Select Committee on Health Minutes of Evidence


   (Jennie Popay is Professor of Sociology and Health Policy, at the Nuffield Institute for Health, University of Leeds. She has recently taken up this post having previously directed the Institute for Public Health Research and Policy at the University of Salford).


  Britain has a long and distinquished tradition of research into inequalities in health. However, there remain major "gaps" in this literature: knowledge gaps; theory/explanation gaps; process and application gaps.

Knowledge gaps

  It is increasingly common for people to argue that resources should shift from fundamental/basic research towards research aiming to evaluate interventions, but this view is misplaced:

    —  There are important gaps in our knowledge about the causes of inequalities that need to be filled before we are in a position to develop appropriate and effective interventions. This is particularly the case in relation to social interventions focused at the level of communities. For example, we know quite a lot about how a "sense of control" can protect individual health. We know much less about the ways in which collective efficacy at a community level might impinge on population health. Similarly, our understanding of the relationship between the places in which people spend their lives and health inequalities remains limited. Without a better understanding in this latter area, major policy areas such as those concerned with regeneration will at best have little impact on population health at worse they may increase inequalities.

    —  The distinction frequently drawn between basic and applied research is too simplistic. There is considerable scope for increasing the "applicability" of basic research by changing the way in which basic research is done to enable a more constructive dialogue between researchers and those who could use the evidence generated.

Theory/explanation gaps

  Scientists need to give more attention to the development of theories, which have utility for policy and practice. It is particularly important that our explanatory models capture the complexity involved in the genesis of inequalities. In particular, there is a need to "put people" and their personal and social histories in the frame as active agents rather than passive victims. Early public health research in the 19th century was rich with the expertise of "ordinary" people. As we enter the 21st century we need to revisit this tradition— to "privilege the voice of experience" as E P Thomson argued. Until recently risk factor epidemiology, for example, with its emphasis on statistical work exploring the relative contribution of what can be a bewildering array of risks has dominated this field. This type of work can contribute little to our understanding of the complex processes and interactions involved. The lifecourse approach has much greater utility, giving prominence to the notion of accumulated risk whist accepting the notion of "predisposition" exemplified in Barker's programming hypothesis. This approach to explanation helps to highlight key points for interventions to have maximum effects pointing, for example, to early childhood and the health of women as especially critical.

Press application gaps

  Research in the UK, in the public health arena as much as elsewhere, is elitist. The process of designing and conducting research typically excludes those who are the potential users of the product until the final stages of "dissemination". The policy of major funders of health inequalities research, such as the MRC, ESRC, the department of health and the NHS R&D directorate reinforces this "culture" informed as it is by a problem-solving model of the research/policy interface. A potentially more fruitful way of conceptualising this interface is as a relationship involving on-going dialogue between researchers and research users at all points in the research process.


  The Acheson Report provides an important and welcome contribution to the development of a coherent and holistic strategy to reduce inequalities in health. However, there are important limitations to the specifics of the report, as well as the general approach, which need to be addressed.


  Acheson, and much current public health practice, focuses on the implementation of projects which seek to change specific risk factors, be they aspects of lifestyle, such as diet or sexual behaviour, or structural factors, such as low income. This pre-occupation with projects is partly driven by the limitations of current evaluation methods. Arguably, it is also driven by limitations of imagination and the tyranny of evidence based medicine. We need to develop new innovative approaches to the evaluation of complex large-scale social interventions—the evaluation in place around Health Action Zones is one such approach—rather than let the methods currently available dictate policy.

Community involvement

  The focus on community/public involvement in policy development and implementation is important and will greatly enhance the sustainability of health gain. Currently most attention is directly to building community capacity for collective action and individual "entrepreneurial" capacity. However, there is a need for much more attention to be directed at the capacity of public sector organisations and professions to engage in an equal and constructive way with "lay publics".


  The current emphasis on a primary care led NHS whilst welcome in many respects, does raise problems from a public health perspective.

Public Health and Primary Care

  There is much " fuzzy" thinking about the relationship between these two "domains". For some they refer to different professional groups, for others they relate to areas of activity or "ways of working" that at least in theory overlap. The expectations for primary care to "deliver" the public health agenda, and in particular, to address inequalities in health, are awesome. This is particularly the case given that there is little if any evidence from research or practice that past primary care organisations or primary care medical professionals have the capacity or the inclination to do this.

Local Public Health Systems

  More attention needs to be given to the potential for developing local public health systems with population focused work evolving within and alongside primary care and involving local government, the voluntary/community sector and the private sector. The current duality within local systems, in terms, for example of activities and accountabilities around Health Improvement Plans and Community Plans, can fragment activity around public health. Important developments within the local government areas, such as the work of the scrutiny committees have much potential to move forward public health practice locally but this is still to be exploited to any significant extent.

Public Health Referral Pathways

  Primary care practitioners are already "doing" a great deal of work that might be termed "public health oriented" at an individual level but it is marginalised by current incentive systems. This includes, for example work on housing needs, occupational health and welfare rights/income maximisation. The scope for developing richer and more accessible referral pathways for people with social needs accessing primary medical care would warrant further exploration.

Public Health Leadership

  There are major questions around the public health role of primary care organisations and professions, particularly general practitioners. There is little evidence to suggest that these organisations and professions are able/willing to develop the strategic population perspective that public health requires. In particular, the primary importance of questions of utility to public health (reflected in resource allocation decisions) does not sit easily with the individualistic caring value base of primary medical care. The public health role of primary care/community nursing professions remains to be demonstrated beyond the rhetoric.

Conflicting normative frameworks for action

   Research has highlighted important discordance between the perspectives of lay people and those of the professionals and organisations that "serve" them. This is apparent, for instance, in relation to lay perspectives on what is a "proper place to live" and the perspectives of local government professionals involved in implementing regeneration initiatives. A clash of normative frames may reduce the effectiveness of interventions intended to improve quality of life and reduce inequalities in health and has major implications for professional education and practice.

  These are new times and new situations in public health new patterns of ill-health in the midst of enduring inequalities. There are also new emerging relationships between lay people and professional experts including public health researchers, policy makers and practitioners. We need knowledge, theories and research processes as well as public health policy and practice that match up to this challenge. This will require a more innovative and inclusive public health which is truly multi-disciplinary and involves lay people as equal but different. Whilst many of these sentiments are captured in the current policy rhetoric they are not yet apparent on "the ground".

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