Select Committee on Health Minutes of Evidence



Examination of witnesses (Questions 180 - 195)

THURSDAY 16 NOVEMBER 2000

PROFESSOR J POPAY, PROFESSOR S MACINTYRE and PROFESSOR R WILKINSON

  180. One of the problems with public health in particular is that it is a long-term measuring process. Politics is all about short-term answers and results.
  (Professor Macintyre) It is long term in terms of things like sluggishness of mortality rates. If you go back to your childhood examples, there have been some trials of early extra childcare, mostly done in the States and you can look at quite short-term health and educational outcomes. You do not have to wait 40 years and look at mortality rates or adult employment, you can look at quite short-term outcomes such as educational achievement or family functioning. One should not be too defeatist. That is one of the defeatisms about experimental methods in that everyone says they cannot do it because it will take years to get an answer. You could look at some of these interventions, bicycle accidents, smoking rates, diet, performance, activity, sport, as intermediate outcome measures quite quickly.
  (Professor Wilkinson) Responding to your question about obesity rates in children, that actually emphasises the need for the more inter-sectoral approach, not just thinking what schools can do about it because crucially transport to school is one of the things which has really changed enormously so that very few children are now walking to school. Professor Marmot and I edited a book a while ago where we divided up the social determinants of health into different policy areas. One of them was transport and issues to do with the transport system affect accidents, pollution, exercise and probably things like social cohesion as well. It is a very clear example of how you need to be doing these things not simply in the name of health, but for all sorts of social benefits.

  181. Just a few weeks ago with the petrol crisis children started going to school in different ways because it was safer for them to cycle to school because there were fewer vehicles on the road. I take your point very strongly.
  (Professor Wilkinson) And cycle lanes, and all the rest of it.

Mrs Gordon

  182. We do not know a lot of the information we need to know about the best interventions. What can we learn from other countries? I feel that in this country there has been a big hiatus in public health in the last 20 years. I shall not make the political point again but in a way we are starting to re-invent the wheel. Are there lessons we can learn from other countries?
  (Professor Macintyre) One valuable tool is always trying to collate evidence in as systematic a way as possible from other countries, particularly some of these randomised trials which have taken place in a number of other countries. They may not be directly transferrable to Britain but it is important. Instead of simply saying that sounds like a good idea, it is very important to try to get hold of the evidence from other countries. Accident prevention is another example in children. Partly for political reasons there is a wish to do something and do it quickly, but it takes time to find out the evidence of what has happened in other countries. We can learn a lot from other countries by going and looking at unpublished evaluations of interventions there.

  183. When we went to Cuba I felt that the sport thing was very important and learning behaviour and early habits are important. All the children have to do various sports. When I was growing up you were dragged out onto the hockey pitch and that was about it. If there is choice and people can choose what exercise to take part in when they are young . . . When we were driving round we saw elderly people in parks doing stretching and aerobics and that obviously feeds through. We do know that there are things that can improve the situation. How can we impose that?
  (Professor Macintyre) An interesting point which comes out of that is that it seems to me in the exercise field, where I have done some research, there is one thing which is to do with culture and expectations and aspirations; those old people presumably wanted to be doing T'ai Chi out in the park and it was part of the culture. The other thing is to do with barriers and facilitators to performance. We have done work in Glasgow where we have looked at relatively deprived and relatively less deprived areas. Interestingly we find a deprivation amplification effect. If you take exercise in the poor areas, there are fewer bowling greens, tennis courts, football pitches, all publicly available or privately available facilities. You might say that does not matter because people can walk around but the physical environment in a poor area was much more threatening, street lighting was more likely to be out, people afraid to walk around after dark because of graffiti and vandalism. In poor areas the children's playground tended to be unobserved, to have discarded syringes and needles, to be built of concrete and a very unpleasant place. In the better off areas people are more likely to have gardens, more likely to have cars to go out into the country. Even if you wanted to give your children opportunities for ordinary healthy exercise like walking or cycling it was actually much more difficult to do so. There are other barriers. We have been involved in a randomised control trial about commuting to work and we found that the encouragement of commuting to work on foot worked quite well but the cycling one did not. It seemed to fail. That was because there were a lot of barriers about what you do with your bike when you got to work and the traffic being dangerous and noisy. There are many barriers in the physical environment, but also the social environment. You could build nice playgrounds in poor areas and people would not necessarily use them because they might not have a culture of it being a good idea to take your kids out to the park.

  184. That is where it is important that it comes from the community. In the beacon project we saw in Falmouth yesterday one of the things they are proudest of is that they had a wasteland which was threatening, violent, needles etcetera. That has now been transformed but it has come from the people themselves. We want the nice play area for our children. Because they own that, they had ownership of that project, then they respect it and it is not vandalised and it is used properly.
  (Professor Popay) It seems the UK in general is a very professionally dominated public health system and that is a problem for some of these community initiatives. There is an issue about building the capacity for professional groups and public sector organisations to allow local people not just to define their needs, but define the solution to the needs. We have now a long tradition of asking people what their needs are, but we are very bad at asking people what they think needs to be done about them. There are some small examples of that which are worth thinking about.

  185. And the top-down approach. You get the professionals in and they say they will do this, they will do that, and then they go. They are either promoted or they get seconded to show other people how this was done and then unless you have built in that strategy to allow the community to own it, it goes, does it not? That is the danger.
  (Professor Popay) The other model it might be worth looking at—you may have seen it—is in Quebec where they have local public health centres not primary care centres and healthy living centres, where there are environmental health officers and social workers, public health engineers. It is quite a different kind of model. They have had some trouble getting it off the ground but they do have primary medical care and nursing care in the centres. It just seems that the few I visited have shifted the focus.
  (Professor Wilkinson) In terms of international examples, it is clear that probably all the outstanding examples internationally of countries with very good health, their good health is an unintended consequence of other policies. If we approach improvements in health by defining each little bit of the problem and trying to provide some service or facilities to deal with that, whether it is obesity or needle exchanges or sports facilities, this is a very expensive way of doing it. In a way what you are trying to do all the time is provide services and facilities which offset problems which continue to be created elsewhere in society. There are nice examples of health promotion in the United States where they had very marginal success in persuading people to eat healthier diets and to stop smoking and they knew that every time they persuaded someone, other children were starting to smoke at the same time. One just has to take a different kind of approach to it. People have mentioned Cuba, which of course is one of the examples of an unusually egalitarian society and there seems to be a relationship between egalitarian societies and better health. Sweden is another example of an egalitarian society which has outstandingly good health. If you look at the Swedish example, I believe it was in the 1930s that the Prime Minister and his Chancellor pursued a policy which apparently children in Swedish primary schools still learn, that Sweden is about equality and diminishing class differences and that Sweden is the "people's home". Apparently those were the phrases through which this policy was expressed. I should be very surprised if they were pursued primarily with an interest in any health benefits. It seems likely that is why Sweden has good health because those policies were pursued right through until the 1960s or so.

  186. Having made that point, having looked at research in other countries, would you support the general consensus of the earlier witnesses that the recent budgetary measures which have shifted resources towards poorer groups was a step in the right direction?
  (Professor Wilkinson) Yes; definitely.

  187. Or would you say we need to go much further?
  (Professor Wilkinson) I should say we need to go further. In answer to some of the questions you were asking the earlier witnesses, if you look at the smoking example, there is a very nice piece of work done by Alan Marsh at the Policy Studies Institute who showed that whilst smoking declined in all the higher income groups, it actually increased in the lower income groups at exactly the period during which relative poverty was increasing most. There is of course also evidence that whilst our income differences were widening most there was a slowdown or perhaps even a reversal temporarily in improvements in mortality in younger age groups. Sir Donald Acheson drew attention to this in one of his later reports as Chief Medical Officer. I believe that these relationships are often very clear. The whole social fabric of society is involved in this and health is only one of the costs we bear.

  188. Presumably you would go a good deal further than simply fiscal measures in relation to creating a more equal society?
  (Professor Wilkinson) Yes. I am fairly agnostic as to what is the best way of diminishing income differences. You can pursue educational policies, industrial policies, fiscal policies and I do not consider it my expertise to know which of those is the right way of doing it, but I do think that from the point of view of health, it has to be done.

Mr Hesford

  189. May I return to the question of evidence-based policy? If we cannot get a grip on that, we are really lost. I was interested in Professor Macintyre's suggestion about randomised trials. I have to say in one sense I am horrified by the idea of that. You quoted some examples about shocking the kids in prison and working out later that they were more delinquent than other cohorts. I do think that there must be factors which might explain that outside the crude correlation between taking them into prison and them turning out to be delinquents anyway. What are the problems around getting a robust examination of evidence? What are the problems here?
  (Professor Macintyre) We need to develop more of a culture of thinking about how we look at evidence and what counts as evidence. One of the problems at the moment is that we tend to take plausibility—it sounds like a good idea—and good intentions as bases for public policy. I worry about that because there is quite a lot of historical evidence that both good intentions and plausibility can be wrong and that unless you look at this systematically and check out what you are doing, you can be wrong. You can do harm or you can waste public money. There tends to be a notion that you cannot do randomised trials but on the point about there being something else going on, the whole basis of randomisation is if you take 100 kids who are all eligible for programme and randomly allocate them to receive it or not, that is go to see the prisons or not, it is quite difficult to see what those other factors were, as opposed to just taking the worst kids and exposing them to prisoners and taking less worse kids and not exposing them. In terms of looking at what other factors might explain that, randomisation is scientifically good and also ethically okay because you are nearly always in a situation of scarce resources, say housing or income support. There is an American example of studies of income support which were randomised. You get a lot of people who all need better housing but you cannot give them all better housing. Why not randomly give some of them better housing and some of them not and see what happens? There are experiments in other countries which have done that. If you do not do that you will never know. There is always the danger of unanticipated harms or the other issue is the opportunity cost; supposing the money would have been better spent doing something else. There is a notion that randomised trials are something horribly bio-medical and nasty and it is what drug companies do or what you need to do for surgery but public policy, particularly as it affect so many more people than a lot of drug therapies or surgery, actually has as much potential to do harm or involve waste of money. So there is almost a moral obligation on us to try to find out whether things do harm or do good.

  190. I am speaking for myself, the Committee will come to a view in due course if it needs to. Could you say to us, if we did this you would have evidence which is so robust that you are going to get your policy absolutely right? Is that what you are saying?
  (Professor Macintyre) You would be much more likely to if you do that. If instead of giving health action zone status to the places which are worst off and also the places where for a variety of reasons you get charismatic people who can write good bids, if you use other indicators and then you double the number of places which could potentially receive health action zones, you give some of them health action zones. If after a couple of years they seem to be beneficial you could then give them to the other lot. If they turn out to be harmful, you can take them away. At least you have a better grip on it than if you put in health action zones and five years down the line the local people say they like them, you have spent X amount of money on them, you have some process evaluation, some indicators seem to get better, but the problem is you have no comparison. If you take your ten worse off places and give them health action zones, if you compare them five years down the line with the next ten worse off, people always say that is because you were not comparing like with like. There is no guarantee scientifically but it is ethical to do those sorts of trials where you have scarce resources. It is not an ethical problem necessarily but you are more likely to get robust evidence quite early on of whether there are any beneficial effects of the intervention or not.

Mr Amess

  191. There are some people who quite outrageously regard this as a "nannying" Government. I regard such people as troublemakers. With the demise of the HEA, health education campaigns seem to have been sidelined. Our Minister for Public Health has said, "Campaigns which just tell people what is good for them without recognising the real-life obstacles that prevent people leading a healthy life is pointless and patronising.", "Nagging health visitors, like nagging ministers, have little effect". Do you agree with that? What do you think is the value of health promotion campaigns? Have the Government got it right or not?
  (Professor Macintyre) I think it is a public duty to make the public aware of health risks and to do that accurately. The Phillips report suggested recently that it is important to do that accurately. There is a lot of evidence that most people in this country know that smoking is damaging to their health but they still do it. Most people know that unsafe sexual practices can transmit HIV but it does not stop people doing it. There are barriers in people's environments. You need to take a two-pronged approach and make sure that people have accurate, up to date information about health risks. Secondly, you need to reduce barriers to people being able to live healthy lives. If you take your example of physical activity in childhood, if there are no sports facilities, if it is dangerous to walk about your streets at night, then you are not likely to take up health promoting guidelines anyway. You need to do both. Most of the evidence suggests that simply telling people what the risks are is not enough to change behaviour. The "nannying" state has an implication to do with people not making choices, but if you do take a citizen's choice view, you may still want to get more exercise for your kids, but if there is nowhere to take your kids and you do not have transport and you are stuck in the top storey flat in a 22-storey block and there are drug dealers in the front hall, you are not likely to be able to take your kids out. I think you need to do both.
  (Professor Macintyre) There is also a slightly different angle on that. The Royal Society in the early 1990s talked about lay knowledge as an essential datum in identifying risk. There is a sense in which people who experience these hazards know them before we academics do. Then they become public knowledge when we do the research and identify them. There is a need to tap into some of that expertise that people have to identify risks as well as make some of the formal public knowledge available. There are many instances in the literature of people identifying negative reactions to drugs, way before medical research had confirmed that was the case. Indeed it took many, many years before research took notice of it and did the work. There is an education the other way that needs to go on.
  (Professor Wilkinson) I agree. There is a moral obligation to give health information. Many years ago I was responsible for health education in Bristol and I remember reading through the evaluations and thinking that it looked as though when new information became available that was enough to change behaviour in a proportion of people. Once that knowledge was widespread, then you got very few further gains by going on repeating it. There are many good intervention studies which show that that does not work. As scares over contraceptives or immunisation or foodstuffs show there are sometimes enormous responses to information, whether it is true or false. One cannot ignore that.

Mrs Gordon

  192. Do you think we should be more innovative and sophisticated about getting the health message across? I am thinking particularly of when we did the tobacco inquiry and had the advertising agencies in as part of the inquiry. They are very sophisticated about how they get their messages across. People I was talking to yesterday were saying that the nutritional message is fine. You try to get it across in schools, you try with your children; the school could be a fast-food outlet who are brilliant at getting their message across. That is why they make such huge profits. Have we given up on really trying to get the message across in an effective way?
  (Professor Macintyre) I do not know enough about current education policies. One of the problems is that there still seems to be a gut reaction on the part of either health educators or policy makers to re-invent wheels, if we just tell the public this is a danger it will change, rather than using the more sophisticated methods.
  (Professor Popay) All the research I have done, and your advisers have done research in this area as well so they will confirm or not, shows that there are few messages we need to get across. People know what most of the messages are. We can spend an awful lot of money still going on about what the messages are. Any of us with children will know that it is not just a question of getting the message about fruit and things to kids. They do not want to eat fruit. If you close down that fast-food outlet they will find another fast-food shop somewhere else. It seems to me that there is a real problem with that notion that there are messages. There are some key messages but generally the health education field is recognising that it is not about message transfer. It is about a dialogue really.

  193. It is about education, is it not? My daughter grew up just loving salad and cucumber. Can you learn that behaviour? Can parents teach that? Why do they not like fruit?
  (Professor Macintyre) In some Glasgow schools eating fruit is regarded as making you a complete wally.
  (Professor Wilkinson) You mentioned the competing sources of information. I had a friend who did some work on the overall information in the media about sugar, looking at both the health education side and the industry's advertising. On balance of course the overwhelming message was that sugar is good for you—Mars Bars "help you work, rest and play". People have not realised what tobacco ads are doing. If you really look carefully and think what the ads are, they are not about brand loyalties, as suggested by the tobacco manufacturers, they are very specifically trying to get people to misattribute the little worry and fear about the effect of smoking and to go on and do it, let themselves have it, to attribute to something else that sense of tension and anxiety that might make you want to give up to. People really have not looked at that properly.

  194. They are very clever. That is why we should try to be just as clever with our message.
  (Professor Wilkinson) The possibility of matching the expenditures . . .

Chairman

  195. Yes, we are aware of that. Any further questions? Do the witnesses have anything to add on areas which you feel we perhaps ought to have covered and have not? Is there anything you wish to add to what you have said already?
  (Professor Macintyre) A lot of strategies like health action zones are area based, other ones, like fiscal policies, are individual based. You need a balance of both. One of the issues is that not all poor people live in areas which are defined as poor. If you have any control over the Government agenda in terms of saying should we be focusing on places and having a place-based policy or should we be focusing on individuals, I think you need both. I think that is quite important.
  (Professor Popay) Whilst I agree entirely with Professor Macintyre about randomised control trials—
  (Professor Macintyre) No, you do not.
  (Professor Popay) I do; I do. There are two key lessons from the Cochrane evidence base movement to avoid a tyranny of that kind of approach. One is that you do need to study the context as well as the outcome of these interventions. Let me give a very quick example, let us say that the evidence suggests that a grade 3 pressure bandage is the best for reducing pressure sores, but old people cannot pull them on; they are too tight. You have the most effective intervention but it will not work because they cannot actually use it. You need to do qualitative research to find out that they cannot pull it on because in the trial they had the district nurse tugging it on. You need the context for these interventions. The other key issue is that it is just as difficult to change the behaviour of policy makers and practitioners in the public health arena, even when the evidence is there, as it is to change the behaviour of people living in very poor material circumstances.

  Chairman: I could see a positive reaction of obstruction by politicians to what you are proposing. I am sure you could as well, for reasons you fully understand.

  Dr Brand: You could stop politicians interfering with properly based trials by selecting areas for political imperatives rather than social imperatives.

  Chairman: There will be non-intervention in the Isle of Wight. May I thank our witnesses for a very useful session? We are very grateful to you. Thank you very much.


 
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