Select Committee on Health Minutes of Evidence



Examination of witnesses (Questions 280 - 299)

THURSDAY 23 NOVEMBER 2000

MS YVE BUCKLAND, PROFESSOR RICHARD PARISH, MR ANTONY MORGAN and MS PATTI WHITE

Chairman

  280. Stop showing off.
  (Professor Parish) Sorry. That is one of the disadvantages of sitting on this side rather than where you are.

  281. Mr Morgan, do you want to come in on this?
  (Mr Morgan) I would like to add to what Richard has already said by referring to a comment that you made in the earlier session around the information that is available to us in order to tackle some of the broader determinants of health and the fact that we have know this for a long time. I think one of the main pushes for the HDA is actually making sense of the vast amounts of information that are available to people in order to inform decision making processes. May I just talk generally about our general approach about how we will establish the evidence based programme for public health. I think in the first instance it is important that we identify a suitable theoretical framework which will allow us to understand how the different health determinants interconnect to produce final health outcomes. The one that we have chosen as a starting point is that one described by Sir Michael Marmot which was actually depicted in the Acheson report. What this will enable us to do is to really think about how we can organise that vast amount of information in such a way as to make it more readily available and accessible to people. Therefore, by doing that it will also allow us to identify gaps in the information. In terms of your question about how linked in are we with the Department of Health Research and Development funding streams, we need better ways of co-ordinating research on how to tackle inequalities so that it is streamlined. The HDA needs to have an important role in making sure that research funded by different agencies is better co-ordinated which will allow us to bring it into our evidence base, so there is an issue there about how we organise.

Mrs Gordon

  282. Following on from that, I think one of the things that worries me as we have gone around looking at community based projects especially is that there is an element of reinventing the wheel, that people are starting from scratch and going through the same sort of agonised processes as perhaps someone else in a different part of the country. I know you have said about how you are going to inform the professionals, but how can you ensure that this reinvention of the wheel does not happen, that locally community based projects also have the information to say "okay, that did not work there, we will not do that, we will go on", actually giving the grass roots the information?
  (Professor Parish) Would it be helpful if I made an initial response? I do think we have some gaps in our evidence base and the gaps are largely around the issues to do with implementation and the ability to replicate what has happened in one part of the country in other parts of the country. We have actually a lot of research, for example, high quality research, epidemiological research, randomised control trials, inferred causality and make the links between different causative factors and different health outcomes. We know quite a bit about the types of interventions that can work and what the policy options might be that are available to decision makers. What we are much less clear about are the reasons why an initiative works in one particular area with a given population group and when you try and replicate that elsewhere with a similar type of population, why it does not seem to work. Indeed, linked to that, how we actually take the learning from demonstration and pilot projects and mainstream those into everyday practice across the country as a whole. In one sense, just as I am sure many of you will be familiar, particularly the GPs here, with Julian Tudor-Hart's comments some 30 years about the inverse care law, we now almost have an inverse research law in that we have most research in the areas where we least need it. One of the jobs, I think, for the HDA is to build that research base around the issues to do with implementation and replicability so that we can actually take the learning from some of these excellent community projects and replicate them with real success without having to go through the process, apart from anything else, of evaluating every single community initiative.

  283. For instance, the project we saw in Cornwall, which was excellent, the Beacon Project, was initiated by a health visitor who just saw the state of the estate she was working on and felt compelled to do something about it. Does there need to be a button or a phone or something that someone can pick up and say "I have had this brilliant idea, have you got any information?"?
  (Ms Buckland) If I could just start. I absolutely agree with you, we have to learn from the good practice. The other point I would like to add strongly is that you have to learn from bad practice which sometimes is more important than good practice in terms of disseminating and learning. Regarding community development approaches, there is that one led by Hazel Stuteley in that very charismatic and very effective way and there are others like that across the country. At the moment there is currently a proposal to look at how we might develop something like a Healthy Communities Collaborative to roll out the good practice and the learning and the generalisability of community development approaches. It is tricky because very often those schemes depend upon the charisma of a local leader who will walk through fire and do anything to make her scheme work, but how this makes such an approach difficult to pick up and transplant somewhere else? The jury is out on that. The Collaborative has got to be set up to look at if there is a model, how it can be developed and how these circumstances can be encouraged to enable that kind of initiative to be replicated elsewhere.

Mr Hesford

  284. Before I come to my main question I just want to pick up something Professor Parish mentioned. When the HDA was mooted and was being set up, certainly myself and others connected with the public health field were rather hoping that the HDA would have a policing function. That seemed to disappear fairly quickly and was pooh-poohed by people who were setting the HDA up. You said a few moments ago, and I was very interested by that, "holding people to account". How can the HDA do that? What capacity, what function does the HDA have in that regard?
  (Professor Parish) I think there are two routes by which we will do this.

  285. How does that intermesh with the Commission for Health Improvement?
  (Professor Parish) With whom we are in regular dialogue to make sure, again, that we do not have any unnecessary duplication of effort. By way of an introduction it might be worth saying that we are very conscious of the fact that we are regarded as a modernisation and improvement agency that sits in the middle and potentially overlaps with a number of other agencies, so we have gone to great lengths to make sure that we add value and do not replicate effort. There are two ways in which I think we can fulfil the function to which you refer. The first is for us to use the evidence to establish indicators that are linked to targets which can be built into the performance management framework for the NHS and other organisations, so we have the clear indicators for success and we use the existing frameworks for managing performance to demonstrate whether or not the necessary progress is being made. The other area where I think we can actually have some impact is to establish a programme of developmental reviews. Not so much audit with sanctions, not the OFSTED of public health, but where we work with other agencies, including, for example, the professional bodies from which you have heard evidence this morning, so that we can actually take part in a programme of developmental reviews to test whether or not the best of good practice is being applied in different parts of the country. If I can give you an example of something that is well down the road in terms of planning at this point in time. We have been working with the Improvement and Development Agency for Local Government to see how we can bring a public health perspective to their best value reviews so that when they undertake these reviews of local government, we bring public health to bear. We are in the process of ensuring that we have people initially trained from the HDA to contribute to that, but the intention is that within a relatively short period of time we will wish to have people from the field fulfilling that role with the HDA merely acting as the public health conduit.

  286. Thank you for that. My main question goes back to what we were speaking about a few moments ago. Professor McIntyre, and I do not know whether you were able to take on board what was said?
  (Professor Parish) I have seen her evidence, yes.

  287. She was very clear about the lack of scientific basis for evidence. You are going to build up the Evidence Base 2000 of "what works". I heard Frank Dobson, who was Secretary of State at that time, indicate in this field about looking for "quick and dirty methods. Getting out there, getting things up and running, making a difference". The two things are polarised. You mentioned yourself randomised control trials and that sort of thing. HAZs, HImPs, they are more quick and dirty. How do you put the two things together? How is that going to work?
  (Professor Parish) Maybe if I could kick off and I will ask Antony Morgan to fill in any gaps in the evidence I provide to you. The first thing I would want to say by way of an introduction to this is that whilst there are significant gaps in our knowledge and in evidence, we also do actually know an awful lot about what works as well. In particular, we have quite good evidence around what one might call on the ground prevention services to do with, for example, smoking cessation or immunisation, screening initiatives in school, workplace health, issues of that kind. We do have some evidence around the types of processes that are more likely to lead to successful outcomes drawing upon the international database, lots of case studies that have been pulled together by, for example, the World Health Organisation. So we know, for example, that those public health interventions that engage the intended recipients, usually the public, in consultation are more likely to be successful. Those that set clear objectives, those that develop a sense of ownership through partnership working, those that tend to go for multi-sectoral wins, and there are some very good examples around diet and sustaining local agricultural economies, those are more successful. Those that set targets with measurement arrangements in place, those that engage the mass media to set the right sort of climate of opinion, we know that all of those are more likely to lead to success. Where I would support some of what Sally McIntyre has to say is that I think we do perhaps need to place some greater emphasis on looking at both intervention areas with controls. In other words, we can try to test the net gain of having made a public health investment in one part of the country as compared to another part of the country matched socio-economically and demographically where we have not made that same investment. Where I think we are going to have some difficulty is that it will always be difficult, if not impossible, to infer direct cause and effect because one can never control all of the variables with these large scale community based public health initiatives.

  288. I made that point to Sally McIntyre. That seems to be quite a big if.
  (Professor Parish) It is. However, there is a wonderful quotation—I cannot remember who the author of it was—that says "the evidence is usually insufficient to satisfy the intellect, but more than enough to justify action". I think that is particularly true for the public health field. We may not have all of the answers but we have sufficient of the answers.

  289. Is that quick and dirty or is that scientific?
  (Professor Parish) No, I think it is scientific. I hope this will not confuse you too much but some of these research approaches are referred to as quasi-experimental. I think the evidence that one can gain from those types of research initiatives is sufficient to justify public investment in taking action and where we make that type of investment it is important then to build in the ongoing evaluation to test whether or not the hypothesis you started with is actually delivered at the end of the day.

  290. Would you agree with Professor Griffiths, who was giving evidence to us before, that you should be prepared to risk failure in these things?
  (Professor Parish) Absolutely.

  291. Politically, how could we be prepared to risk failure?
  (Professor Parish) I think we have to be prepared to risk failure. At the risk of giving you too many quotations, when I started in the public health field the first quotation I pinned up on the wall in my office was "to try and fail is to learn, but to fail to try is to suffer the inestimable loss of what might have been".

Chairman

  292. We might include that as a quote in our report.
  (Professor Parish) I do think we have to take some risks. We need to be in a position to ensure that we learn from the failures so we do not repeat the failures, and that is something that happens more often than it should in the public health field. If we are going to make real progress in the public health field, the people who do take the political decisions have to accept that whilst we should have more successes than failures if we have got the evidence base right, there will be times when we get it wrong but we will have learned as a result of that exercise.

Dr Brand

  293. That is very interesting. I think you are absolutely right, local projects must be encouraged even if perhaps they fail. I have a concern about some of the imposed projects from the top. In your evidence you said there is evidence of initiative overload and that gets in the way of effective delivery. You clearly have an important role in influencing what happens in the field, which seems to be your favourite phrase for what happens in the sticks, but are you going to have influence in what the Government itself does? Are you going to have some control over this initiative-itis and project overload that we keep seeing?
  (Ms Buckland) I think the first point to make is that the initiative overload has already been recognised by the Government. There is this document, Reaching Out, which was produced, I think, by the Cabinet Office which has pointed up the fact that there are too many initiatives going on at the local level and there needs to be better joining up. They have recommended the regional structures as being an area where they might—

  294. I am sorry, my criticism is not what happens locally, my criticism is what is being imposed from the top in the way of local activity.
  (Ms Buckland) I would not say the HDA has control over Government. The Health Development Agency has been set up to advise Government and to advise Government from the evidence base. The evidence base will be publicly available. There is an autonomy in our relationship with Government. We will be pointing up to Government the things that come out of picking up the evidence in the field and some of the lessons of implementation.

  295. So you would be quite worried, for instance, if Government action destroyed an evidence base against which you could measure an initiative? I am thinking about NHS Direct where it is being rolled out before it has been evaluated, so you cannot now have controls.
  (Ms Buckland) I do not know the specifics about NHS Direct, but we are urging—

  Dr Brand: It is probably the most expensive and the biggest project that the Government has undertaken.

  Chairman: Take this with a pinch of salt, he is a GP.

Dr Brand

  296. I have got an open mind on it but I have got a real problem that it cannot be evaluated now.
  (Ms Buckland) To pick up the general point about making the case to Government for evaluation, which is part of our role, for example the free fruit in schools scheme which has been set up within the NHS Plan, certainly the Health Development Agency, together with the Food Standards Agency, has been providing advice to Government and urging Government for not only a short-term evaluation but a long-term evaluation of that scheme so we can start to build up an evidence base that looks not just at the effectiveness of the implementation of a project but its effect on the long-term health of the children at whom the fruit is focused.
  (Professor Parish) May I add to that, Chairman. I think there are some ways in which the HDA can add some value to all of this as well. You referred to the quite large number of policy initiatives. One of the things the HDA can do, and indeed has recently done in the first instance for the Regional Directors of Public Health, is to map the policy context around inequalities, for example, to bring some sense of cohesion, and that has been extremely well received. I think it would be fair to say that we do have a role, and we would certainly hope to have a role, in feeding evidence into the process of policy formulation and also as part of that exercise to sometimes act as a vehicle for feeding views from colleagues working more locally and, indeed, from organisations like the UKPHA and the Faculty of Public Health Medicine, into that debate so that we end up with the HDA having a mix of priorities that are set partly centrally in support of Government policy and partly a response to locally determined needs.

  297. Do you publish your advice to Government?
  (Professor Parish) In the sense that our evidence base will be publicly available and any advice we provide to Government will be based upon that evidence then the answer is yes.

Mr Amess

  298. In your Business Plan you say you want to establish your agency as "a working party with the national network of public health observatories". What exactly does that mean and how will it work?
  (Mr Morgan) What it means at the moment is that we are considered to be a partner of the National Association for Public Health Observatories, which is an Association which was set up in June of this year to bring together the eight regional observatories to talk about and share information on progress within developing their observatories, but also to think about and share information which would allow them to think about the sorts of collaborative projects that they might undertake, to talk about general issues, for example the development of indicators for health improvement, which is a general issue that touches all public health observatories. One of the ideas is that the Association can bring together expertise in order to push something like that forward. Another example is on access to data and how do local players get better access to data and data that is more locally based using small area statistics, those sorts of issues. I suppose in terms of how we feature in that, as a national agency we have something to offer the public health observatories on those general aspects that can be infiltrated into the eight regional observatories. In terms of our remit in building the evidence base, I think we need to use agencies, such as public health observatories and other agencies, to help us build the evidence base. We will not be the only people who will be building the content, what we need to do as an agency is draw together experience from out there working locally, and it will be of value for us to be a partner in that respect. It is still early days and they are still developing as observatories themselves, so we have to develop what it means to be a partner.

  299. Thank you. Have you got enough staff to achieve all of this?

  (Professor Parish) We have enough for our first year but there are three areas where I think we would hope for additional resourcing in the future. One would be around some additional skills, some additional people, within the Health Development Agency, particularly related to things like workforce planning and some additional IT skills to enable us to handle a lot of the work around the National Electronic Library for Public Health, for which we have been given the responsibility. The second area where I think we would require some additional resources in the future would be to enable us to commission the research to fill in the gaps in the evidence base. At the present time we would not be able to do that. The third area, if I can refer back to the earlier point that Yve Buckland made, is to provide the development monies. In effect, we are an R&D organisation and we will need to have the D, the development resource, to pump prime initiatives in the field, to provide the necessary resources that will have a practical impact for people working either in general practice or as a health visitor in the field, someone working in a local authority, in a leisure centre or whatever it might be.


 
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