Examination of witnesses (Questions 160
- 179)
THURSDAY 16 NOVEMBER 2000
PROFESSOR J POPAY,
PROFESSOR S MACINTYRE
and PROFESSOR R WILKINSON
160. Professor Macintyre, can you offer the
English any assistance from your Scottish perspective?
(Professor Macintyre) No, I am not competent to do
so.
Mrs Gordon
161. Could you tell us how you make sure that
there is a high standard throughout the country if it is going
to be placed with local authorities? You were talking about the
variations in good officers and the way it is done. How can you
monitor and ensure and put strategies in place to make sure that
everybody is getting the best?
(Professor Wilkinson) My feeling is that there is
rather too much direction, that most professionals are interested
in achieving higher standards and learning more. You could have
at least some element of league tables in which we know how well
areas are doing in various different fields, and systems so that
people can learn and evaluate their own work. The desire to raise
standards is part of any good professional ethic. It is that which
should be encouraged rather than telling people what to do from
a central point of view.
162. May I come back to Professor Popay on the
point you made about primary care? My constituency is Wakefield
which you will go through now and again possibly. It includes
two local authorities and two health authorities. I shall not
mention which one, but I met a number of GPs in one part of my
constituency who had no connection whatsoever with the public
health function of the health authority. I see some extremely
well written reports from expert public health people in my locality,
some very good people who offer a great deal but in some respects
they are removed from the process of change. In particular what
concerned me was that the GPs I met did not even know the name
of the key public health people in the health authority. I understand
where you are coming from in relation to PCGs PCTs and the possible
proposal in terms of public health, but how would you link in
primary care to the public health function in a way that clearly
is not happening in areas like mine at the moment?
(Professor Popay) Primary medical care already does
a lot of what I would consider public health oriented work at
the level of responding to individual social needs, the kinds
of things people have been talking about, housing needs, educational
problems, problems with children who are disruptive, etcetera.
There is a problem for them in that local systems do not have
readily available referral pathways to deal with those so it is
all done in a very ad hoc way. GPs are already incentivised
to contribute to public health at the medical end in terms of
immunisation programmes, advice about lifestyle choices, those
kinds of things. I think that there is an issue about how much
more you want general primary medical practitioners to do. How
much more they are competent to do versus how one links them in
to a local public health system, a local system which is about
health and social development really.
163. I am not asking them to do more, but maybe
be aware of their role in public health in general terms. For
example, they have frontline intelligence on issues in each locality,
they are close to the ground and perhaps can see more closely
than many other professionals exactly what needs to be done in
a wider sense. The worry I have is that compared with some other
countries we have been to as a Committee, there is no connection
enabling the GP to drive on some of these changes. They cannot
contribute to the wider processes of the policy change that we
saw in Cuba for example. The Cuban system is very different.
(Professor Popay) Cuban doctors are very different
too.
164. They are indeed; we met quite a few. I
understand we are not comparing like with like, but what we saw
there was the involvement of the family doctor in the process
of public health in a way we do not have in this country. I wonder
how we can bring that about, how we can change that.
(Professor Popay) You do need to place that in the
historical development of medicine within the United Kingdom.
I know the Cuban system a little but I know the French system
as well. French medical practice is also very different from British
medical practice or clinical practice. It might be a tall order
to shift British primary medical care around to fulfil that Cuban
model, but it may well be that we have an alternative clinician
in our community nurses who can do that, who are close to the
individual living in different kinds of communities. It would
be a mistake to fix on the doctor as the frontline workers you
need to involve in the public health arena. It seems to me that
there is a major issue around pushing up quality of primary medical
care and that should be the primary concern, certainly for the
next five or ten years, whereas the nursing possibilities are
huge.
165. Perhaps I offered the wrong question in
a sense because I would entirely agree with you. I have argued
very strongly about the role of the health visitor and what saddens
me is that since 1974 I have seen that role change and move away
from what was then a public health function in my view.
(Professor Wilkinson) Surely a logical distinction
between the roles is a fairly simple one. The GP is dealing with
people as individuals and in so far as he takes on a public health
function, it is presumably only the things which can be dealt
with on an individual basis, not only immunisation but smoking
advice and so on. He cannot be expected to do a whole range of
other things which work at a more societal level to do with transport
systems, education, housing, all the rest. Those are quite different,
they are not a matter of individual concern, they are a matter
of the whole social and economic environment locally.
166. What I was trying to say, and probably
did not make it clear, was that I am not expecting them to involve
themselves in those areas other than at the present time there
is no mechanism for their knowledge of such problems to be communicated
in a way that something could be done about that in their local
areas.
(Professor Wilkinson) There are lots of different
professions, occupations, people who have expertise and knowledge
of these problems and one wants to tap into lots of them, not
just the GPs' knowledge.
Mr Hesford: You have really answered the questions
I was going to ask on public health delivery systems and that
is what we have really been discussing for about the last 15 minutes.
It has already been suggested that what action takes place should
take place at a local level. I think there is broad agreement
about that. Unless anyone else has any comments around that, I
think we have covered that.
Dr Stoate
167. Briefly to pick up what Professor Wilkinson
just said about not just GPs, it is not actually true that GPs
do not involve themselves in public health in a wider sense. GPs
are now members of primary care groups and primary trust boards,
they interact with the public health function. They are involved
in the setting up of the health improvement programmes, they are
involved in setting targets for their own areas, they are involved
in audit for the diseases which might be of great interest to
their particular area and the whole point about PCGs and PCTs
is that they do set local priorities which are dependent on local
needs. If there are very high rates of teenage pregnancy they
will focus on that. If there is a large number of elderly people,
they will focus on that. I do not think it is right to say that
GPs could only deliver health care on a one to one basis. They
do not. They do involve themselves in a much wider part of society.
(Professor Wilkinson) I agree, every group, not only
GPs, but teachers have an awareness of the scale of kids with
behavioural problems and so on at school, and police have a knowledge
of factors underlying crime. I would emphasise again that you
need all these functions feeding in. They all have some important
common threads, not just the medical knowledge, but knowledge
from all these other areas as well. Although they often deal with
things at an individual level, I agree that they do have a function
in increasing our awareness, as a society and for policy makers
at other levels, of other responses to these problems.
168. The question I would want to focus on with
primary care workers is what they can do at a primary care level
to reduce inequalities. Really what this inquiry wanted to focus
on was the inequalities problem in public health. What do you
think the role is of primary care practitioners and the primary
care function in trying to wrest with inequalities? Any of you
might want to answer that one.
(Professor Popay) It is a really difficult question.
One could think of a myriad of tiny things they could do. I get
obsessed for example with the notion of developing a really effective
tapestry of socially oriented public health referral pathways
so that people can readily access housing advice, welfare rights
advice, advice around children's behavioural problems, rather
than that being dependent on the knowledge of an individual health
visitor or individual GP who has been interested enough to build
up that kind of knowledge base. That is the way that the knowledge
of these primary care practitioners can be powerfully used. That
is a different set of issues and it could be much more effective
in having an impact on social development in local areas. It does
seem to me that is different from how we get more coordination
amongst this bewildering array of initiatives like Sure Start.
I am the Chair of an early years development childcare partnership
and we only just started talking to the Sure Start people. Then
there is the SRB5 and 6 people and it is very uncoordinated really
with lots of overlap. It seems to me in that context that the
primary care trust is going to be a minor player if they are going
to do their driving up clinical practice job properly. They cannot
do both, certainly in the immediate future.
(Professor Macintyre) Not following on from the primary
care point but following on from the anorak/visionary distinction
and partly from where the director of public health should be,
what I think is the missing link is that the anorak function of
directors of public health tends to be the output measures, the
low birth weight, smoking amongst pregnant women, coronary heart
disease, mortality trends over time. The thing I think is missing
is monitoring of some of the determinants of health at a local
level. What you want to know more about is street lighting, local
transport, public transport, schools, retail development, policing,
some of these things which will affect people's opportunities
to live healthy lives and to be healthy. You need not necessarily
ask where the director of public health should be, which of those
places, local authorities or health authorities, but I think somebody
in the local authority needs to have responsibility for monitoring
some of the activities of local government and the private sector
which could be affected by local government, like regulating planning
permissions, tax rebates, things like this, all those things which
locally could affect population health. That is where I see the
missing link. It is not really the job of directors of public
health to monitor those things because they do not know what is
coming up, they do not know what planning permission has recently
been given. That is missing. It is a visionary in an anorak but
in local government.
Dr Brand
169. The interesting discussion should not only
be around the primary care team. It is wrong to talk about GPs
actually because it is very much at practice level, it is team
work and there are different lead players for different things.
That really represents the wider community. I have a real concern
that the plethora of initiatives is creating this project fatigue
that I talked about earlier, especially where it involves competitive
bidding for things. It strikes me that the people who are best
at bidding for funds are probably not those who need the funds
the most. It is the same as lottery bids by charities. There is
now a great industry in creating bids and setting up bids. Is
there any evidence that you have gained in your work that shows
that (a) there is a detrimental effect in not getting the people
to feel part of a bid, because there are so many of them and (b)
is there any evidence that successful bidders are not actually
necessarily those who need it most?
(Professor Macintyre) May I respond at a slightly
abstract level? When you asked the question before about whether
there was any evidence that having everything in one place is
a good thing or a bad thing, I was dying to jump in and say we
have no idea. One of the reasons we have no idea is that a lot
of these interventions are not set up in a way that can be fairly
robustly examined. The temptation is to take the worst places
and give them everything. We do not know whether that is a good
thing or a bad thing, whether it would be better to spread that
around, we do not know whether harm is caused by having everything
going on at the same time. There is this obvious political desire
to take the worse places and give them something, but often that
is related to who is best at writing bids. I wonder whether some
of the ways we allocate things like health action zones, healthy
living centres, all these huge numbers of interventions, could
not be somewhat more systematic and allow us to evaluate their
outcomes. I have a slightly sceptical hypothesis that the time
people spend in partnership arrangements may well be a waste of
time. They may be better not doing things in partnerships.
170. This is perhaps one of the reasons why
GPs tend to withdraw. They start full of enthusiasm—and
as a socially aware general practitioner I found myself at one
stage on about 30 different committees—and then they have
to stop because they cannot do it.
(Professor Macintyre) Yes.
Dr Brand: You get a professional who is a committed
liaison person who no longer has any links with the organisation
on behalf of which they are liaising.
Chairman: I understand the point you are making.
One of the reasons I harked back to pre-1974 is that I believe
so many of these initiatives we are bringing in now attempt to
re-create the relationships which were in being pre-1974, which
I have worked in when I worked in local authority social services.
Dr Brand: It was not that perfect before 1974
either. I too was around.
Chairman: It was not that perfect but there
were many strengths there which these initiatives are attempting
to re-create.
Dr Brand
171. Is there any hard evidence? Has anybody
evaluated not just outcomes of the effectiveness of the work which
results from a bid, but also the effectiveness of the bid evaluation
process?
(Professor Popay) Some of the process evaluations
which are going on of health action zones and the implementation
of PCGs and PCTs and the PMS pilot schemes are generating evidence
that there are too many initiatives for people to manage. There
is also another story in there which is a bit less visible and
that is that the process of bidding may have implications for
the sustainability of any progress. In both Salford, and it appears
in Leeds, people are very good at bidding and they tend to get
the bids into the right places, in my view. However, they cannot
involve the people who live in the right places in any meaningful
way. Involving people who live in the places where the initiatives
are being rolled out seems to me to be the key to sustaining the
benefit of them really. I constantly hear the refrain that a good
enough bid is being put together for whatever it is but it then
has to be taken to local people and explained. Only at the margin
are they involved in producing them. The new wave of regeneration
is different, but there is a real danger that the timetable around
that will squeeze out building real involvement and ownership
really. It is a slightly different issue.
172. Professor Wilkinson was saying that there
are all sorts of groups which should be involved with public health
in the broadest sense. I agree with him entirely. Unless the groups
within that community feel they have ownership of what is being
proposed for them as a result of these bids or Government initiatives,
they are going to feel marginalised from the outset. Have you
seen any evidence of what works for communities? Is it something
that is top down or bottom up?
(Professor Wilkinson) I feel this is outside my area
of competence. I have spent very little time on the local policy
initiatives.
173. In that case it is difficult for you to
judge the significance of a primary care team within a village.
I can tell you that it can have an enormous influence. It runs
the breakfast group for children at the school, it organises public
transport.
(Professor Wilkinson) Yes, my desire comes from knowing
something about the determinants of population health. I feel
that that is not where the driving force is going to come from,
it is not where the big changes are needed. It is a mistake to
be doing this simply in the name of health because similar things
need to be done in the name of educational failure and so on.
One has to put these things together and have a Minister responsible
for those developments at a much higher level in Government. I
remember being invited to talk to the Deputy President, or Deputy
Prime Minister, in Chile who was a Minister without Portfolio.
I thought that arrangement had important possibilities for the
sorts of things I am interested in as a result of my work on health
inequalities and social determinants of health. You need someone
at that level in Government with the clout to pursue things not
simply for health but much more broadly in society.
174. Do you think the new regional public health
forums are going to be of any use in delivering the agenda we
have been discussing?
(Professor Popay) They probably have quite an important
contribution to make, but it still requires us to get the local
delivery system sorted out for real impact. It is about setting
up a regional frame, particularly at the economic level at the
moment.
175. Distribution of the monies.
(Professor Popay) Yes.
Chairman
176. May I go back to Professor Wilkinson on
a point you made a moment or two ago about looking at how we impact
upon health? In the first session you heard great emphasis on
the importance of childhood in this respect. I am interested in
your thoughts on what might be done with children via a changed
role in respect of our schools. There is the healthy schools initiative
which does touch on a number of problems but taking account of
the point you made about a wide-ranging Minister looking at the
impact of various policies, what would you see such a Minister
doing in respect of our education policy?
(Professor Wilkinson) Talking about the importance
of early childhood to health and other outcomes it is quite clear
that a lot of what needs to be done needs to be done before school,
so there is all the pre-school stuff, support for families and
so on. In schools we are not paying nearly enough attention to
the quality of the social environment, the amount of conflict,
the bullying that goes on, all those kinds of things which I see
as crucial to the kind of psycho-social factors which are feeding
into health then and later on. It would be in that area I would
want to concentrate, the sort of work that the schools health
education unit is doing. When you start looking at why kids are
taking drugs and at educational failure . . . I remember even
in the 1958 cohort study the best predictors of health in early
adulthood were assessments of children's behaviour at age 16 by
teachers. Kids who were having problems in terms of behaviour
and education at that age were the ones who were doing badly in
health later on. These problems just cannot be separated and it
does mean thinking crucially at the social environment. If you
ask me about schools, then in schools but also in workplaces,
as a result of Professor Marmot's work on the Whitehall study
and a number of other workplace studies, it is quite clear that
for most of the population the most important determinant of health
in the workplace is the social environment, often built or structured
on material or economic foundations but mediated by what those
do to the quality of social relations between people.
177. May I broaden the question to look at the
emphasis we have within our schools on standards, on league tables,
on achievement on comparative stats between one school and another?
The impression I get as a parent—and I have two kids in
secondary education currently—is that the pressure on youngsters
academically now is far more than it was even five years ago and
the teachers are under pressure, the head teacher is under pressure
because of all the comparisons. Do any of the witnesses see that
as a factor currently in the future determinants in respect of
health for our youngsters? I see with my own children that they
have less space in their childhood than I had in mine. The other
factor here is that a lot of their leisure time is sitting at
a computer, a playstation. We have had evidence from the Yorkshire
Post, based in Leeds, which has done a major campaign on school
sport. One of the central arguments they are making is that because
much of our childhood and youth leisure is now sitting with electronic
media we need to re-emphasise the role of sport and activity in
a school environment. What are your thoughts on these points?
(Professor Popay) Slightly tangentially, for me there
are two really profound gaps in our research base for all of this.
One of them is the voices of the people we are talking about.
In particular, we know very little about children, about their
experience of the social environment and what impact this stress,
that league tables undoubtedly places on teachers, head teachers
and parents, has on children and particularly on children who
are in schools which are failing. Yesterday's newspapers were
full of it. What does that say for the kids at Windsor High School
in the centre of Salford inner city area which is at the bottom
end of the league table. I remember when I was a kid I was born
in Salford and I was really proud at being top of the league and
I still have a really vivid memory of it. I discovered afterwards
that it was the pollution league. We do not really understand
those kinds of impacts. We talk about the impact on children but
we need more research into children's experience. Until we get
that there is a danger of us imposing on them our view of the
world and our view of impacts and our view of what schools should
look like if they are going to be health promoting, which is very
much the case at the moment. The model of the health promoting
school is not really coming from what children want, it is coming
from what parents, teachers, health visitors think it should be.
178. If we look at the actual measurements of
the health of children, the figures we have show a huge increase
in obesity; doubled for six-year-olds in the last ten years; tripled
for 15-year-olds. These are quite worrying. What do we do about
this? How do we deal with this? What would your suggestions be?
(Professor Macintyre) I agree with Professor Popay
but I also take a hard-nosed approach. You have all been asking
us what we know about, what the evidence is. In fact in Britain
there is very little evidence from social policy or health policy
experiments. Most of the research we have on inequalities of health
and population health is excellent epidemiological observation
research which says we observe this, we see what happens, we follow
people up. A lot of the issues are actually susceptible of experimentation,
perfectly ethically, but we just do not do it in Britain and we
do not know the answers, like whether it is better to have lots
of initiatives in one place or not. We do not know. You could
answer that. You could take all the bad areas and give half of
them one initiative each and the other half lots and then another
group none and see what happens and then we shall know and we
shall also measure the harm. In other countries there have been
better experimental studies looking at some of the impacts on
children's health. One of the things about some of these studies
is that they demonstrate the point I made earlier about unanticipated
increases in inequalities in health. I shall give you two examples
from the States. There was a controlled trial of watching Sesame
Street on television. It showed that it did improve reading but
it improved reading skills most in those who were already good
readers. Watching Sesame Street increased the gap between poor
and rich children in America. Another was a bike education campaign
in Australia which was very well intentioned. It was a health
promotion one which talked to parents of children about safe practice
in bicycling, which would be of interest if you were looking at
obesity. It was a randomised control trial and what it found was
that it increased the accident rates from bicycling. Secondly,
it increased the accident rates most among boys, who of course
have the highest accident rate and among children from poorer
families. We just do not do those sorts of experiments in this
country. We ask what is going to happen in community schools,
are they better, what happens with pressure about league tables?
We do not tend to introduce policies either locally or nationally
in a way which would allow us to answer the questions and to say
what works and what works best. The problem with some of these
big expensive initiatives in public health like health action
zones and some of the other ones is that money could be spent
on other things and we do not know whether it is best spent on
these programmes or other programmes or whether we are setting
them up in the best way. I can understand the political desire
to be seen to be doing something. I can also understand to a certain
extent the perception that it is unethical to experiment but we
are experimenting all the time. You are experimenting by introducing
health action zones and most of the evaluation of those health
action zones is a process evaluation; it says let us look and
see what happens. Because we have a social gradient and not just
the extremely disadvantaged, a lot of our policies take the ten
worst places or the places with the worst health outcomes and
give them an intervention, but it does nothing for the next 20
up who have the worst 20 per cent. We ought to think much more
about taking the top 20 or 30 per cent and randomising and systematically
think about how we introduce interventions and look at the outcomes
and not just the process. There have been studies, to quote an
example from the criminal justice field, in a programme called
Scared Straight; seven randomised control trials. This is the
one where you take potential delinquents into prisons and introduce
them to hardened criminals. The criminals say it is great, the
governors say it is great, the parents say it is great and the
kids say it is great. If you monitor this in terms of whether
everybody likes it, which is a typical process examination, it
is fine. All seven randomised control trials have shown that the
treatment group had higher delinquency rates afterwards which
was the real outcome they were interested in. There is a real
problem. They still do it. New states in America are introducing
it and I gather it has been floated in Britain. This can happen
to all sorts of things which are very well intentioned in the
public health field. We monitor what happens in surgical interventions,
pharmacological interventions. We understand they can have unanticipated
side effects, but we are really ignoring some of the unanticipated
side effects, for example of health action zones or multiple interventions
which may be disempowering the local communities, they may be
taking money away from something else. One of the problems of
this session in the sense that you are asking us what the evidence
is about X versus Y is that we do not have it, we do not really
have it.
179. What you are saying is that we should have
it.
(Professor Macintyre) I am saying we should have it.
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