Examination of witnesses (Questions 280
THURSDAY 23 NOVEMBER 2000
MORGAN and MS
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
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
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
(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
quotationI cannot remember who the author of it wasthat
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
(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".
292. We might include that as a quote in our
(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.
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.
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
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.
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.