Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 560 - 580)



  560. Why are we not? Given that it is 30 per cent of the population of London and given that 90 per cent of the beds are occupied by people from ethnic communities, why are we not doing better and what can we do to make it better?
  (Mr Blake) I have to say from my own view it is an issue in terms of our institutions taking on that importance. The executive office of the NHS in London actually produced a Mental Health Strategy last year, a 28 page document with lots of outputs and targets and things related to the National Service Framework etc, and they had one page on race equality.

  561. But why, that is again the question? You are giving me reasons why it is not working, which I understand, but what can we do to make it work?
  (Mr Blake) One of the key things has got to be around making the issue a priority. If people do not see it as a service priority, if they see it merely as an equal opportunity issue, which unfortunately relegates it to being a side agenda issue, if our institutions do not see it as a core service issue, that in terms of targeting these particular needs we could actually do a lot more in terms of enabling people not to get to that acute stage and all the benefits to the health service that would gain, then how do you get there? I think we are starting to wake up to the issue. Within London we had an excellent Health Strategy for London which was produced by the NHS Executive in London last year and the Mayor's office is also bringing a new impetus on a London level to all of this. Quite crucially, our institutions have to change. I walked into the NHS Executive in London's offices in Paddington and the people there do not reflect London.

  562. Do you think that the communities themselves ought to be more proactive in that case? If the institutions that run the system do not seem to recognise these problems then why is it that the communities themselves are not coming forward and actually organising themselves better and being more proactive in bringing these issues to their attention?
  (Mr Blake) I think we saw some of that coming through in the consultations for the London Health Strategy because, quite frankly, the regional office were not prepared, I think, for the onslaught that they got, not just from people like me but from people working within the NHS at the ground level who said "folks, these are big issues and we have not done well enough". That started to happen through the consultation for that particular strategy. I think that people at Eastbourne House started to wake up and to take these issues a wee bit more seriously.

  563. Do you think that things will get better?
  (Mr Blake) I think things will get better but it is (1) around having a long-term view and (2) viewing the issues as core service issues, not as a peripheral equality issue that we have to pay some lip service to.

Mr Austin

  564. Can I ask you if you attribute any of your successes to national initiatives or have you succeeded despite dictats from—
  (Ms Edmans) The project that I worked in started during the Conservative Government, so many of the initiatives that are talked about now did not exist. It was mainly funded through the Health Action Trust thinking about what were the links between health and regeneration, but also at that particular time there were the London Implementation Zone monies around to look at pump priming primary care. It was a very difficult time when we could not talk about health inequalities. We could talk about the health divide but not health inequalities, so it was a bit of a struggle. The change in policies and thinking has helped tremendously. There was a point when the LIZ money was running out and projects like ours were going to be stopped. The new policy changes and thinking helped people to realise that these were the kinds of things we should be thinking about doing because they were starting to provide some of the answers for the new agenda. It has helped me tremendously to come from what was a very tight struggle to something where you sit around the table and start talking about health and regeneration, the wider determinants of health, public health, partnership working, etc., etc., which was very difficult before. In addition to that is the additional money that comes along with it that has helped to lubricate and provide opportunities that were not there before or were very difficult before.

  565. You were within the health authority itself but for someone from the voluntary sector have those sorts of initiatives made your relationship with local health and social services easier or does it still depend on local personalities?
  (Mr Blake) I think to an extent it still depends on local relationships. The framework that some of the policy initiatives have created, picking up some of the points Teresa has made, has been positive. Specifically for my organisation, around HIV and Aids it is incredibly difficult because we are advocating for communities that are seeing the greatest increases in terms of people presenting with HIV. Unfortunately it is within a context where more of the resources, if you like the HIV pot, are being spent on drugs. That is an issue for organisations like us who are very much focused on community responses and initiatives. I do welcome the Government's move around the Integrated Sexual Health Strategy because I think one of the pitfalls in the past was that the whole focus specifically in terms of sexual health in the last decade and into the late 1980s basically meant HIV prevention and we did not have a holistic view. Some of the chickens are now coming home to roost around that and particularly around the rise of other sexually transmitted infections, which is incredibly dangerous. I also have to commend the Government around the Teenage Pregnancy Strategy for acknowledging that particular issue and trying to make a response in terms of tackling that.

  566. All of you are working with some of the most disadvantaged and deprived communities, often in small projects. Is there a danger that there are lots of groups all trying to reinvent the wheel? If you have successes how do you think they can be exported elsewhere or how can you learn from good practice and successes elsewhere?
  (Ms Edmans) Certainly from the point of view of the Community Health Project, yes, it did start as a very small project, one person on two housing estates, that then developed and took a larger community. Looking at the benefits and the integration of the things we were doing in terms of trying to tackle unemployment, the wider determinants of health, etc., etc., we wrote an SRB bid—Single Regeneration bid—looking at single regeneration and inequalities in health and we were successful with that, as well as some other things. Here is a small model, it has worked, how can we build on it, how can we extend it? We have been successful. We then tried to look at how we could transfer that to another borough and that was where we came into some slight difficulties because part of the thing that made the project successful was engaging the community and community ownership and it was much harder to start transferring those things without having to do that ground work, engaging the communities and helping the ownership, because there was a lot of distrust and some feelings of "that worked there, that is that borough, we want to do it our way". Although you can use models of good practice to help inform and show people how it can be done I still think you have to do some of the community involvement if you are going to do community projects. It is very important to have local ownership, whether that is in the statutory services as well, because people can be a little bit suspicious.

  567. We were talking earlier about the need to recognise issues and Dr Hussein was talking about female genital mutilation, and we would all agree that the authorities have been somewhat slow to recognise the extent of the problem. You were talking in terms of the long-term effects for those people who have suffered under this but, as far as the community that is here now in terms of public health, is there an issue for young girls who are here and is that being successfully addressed and tackled?
  (Dr Hussein) What I believe is that people do not have access to have that operation done in this country because it is really difficult. I am looking forward to a new generation that will be out of this problem. On the other hand, we know that some people do come with their young children already circumcised from Somalia or somewhere else. These young people do have the same problems as the older women. This is what we are working on, to talk to the young people about the health problems of female genital mutilation. Women do come to me with their problems and with their daughters' problems and I refer them to the service appropriate for them and talk to them and give them more information about their problems and how they can help themselves.

  568. You are aware of the issues?
  (Dr Hussein) Yes.

  569. Do you think that your local health authority and service providers are aware that this is an issue that needs to be addressed?
  (Dr Hussein) Here is the problem really because women do not like to talk about it to anybody, even to their GPs. They like to talk to somebody who understands the problem and for that reason they are coming to me. On the other hand, maybe their GP is not aware of which communities practise this type of circumcision. It is something really sensitive and women do not talk about it openly to anybody. If they have a problem they do not go to their GP and talk about it. I have some women who have been married for one or two years who still have not had any reversal operation done to them because they are afraid to go and ask their GP or talk to their GP about it. If she gets pregnant maybe that will be found out on the delivery table, that is a real problem. This is why we are giving health promotion, talking to them about the services available to them which they can use.

Mrs Gordon

  570. Can I just ask how you actually reach out to every woman in that community and how they get access to you, how do they know about you?
  (Dr Hussein) Knowing about me is word of mouth mostly. That project is based in East London and it is for the community located in that borough but I have clients from Liverpool, from Manchester, from everywhere in London. They know me as a gynaecologist from Somalia who worked there for 20 years, so by word of mouth they come and look for me[1]

Dr Stoate

  571. Ms Edmans, how easy have you found it to get money for your projects? Is funding a constant problem? You have mentioned already the change of attitude and more openness and awareness about these issues and it does seem that things are getting better, in your own words, but is money still a problem?
  (Ms Edmans) There are some difficulties. For example, Faduma has just spoken about how people come from all around the area and officially our money is meant to be for a specific catchment area but we try to flex that a little bit because of the needs. There are difficulties in the way in which money is given to you, whether on a community basis or a bigger basis. I think a lot of the problems around the additional money coming on stream are to do with the administration, particularly among community groups and voluntary sectors, the administration that you need to do it and the amount of time you need to make the bids and do the bids, that is quite difficult. Also hearing about what money becomes available. The people this morning talked very much about the fact that it feels a bit like a patchwork quilt or bits of a jigsaw puzzle and sometimes those jigsaw puzzles meet together. For example, you might have SureStart here, New Deal for Communities here, sometimes those things meet together and sometimes they do not and there are all sorts of complications around trying to get all of those bits to fit and meet all the criteria outputs and monitoring, etc., that are required for those things and a lot of resources go into doing it.

  572. You have been quite successful by all accounts. Why have you succeeded in getting money when other people constantly complain that they have not been successful? What is the difference?
  (Ms Edmans) I think you get good at it after a little while, after you have done a few. I think it is also about the fact that we can show how we have involved the community and involved partnerships, we can demonstrate that. Sometimes it is a bit difficult when things that have been successful get more money and things that have not been successful do not and that keeps happening. Sometimes I feel a bit bad when we are successful and getting things when I think that some other groups should be beneficiaries of things like that. Although there is scope in saying you should build on what is good and what is working, it is about how do you support and develop those who are struggling, who may not be successful, who may have systems that do not always work for them.

  573. That is a fair point. How easy is it to secure long-term funding to keep those successes going rather than letting them fizzle out after one or two years when the money runs out? How do you continue to ensure that you can look to the future on successful projects?
  (Ms Edmans) I think you expect that some of them will fizzle out because some of it is about pump priming, making changes, and using that experience to test out things, to try to get people to take a bit of risk, to use money that is not already tied up because there is not the money, to do that by showing and demonstrating how you can change mainstream services, bring partnerships together or get better value for money. You hope that it will become mainstream because that is what you try to do, but also that it will strengthen people like the voluntary sector and the communities to start being successful in their own right.

  574. My next point was going to be is there not a risk if something becomes mainstream that it loses its immediacy and ownership for ordinary people if it becomes part of the institutionalised mainstream services?
  (Ms Edmans) There are two factors. One is that mainstreaming helps keep it on the agenda but it also makes it quite vulnerable because it is often at the fringes. I do not think it is one answer or another answer, it is a combination. There should be some money that is not mainstream that is specifically for pump priming, testing out, etc. It is very difficult year on year to keep justifying your work, to keep doing the things to ensure you get the funding. It is about the disappointments that are created in the communities and the distrust when things do not get funded. What you are trying to do is to build that trust after a long history of distrust. If you are continually coming up with "this might be cut", it does not do that, it undermines some of that joint working and the community trust.

  Dr Stoate: Sure. Thank you.

Mrs Gordon

  575. Is there another way rather than the bidding process to actually get access to funds? Can you see a better way of doing it?
  (Mr Blake) Speaking for my organisation, you have got to try to have access to different types of resources and certainly not being reliant on one particular source of funding is absolutely key. In terms of is there another way, certainly we could improve a lot of the bidding processes. In our Health Action Zone in South London there have been lots of discussions around the bidding process and one of the suggestions we have made is rather than sending out these massive forms which are 20/30 pages asking for information going back ten years, why not have a two stage system where you ask for short expressions of interest maybe around particular projects, assess those and you might have two or three different bids that you might invite to become a consortium and to bid together? There are ways around improving the bidding processes and one of those is encouraging consortia and organisations to bring different skills to joint partnership bids.
  (Ms Edmans) I do not think there is an easy answer. Ring-fencing pockets of money has advantages and disadvantages, as does the bidding system have advantages and disadvantages. It is thinking about how you can streamline those and make them more user friendly, less administrative, looking at the way in which outputs are set, things like that that are much more user friendly so you can get on with the job really. I do not think there is an easy answer because both of those have pros and cons to them. When we had ring-fenced money there was internal resentment because you had got this money and it was easy and you were very vulnerable when that ring-fencing then went away. I do not think there is an easy answer.

  576. Are there ways of coping with the disappointment that you mentioned when people do not have a successful bid? Is there enough feedback or support? How can that disappointment be helped?
  (Mr Blake) I think certainly within the voluntary sector there is a lot of use of this term "capacity building". Maybe an organisation just does not have the capacity to manage a large project. We have had lots of examples where money as a quick fix has been thrown at voluntary organisations and they have not delivered and we need to be aware of that. I think supporting organisations in terms of building up their capacity, building up their skills and their expertise, is crucial. I think also the other side of that, which we have seen at a local level, is sometimes with these bidding processes you could have identified the successful bidders before the processes started and that is something we have been aware of and have tried to avoid as well.
  (Ms Edmans) I think the reality is that there is a lot of need out there, lots of people wanting resources, whether they be financial or other. It is also about acknowledging that and, therefore, being more realistic about what bids are going to be able to do and what they are not going to be able to do. I think also something around giving feedback earlier, what Mark was saying, not expecting people to put a lot of work into bids that are not successful, having some kind of first stage thing and then people have less disappointment than when they have put lots of staff time, energy, commitment and work into doing a bid. I think it is about streamlining some of that that will reduce some of the disappointment.

  577. The buzz word now is partnership, and quite rightly so, it is obviously better to work with others and you can achieve much more. There are all these different partnerships appearing all the time. Is there a danger that the actual process of getting these partnerships is a substitute for action? As you said these are fairly new initiatives and there are cultural changes to make about attitudes between different agencies and professional pride and all this sort of thing. Is the actual process of creating partnerships stopping you from achieving anything?
  (Ms Edmans) I think it is the number of partnerships. I do not think partnerships themselves are stopping anything, partnerships are useful, they have certainly been useful for me. Partnerships with communities, partnerships with the voluntary sector, have enabled us to do the things we have done. It is the number of partnerships and the complexity in having to be in all sorts of places all at once that prevents you doing what you need to be doing, providing the services at the ground level, supporting the communities. I think there should be a streamlining or rationalising of some of the way in which partnerships are done across agencies. Often you see the same people, you have ten meetings and the core of them are the same people. It does make you wonder how is that the best use of people's time.
  (Mr Blake) There is an issue around the whole bureaucracy that can be generated, and duplication in terms of different Government programmes. You can have Regeneration Programmes, Health Action Zones, Education Action Zones, all these different things going on in a particular locality, and there is certainly a good deal of duplication going on there. I think, also, in terms of how many different bureaucratic structures have to be created, in relation to the Health Action Zones, with most of those we saw whole new bureaucratic structures being created. I think there is an argument that really a lot of things that should have been coming out of the Health Action Zones should have been mainstreamed anyway, why could they not have been managed within existing structures? There are issues around bureaucracy.
  (Ms Edmans) If I can add just one more thing. The links between the partnerships tend to be quite weak. There is not enough linkage and rationalisation between what these different partnerships are doing and often they are actually overlapping.

  578. Is there a solution to that and, also, this thing you mentioned about seeing the same people at the meetings all the time?
  (Ms Edmans) I think the people this morning started to touch on that and it was about having one overarching partnership to which you may have certain subsets that tackle certain agendas. That would be one of the ways. Also, looking at how the organisations might encompass much stronger participation from the community rather than being very top heavy and professionally heavy.

Mr Austin

  579. It has been acknowledged that there are often positive health outcomes from successful regeneration projects and health is usually the beneficiary, whereas in some areas health has been the engine and the driver for some regeneration projects. We have seen some examples of where there are opportunities for the creation of employment, particularly with Community Health Programmes and we have just been talking about the Sandwell area. The NHS itself in any event in most of our areas is one of the largest, if not the largest, employer. Very often some of the most disadvantaged people in our communities, particularly from ethnic minority groups, may not have the necessary skills to access jobs there. Do you think that the NHS could be doing much more—and if so, what—to open up access to employment both in creating posts and mainstreaming employment practice?

   (Mr Blake) I think the NHS could be doing a great deal more. It is starting to do that but it could possibly learn from some of the initiatives from other public services, such as the police and the army. I certainly feel that—

  Mr Austin: I have not heard the police held up as an example of good practice.

Siobhain McDonagh

  580. Or the army.
  (Mr Blake) Both of those have spent a great deal on targeting ethnic communities and there are certainly lessons that can be learned there post the Stephen Lawrence Inquiry report. Just coming back to my organisation's own specific area with regard to sexual health, just a local example within South London. There is a major shortage of health advisers within sexual health clinics from the ethnic minority communities and, unfortunately, as I alluded to earlier, these communities are over-represented amongst the user group and there is a lot that could be done there locally, specifically talking about within South London, to promote this as a career with young people. There is a lot of work that could be done there.
  (Ms Edmans) I think there is a lot of work that could be done within the NHS. It is often one of the largest employers. The Single Regeneration bid that we wrote was about how you could create stepping stones for local communities and the benefits of local people becoming employed. It is one of the organisations that has such a diversity of skills within it from unskilled to the most skilled people and different kinds of employment opportunities. I think people are beginning to grasp that because that has been partly forced by the shortages in the NHS. For example, I was working in an area that had the fifteenth highest unemployment rate, yet in our trusts alone we had 500 job vacancies. There is a huge mismatch, why is this happening? We are beginning to get our heads around that but there is a long way to go. In addition to that, the health service is concentrating much more on the modernisation agenda and they see this as another thing rather than something that is integrated and can show the benefits to their organisation. It is somehow about saying how can we say this is not an additional thing but it is integral to what our business should be? It is not just about employment, it is also about the NHS being big spenders in terms of what they purchase because the way in which they could support local businesses, even in a small proportion, would substantially help the local economy and health in the local population. It is those two things where the health sector does not traditionally think about what its role is, it thinks more about health improvement, health services, and I think we need to start shifting and getting the thinking and discussions around what else could the NHS be doing around being employers and also about purchasing strategies.

  Mr Austin: Do any of my colleagues have any further questions? Can I thank you very much for coming and for the written evidence you have provided as well. Thank you very much.

1   We also produce leaflets in English and Somali. We also contact the local Community Group. Back

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