Examination of witnesses (Questions 517
- 539)
THURSDAY 11 JANUARY 2001
MS SHIRLEY
GOODWIN, MR
GRAEME BETTS,
MR TERRY
KELLY, MS
VALERIE LITTLE,
MR JOHN
GOALBY and MR
JOHN PARKES
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 currentlyjustDirector
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 whyand I am sorry to slightly
evade, I hope I am not evading your questionI 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 arrivedand I was appointed to lead
that workokay 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 massivemassivestrides
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 yearessentially
the first eight or nine monthswas 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 stillwe are making progress but are not there
yetessentially 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 projectI say "started"; we are in the planning
phaseto 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 areasit makes senseand 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 processconducting
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 particularit
is appropriate this weekthey 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 focusquite
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-limitedit
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 timescalesthree to five-yearscan 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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