Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 517 - 539)



Mr Austin

  517. Good morning. Could I welcome you to the Health Committee and, firstly, can I offer the apologies of the Chairman, David Hinchliffe, who is unwell and unable to be here this morning. Can I also, at the outset, say that although there are microphones they are not for the purposes of amplification, they are for the purposes of recording. The acoustics in this room are not terribly good, so if I could ask our witnesses when they speak if they could speak up, it would be very helpful. Our first set of witnesses are from Hillingdon and Sandwell. I wonder if we could ask you briefly to introduce yourselves?
  (Mr Parkes) Good morning everyone. My name is John Parkes. I am the Community Director of a registered charity in Walsall, Pool Hayes Community Association. I am one of the two voluntary sector representatives sitting on the West HAZ, West Health Action Zone Steering Group in Walsall.
  (Mr Goalby) My name is John Goalby. I am the Public Health worker who works to facilitate the Walsall West Health Action Zone Steering Group. I am very much into action planning, working with communities and the interface between the community and the local services, particularly health.
  (Ms Little) My name is Valerie Little. I am currently—just—Director of Health Planning in Sandwell Health Authority but I move in a couple of weeks' time to Walsall Health Authority to be Director of Health and Regeneration which is a joint appointment between the local council, Walsall Metropolitan Borough Council and Walsall Health Authority.
  (Ms Goodwin) My name is Shirley Goodwin, Deputy Director of Health Strategy at Hillingdon Health Authority working from within the Public Health Department there. My main responsibilities are to develop the Health Improvement Programme across the partnership in Hillingdon and also to support and promote partnership working. In that respect I have dotted lines to the Director of Social Services, my colleague here, and to the Head of the PCT in Hillingdon, while actually directly being managed by the Director of Public Health.
  (Mr Betts) Good morning. My name is Graeme Betts and I am the Corporate Director of Social Services in Hillingdon Council. As part of my corporate role I chair the Council's Corporate Health Group and I am also the Chair of the Health and Social Care Executive which is a joint body across the health economy and the local authorities.
  (Mr Kelly) Good morning. My name is Terry Kelly. I am the Head of Health Promotion Board for Hillingdon, a joint appointment between the health authority and the local authority, responsible for development of health promotion strategy within Hillingdon and also development and management of the jointly funded Health Promotion Service which is based within education, youth and leisure within the local authority.

  518. Thank you very much. Can I put a question to both areas, to whoever wishes to go first, to ask you what do you think have been the main achievements in the improvement of health in your areas? Have you actually seen measurable health gains as a result of your work? Do you think that any successes you have had can be exported to other areas or are they peculiar to your own environment and situation?
  (Ms Little) I will start. If I can speak, first of all, about Sandwell. We have seen improvements, steady improvements, as I look at the Health Improvement Programme review in the first year in all of the main indicators. We have improved on perinatal mortality, we have improved on coronary heart disease, we have improved, though not enough, on strokes. They make our targets that we have set in our Health Improvement Programme look as though we can meet them, query what interventions have led to that improvement. I think that is the difficulty in linking the intervention to any improvement in the statistics. Where we have not made progress is on teenage conceptions. We have had a lot of work around all of the main areas like CHD, like strokes, like teenage conception well before the advent of the Health Action Zone so we have to assume that some of our programme work there has contributed to these results but I do not think we have sufficient evidence to say what contributed, how much. As I say, where we have not made the progress is particularly in the teenage conception rate which remains stubbornly high despite having done quite a lot of joint work pre Health Action Zone. In terms of particular areas and projects which might be deemed a success, I would highlight our Akash project which is essentially a project about the engagement of Asian women in health issues. The uptake of services has been historically very poor. We used Single Regeneration Budget funding to train local Asian women to facilitate and run education sessions for other Asian women. These lay workers are paid and we were able to put together health matching money with regeneration money because the training of those workers also gave them a route into employment which was an important outcome on the regeneration side. That was done through Round two of SRB. We have had about 5,000 contacts with women over the lifetime of the project and it has certainly met all of its employment targets, but more importantly it has met some of its health awareness targets focusing on diabetic support groups and mental health. On the diabetes front, we have had a bit of a self-evaluation from the women themselves in terms of self-care, self-referral, appropriate or non appropriate attendance at clinics and that has had some positive figures. What we now feel though is that we need to have a more systematic research effort there and so we are commissioning the research study. I should say that what it has also provided us with is a model that we have now moved on with other areas and other projects. So, for example, we are HAZ funding a project which is just getting under way to train some more lay workers in relation to access to services and advocacy. More particularly, one of our primary care groups has picked up and funded a lay worker scheme for the Bangladeshi community which is one of our poorest communities, poor both in terms of material deprivation and poor in health, a community that does not easily access the mainstream services. We are now training and have put in place Bangladeshi lay workers and similarly budgeted for Pakistani lay workers. The fact that we had done the original one with SRB funding, showing that this could work, I think was a factor in the primary care group continuing the funding. The GP colleagues in the primary care group saw that this was an interesting way of improving access and, in this particular instance, it is about improving access to primary care services. Again, I think that is worthwhile. That is the first success in project terms. The second thing I think I would have to highlight would be fluoridation in Sandwell. I know it is not news but the latest dental health survey is just out. We have been fluoridated in Sandwell for just over 13 years and the epidemiological results for 14 years olds are now quite dramatic. In 1984, decayed, missing, filled teeth was 4.1, that is the average, in 1999 it is 1.2 so that is, in terms of the way those figures move, a substantial reduction by the current 14 year olds who have had almost a lifetime of fluoridation. It is interesting because if you look at league tables for five year olds, we are seventh from the top for DMF. Sandwell is a very deprived area. It is virtually seventh from the bottom on deprivation so it completely reverses the health inequalities and it is quite a dramatic example. As I say, it is not news, it is not the latest but it is a substantial result and should be noted.

  519. Can I ask Hillingdon?
  (Ms Goodwin) Yes. Hillingdon is a somewhat different area, a very different population. Generally most of our indicators are better than average. Historically, I think, much less of an incentive for us to collaborate and without the benefit of additional funding or the incentive which a Health Action Zone, for example, offers. I think, until very recently, with the establishment of our partnership, there has not been really very much collaboration at all across the council and the NHS locally in Hillingdon. Our indicators are better than most. We have pockets of deprivation. We have specific inequalities around coronary heart disease, diabetes in our South Asian population, for example, uptake of breast screening, cervical screening and I do not think we can show you at this stage, two years in, that we have produced any measurable effect at this stage. However, we are working to address the underlying determinants of health across a whole range of services, functions, strategic planning areas. We have introduced in the first two years common goals. We are adopting a set of headline indicators to help us monitor progress in the areas of education, housing, income, environment and so on. We have already started specific projects and joint services which we think are showing benefits to the populations receiving them but we cannot turn that into documented statistics at this stage. If I can just mention two examples, and colleagues may want to come in. On probably what is one of our most deprived housing estates over the last two years we have brought together a partnership which has bid successfully for SRB funding (which covers a small portion of our Borough's area) and a community cafe focused on family learning, health advice, internet skills in due course, job training, food and health will start to function any day now. We have appointed a cafe manager and that is for us a very concrete example of something that has come out of the partnership. Another example is the appointment of a specialist health visitor to look after looked after children which our Director of Social Services says is already, again, showing gains for the population of vulnerable children who are receiving that service.

  520. Mr Goalby?
  (Mr Goalby) In terms of Walsall, I think it is fair to say that Walsall has taken a very regeneration and health approach to public health. From the historical perspective, Walsall had the opportunity to set up 19 local neighbourhood committees which operate through SRB. From that process, alongside health watch groups, we have actually linked Walsall together within the PCG boundaries into four Health Action Zone Steering Groups steered by local people who are representative of local committees and who are supported by officers from the local authority, from the health authority, from the health trusts and primary care groups. From my perspective, as Public Health Worker for the Walsall West Health Action Zone Group, I think it is fair to say that we are taking a very long term view. It was always the case that many of the problems associated with the west of Walsall, around coronary heart disease and strokes and cancers were not going to be solved in the space of a year. We have had one year's activity. We have, however, put together a very strong programme locally, determined by local people, focusing on sexual health and teenage pregnancy, domestic violence and drugs, transport and coronary heart disease, the NSF factors: coronary heart disease, cancers, mental health. Some of the measurable health outcomes are that we feel we are reaching quite deep into the community to engage people at a very local level to think about their own health and to actually work with each other within specific geographical areas to try and overcome some of the health inequalities which do exist and to work with the local authority and the NHS to work together and overcome that. The health inequality agenda is something which we are very keen to ensure progresses and something which is very central to our programme.

Dr Stoate

  521. A couple of things I would like to pick up with Ms Little. It is extremely good news about the fluoridation because that is something I have been pushing for for a very long time. That is excellent news that you have managed to achieve such a great improvement in dental health amongst youngsters. My great regret is that we have not been able to fluoridate the whole country yet but we are working on it. The point about that is though it is a very specific intervention with a very well established cause and effect and therefore, of course, over 14 years you have been able to produce some excellent results and good luck, I was slightly more concerned about your coronary heart disease statement. You said that you had managed to achieve improvements in coronary heart disease. The difficulty I have got there is how can you be sure what is the cause of that reduction? What is it specifically you are trying to do to intervene? My worries as a doctor of coronary heart disease is that it is a very long term condition and any interventions of necessity are going to be extremely long term and difficult to pinpoint and even then you can only get associations rather than cause and effect.
  (Ms Little) Yes. Well I think that was the burden of my point, Dr Stoate, really. We have seen some improvements. We did not just start working on coronary heart disease in Sandwell the day the Health Action Zone was announced. When I went there in 1991 we had a programme relating to coronary heart disease.

  522. What I mean is what exactly are you doing to intervene? What measures are you using?
  (Ms Little) It is across the range: it is across diet, it is across smoking. We had started a smoking cessation service before it became a national target, and so on. I cannot say that from any specific thing that we have done I can produce you a research study which shows that this resulted in an improvement in the health in Sandwell; I cannot do that. That is why I think that we have to get a little bit more research into some of the individual areas. That is why—and I am sorry to slightly evade, I hope I am not evading your question—I think the answer is I cannot tell you that. In order to enable us to try and get a better handle on that in some areas where we have got the funding and where we can do it, we are now putting in a much more rigorous piece of work. For example, our Health Action Zone project in the housing and health work stream is looking at repairs on prescription in relation to asthmatic children and we are putting in an RCT design to try and get a solid research result out of that in relation to the repairs and prescription programme and wheezing and asthma in children.

Mr Austin

  523. Can I ask whether the initiatives which you think have been a success are the ones which have followed through programmes which have been tried elsewhere and which appear on the evidence to work?
  (Ms Little) Yes.

  524. Or have you tried new and innovative things which may not have been tried and proven elsewhere? That is the first part. The second part is there are some programmes which appear to have been tried and proved if one looks elsewhere. For example, the area you say you have not succeeded in is teenage pregnancy, if we look at what has happened in Holland it is a dramatically different position. Are we not doing what they are doing in Holland or is what they are doing in Holland not working here?
  (Ms Little) I do not know. I do know that there does not seem to be the evidence around in relation to some of the interventions on teenage pregnancy, certainly culturally specific to our country and our sorts of areas. You are right, what we tend to do is look at things that seem to have worked elsewhere and then try and tailor them into our own areas. I think in terms of brand new different things, Walsall has probably got something to offer on men's health. Perhaps you can just mention that for the moment, John?
  (Mr Goalby) Certainly. Obviously we have found engagement of people is one of the greatest difficulties. In Walsall, through the Health Action Zone process, we have had the opportunity to work to engage men, particularly around men's health issues. I think you may have heard of it, it has received a fair amount of publicity, men's health screening in pubs and working men's clubs has gone on using an arts approach. The message being that men tend to feel that they are being lectured to and switch off and actively avoid going to the GP. So we have tried to use a different approach to get men involved, to get men to start thinking about health issues. Obviously if we look at coronary heart disease and cancers, we have to be able to detect them to treat them so we have actually got this problem replaced by using arts, comedy particularly, to break down some of the barriers in pubs and clubs and get men talking about their own health and then do a screening process whilst we are there. That has brought up some significant issues of people with undetected diabetes and various conditions which they have. It is a case of getting out into the community to try and make the change from the start so that people have the opportunity to access services effectively. What we are ensuring we are doing is to link that into a referral scheme and to make sure that the contacts which are seen are followed through and people are treated effectively. Obviously, again, it has had a very short life span so far but we are very hopeful and we have managed to produce some early evaluation. This particular one surrounds testicular screening but is focused on men's health.

  525. It would be useful if we could have some information on that.
  (Ms Little) We can send you some details.

  526. Mr Kelly?
  (Mr Kelly) I think one of the things which has helped in the development of a number of programmes is the direction that we have had from the Department of Health and particularly the way it has been linked with the Department for Education and Employment in relation to implementation of the National Service Frameworks, for example, and the NHS plan. I think one of the successes that we are starting to see now is the number of people who are coming forward for help in giving up smoking, for example, largely facilitated and resourced through central government. I think that is a real success which will be mirrored across the country. From our point of view, we are starting from somewhere behind where other areas have been for some years. The benefits that we have seen of the health partnerships and the work with both the local authority and the voluntary sector is the rate of progress that we have been able to make to catch up to areas like Sandwell and Walsall which have been probably further ahead than Hillingdon certainly in terms of health promotion input and health promotion programmes. Within a year we have been able to start from a standing start to put together a healthy schools programme which has now engaged 30 schools which has been agreed by the LEA and which has been agreed by the partners and has the full backing of Head Teachers Associations and so on. My experience is that in other areas they have taken three to four years to get to the same position that we have taken in a year, and largely that is down to the learning that we have had from the experience of developing these programmes but, also, it is largely a function of the education authority seeing the relevance of health to its own agenda and its own agenda in terms of raising attainment and raising educational achievement. I think one of the big successes for us in terms of Hillingdon is the way our Health Improvement Plan is structured and the fundamental premise of it in terms of influencing the big determinants of health makes health relevant to every organisation and they can see where they fit in. That has been fundamental in getting them engaged in the health improvement agenda.

  527. Can I ask as a late starter of rapid improvement whether you have done this despite national initiatives or because of them? You were saying there had not been a tradition of partnership working in the past, has that been on account of the lack of structures for that or because of personalities? There was a reference earlier that people had come together because of SRB. How important are structures as opposed to personalities?
  (Ms Goodwin) Can I start. Historically there were difficulties of various kinds between the council and the health authority in Hillingdon which were partly a function of personalities and politics and all the usual things which happen in most local areas. I must say that Terry Kelly and Graeme Betts have arrived in the most recent period, two or three years, and, therefore, we date what we are talking back to them, but I have been there longer so I have seen some of the other stuff and the failed attempts really to try and get some kind of strategic working across the area working. Over the last two or three years it has changed and one of the factors that changed that was, first of all, the arrival of two new chief executives, a chief executive for the council and a chief executive for the health authority. That has certainly made a difference because those two people decided it was time we stopped all this rubbish and let us just get going. They formed a Health Strategy Partnership within a year or two of them both arriving. The next big thing that helped was the HImP, the requirement to develop a Health Improvement Programme. I think having got the basis of the partnership, when the Health Improvement Guidance arrived—and I was appointed to lead that work—okay we have got our Health Strategy Partnership, it had just started going, they had done some work to identify some common areas of concern and I used that to work with all the partners to develop the first Health Improvement Programme. I think that was certainly a major impetus for us to start to work across the areas, the underlying determinants of health, the different services and sectors including voluntary and our local race equality council. For me, the HImP was certainly a very important incentive to get the partnership going beyond talking nicely to each other and actually agreeing priorities and working together on them. In two years we have made massive—massive—strides to the point where we now have a joint commissioning team for all the client groups which Graeme will speak more about. Also I think the jewel in the crown of our first Health Strategy was Terry Kelly's service, the fact that we have a joint funded NHS/local council Health Promotion Service which is uniquely located within the education, youth and leisure directorate of the council. Terry himself has a contract with the health authority but because he is physically located in another bit of the council, line managed within a directorate of the council but also part of the public health team in the health authority, he really is seen as one of us by everybody. He will tell you how much difference that makes to his ability to work not just with education, within education but across other directorates: housing, environment, social services and so on.
  (Ms Little) Can I echo the importance of the Health Improvement Programme, although I have to say that in Sandwell and in Walsall and indeed in Wolverhampton and in Dudley, the other Black Country health authorities and metropolitan boroughs, there is quite a long tradition of joint working and we have got a pretty sound background because Sandwell in particular, initiatives at political level, one of the chairs of the health authority had a substantial background in local government and was able to work very closely with council colleagues to give that political okay. We have been partnership working with the Health Forum for many years. The Health Improvement Programme gave us a bit of a structure. I have expressed, I think, in my short note to you some apprehension, and it is no more than apprehension at the moment, that the Health Improvement Programme will now be driven by an NHS Modernisation Plan which is heavily focused on services and not on this inequalities agenda that we have been so concerned about. I think I would want to log that with the Committee. I am not saying it is going to happen, it is just a bit of a fear that the driver is there. The second point about structures and initiatives from government that I think I would like to make to you is around the joined-up working at central level. We have a lot of partnerships. We have what we refer to locally as a plethora of partnerships because it is quite a Government flavour at the moment so everything is done in partnership and if you are not careful you can end up with an awful lot of partnerships and that is very difficult for community and voluntary sectors. They are stretched to the limit. So the recent DETR guidance on local strategic partnerships and a desire to rationalise this a little bit was very welcome. Then I had the direction from the Department of Health to set up a Modernisation Board in every health authority which was like a partnership but not quite the same and did not match the local strategic partnerships. We are now trying to make all that fit together on the ground. I think there still is quite a cleavage between DoH and DETR. Would you agree?
  (Ms Goodwin) Absolutely.
  (Ms Little) If we can just get that a little bit better on the structural side I think we will find it a lot easier on the ground.
  (Mr Betts) Many of the structures that have been put in place we are finding very helpful in actually comparing, for example, where mental health is getting to compared with where other people's services are at the moment. Without a doubt the NSF has helped with that. The only danger is there is almost the initiative overload that we feel at times and the lack of-joined-up-ness centrally. Locally we are overcoming those issues but sometimes it feels we are doing that almost in spite of the lack of thinking centrally.
  (Ms Goodwin) A little point to complement what Valerie has said. Yes, we would share the concern that the HImP is in danger of becoming entirely service driven, particularly this year with the drive to implement NHS planned targets which we support utterly. There is no question that they are the right targets and we are committed to delivering them. Early discussions that I have been having with local partners suggest that what we might do in Hillingdon to make sure that does not happen too much, we have the joint Health Strategy Board which is our overarching partnership board that Graeme referred to earlier. We are thinking that the NHS Modernisation Board might be a subset of that group. That then puts that NHS focus in the right context across the partnership and although there will always be the fear, and I get it continually from colleagues across the partnerships, that health is driving everything and forcing everything on, in fact putting the NHS Modernisation Board below, if you like, the overarching Health Strategy Board will deliver a very strong message that we are committed to working across the whole piece and not just on delivering NHS short term targets.
  (Ms Little) Personally, I would like to see the NHS modernisation board in a health authority being some kind of subgrouping to the local strategic partnership to the LSP, which has that overarch. It is not just health; it is the business links and so on. That is how I would like to see it done. Whether we can pull that off locally or not I do not know. But we are not edged in that direction by the guidance at the moment.

  528. Are we also talking about bringing together the health improvement programme and the local authority in the overall community?
  (Ms Little) We have done that.
  (Ms Goodwin) Since the first HimP we have done that.
  (Ms Little) In Sandwell we have parallel meetings with the health improvement programme and one of the workstream programmes, and it is highlighted in the LSP guidance. It is really the partnership structures and getting the situation such that people from community and voluntary groups can participate. They can be required at too many meetings when there is only one person and a dog in the office.
  (Mr Parkes) The difficulty we share is that we have to get away from all the bureaucracy. I keep hearing the term, "joined-up thinking". One of the things we pride ourselves on in West HAZ is joined-up action. In joined-up thinking there is only so much talking, hot air, paperwork and whatever that you can do. What we want to see is action on the ground.

Mrs Gordon

  529. Perhaps I can address the first question to Mr Kelly. You have already talked about the Healthy Schools initiative. I wonder if you can give us a run-down on how this initiative has actually made a difference to the health of children both in schools and outside. Perhaps Mr Betts could comment on his initiatives on children's social services as well. What particular projects do you run and how do you involve the children in the process?
  (Mr Kelly) Probably the last question is the most difficult to answer at this time. Again, we started our healthy schools programme in June 1999 from scratch and so the first year—essentially the first eight or nine months—was a process of development involving the different partners, documenting the scheme, agreeing the aims and objectives and so on. We have, like many other areas, a healthy schools programme which is holistically-based. It is aimed at improving the health education within the curriculum and we have already seen some major changes around there, particularly in the way visiting speakers are used and the way lessons are planned, curriculums are structured around different health topics; for example, substance abuse issues. We have now based that curriculum programme on principles of good education practice much more now than it was in the past. We have started to develop a number of criteria-quality standards-for the development of and delivery of health education within the classroom and quality standards in terms of the use of visiting speakers. In the past, and to some extent still—we are making progress but are not there yet—essentially schools would bring in various people from outside with no structure, no pre-planning, no post-feedback or whatever. So the aim has been to improve the curriculum and we have produced a number of documents which support the curriculum, particularly around substance misuse. Last year we produced and disseminated a curriculum plan on education around substance misuse across the four key stages. Hillingdon has about 90 schools. That pack is now in over 50 per cent of those schools. But we do not simply send a pack out. It has to be linked with the standards around substance misuse within the healthy schools programme and linked to training. So we are starting to get a more structured and systematic approach to curriculum learning and health education and we are starting to see the benefit of that. The whole school approach is aimed at reinforcing what pupils learn within a classroom, within the whole school environment; for example, if kids are doing food nutrition education in the classroom, then we look at supporting that in whatever food is available within the schools so we have a number of projects which are ongoing.

  530. In other words, practice what you preach.
  (Mr Kelly) Yes. There are a number of projects in train from the development of breakfast clubs, which help to get children into school to start off with, so you help the attendance agenda. It also prepares, in particular, young children to learn. If you are five or six years old and hungry at 11 o'clock, it is difficult to concentrate on your learning. So the development of the breakfast clubs is one area of impact. We have also started a project—I say "started"; we are in the planning phase—to introduce special swipe cards into some secondary schools to encourage secondary school pupils to take up healthy options in the canteen. We are developing a project which essentially gives them points for choosing healthy options which they can then use to redeem for things like Cds, or maybe sports equipment or computer equipment. As the scheme pans out we are hoping that they will be able to redeem them on things like help with their homework, access to IT screens and those sorts of things. That is an example of how the classroom education can be reinforced in the overall school. We are still in the early stages. We have 30 schools engaged in the scheme and we are in the process, as we engage the schools, they agree which areas they want to work with. We audit where the school was because that is a vital point. We are now in the process of putting actual plans together within the individual schools to enable them to move on and measure progress towards the standards within the scheme. How do we involve the pupils themselves? Probably not as much as we should do at the moment. It has been an extremely difficult area to work with. We have involved the pupils in a number of specific activities, particularly around things like peer mentoring and peer education. We have a strong programme of peer mentoring within the borough, which is in at least one-third or one-quarter of secondary schools. That sounds grand but we only have 15 secondary schools. So the peer education and peer mentoring programme is developing and is fairly well established now. We also put in place a programme of support for pupils involved in drug-related incidents, the aim being to keep them in school and support them in schools. We provide them with a support plan which is provided first by the people from the health promotion services in conjunction with peer mentors and peer educators. So we are involving pupils in the developments of those things, but probably not enough in the development of the overall scheme.

  531. One of the things about practising what you preach, you did not mention whether the schools actually audit their own physical environment. One of my hobby horses is back pain and there is a growing incidence of back pain in young people. Is that taken into account? Are you doing anything about that?
  (Mr Kelly) One of the areas within the healthy schools scheme is the physical environment and physical safety. The way we have developed this is that we have worked with schools and encouraged them to choose what is important to them at that time. The idea is that they work through the whole programme over a period of four years. So some schools have taken on the physical environment both within the school and the external environment in terms particularly of things like safety in school and developing those. But it is not across the whole school environment at the moment.

  532. You say you started from scratch. As we have gone round and looked at various initiatives, it keeps coming back to me that some organisations are re-inventing the wheel. When you say you are starting from scratch, did you have any input from other authorities or did you have any shared best practice that you took on? How do you now devolve what you have learnt to other organisations?
  (Mr Kelly) In truth, we pinch some of the ideas from other areas—it makes sense—and from some of the experience I have had in the Northwest, working in both Liverpool, West Lancashire and Manchester. So where we start from scratch, we are not starting from scratch in terms of a knowledge base, but we are starting from scratch in terms of what was developed and what was available.

  533. But that was your own experience really. Were you able to access any information from nation-wide initiatives?
  (Mr Kelly) We also used the results from the European network of healthy schools programmes. A three-year study was commissioned and organised by the health education authority, as it was then, and we have also taken our reference from the DfEE publication on healthy school standards.

  534. Can I just pick up with Mr Betts? Does this link in with the social services and the initiatives you are taking?.
  (Mr Betts) It does not, but there are very close links between education, health promotion and social services and so on, particularly around looked-after children, the most vulnerable group. The point I was going to add in terms of involving children and so on is that for both health and social care in Hillingdon, we do put users as the focus of all our activity. So for children we are trying to actively involve them in their care, all aspects of their care, and within their level of ability to allow them to take control of the services that affect them directly. For example, even in areas which are quite difficult to manage, such as child protection conferences and so on, we are trying to take steps to enable children to take greater control of that process—conducting them in a child's first language rather than in English; enabling children with learning disabilities to make their own statements about their needs. In that way you could say there are lessons for all health and social care services in taking that approach. In terms of health specifically, we have got children's health plans which again focus on particular issues of care in the same way that, as a parent yourself you would be interested and as a corporate parent we need to have that interest. These plans help focus in on that. The health visitor role, we do not just say the immunisation has been done. Someone is there following through and making sure that they are done. The same with visits to the dentist. It is particularly important in Hillingdon where we have a large population of unaccompanied asylum seeker children. In fact, it is nearly half of our looked-after children who are unaccompanied minors. Because of that we have to work particularly hard with them to make sure that we do hear their voice and involve them in these processes, particularly for some of the children and some of the things we do do in terms of health education. They have different experiences and we could only achieve that if we worked in the way described in terms of partnership.

Mr Austin

  535. Can I ask, Mr Kelly, what the role of the school nursing service is and whether the role of the school nurse has changed significantly as a result of the Healthy Schools Initiative?
  (Mr Kelly) I think the role of the school nurse is changing rather than has changed, significantly, again learning from other areas like some of the work that was done in Liverpool. We are starting to look at the school nurse not just in terms of a health surveillance role.

  536. No longer just the "nit" nurse?
  (Mr Kelly) Yes. We look at the school nurse as a health adviser to the school and as a link to the other agencies; as somebody who can co-ordinate input into the school; can advise the school on the development of health in total, not just health services. They can also provide some services and in particular—it is appropriate this week—they can advise on sexual health and offer confidential advice, information and support that cannot be given in the classroom. One of the things that we have tried to do with school nurses is move them away from being teachers of some difficult subjects. Again, sexual health and substance misuse are the ones that spring to mind. So we are moving the school nursing role to a more strategic role within the school and there are three pilots underway at the moment within Hillingdon, two in primary, and one in a secondary school, to actually test that role out.
  (Ms Little) May I add an addendum on healthy schools? Sandwell has had a healthy schools programme and I will not go through that. But one area that we found important was governor education; working with the governors to make sure that there is an understanding about the programme and what it is there to do, and indeed changing roles. Many governors were at school when the nurse only did certain things. We found that to be particularly beneficial.

Mr Burns

  537. I don't know if you could briefly, both Hillingdon and Sandwell, give me an answer to these questions because you have got another half an hour and we have asked only 25 per cent of the questions. What I want to know briefly is how helpful or unhelpful have you found the various bidding processes and how relatively easy have you found it to be successful in your bids?
  (Mr Kelly) From our point of view, the criteria that are laid down within a number of funding areas and the consistency of those criteria have been really helpful. Sometimes actually addressing those criteria and meeting those criteria has been extremely difficult. Some of them are extremely tough and complex and I am thinking in particular of things like the healthy living centre funding, for example, which was in its initial stages quite confusing in terms of what people wanted and what, for example, partnership working they wanted to see. But there is a measure of consistency now starting to develop across the whole piece of different funding streams, which is extremely helpful.
  (Ms Little) I would like to highlight the importance of the regeneration funding stream to joint work. It is sometimes difficult to get people to commit mainstream health funds to some of these public health initiatives. If you could put it together as a matching funding in a regeneration programme, that has been the driver for a number of innovative public health initiatives and I would highlight again another apprehension in relation to the latest revised guidance to RDAs on regeneration funding following the comprehensive spending review. There is a clear economic focus—quite correctly; jobs are what they are there to generate. But I hope that that does not mean that some of the community capacity building projects are going to find themselves no longer able to be funded from regeneration money. That is one point. Secondly, I would echo the point on healthy living. It seems to be over there and not of a piece with the other funding bids that we have had to make. Thirdly, I think in the Department of Health sometimes the bidding criteria for quite small sums of money seem to be as rigorous and as difficult as the bidding criteria for some very big sums of money. So when you have a waiting list pot, you do not have to say very much to get quite a lot of money, and you have to say an awful lot about a very small amount of whatever it is, for a little bit of public health money. So there needs to be some kind of horses for courses appreciation of that. If it is small amounts of money, we do not need five pages of forms.

  538. Thank you. Can I ask you both again briefly, how successful have you found it, when you have had a short-term project, to be able to develop it into a long-term more permanent project?
  (Ms Little) It depends really. I mean, you only want to carry on if the thing is successful so sometimes the short-term funding gives you that opportunity. If something is not working, you are able to say that is enough. So it has its benefits but you need to get on to it early. Walsall in particular have been very good at mainstreaming the HAZ because that is time-limited—it is five years but it is time limited. We are already bringing all those on stream now. I think it is about good management personally. I do not think it is a matter of the type of funding. If you are going for short-term funding then you have got to know the basis on which you are going for it. If it is on offer on short-term, then you take it with that knowledge. So I am a little bit pragmatic about that. I think there is a place for short-term funding. What I do not like to see, and the people who I think do perhaps suffer are the voluntary and community organisations who are on a series of short-term funding things. That is something the health service and local services to the same extent have got to get a grip of. If we really want the voluntary sector to do this type of work for us, and it is shown to be successful, then we must give longer-term commitments to those things that work that are delivered for us by the voluntary sector.
  (Ms Goodwin) Can I just answer as well? Just to take that last point, an example of what we have managed to agree across the partnership in Hillingdon is that the former joint finance allocation, which was moneys given to health authorities to be used jointly between health and social services on statutory as well as voluntary schemes, that separate allocation has now disappeared and is now combined into health authority main allocations but, as in common with other areas, we have decided to keep it separately identified. The vast majority of our £700,000 or £800,000 annually is in fact tied up in existing schemes, of the kind that Valerie has just described. We have more or less decided now to say that these are virtually mainstream; they are important schemes. Let us take the uncertainty away for most of them if they are good and they respond to our formal evaluations and reviews and say, let them carry on; that now belongs to them; they will get that money forever. And let us use what is left, a much smaller amount of money, to build capacity and so on. So there is a point where you have to stop particularly subjecting small and voluntary sector bodies to this continual uncertainty, having to keep bidding and bidding all the time. The other point I wanted to make in response to your question, was that we have found that although bidding for short-term funding and having to plan around quite short timescales—three to five-years—can be a problem because you are always worrying about what will happen in two or three years' time, I think the impetus that those processes have given to us in Hillingdon to build strong, long-lasting partnerships outweighs the anxiety we might have about what might happen in the future. We feel that what we have built is utterly sustainable and will last well beyond the lifetime of the projects and whatever other funding we might get for them.

  539. That is good. That leads naturally to my last question, just to Hillingdon. How much do you think your success has been because of your relatively small size? If you were to be subsumed into a larger West London-type health authority, do you think you would be adversely affected or you would cope?
  (Ms Goodwin) I think the fact that Hillingdon Health Authority, for many years, and its previous health authority as well, has been coterminous with the borough has been of undoubted and immense value. I would attribute a great part of what we claim as success to that simple fact. It is small, with 240,000 odd people. We know everybody. I mean, I know every single GP in Hillingdon one way or the other over the past six years I have worked there. Everybody knows everyone else; lots of people are related and know each other in different contexts, wearing different hats. That makes a huge amount of difference and has certainly helped us. But whether or not reconfigurations of the health authorities or of other kinds in the longer term will make a difference, I am afraid the reaction of me and my health authority colleagues to the current study that is going on into what precisely the West London health authority configuration should be, to be frank, is very much, carve it up whatever way you need to. As long as we can continue to maintain our relationships at borough level I do not care who pays my salary. I will find myself a little desk in the chief executive's office or in Graeme's office and continue to promote the Hillingdon borough-wide partnerships whoever I am formally employed by in the future. It really does not matter.
  (Mr Betts) Can I just add to that? Myself and the chief executive of the primary care trust led a seminar for social services and primary care trusts and they have gone through in the first wave. We are clearly a long way ahead of the other trusts and social services and without a doubt, the fact that we are coterminus helped because it does mean you can drive things forward at a local level; you are not trying to relate to lots of different bodies and that is really becoming the axis which is enabling us to drive change through rapidly.

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