Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 160 - 179)



  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.


  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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