiercely controversial outside – and perhaps within – the party. But here again, the health secretary must remain pragmatic.

‘We are in the position now where, if we want to get ahead with a number of hospital schemes, then basically the PFI is the only show in town,’ he admits. ‘I don’t think that most people in the places where PFI schemes are nearest to coming to fruition are likely to reject them.’ Yet he seems to hold little enthusiasm for the policy.

‘For some time to come the hospital schemes are going to come either via the PFI model, or not at all, and so we’ve got to do it that way. We’ve got to accept that it can build certain inflexibilities into the system and it certainly will add to the revenue costs, because the cheapest way of building a hospital is by building it with the capital coming from public funds. There’s no doubt about that. So we’ve got to accept there is the downside of increased revenue costs in the future.’

But is there a risk that bringing private capital into the NHS hastens the drift of health care into the private sector? ‘No – it isn’t the thin end of a privatisation wedge,’ he insists.

While the PFI may represent an uncomfortable continuity with Tory policy, Mr Dobson’s strong belief in the importance of an active role for government – both national and local – in public health promotion, and willingness to tackle health inequalities head on, marks a clean break with the previous regime which is sure to bring smiles to the faces of health professionals and campaigners up and down the land.

As will Mr Dobson’s personal philosophy of health service reform: ‘The best way to succeed with the health service is to engage the full-hearted commitment of the various professions. I do think that what we are trying to do, at all stages, is to command the support of the people who have got to do the work’.