UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 422-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

HEALTH INEQUALITIES

Thursday 13 March 2008

DR FIONA ADSHEAD, MR MARK BRITNELL and MS UNA O'BRIEN

Evidence heard in Public Questions 1 - 86

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 13 March 2008

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Mr Peter Bone

Sandra Gidley

Stephen Hesford

Dr Howard Stoate

Mr Robert Syms

Dr Richard Taylor

________________

Witnesses: Dr Fiona Adshead, Director General, Health Improvement, Mr Mark Britnell, Director General, Commissioning and System Management, and Ms Una O'Brien, Director of Policy and Storage, Department of Health, gave evidence.

Q1 Chairman: Good morning. Could I welcome you to what is our first evidence session in our inquiry into health inequalities. For the sake of the record could you give us your names and the positions that you hold.

Ms O'Brien: Good morning. My name is Una O'Brien and I am the Director General for Policy and Strategy at the Department of Health and I am responsible for the strategy refresh on health inequalities.

Dr Adshead: I am Fiona Adshead and I am the Deputy Chief Medical Officer and the Government's chief adviser on inequalities.

Mr Britnell: Hello, I am Mark Britnell and I am the Director General for Commissioning and System Management, so I take the lead in commissioning in primary care in the Department of Health.

Q2 Chairman: Once again welcome to this inquiry. Could I also thank you for the publication this morning on tackling health inequalities. I know that it is absolutely coincidental that we are starting this inquiry this morning just when there was the publication of this document, as was the announcement last week of the ring-fencing of dentistry budgets for an on-going two years to that particular evidence session. A question to all three of you: what is your definition, or your working definition might be a better expression, of health inequalities?

Dr Adshead: One of the problems, as you will no doubt be grasping for yourself, is the concept of health inequalities has a very broad impact because it is about the way that society is structured and social factors and economic factors that impact on people's health, and I think what we have tried to do in the Department is to get it down to something that is workable. Essentially it is about differences in people's health status and outcomes. I guess there are three broad ways that can be impacted on. One is the utilisation of health services and other broader services. One is perhaps how those services then impact and relate to the health outcomes that people experience. And, very importantly, people intrinsically have differences because of who they are, because of their ethnic minority status for example, in terms of their health, their life expectancy and also their quality of life. We try to get a focus by looking at our cross-government action plan, what we need to deliver and, very importantly, our two main targets on life expectancy and infant mortality. That is in a way how we have tried to focus it.

Q3 Chairman: Why life expectancy when obviously, as you pointed out, the issue of ethnicity and potential geographical locations jump out at you as well? Why would you use those broader brush measures as opposed to looking at issues around ethnicity?

Dr Adshead: When the targets were originally formulated a while back at the beginning of 2000, it was felt that life expectancy, because it is a broad-based indicator of many other things, was a good summary measure, and life expectancy does in fact have a geographic basis because we are comparing the fifth most deprived areas of the rest of England. Infant mortality, by contrast, compares the most deprived groups but, very importantly, with a duty on equality. Services need to look at issues like ethnicity both for us in terms of policy development and implementation but also at a local level.

Q4 Chairman: Do you measure and target ethnicity? Do you see what the movement is in ethnic groups as opposed to the general population?

Dr Adshead: We are aware of differences in inequalities in health relating to ethnicity. One of the things we are doing particularly in the Department at the moment is looking at how we can strengthen our ethnic monitoring, because I think there is a lot we can do through using the information we have on the system in a way through routine service provision and actually strengthening that. One of the lessons we have learned is that you cannot just assume that services will be equally distributed. You have to check, so checking against things like gender and ethnicity for example is really important.

Q5 Charlotte Atkins: The Department of Health evidence indicates that fewer than half of local authority areas, even the spearhead areas which are most concentrated in terms of deprivation, are likely to meet Government targets despite the fact there are only two years to go before they have to meet the targets on inequalities. Do you think they are likely to meet those targets?

Dr Adshead: What our evidence shows is that if you look at local authority areas across the piece, 41% are on track either for male or female life expectancy or for both. I think what comes out in the status report that you got this morning is that in fact one of the issues for us is there is a time lag between the data being available. The Acheson Review made it very clear that we were not likely to know until towards the end of the decade of action whether we were going to be on track. Frankly, I think it is too early for any of us to know whether we are going to be meeting those targets, but what we have done is try constantly to refine the way we are tackling things at the local level through the toolkits we outlined in the evidence we have submitted to you but also, very importantly, by getting more timely data, so looking at other kinds of mortality data, all-cause, all-age mortality which is basically all ages of people dying of any cause, and to try to get quarterly data so that we do not have this problem of timeliness in the same way, so we are trying to step up action and look at how that action then relates to changes at a local level.

Q6 Charlotte Atkins: The Health Care Commission has suggested that the targets have encouraged PCTs and other authorities to look very much at short-term action on the mid-50s to reduce the mortality among that group, and that in some ways creates a perverse incentive to look at short-term action rather than looking at more sustainable and widespread action. Would you agree with that?

Dr Adshead: I think one of the things that we have tried to do is look absolutely at the actions we need to take to hit the 2010 target, but the point of the cross-government action plan is actually to give a much broader range of actions on things like housing, educational attainment and child poverty that give a broader base for action. Increasingly, because locally primary care trusts are working with local authorities across a broad range of issues such as employment and health, children centres, et cetera, that broader context is there and that joined-up action is really beginning to happen and take off, so whilst for us quite rightly we are focusing on stopping people dying young, which is what we should be doing in the NHS, we have a much broader range of cross-government action to back that up so that it is a "and" approach rather than "either/or".

Q7 Charlotte Atkins: Obviously partnership is very important but clearly the Department has to be focusing a lot more on health promotion. It is very obvious that many PCTs are not really focusing on that as a key priority. I am particularly concerned that in a spearhead area very close to where I am, Stoke-on-Trent, that particular PCT is presently having to waste £1 million a year on a contract with an independent sector treatment centre where the take-up by their own patients within the PCT is below 10%. How can that be justified when you have a spearhead area which is really facing huge inequalities in health and they are having to waste £1 million a year on a contract which is going to be pursued until 2012 and they have no way of clawing back that money?

Mr Britnell: I had the privilege of working in the West Midlands for eight and a half years as Chief Executive at University Hospital Birmingham, so although I do not know the specifics of the matter that you have just raised clearly the ISTCs have made a contribution to the reduction in waiting times that the Government is so rightly proud of. Clearly some independent sector treatment centres have taken a bit longer to get going than others. From April this year you will probably be aware that all patients will have the right to choose their provider of choice, be it in the public or the private sector, but funded by the NHS, so I think it would not be fair to suggest that it is a question of either/or. I think those facilities will develop over time as patients choose where they wish to be treated. I do not think it is right to say that the first two years of the operation of the ISTC, say, in Staffordshire will not bear fruit in the future. However going to your specific point about PCTs and the nature of their short-term investment, I think it is a fair observation in part. The world-class commissioning programme that we have now launched across the NHS will encourage PCTs to plan strategically over three to five years and so be much more explicit for the local populations that they serve about the outcomes they are expected to achieve. The strap line is "adding life to years and years to life" so focusing on those things that really do make a difference for populations. In the 19 years that I have worked in the Health Service I have not seen a period where we have had some organisational stability, but hopefully, for the next period we will have that in terms of the PCTs. The Secretary of State has gone on record to say that there will be no further reorganisation for the foreseeable future. I do not know how long that will be but I am sure it will be for a while. The PCTs now have a good investment platform on which they can plan over the next three to five years. I think PCTs will get better at long-term health investment planning.

Q8 Charlotte Atkins: Mark, you have really hit the nail on the head there. Patients can choose where they go and given that you worked in the West Midlands you might be aware that the journey from Stoke-on-Trent to Burton is an impossible journey to make, particularly if you have no transport of your own, and that is why they are choosing not to go to Burton. I say again, how can you allow a spearhead area to waste £1 million every year on a "take-or-pay" contract where they have to bear that loss and they cannot do anything with it? It cannot be acceptable - and you are head of commissioning - that a PCT has been forced to commission a contract from an independent sector treatment centre. The actual care that they are providing is, I believe, excellent but the point is that people will decide not to go there and therefore they are wasting £1 million of very valuable resources on a centre for their patients which their patients choose not to use. It is the same also for North Staffordshire PCT as well. What are you going to do about it?

Mr Britnell: PCTs in your part of England obviously control considerable resource and £1 million in absolute terms seems like a lot of money.

Q9 Charlotte Atkins: A lot of health promotion could be done with £1 million.

Mr Britnell: The PCTs have to balance where they place their investments between promotion and investment and also treatment and cure. The ISTC programme is just one small part of giving patients choice over the next period. I would not quite say it is too early to say but I do think with the advent of increased patient choice, which is something PCTs must also believe in and champion, ISTCs have a small but important part to play in promoting that part of the Government's agenda. I would not see it as a choice of either/or. With the world-class commissioning programme the full weight of all the resources available to PCTs can be further directed and prioritised on the ten or 15 things that PCTs will be the most important things over the next three to five years.

Charlotte Atkins: That is maybe the reason why Stoke-on-Trent is not doing particularly well on meeting their health inequalities.

Q10 Sandra Gidley: Could you clarify please what you actually do to hold NHS organisations to account for reducing inequalities because although we have heard of chief executives losing their jobs for not hitting various financial targets, I am not aware of anybody ever losing a job for not hitting some sort of inequalities target?

Mr Britnell: We are getting better. The planning framework between local government and the NHS is better than it has ever been. I think the prospect of joint strategic needs assessment give us more confidence and hope that this will remain a key priority. It is a key priority in the Operating Framework, the NHS managers' Bible if you like. It is one of the top five priorities in the Operating Framework for 2008-09. People are now having to make demonstrable progress and also demystify the actions they are taking to improve life expectancy and reduce inequalities both through the Vital Signs which we have recently published as the Department of Health, but increasingly through the local area agreements ---

Q11 Sandra Gidley: You have lost me completely. What are the Vital Signs you have just referred to?

Mr Britnell: They are a list of about 50 to 60 key indicators that, as a result of the Department of Health's agreement with the Treasury on the public service agreements, we expect PCTs to be making progress on across the next period of the Comprehensive Spending Review over the next three years or so. PCTs are monitored on all of these indicators, which include indicators towards health inequalities, and we will be holding PCTs to account as they make progress over the next period. With the world-class commissioning piece that I referred to earlier, we will be expecting PCTs to focus on those ten to 15 things that are the most important and in the same way that they make investment plans for 18 weeks for C.difficile or MRSA, we are expecting the same amount of rigour to be applied to those indicators that are most important.

Q12 Sandra Gidley: That is PCTs and I am still not quite sure how they are held to account, but what about acute trusts, mental health trust and other broader organisations, do they have a role here?

Mr Britnell: They have a role. I think it is not as prominent at the moment as primary care trusts in terms of the joint strategic needs assessment between the PCTs and the local authorities. The plans that PCTs formulate will include mental health providers and also acute providers to a certain extent, but you are right to say that chief executives in the acute sector per se would probably not have that as one of their top five priorities. However, they will be involved in making sure that PCTs' plans are robust and where they have a role to play, such as CVD reductions in terms of angioplasty, and so on and so forth, they will play their part.

Q13 Sandra Gidley: Would it be helpful to have this as part of the Health Care Commission's inspection regime? I do not know if you are aware of Anna Walker's words when she addressed the committee stage of the Health and Social Care Bill talking about setting up the new Care Quality Commission, but she was very clear that the Commission should not be about the hard-edged end and that it should be looking at wellness in a much broader context. Would you agree with that? Will there be a role for the new Commission?

Ms O'Brien: Perhaps I could comment on that because I am involved in the preparatory work to set up the new Care Quality Commission, which, as you know, comes into effect from next year. The first thing to say is that we are absolutely determined to build on the good work of the existing three organisations, and I think given the absolute priority that the Secretary of State has placed on action to reduce health inequalities it is absolutely inevitable that this will suffuse the work of the Care Quality Commission in a number of different ways: in relation to the way that registration requirements for new providers are implemented; in relation to the way in which the Care Quality Commission will report on the performance of PCTs in their commissioning function; and I think thirdly in the expectations that we have on the Care Quality Commission to report on the performance annually of all providers. Of course, many of the details have yet to be worked out but I think the intention is definitely there that it will be a full partner in the system and that it will help us to drive and achieve the improvements that we wish to see.

Q14 Chairman: Are the 50 key indicators for PCTs published?

Mr Britnell: Yes they are published. They are still being developed. They have come out of the Comprehensive Spending Review so we have just shared them recently as part of the annex to the Operating Framework so they are now available to PCTs to start working on.

Q15 Chairman: Could you share them with the Committee?

Mr Britnell: Yes.

Chairman: We will move on. Howard?

Q16 Dr Stoate: We have had a welfare state in this country since the 1940s and I think it is something of which Britain can rightly be proud. However, the irony is that relative inequalities have been steadily increasing ever since the inception of the welfare state and the NHS. How do we explain that?

Dr Adshead: I think there is a difference about where we were. I am not a historian but in the 1940s one of the issues was to provide access to people at all and to make sure that potential catastrophic poverty that came from serious ill-health was overcome by a universally available health care system. In the 21st century perhaps one of the paradoxes around the inequalities that have arisen is that we have a universally accessible health care system and we still have issues around the inverse care law that, as you are aware, those who most need help are least likely to get it. Increasingly on the inequalities agenda what we know is that we need to understand communities and individuals, we need to design the services around who they are, their aspirations, and rather than expecting people to be grateful for the services and go to them, we have actually got to bring services to people. In public health we have been doing that more for example in smoking cessation services in places like pubs, and the ethnographic-type work we have done with smokers in deprived communities shows that they find what they think of as traditional smoking cessation services in draughty community halls with orange plastic chairs, as they describe it, not attractive, so what we have got to do is design services that people want to go to.

Q17 Dr Stoate: I accept all that and we could have said that in 1948 when the Health Service was set up. I am quite sure that Nye Bevin did say that in 1948 because he was talking about improving prevention and stopping people getting ill. He envisaged an NHS which virtually was unnecessary because we would get rid of all the causes of illness. Admittedly that was proven to be rather wrong, but 60 years on we are still talking about how we can make the NHS more accessible to people and inequalities. That does not seem to make a lot of sense.

Dr Adshead: I think it is a fair reflection of where we are. The question I think is what we are going to do about it and how we step up action.

Q18 Dr Stoate: You have certainly said a lot of things which we could do about it but we could have said that a long time ago. The fact is we have not improved things. Although life expectancy is improving for everybody, the gap is, if anything, widening between manual and non-manual workers over the last however far back you want to go. Why is it getting worse not better?

Dr Adshead: There is a broad range of reasons for that some of which are the broad socio-economic reasons that are captured in the status report - and we will not go into those in any detail and some of them are quite simply that we are not doing the things that we know we should do systematically and on a scale that would work. One of the things we have been doing with the national support teams for example is working with primary care trusts and local authorities to look at simple interventions such as stopping people smoking, getting people on statins for high cholesterol and controlling their blood pressure. It is not sophisticated, it is not even new, but what we know is that we need to systematically apply it. Whilst that may not be a very radical lesson, by scaling things up, by systematically applying them, by reaching people and understanding them in different ways, and applying that systematically, that is part of what we have to do. The fact that we are in this situation now is where we are. I think we need to really get out there and scale it up, which is why we have developed things like the health and inequalities intervention tool so that commissioners can model what they need to do at a local level and why the NST is trying to spread best practice.

Q19 Dr Stoate: So you can honestly say that we are making progress, because it is rather embarrassing as a Labour politician that ten years into a Labour Government we have not actually managed to make a very big difference yet?

Dr Adshead: As we were saying earlier, some local authorities are actually making progress and some are closing the gap. Male life expectancy is beginning to stabilise and infant mortality is beginning to stabilise. If you look across the status report, some indicators, both in absolute and relative terms - child poverty, housing, educational attainment - have changed in both and some are only in absolute terms, like heart disease and cancer, so it is not that we are not making progress. The question I think is literally what we are trying to do which is scale it up, systematically apply it and make sure as part of the review we are currently doing for our Secretary of State that we apply what we know and really make this work across the system.

Q20 Dr Stoate: Is it fair to say that it is largely to do with lead times and the length of time it takes to make a difference? Is that a fair assessment?

Ms O'Brien: You mentioned the 60 years and I think certainly from my experience working 20 years in and around the Health Service, nobody would have imagined that we could get to a point at the start of the decade where we would actually set targets to reduce health inequalities and that we would actually understand that there are things that we could do that would make a difference. A really significant thing about the last seven years is that every single year we have learnt from the evidence of what works. We have taken that evidence both into the Department of Health, across government and out into localities, and we have changed what we have done to try and get closer to what we know works. There are fantastic examples out there of local health organisations working with local authorities who are making a difference. They are places like Wakefield, they are places like Tower Hamlets, places like City of Birmingham, and a district council like Derwentside, which I know is only a small place but is doing fantastically well working with the PCT, so as we try different actions, as we get a deeper understanding of what makes a difference in terms of connecting health services to people, we are applying those lessons. If you think about it on that historical period of time, the approach going back decades was to provide a service. Let us put the same service everywhere and let us let people come and use the service. What we have learnt increasingly is that for disadvantaged communities, for the black and ethnic communities, just being good and being there is not good enough. We have got to very much, as Fiona was saying, redouble our efforts to understand communities and to reach out to where people are and make services relevant to those differences in communities, and that really is the challenge that we face now.

Q21 Stephen Hesford: Just very quickly looking through the report, Sir Michael Marmot in his preface speaks about Acheson. Would I be right in thinking that Acheson is still the basis for what we do in health inequalities?

Dr Adshead: It is a major review. In fact Sir Michael is chairing an international commission on the social determinants and the causes of ill-health and that will become the international benchmark of best evidence. We have been working closely with him so we can then use that, and Sir Michael and the expert group are looking at Acheson ten years on.

Q22 Stephen Hesford: Acheson called his recommendations the "39 Steps". Of the 39 how many of the proposals can we say realistically have been implemented?

Dr Adshead: I cannot answer the question as to the 39 but many of his recommendations were translated into the cross-government action plan and of the 80-odd there, about 91% have been met, 75/76 I believe, so we have done a lot based on the evidence. The strength of the Treasury cross-cutting review across government to look at what worked was that it was based on Acheson and then it translated it into what the Government's own targets for action were and that is what the status report is based on. Sir Michael in his own preface reflects the fact that this is as good as it gets in terms of evidence-based policy-making building on Acheson.

Q23 Stephen Hesford: Are there some obvious failures that we can be surprised are failures in terms of what Acheson wanted us to do?

Dr Adshead: I think some of it is about what we have already talked about which is are we achieving to the scale and the scope that we would want to, for example in evidence-based systematically applied primary care treatment, which is why we are focusing on that. That would be one thing. I think, as with most policy, translating the recommendation from a principle into practice is always difficult, and I think as Una was reflecting we have learnt from the challenges that we face in trying to do this and that is what we need to do continually. The issue of inequalities and talking to professionals from other countries is that the task of tackling inequalities is never over. You have to constantly monitor the services that you deliver, you have to check that what you intend is reaching the people that you want to reach.

Q24 Stephen Hesford: In terms of one of the ways Acheson thought you might audit yourself is health impact assessments, and it is arguable that the Department of Health has taken few equity-focused health assessments of Government policies. That was despite arguably the commitment in Saving Lives: Our Healthier Nation White Paper. Why is this or why is this maybe so?

Dr Adshead: We have worked on that recommendation and in fact with the Cabinet Office part of their good guidance for looking at legislation across government and policy is actually to include health as part of the impact assessment. I think there are good examples of policy where we have worked across government to look at how we can potentiate impact for health work, the work that we do on drugs and crime would be a good example as would the work that we have done with the Department for Children, Schools and Families around schools and how we can use the schools system through Healthy Schools to potentiate health. Those would be some examples.

Q25 Stephen Hesford: In terms of the big picture, does the Department of Health see a role in challenging or looking at macroeconomic policies in term of the effects of big picture policies on inequalities in health?

Dr Adshead: Yes and, as you will know, the cross-cutting review and status reports, reports on things like child poverty for example, and obviously the Budget yesterday are redoubling the Government's efforts on that. In our modelling of the infant mortality target in the guidance we sent out to the local system on what works, one of the things we identified in there is that three of the ten percentage points that we need to deliver for closing the gap on that target are actually related to reducing levels of child poverty so, yes, we have looked at those factors.

Q26 Stephen Hesford: In the work that you have been doing, if there were three policies that have been successful in reducing health inequalities over the last ten years, what might be the three most successful?

Dr Adshead: Child poverty would be one across government and tobacco control would be another. I know this Committee has taken a keen interest in that but I think the smoke-free public legislation last year was a major step forward. We already know that we have been successful in getting a 2% drop in the general population smoking figures but also in the manual and teen groups, which is a major step forward. It is not proportionately more, which is what we would want, but they are actually keeping pace with the drop, which is very good. The other area I would select is probably some of the work that we have done on food reformulation and the work with the Food Standards Agency on salt where if you look at data from the beginning of 2000-01 and then 2005-06 on salt levels that people excrete in their urine, it shows that the work done with the food industry to reformulate food has led to a drop overall in people's salt intake. That saves on average 3,500 lives a year which is significant, it contributes to a reduction in early deaths from stroke, and I think it is a good example of how we can work across society with what can be quite small changes at an individual level but which can translate into quite big public health changes as the smoke-free legislation would. There are many others I could pick but those are the three that I would select.

Q27 Stephen Hesford: Conversely, if there were areas where we are not doing so well where we should be doing better, could you pick three areas?

Dr Adshead: The first one would be obesity and I think as a Government we have recognised that we need to step up action on that. The publication of the Foresight Report towards the end of last year and the follow-up with the Government's own strategy Healthy Weight, Healthy Lives demonstrates that we need to step up action on that and we have interestingly, and very importantly, a policy that has a social model of intervention looking at everything from town planning through to individual support, so I think that would be one. We are increasing action on alcohol through brief interventions and whilst at the moment that does not contribute significantly to life expectancy in the age group that we have been talking about, in the future that might be important.

Q28 Stephen Hesford: The age group?

Dr Adshead: I think if you look at the relative contribution of the different risk factors to the current life expectancy target, tobacco well outweighs any other, so alcohol does contribute but it is a much smaller contributor. I think that the current work to step up action across government on alcohol is a reflection of the fact that we have to keep vigilant not only about the issues of the past but also the issues of the future. One of the things we recognise in life expectancy figures to date is that in some respects they reflect past behaviours, so in a way if we are going to keep on top of inequalities then we need to look at things that will contribute to deaths in the future as well.

Q29 Stephen Hesford: That was two; is there another one?

Dr Adshead: Goodness. I think the third area - and it relates back to obesity but I think it is broader because it goes back to salt - is that we need to think about how we work across society more. When we published Health Challenge England in 2006 a lot of what was behind that is that government cannot improve people's health on its own. In a sense that is an obvious thing to say but maybe not something where we have focused action. Some of the work we have been doing on health, work and well-being, with business in the community and with the private sector in terms of improving health at work is instrumental. We know that influencing people where they live their lives at work is critical, so we are stepping up action in that way. Working with the private sector, as we have been doing on food reformulation, would be a good example, and then working for example with the alcohol industry in terms of the Drink Awareness Trust. We need to make sure that we are engaging not just the public sector but the whole of society and finally obviously with people themselves, and the work we have been doing on social marketing to understand insights, behaviours and motivations ---

Q30 Stephen Hesford: Social marketing?

Dr Adshead: The private sector has been excellent for years at understanding people's motivation and behaviour and using marketing techniques to change people's behaviour. In the public sector we have used that more in recent years and social marketing is a term that means using those deep psychological insights to change behaviour for social good.

Q31 Stephen Hesford: In terms of health promotion policy?

Dr Adshead: Exactly, so that for example, going back to salt, Nottingham PCT has been looking at their Afro-Caribbean community and what they have found is that, unlike a lot of the population, they do not have high salt levels in processed food; they have very high salt levels because they add it to their cooking or at the table, so they have been doing campaigns where they have been trying to raise awareness that that is the issue for them as a group. That would be a simple illustration but again it is about tailoring it to different groups.

Q32 Chairman: What do you think drives the Government's overall policy on alcohol; is it the threat to the individuals concerned of their consumption or is it issues around anti-social behaviour?

Dr Adshead: I think it is a mixture of both. I think that often communities' concerns are around anti-social behaviour because that is what visibly impacts on people in communities - issues around domestic violence within families for instance - but I think increasingly there is awareness that it is important about how this impacts on people. The most recent Alcohol Strategy, as you will be aware, emphasised the risk to adult drinkers who, if you like, are quietly drinking at home maybe with no immediate broader social impact but are actually damaging their health, which is why we have been putting emphasis on things like brief interventions.

Q33 Mr Syms: We have touched on this already, what percentage of the burden of health inequalities results from factors which can be remedied through effective NHS policies?

Dr Adshead: It is difficult to give an exact percentage. Some of the academics I have been working with have estimated that it is perhaps less than 10%, but I think, going back to the point colleagues raised about timing, for people who are in their 40s and 50s, getting the right treatment quickly and being detected quickly if they are at risk or already have disease can make a big difference, so I think that it can have a really significant difference particularly in the short term. The NHS can also play a role championing this within local partnerships. It can play a very important role in terms of the way it does its own business, what we term corporate citizenship, how it employs people, how it procures services, how it works with local communities. It also provides very important technical resource, going back to health impact assessments at a local level. There are examples of PCTS which have done very important health impact assessments on broader policy issues where the technical expertise tends to come from the NHS, so those would be some illustrations. I would not underestimate its role, but clearly this is in the broader context of major social and economic forces that we have been talking about.

Ms O'Brien: I would very much agree with Fiona's analysis but I suppose I would put a slight twist on it because it is one thing to say what percentage is the NHS contributing, and we can look at it in that perhaps rather abstract way, but another way to look at it is that these are real people's lives in the here-and-now and surely the NHS can get better and more systematic at finding people who are not accessing services, people at risk of early death, at risk of cancer not caught early enough, at risk of cardiovascular disease, and surely we would want an NHS that knows how to be proactive at reaching out to those communities. It is one thing to say in the overall scheme of things it looks like a relatively low percentage (such as we can tell because the evidence is not really firm on this) but at the same time if we think about our communities and think about people's lives in the here-and-now, that is very important. I would reinforce the point I made earlier about the shift that we are now in the process of from an NHS that looks in on itself to an NHS that looks out to its local community and an NHS that engages differentially with its community according to the particular challenges and needs of that locality, and also an NHS that is increasingly focusing - I think this point was raised earlier - on prevention and helping people to stay well. An example of the direction was set out very clearly in the Prime Minister's speech in January where he signalled this direction and the importance of the NHS having a key role in that, so I would agree with Fiona and I would add the importance of being proactive in the community.

Mr Britnell: Going back to the previous question about some of the challenges, I think one of the biggest ones we face is the issue of personalisation because historically we have always provided services and expected people to be grateful for the services provided, and increasingly we have to find ways in which services are more tailored to the needs of individuals, whether that is through choice in elective care or finding out specific information. For example, some of the social marketing in Slough was looking at the way that specific elements of the Asian population were underreporting their incidence of diabetes and there were some very startling results. Perhaps it is only 10% as far as the evidence supports it at the moment, but what gives me some hope for optimism is the work through the national support teams where they have been going in specifically to the spearhead areas (41% of which are on track at the moment) and as they start to demystify the interventions that you can make in smoking or cardiovascular disease or cancer, there are things that we can start to do in prioritising investment and then mobilising people to act together. I would think, a bit like Una said, some of the evidence does not exist, but some of the evidence is being demystified about what works, and we are getting better at holding people to account to invest in what actually makes a difference. I think the national support teams are a quiet, unsung bunch of heroes in my opinion and they are starting to tell PCTs and show PCTs how they can make improvements with other people, so I am pretty optimistic about learning that and then applying it on an industrial scale. We have had a conversation already about the ISTCs. Let us not forget they have brought down for example cardiac waiting times. In my old hospital in Birmingham, 18 months was not unusual three or four years ago and people were dying on the waiting lists; now look at the impact of choice in cardiac surgery for example. I think the practice-based commissioning, looking at the Quality and Outcomes Framework, which hopefully we will talk about later on, the way that we are looking at the GP contract and the review that we are looking at through primary care, in all of these things health can start to play a greater part in the fight against inequalities.

Q34 Mr Syms: We have already discussed a little bit about how the Department of Health works with other organisations like the Food Standards Agency. The Government itself tends to have a silo mentality if you are in a particular ministry. What I would like to press is clearly sometimes the Treasury may have different objectives that may be counter to some of the objectives of the Department of Health. What sort of dialogue do you have with them and have you ever beaten them?

Mr Britnell: I have only had the privilege of working in the Department of Health for the last seven months but I think that the key outcomes and hopes between the Treasury and the Department of Health on inequalities and health promotion are pretty symbiotic, and certainly I have not noticed any disagreement in terms of the ambition for Treasury and also the Department of Health on these specific issues, because we do know that by not tackling it sooner rather than later the burden of disease will place great pressure on the affordability of the NHS. Amongst other matters of course, I think the planning over the PSAs and the Vital Signs (which are the indicators we are held to account to by Treasury and then we hold the NHS to account) is pretty linear and pretty well-planned. The work of Derek Wanless has helped our thinking in terms of both HMT and the Department of Health, so from my perspective I do not think it is a question of winning or losing; I think we are on the same side and facing in the right direction.

Ms O'Brien: I would absolutely agree with that. If the objective of the Treasury is to help this country to have a healthy and prosperous economy, surely part of that is to have an active population who can participate in the lives of communities, who can contribute to society, who can go to work and who can live fulfilled lives. I think absolutely that our objectives are on the same page. I have been around government for a while but we in the Department of Health have been hugely impressed by the effort that has gone in this time on this Comprehensive Spending Review to the creation of 30 cross-government public service agreements. If you go down those agreements you can actually see how they offer a fresh and stronger platform for tackling health inequalities in a way we have not quite had before. You are absolutely right, we do and have suffered from this silo mentality of each department doing its own thing. What we know is that on some of these big, intractable problems we will only make sustained improvement if we act together and in an aligned way, so I think for the first time you can really see now a very strong base for government departments to work together with the Treasury fully behind that. The challenge for us now is can we translate that into meaningful action on the ground where different interests of departments come together around a common purpose. I think there is a stronger platform and I am optimistic about the future.

Q35 Dr Taylor: I am very encouraged to hear that there are 30 cross-government public service agreements and that you have got to translate them into action because I am rather sinking under the mass of strategies and plans. Una, you talked about the strategy refresher on inequalities; we have got this paper, and I do not know if they relate; Fiona talked about cross-government action plans; we have heard of cost-cutting reviews; we have got a cross-cutting strategy on health inequalities, so how do we bring all these together? Are we not sinking under a load of paper rather than action as you point to?

Ms O'Brien: I can quite understand why it might feel like that and I think there is always a challenge. I know that you will have met David Nicholson, the NHS Chief Executive, and I think he has put a very fresh and sharp perspective to the weight of paper that comes from the Department. There is an understandable need to write things down but what really matters, as you say, is communication and action. Having said that, let me just try and suggest how those different pieces are connected because they are in a very important way. The document that you have today, the status report on the programme for action, is essentially a report on where we have come from. We set a series of targets at the start of the decade. We asked an independent scientific reference group, Sir Michael Marmot's group, to report on progress. I think it was a real strength to do that, to make the information public. I do not know any government in the world that has done anything even like that. That has given us an independent assessment of what is working and what is not. I think our task now is to take that learning and to look forward and in the strategy refresh which my team are undertaking, with advice and guidance from Fiona and other experts across the country, what we want to do now is say, what next? We want to look forward and we want to bring together the lessons from what works. We want to redouble our efforts and we want to look forward to 2010 and beyond. That is how those two pieces of work inter-connect.

Mr Britnell: It is not a question of either/or. People are getting on with the job locally as well. Whether it is actually improving access to primary care or demystifying the interventions that we can make on smoking cessation or cardiovascular disease, there are things that we are doing. As I mentioned earlier in reference to another question, I think some of the work of the national support teams is really starting to bear fruit in terms of what works and what action can be taken.

Q36 Dr Taylor: Can I ask specifically about one item of cross-government action that does not seem to be working because in the sexual health inquiry we did quite some time ago we recommended very stringy that sex and relationship education should be compulsory in the National Curriculum. One of the bits of evidence from the Health Care Commission says that this still has not happened and in the Department of Health evidence we have got an example of the DH working with DCSF on a wide range of policies including PSA targets on under-18 conceptions, but the really basic thing that we suggested a long time ago - compulsory sex and relationship education - according to the Health Care Commission, is not there yet.

Dr Adshead: That is true. We are working closely with the department you reference to make sure that sexual health education is integrated into general education and into Healthy Schools as well. There are good examples of where sexual health services are co-located particularly with secondary schools. Actually there is a great benefit and there is no evidence - as I know you as a Committee will be aware - that increasing people's education on contraception leads to increased sexual activity or any of the adverse outcomes that people often worry about, so there are good examples of good practice on that but at the moment it is not a compulsory element, no.

Q37 Charlotte Atkins: Could I quickly come in on that. What is the Department trying to do to roll out good practice? In my patch we had multi-agency centres at some high schools and they were incredibly successful. They were places where young people could drop in at lunchtime or break times and in a purely confidential but relaxed atmosphere to talk about a whole range of issues, whether it be alcohol abuse, whether it be sexual health, and they were marvellous and I do not think they cost a huge amount. They were piloted and they were then dropped because it coincided with problems of funding at the time. What does the Department do to try to roll out some of this good practice which is cross-cutting good practice? When things seem to work they then just disappear.

Dr Adshead: I think one of the things that we committed to in Choosing Health in 2004 was to formulise and increase the standards of the Healthy Schools programme because before it was often not participated in and it was not clearly laid out what schools had to do. The commitment was to get all schools to participate and essentially we are, as at the end of last year, on track to get all schools to engage, and we particularly put effort into the schools that have the higher proportion of free school meals which are, as you are aware, an indicator of those in deprived areas, so it is systematising it through the mainstream of what schools are doing. The other example which I think is a good one around public health capacity is teaching public health networks (which have been established and which have been working, for example in the South East) and teacher training programmes to get health as part of their curriculum, so that when they are training they get a greater understanding. The College of Child Health and Paediatrics has been working again with children's centres to try to increase that. I think the message is similar to what we have been saying, you have to systematise that into how organisations like schools do their business, make sure that it happens everywhere, and increase capacity and understanding not just within the health sector but much more broadly. That is the kind of approach we have been taking.

Q38 Chairman: Could I just on that ask have you ever had discussions with your counterparts in what was the Department for Education about health education being a part of the national curriculum in as much as science or many other things are?

Dr Adshead: Yes we have and I think there are good examples of sometimes how health issues are used as part of the National Curriculum. I know that schools in Birmingham for example around obesity are looking at how some of those examples can be included in what children are taught in the mainstream. That has to in the long run be the way forward and the ethos, as you will be aware, of Healthy Schools is to get the whole school to embrace health through everything it does, not just the programmes on physical activity or the specific health behaviour things but actually in terms of what they do in all their business.

Q39 Chairman: There is good practice, and I accept that, but on the same ground there is bad practice or no practice on occasions, which is deeply worrying. We hear things quite often in the media about how we want drama to be an issue in terms of schools or indeed we want sports activity to be an issue in schools, but I never hear much about health education being an issue in schools in the same way that that comes out. It does worry me a little bit; would you share those concerns or do you believe best practice is going to serve all over time?

Dr Adshead: I think that trying to systematise things over time is a good idea, which is why we have been trying to promote the Healthy Schools programme, and I think one of the issues it comes back to discussion about how we work with other government departments where we have potentially competing interests and how you can look for the win/win in situations. Things, as you are aware, like breakfast clubs and including health on the curriculum get better educational standards and outcomes, and I think that is the kind of approach that we increasingly need to take across government because we need to avoid what I would term "health imperialism" which is thinking that health is the only reason why society exists. It is a reason but it is not the only outcome we would all want to achieve. The trick I think for us as a department is to couch things in other people's outcomes and objectives. This works very well for health and is the reason why a lot of private companies, particularly the bigger ones, are championing this, because they know it improves their bottom line and for every £1 they invest they get £3 back in term of productivity. There are some hard-nosed economic arguments and I think we need to get smarter at putting those win/win arguments and then it becomes less of a competing issue and more something that is an integral part of how you deliver your core objectives.

Q40 Chairman: Did your Department enter any discussion about the introduction of change of school menus, Jamie's school meals?. Were you involved in that discussion with educationalists or not?

Dr Adshead: Yes we were and when we developed Choosing Health we had a standard of "seriously consider improving standards", or something along those lines in school meals and we have worked with them and we have worked with the School Food Trust in implementing that. We are very keen that that promotes some of the changes we want to see like "five a day". Interestingly, one of the things we know in terms of inequalities is that children who eat school meals (improved school meals we hope) are much more likely to eat their five a day. Thus there are good examples by again working through the mainstream of improving health overall so, yes, we are actively involved in this partnership.

Q41 Chairman: I know it is not your responsibility out there but given that you had these discussions, was there any discussion about talking to the children concerned about what was clearly going to affect their choice when it came to what they were going to have for lunch? Was there any discussion about why these changes took place and should that be a part of the change, as it were, because this was not a best practice situation, this was "you shall have a change in your menu".

Dr Adshead: Certainly when we were implementing the changes we had a very focused discussion with the other department on how we actually took people with us as part of that, and I know through their teaching networks we did that, and I think you are right, it is very important that we take young people with us, and I think a lot of the implementation of the changes with good practice have taken young people with them in terms of how they design the changes, listening to what they wanted, that kind of thing. It has not been universal where that has not occurred.

Q42 Stephen Hesford: Coming back to Mark, you mentioned Wanless before and I am interested by the fact you mentioned Wanless. Is Wanless alive and kicking and still relevant, and if it is does it feel as though we are in the fully engaged model that Wanless wanted us to be in?

Mr Britnell: Wanless is all around us. Certainly speaking in terms of Health Service management, he clarified and demystified a lot of things that people had known in other quarters for a long time. I think it is fair to say we are not yet at the fully engaged scenario but the evidence base, as we mentioned before, for making sure that we try our very best to get people to that level is getting much better, so it is making it easier for people who run organisations in health to make the right investments and, as Fiona said before, to think about how with stratify populations to make sure that services are attending to their needs. We are not there yet; it is going to take a bit more time but certainly he has been very influential in influencing our thinking in the Department of Health, and indeed in the NHS, and will continue to be so.

Dr Adshead: As you will be aware, Derek Wanless did a review for the King's Fund on how we had done, and I think his reflections of that were fair in terms of the fact we have done well on tobacco, and some of my previous answer to you on the areas of prioritisation partly reflects that, and he also felt that we needed to go much further on obesity, which is one of the issues he raised. I think for me it led to a total shift in mindset around how public health was looked at because once you start linking issues around how you improve people's health and indeed inequalities (because that was part of Derek's argument about the economy and how we are successful as a country and how sustainable the financing of our health system is) then you get a very different way of looking at things. For me it has been extremely important to shift things on to a more important setting. That is one of the reasons, quite rightly, the Treasury has championed public health and inequality so strongly because it makes very good sense for the country as a whole.

Ms O'Brien: To support what Mark and Fiona have said, and simply to say this: one of the most powerful things the Wanless analysis did was take a very long-term look at some of the demographic trends and the trends of the trends of the trends, and they are there and we know looking to the medium and long-term future planning for the NHS, ten years and beyond, that we have to be prepared as a country for a population where a higher proportion of people are in the older age groups and where unless we act there will be increasing numbers of people with long-term conditions. I think that absolutely that acts as a shaper of the priorities that we are working on currently and it acts as a backdrop to Lord Darzi's review as well. In that sense it set down a very powerful challenge not just for government but for the NHS, for health acting with local government across the piece, and it sits there as a challenge as we work our way through these issues.

Q43 Mr Syms: Just a quick one. We no longer have a static population, cradle-to-grave planning, where we can measure as people go through the system. Hundreds of thousands of Brits are on the Costa Blanca. We have lots of workers not only from the Far East but indeed from Eastern Europe and that inevitably within this whole mix is going to throw up challenges and problems. Has the Ministry really thought about this? How do we deal with 600,000 workers from Eastern Europe within the whole debate?

Dr Adshead: It is one of the reasons why we have been placing so much emphasis recently on global health. Health is not just something within the shores of us as an island that exactly the factors that you talk about with migration, and it is why we have been working so closely with Sir Michael and also the European Union on their recently published health strategy which placed a very strong emphasis on equity because we have to take an interest now in health in other countries and we have to think about how we can share information and advice. At a local level, population change can pose really big problems. We were talking earlier in the week about Lewisham PCT where some of the primary care lists churn over at about 30% a year, which was certainly my experience when I was Director of Public Health in Camden. In south Camden the list changed by about 40% a year, so you were getting a real flux. What we have to focus on is that we still in the public sector have to provide excellent services and keep on top of how our population changes. It certainly does face challenges but not ones we are alone in as a country and I think we need to increasingly learn from others and make sure that we take a proactive interest in health beyond our own shores because it will certainly influence our own populations and our own services.

Mr Britnell: Of course it is a great challenge but just going back to some of the work from the national support teams, if you look at the work of Tower Hamlets for example which certainly has a flux of people coming in and out of that part of London, they have made very impressive progress on some of the issues in inequality, so once again your point absolutely stands, we are learning more about what works and trying to apply that across a much broader canvas inside the NHS.

Dr Adshead: I think our comparators might change. Tower Hamlets PCT for example recently did a visit with the local authority to Bangladesh and was looking at micro credit systems and how they improved women's health as one outcome. We need to get much more sophisticated. Health trainers is one of the models we have introduced and is actually a peer education programme from the Indian sub-continent and that was where we got the idea from. We need to have a much broader perspective on how we tackle these problems because people are people and we can learn from other countries and often they are more directly relevant for some of our primary care trusts.

Q44 Dr Stoate: Mark, you were talking earlier on about the Quality and Outcomes Framework. What do you think that has done to reduce inequalities?

Mr Britnell: I think it is very progressive. I think it is still relatively new. There is some evidence emerging from the University of Manchester, Roland et al, that they are starting to make some difference in asthma and diabetes. It is not quite too early to say and it shows promise and I think at least it is starting to look at and track the right things, so I would rather have it than not have it. Of course it always needs to be reviewed. In the work that we are doing with Lord Darzi in terms of the next stage review on our primary and community care strategy we are looking at whether we can make QOF even more relevant to the people that we serve.

Q45 Dr Stoate: What sort of things do you mean? How would you make QOF more relevant?

Mr Britnell: I think there are two or three different ways, and without giving headlines before the strategy is completed, for example looking at thresholds, to make sure that we are raising the bar of quality where it is appropriate to do so with a strong evidence base; seeing whether the clinical evidence base that we have got is all-encompassing, so whether there are other conditions that we could apply or put into the QOF that have a clear evidence base such as osteoporosis for example might be one that we are looking at. I think also in terms of how we use the broader elements around the contract to make sure that people are cared for in a more personal way. In terms of the Prime Minister's speech about promotion of well-being, we are looking across the GP contract more widely to think about how QOF can play its part in promotion and well-being. Specifically on some of the areas that work in terms of smoking, cardiovascular disease and diabetes hypertension, we are seeing whether we can do more in those areas that we know make a difference in terms of health inequalities.

Q46 Dr Stoate: One of the criticisms of QOF is that it is much easier to hit the QOF targets and the thresholds if you are in a nice, middle-class area with not much deprivation than it is in areas where there is a huge shift in population and people are less engaged with health where it makes it much tougher. Surely there is a perverse incentive in the QOF system that benefits those areas that are already doing very well?

Mr Britnell: I have heard that said quite a lot and of course it is a view. The evidence suggests, fortunately, that practices in deprived areas have QOF scores which are nearly as good as those in more affluent areas. In one sense your point is well made but rather pleasingly the results do not seem to be too differentiated depending on the parts of the country that we look on.

Q47 Dr Stoate: I would certainly like to keep an eye on that. I would certainly like to see some evidence of that. Do you think there ought to be more local flexibility in QOF? Do you think PCTs ought to have the power effectively to vary QOF dependent on local circumstances or do you think that would be a bad idea?

Mr Britnell: That is a thought. Certainly we can consider it under the primary community care strategy. Speaking honestly, I think we are spending quite a lot of time making sure that the QOF has the best clinical evidence base that we can find and, in a sense, that might be an argument for making sure that you have good national evidence that is consistently applied. However, in other parts of the contract, which we may come on to later on, in terms of access and responsiveness, it may well be a good thing for PCTs to have more local discretion about what works because patient needs do change according to local circumstances.

Q48 Dr Stoate: There is still this issue that the QOF is a slightly blunt instrument and if you do have areas with a particularly high level of mental health problems or high levels of heart disease, can you not see a role for there being more flexibility or do you think that would be more confusing rather than less?

Mr Britnell: We are looking at it as part of the primary community care strategy. As I said, more from the perspective of what is the best clinical evidence base we can get. We can certainly look at that and it is a very welcome suggestion and we will go back and have a think about that one.

Q49 Chairman: Do you think it would be easier to have a QOF on prevention?

Dr Adshead: We have some, as you are aware, elements of the QOF that are on prevention such as smoking and things like that. I am not sure that we would want to have a separate QOF on prevention because I guess my own philosophy is it is much better to have public health integrated into mainstream mechanisms. I would of course wish to see prevention promoted as much as possible within the QOF. I think the principle behind the QOF is obviously one of continuous improvement and I think that I would wish over time to see, for example, smoking to be reflected more not just in recording smoking prevalence but also in how many people quit as well. There is always the dilemma about how much individual practice can influence outcomes, given that they are not just related to practice, but ultimately I would like to see some measures that actually linked what happened to patients in overcoming inequality so, if you like, proxy measures even on outcome.

Q50 Dr Taylor: Going on from there, how do we actually make health information and advice a part of routine clinical practice?

Mr Britnell: Part of the team that reports to me is working on information on prescriptions and whether we put more investment and more time and effort in ensuring that patients get good information. That seems a core part of their clinical care and treatment. There are two or three other ways we are exploring as well which you may be aware of. We are trying to make NHS Choices not only more professional but more accessible. Certainly in terms of the work that we are doing on the Expert Patient Programme, where we have invested quite heavily, the results suggest that that is that working quite well. We are thinking about whether we extend that as well as well as some of the issues that Fiona raised more in terms of social marketing and getting the right bits of information and support to the right people, trying different approaches as opposed to the one size fits all. There are examples up and down the country where that seems to be working.

Q51 Dr Taylor: Do you think the current education of medical students, doctors and nurses, focuses enough on health promotion?

Dr Adshead: We have been trying to strengthen that in recent years and we are also trying to strengthen it through the teaching public health networks that I referenced earlier. The idea behind those is to get health promotion into undergraduate curricula across the board. The Royal Institute of Town Planning now has health as part of its undergraduate curriculum for example. I think reviews of undergraduate medical education have emphasised the need to strengthen public health and we have been working on how we do that. I think one area we have not touched on, though, is how we improve patients' and communities' own ability to deal with health information. I think a good example of cross-government work has been the work we have done on health literacy. In fact, that has been an example of a win/win where quite often it is very difficult, as you will be aware, for adults to admit they have problems with literacy or numeracy. If you get people into the system with improving their own health as an issue, often that is a way of destigmatising literacy skills. Just building on Mark's answer, for NHS Choices we did 60 focus groups around the country on health improvement in deprived areas asking local people how we could help them and what support they wanted and they were keen on things like mobile phone messages, and the intention is to make NHS Choices multi-media and some of the pilots that are going on at the moment are actually adopting that.

Q52 Dr Taylor: One of our advisers has pointed out that a marvellous time for getting at patients is when they are sitting waiting in hospital waiting rooms or doctors' waiting rooms. Has there been any thought to using this to drench people with health advice?

Dr Adshead: There are - and I cannot remember the specifics - some examples of how that has been done, but I think that is absolutely right, and one of the principles we had in Choosing Health was to make every health care contact a health promoting contract and we have got a way to go to make that a reality. I think you are absolutely right and certainly when I am lucky enough to use the Health Service, as you say, you do spend quite a lot of time sitting waiting so that is the kind of opportunity we can use to reach people where they are. Often there is literature available and information for people and so I think there are examples of that; we just need to build on them.

Mr Britnell: It is a very good idea. Going back to the discussion we had about choices, on the Live Channel we are proposing in 3,000 GP surgeries to have a video explaining to people they have got some choice so I do not see why we could not look at doing the same for health promotion as well.

Q53 Dr Taylor: That could tackle people who are illiterate if it is visual sort of thing.

Dr Adshead: Indeed and I think that is why multi-media approaches are important in understanding where people get information from. Some of that is face-to-face which is the reason for the health trainer model.

Q54 Dr Taylor: Are there any thoughts of penalties or "anti-QOFs" for practices that do not promote?

Mr Britnell: We have not thought about an anti-QOF yet although we can certainly ---

Q55 Dr Taylor: It comes from one of our advisers; it does not come from me.

Mr Britnell: I think in response to Dr Stoate's questions, this issue about thresholds is quite an important matter to give further consideration to. I would not say that is an anti-QOF; I would say that is an encouragement or keenness to improve quality continuously. Perhaps that is a better way of describing it.

Q56 Charlotte Atkins: I think this is for Mark initially but people can come in. What would you say the role of commissioning is in helping the NHS reduce health inequalities?

Mr Britnell: I think it is really important and if you can spare me just a second, with six or seven reorganisations since 1990 of PCTs that have focused on purchasing and contracting, ie giving hospitals money to provide services that they have always provided, in one sense has to change profoundly. This is the moment for commissioning, to be honest with you. It has to focus on health outcomes as much as health inputs as well. Although it is a bit hackneyed this phrase that we use of "adding life to years and years to life" it really does try to make sense of the clinical purpose of commissioning. So I hope that we can improve the competence of commissioners. I absolutely believe that the focus that we are going to make commissioners have on health improvement is going to be here for a while. We are working very hard now with PCTs up and down the country to develop this framework where we are going to ask them to look at 15 very important outcomes that they want to improve for their local populations, and whether you are in Stoke, or in Bournemouth or in Blackpool, where I am going later today, I know that people are starting to look at it. It is going to take some time but I am pretty confident that we have got the right sort of focus now on the matter.

Q57 Charlotte Atkins: What sort of incentives do PCTs have to comply with this world-class commissioning programme? Everything else is incentivised and if they are not incentivised --- and I am in Staffordshire Moorlands in North Staffordshire and the challenges for different PCTs are very different, even in adjoining PCTs.

Mr Britnell: It is a good question. Not to bore you but the first two of the three component parts of world-class commissioning are the focus on outcomes and the focus on competencies. We have looked all the way around the world and said there are 11 competences on making a really good commissioner, looking at America, North Europe and Australasia. The last bit is the traditional governance with a twist about making them put their money where their outcomes should be, so forcing them to prioritise and make economic investments and demonstrate to the public that these are the things that they are going to try and do over a period of time. The thing that I learned from monitoring when I was a foundation trust is that it is necessary to have a pretty strong compliance and assurance framework to grip that and hold people to account for their ambitions. This will be built over the next three or four months and we are hoping by the autumn or winter of this year, after the next stage review has been published in the summer, that we will turn all of that, including health inequalities and health promotion, into three to five-year strategic plans which are backed with money so people can actually see where the investments are going over a longer period of time. Certainly I have not witnessed that sort of discipline in the NHS for some time and I know that we are going to do it. In terms of the incentives, we are working on that at the moment in terms of what success looks like and indeed what the sanctions for failure look like as well. We have not actually arrived at any conclusions. There is quite a lot of debate about what those freedoms should be and what the sanctions should be. Without sounding too pious, one of the rewards is just doing a great job for the people that you serve. Many people think that has great intrinsic value. Clearly there will be other matters to do with money and freedom to operate as well that no doubt ---

Q58 Charlotte Atkins: One hopes that GPs also have that incentive of wanting to do the best job for their patients, but they also get monetary incentives.

Mr Britnell: At the moment we are looking at the freedoms that have been applied to foundations and we are considering whether they are the right sorts of incentives for PCTs that outperform on the compliance and assurance framework. It is too early to say whether we will adopt those but we are absolutely clear that we want to make sure we reward and encourage those who are successful to be even more successful. We will try and build that in as part of the compliance and assurance framework. The key focus on outcomes, as people start to make progress - and, by the way, I should reassure you that this is all relative, so we are not going to compare Kensington and Chelsea with Manchester, that would be simply unfair, so it is all relative improvement and we will work in ways in which we should incentivise people.

Q59 Dr Stoate: What is the Department doing to try and improve the position with some of the traditional public health functions like immunisation and cancer screening with inequalities in those areas?

Dr Adshead: Both are important and both have, along with other health promotion programmes, in the past suffered from inequalities in terms of who gets them, as you rightly pick up. As the status report picks up, we have got a good story to tell on flu immunisations for older people where the absolute gap and the relative gap in immunisations has been closed, so that is a success story and it shows that we can do it. On cancer screening in particular the plan that came out just before Christmas has got a very strong equity element and one of the issues they has picked up on is the unequal screening between different groups. We have commissioned the Improvement Foundation through the Healthy Communities Collaborative to look at early detection of cancer (and they are doing another one on heart disease) to look at what the barriers are for people, why some people go for screening, why others do not and how we can help. I think it is great that the new plan for cancer has a strong emphasis on equity and it is that kind of approach that will drive things forward. NICE is looking at immunisation and the relationship with inequalities as well, so I think that that is going to help us in terms of the evidence.

Q60 Dr Stoate: That is fair enough but if you look at the figures, for example 90% of woman who die of cervical cancer have never had a smear and we know for example that MMR is enormously linked to socio-economic deprivation, and we are now seeing measles outbreaks in this country, albeit contained ones, but that is a worrying departure from where we ought to be; what are we doing specifically to try and narrow those gaps?

Dr Adshead: The figures that you share demonstrate that you are right. With MMR, I think (and this is not my policy area) the converse has been true, that the more deprived areas are more likely to take up MMR and the richer areas have been more tending to be worried about it, but that is only my impression. However, I do not think the messages are different. I think we need to understand why people are not going for immunisation. Is it because they are busy working and they cannot take their kids to the clinic? What are the issues? That is the way that we tackle this. It will be different for different groups of people and for different areas. As we have done with the flu immunisation, it is really important that we do that, so there are examples of PCTs in London who have used Ramadan and worked through mosques for example to get older people to take up flu immunisation, I think we need to be inventive and creative and I think the kind of commissioning that Mark was talking about will help with that. The key thing is to recognise the problem and have the data in the first place to deal with it.

Ms O'Brien: I was simply going to add there is always a challenge with issues about individual groups, whether you focus in on an initiative to do with that group or whether you try to make an across-the-board improvement that will benefit people in a population. Just building on what Mark said earlier, the really significant change that is going to be introduced from this year is the work where local authorities and PCTs are going to come together to do a joint strategic needs assessment. We know historically that local authorities are very good at their populations. They understand where people live, they have got a deep understanding of neighbourhoods and differences and we are really looking now to local authorities and PCTs to come together to share that information about what is happening in populations, to support one another in the local strategic partnerships with other partners, and to develop locally based solutions to address these inequalities for particular groups. While I think there are things we can and should be doing nationally, and particularly spreading good practice, I think at the same time it is important to place the responsibility with a local authority, the PCT and other partners working together to tailor interventions for the needs of their particular population.

Q61 Stephen Hesford: Coming to the resourcing of the Health Service, you have got money going into what might be described as the traditional medical model - hospitals and all the rest of it - and you have got money going into tackling health inequalities. Over the last ten years have we got the balance of spending right in terms of the medical model and tackling health inequalities?

Dr Adshead: I think, as we have already described and Mark was talking about in terms of the Wanless reports, what has changed over the last ten years is we have begun to question whether we have got the balance right and very much Government policy has been trying to shift funding more towards prevention and the Our Health, Our Care, Our Say White Paper focusing on primary care actually highlighted the fact that compared to some other OECD countries we spend less on prevention, and that is why we asked Julian le Grand to set up Health England which is looking at precisely that. It has basically got economists, people from local government, people from cross government to look at issues around the right balance of preventative spend, and looking at programme budgeting and how that can be used to shift things towards prevention. I think it is something that we are working on. What I would say, though, from a public health perspective is that the emphasis on public health and the need to spend resources on it is utterly different from ten years ago. It really did not feature very much. To build on Una's point, when we were looking a couple of years back at local area agreements and how they tackled obesity, local authorities are now investing their own resources across the system into public health as well, so I think increasingly we need to be looking at resource across the LSP and across local area agreements as well because - precisely the point about inequalities - if you are going to tackle them effectively you have got to tackle them across social policy areas not, just within the health sector, so it is both approaches.

Q62 Stephen Hesford: Howard chairs and I am Treasurer of the All-Party Group on Primary Care and Public Health and we were set up ten years ago with a specific remit of investigating how you put the two areas together. We did a report a few years ago and we were looking at the question of resourcing, in a kind of blunt way, but were trying to be helpful to put it on the agenda, and we suggested that every PCT should have a say in a ring-fenced public health budget of about £4 million that cannot be used for anything else and must be used for public health. I think that figure will be out-of-date and you could argue for more resources than that, but that as a minimum level, because when we heard evidence (and you will know better than I) when you examine the performance of individual PCTs some are very good, and some are very good on the same money, and some are very bad, and it is still not on the radar screen, so is there an argument for ring-fenced money for the public health function?

Dr Adshead: This, as you will be aware, has been a hot subject for debate and as a Government we have tried both approaches, so for example the resources that went in to smoking cessation services were ring-fenced. When we put the investment in for Choosing Health our sense was that it was important as we did that to indicate nationally the proportion of spending we thought was needed to deliver, so the money did not get bundled up into little packets but we showed nationally how we thought the extra resources that PCTs were getting should be distributed. One of the problems about ring-fencing - and it comes back to our understanding of how you tackle inequalities best - is that a) it suggests that is all you need to spend; b) it suggests that that is the priority that you at a local level should have, and as we have been talking about what we realise increasingly is that it needs to be tailored more to local needs. The key thing has to be, as you reflect, that you have to look not just at the money that is going in but the outcomes that are happening. Sexual health has been area where it has been hotly debated and we are on track to achieving the 48-hour waiting target on sexual health, which is very encouraging. One of the things that Sir Michael Marmot has looked at is the proportion of GDP country spend on health and bringing that as public health actually the health outcomes they get are highly variable, so America is more or less on a par with Puerto Rico or one of the central American countries, so the question is how we use it effectively, and that is precisely why Mark has been placing so much emphasis on things like the national support teams because in a sense what we have to do is maximise the resources we have got in the system, make sure they are achieving the things that we know will work and constantly reinforce the fact there has got to be a shift towards more prevention. As you rightly suggest, it is pretty complicated but we are in a different position from ten years ago and your group's work began to shape the agenda of how public health and primary care work together, and I think PCTs are a good example of how that has begun to happen well.

Q63 Stephen Hesford: Flattery will get you everywhere! If you do not have an audit trail of resources, how do you performance manage public health, because one of the key weaknesses of public health is that it is either sketchy evidence - and Wanless talked about that - or you do not know if what you are doing works or whether you should be doing. How do you performance manage? Is not audit trail on resourcing one way to do it?

Dr Adshead: Inputs, as Mark was reflecting, are one way to audit things in the system and they are. We have, though, been trying to move to outcomes, so for example the quit rates that PCTs achieve for smokers. We know that there have been relative inefficiencies if you look across the country at the resources going in and the quit rate that is coming out because it was actually ring-fenced. A lot of what we have been working on is how we improve that effectiveness. I personally feel really strongly that the way to performance manage public health is no different from any other way, that you need to look at outcomes; you need to look at proxy measures such as smoking quitters for example because ultimately you want an improved health outcome and smoking quitting is just one way on that route. That is the way to do it. I do not think that looking at inputs is going to be particularly fruitful because you end up spending so much time looking at the input you forget about the outcome. I think it is the outcome that matters; I really do.

Q64 Charlotte Atkins: How do you see the extra resources for water fluoridation working in terms of reducing dental inequalities? Obviously it is a relatively small amount of money but how do you see that is going to be fed into this programme for reducing health inequalities?

Dr Adshead: As our Secretary of State has already said, we feel that dental inequalities are very important, and I know that you have discussed as a Committee that fluoridation is one of the most effective ways, coupled with some of the other measures such as reducing sugar consumption by children and other things. The resources are really to capitalise on change. Mark's previous health authority has gone a long way towards looking at fluoridation and the North West as well, so I think we need to use those resources as is intended to help with some of the capital investment.

Q65 Charlotte Atkins: It is a matter of incentivising PCTs to take up this challenge, is it not really?

Dr Adshead: Yes.

Mr Britnell: I think the money has been really helpful. My own personal experience when I was looking after South Central, from Oxford to the Isle of Wight - and Southampton is going to go early on it, and Yorkshire at looking at it and obviously the North West, Manchester in particular - is that it just gives people a bit more capability to get up and think the issues through so they can think about how they consult and how they engage. I get no sense that the money is not going to be well spent or indeed has not been considered to be really helpful. There are also issues in the Operating Framework which back up the Secretary of State's recent speeches on fluoridation. My general sense is that people now are much more actively looking at the issues so the money is likely to be well-spent, and is also most welcome as I said.

Q66 Charlotte Atkins: You will be monitoring what happens?

Mr Britnell: We will be monitoring and holding SHAs and PCTs to account for how they decide to take forward this very important part of the health inequalities agenda.

Q67 Dr Taylor: Mark, you reminded us that the Secretary of State had made the very welcome promise that there would not be any more reorganisations for the moment. Do you think the re-organisation of PCTs did have an effect on their aims to help tackle health inequalities?

Mr Britnell: That is a good question.

Q68 Dr Taylor: There ought to be an obvious answer because the London PCTs were not re-organised, so have they done any better?

Mr Britnell: If I can give you two different answers to your question. Obviously the factors that influence progress on health inequalities are many and varied, and therefore one should always bear that in mind, so I do not think it is possible to compare and contrast in a linear fashion those organisations that were reorganised with those that were not because the fact is they are very broad. However in any reorganisation people can only concentrate on four or five things in terms of what are the priorities, and that is why I think there is a growing body of literature that suggests you have to think very carefully about the preconditions in which to reorganise large parts of the NHS, and that is why I think most people have welcomed what the Secretary of State has said about not thinking about reorganisation for the foreseeable future. As you know working in hospitals and as I do as well, building relationships of trust and understanding take time and they are the most important glue the Health Service has. In a sense being optimistic about the future if we get the planning framework right, the joint strategic needs assessments with PCTs, and leave them alone for a while and let them get on with their job, I think things will improve.

Q69 Dr Taylor: You said that PCTs could reasonably concentrate on four or five things. One thing they have had to concentrate on, quite rightly, to get things into balance is the huge deficits, so it does appear to us that perhaps some of the money that was promised to the NHS under Choosing Health went into general PCT budgets.

Mr Britnell: If I could just say two things. PCTs have to concentrate on lots of things but in any large organisation if you are going to make big change on more than five or six things over a period of time, it is difficult to pull off on occasion, that is my personal experience. However, they have to be attentive to all of the things that the government and their local populations expect them to be attentive to. On the issue specifically about the re-organisations and the financial deficits, we have been through the reorganisations and we have been through the financial deficits. I was speaking for example to the chief executive of the PCT in Rotherham this morning and, speaking absolutely frankly, now that people are in a much better fiscal position, they are not going to be reorganised, they have time to plan, they are building up relationships, I do feel much more optimistic about people making progress on this agenda and many others as well. I do not think it is the case that Choosing Health money alone was gobbled up to address the financial deficits. There was much wider action taken because of the position the NHS had found itself in. I do think the position we are in now really does strengthen the health inequalities agenda. Going back to the question before if I may, I think it would be a real mistake to say that success is ring-fencing a budget for public health when we should be holding public health to account, like finance directives and HR directives, on what they do and what they provide for their populations. The compliance and assurance framework for world-class commissioning will do that and I think that is more powerful.

Q70 Dr Taylor: Now we have got a £1.8 billion surplus or something like that, will you all be pushing for some of that to be going into reducing health inequalities and into health education?

Mr Britnell: As I said, world-class commissioning has to add life to years and years to life. Given that broadly we all die of the same things but just at different times, I am looking forward to PCTs' plans in the autumn and winter of this year addressing those issues which are most pressing for their local populations.

Dr Adshead: I think it is also worth adding that the comprehensive area assessment that the Audit Commission is planning for local government is, as you know, an assessment of partnership, so it will be the health players locally and that is going to reinforce some of the accountability and also how resources are shared because, as Una was explaining earlier, we have got shared resources now across the system.

Ms O'Brien: I think in the Operating Framework we made very clear that we do expect PCTs to come back with proposals for three-year investment plans. It is a good position to be in that you can see a line of sight that allows you to make those sorts of investments. We know particularly in terms of improvements in primary care and improvements in other programmes that reach out to the population that you need to think beyond more than a single year horizon, so I think that we are in a good position to do that. I would just add on the point about the alignment, we have pretty much now got an alignment between PCT and local authority boundaries. It took a lot of pain to do that and it was not embarked upon lightly. It does not guarantee that anything will be necessarily better on health inequalities but it gives us a much bigger and firmer platform for relationships to work together locally. We have got co-terminosity in most parts of the country and if you combine that with the new arrangements on the way in which local authority performance and health performance are now going to be aligned for the first time, it takes away the excuses that we have had in the past around that it is too complicated, there are too many organisations, misaligned indicators, and it actually is about central government creating a much more coherent platform for action between health and local government, and that is why I think we are at such a critical stage now in terms of the challenges out there to say can you use this to make a difference for your population.

Q71 Dr Taylor: You do not think those places where they are appointing the same chief executive to the local authority and the PCT is bringing them too close together?

Ms O'Brien: I do not think there are very many of those.

Q72 Dr Taylor: There are at least two I think.

Ms O'Brien: I know Herefordshire is one. The accountability structures as between local government and PCTs do remain exactly the same even where there are joint appointments of chief executives. A real strength to be noted are the joint appointments of directors of public health working across local government and health, and I think if we are really serious about tackling some of the issues around housing, the issues around planning that are affecting the conditions in which people make choices about their lives, actually bringing those two together closely is going to be very important.

Q73 Dr Taylor: I have just been handed a stop press! Local government in London now has statutory responsibility for health inequalities. Would this be desirable throughout England?

Dr Adshead: As your note refers, the Mayor has responsibility for an overall health and inequality strategy and it has been published and is very welcome. However one of the things we have not emphasised enough is that we have had a parallel and linked programme of action in local government for a long time, for at least six, seven, eight years. We have work with the Improvement and Development Agency on leadership working with both politicians and officials in local government. We have got Beacon councils for inequalities. We have got healthy communities programmes which actually are run through local government so we have placed an equal emphasis of co-delivery on local government. I think the issue is through the assessments that the Audit Commission do presently because all local authorities are held to account on inequalities at the moment on all-cause, all-age mortality. That is an indicator they all have to this year report to. The more you get political leadership through local government on health inequalities the better and Sheffield, going back to your question on duration of partnerships, is an example where the council there has led a WMO Healthy Cities programme I think for nearly 20 years - a long time - and they are doing extremely well on inequalities. One of the messages we have learnt and why we have been so keen on co-delivery with local government is that local and political leadership is really important on this as well, linking with the NHS so it is not something where we feel this should just come through the NHS.

Q74 Mr Syms: We have heard this morning that a lot of it is about taking services to the people, support teams, innovation, creativity, all these words were flowing out. Do you think tackling health inequalities is an issue of leadership and taking the resources which are there already or do you think there has to be a reallocation of further resources between various parts of the NHS?

Mr Britnell: You probably are aware that ACRA are considering the funding formula for PCTs in the NHS and their report is expected at some point in the summer, so further work is being done about that. Let us not forget the pleasing work about moving from distance from target. I think the worst placed PCT is just 3% from target and ACRA are looking at the formula and whether it can be more sensitive so let us look forward to some good work there. Going back to the national support teams, they have ten top tips for success. I am not going to bore you by reading all ten out but the first one is leadership. You are absolutely right to say - going back to the public health debate - for me it is not just saying public health people have a role in health inequalities - they do - but the organisations that consume millions of pounds have to lead those organisations through improved outcomes, and I think that is the change with the commissioning piece, if I can be frank with you. Yes, we will be bearing down on leadership and indeed supporting it as well, but it is number one on the top ten tips.

Q75 Mr Syms: In terms of creativity, we have the Olympics in 2012 and one presumes that Coke or Pepsi on the back of that will be advertising that. Has the Department of Health had any discussions with the Olympic Authority about things like exercise? For example we have Olympic rowers who have diabetes and there seems to me to be an opportunity particularly to get to those areas of the population which are missing out at the moment. What discussions have you had?

Dr Adshead: When the Olympics Bid was put forward we had to look at the health legacy as part of the overall legacy, and that included a whole range of things from getting the population more active to things like introducing sports and exercise medicine as a speciality so it was across the piece. One of your advisers, Sheila Adam, was very active in London and her successor Simon Tanner has done more of the same. Absolutely we are going to be using the opportunity to think about how we can get those messages not just in London but around the country on getting active and also all the other associated health things.

Q76 Dr Taylor: Just a quick question about research and development because we cannot rely on the drug firms to research into health inequalities. What investment has the Department made into programmes to reduce health inequalities?

Dr Adshead: The Public Health Research Consortium - and I may be getting the name wrong but that is the principle - actually tackles health inequalities and I believe one of the people who is going to give evidence to you in the next session, Hilary Graham, is one of the leaders of that, so money has gone into that and that is policy responsive. There has also been research and evaluation of some of our public health programmes for example our evaluation of the tobacco programme which looked specifically at whether our tobacco control and particularly smoking cessation schemes were good or not good, looking at inequalities. In fact, what it found was that it does not generate inequalities, that some of the most effective services are in some of the most deprived areas. Inequality is a theme that runs through a lot of the research and evaluation that goes on generally in public health but there is also a research consortium on inequalities. We hope that as part of the new research initiative that was announced last year that there will be more research into public health and that inequalities will have a strong theme within that.

Q77 Chairman: Just on that there are NHS policies and interventions to reduce health inequalities that actually increase them. Is this what this group of researchers is looking at? Why is this?

Dr Adshead: Do you want to give me an example?

Q78 Chairman: Smoking is the obvious one. With the current smoking cessation programme that is now targeted, if you look over the time when public health has been arguing about smoking cessation, it is the C1 and C2 groups that have stopped smoking more than C4 and C5.

Dr Adshead: Absolutely. As I was describing, what our evaluation programmes have looked at is the interventions that we have put into the system such as smoking cessation clinics whether they are exacerbating the situation by not reaching people and making it worse? The answer is that it is not making it worse. That does not mean, though, through our tobacco policy that we should not be redoubling our efforts and in fact, as you are probably aware, a lot of the public education campaigns are now particularly targeted at the groups you were describing, issues around smuggling and other things. That is absolutely at the centre of what we are trying to do in policy.

Q79 Chairman: In the report that has been put on the desk this morning for us, I have not gone into it in any great detail as you can imagine being sat here but actually the female life expectancy gap is increasing, I understand it is now 11% which is higher than 1995-97. Do you know why that is? That is the real issue, is it not? Is this evidence based and do we measure this and know why this has happened?

Dr Adshead: Certainly it is something that has been looked into. My understanding - and this may be something where we can provide you with a further note - is that it is not easily explicable. There are some trends that link behind it but I think that is something we can perhaps come back to you on. We do not have a simple answer to that.

Q80 Dr Taylor: This is rather unfortunate because it is a huge question coming at the end of the day so you can pick out bits that have not been covered. The question is really if you think of the Choice agenda, payment by results, practice-based commissioning and the introduction of the private sector, what effect do all of these have on health inequalities?

Mr Britnell: I think beneficial, to take most of them in turn. There is evidence in Choice in terms of working-class people in Birmingham in my own area in cardiac surgery, and in London, that with the right support they make good choices, and we do know from polling that people from certain economic groups certainly have a very strong appetite for choice, so I do not think choice is antithetical at all to the inequalities agenda. In some senses I think it can support it.

Q81 Dr Taylor: Even in those Class 5 examples who do not have the knowledge to make the choice?

Mr Britnell: Our polling suggests, and perhaps Una might want to say a bit more, that there is a bigger appetite there and greater support for choice than there is amongst other classes. I think I am right in saying that.

Dr Adshead: That is right. The concept of choice is pretty new, as you well know, in public services in the NHS, but the polling we have done suggests that there is a great appetite for it and I think with the right support, which is an important matter, whether it is a nurse or a health coach or an adviser, I think people will make good choices and I think it can play a part in inequalities. On practice-based commissioning I absolutely think clinicians working with their local patients on their registered lists - and do not forget GMS also places an obligation on well-being and promotion as well as treatment - given time, will start to have an impact on health inequalities. I have explained already that we are looking at QOF to see whether that can become more sensitive in terms of the best evidence for clinical interventions. I am quite hopeful that we can do more work there. I think it is difficult to say whether the tariff absolutely supports health inequalities. However, what I would say is that as part of the primary and community care strategy we are looking at whether we can develop tariffs for community services for example, so I could potentially see over a period of time how the development of some tariffs in areas which are important in the community may support quicker service. We also know from pharmacies (where there will be a paper coming out very shortly from the Government so I cannot say too much about it) that certain tariffs may be developed for treating people and allowing people quicker access to pharmacies to support them with their health care conditions. Finally on the private sector, there are lots of things we can learn from all sorts of people, social enterprises, the third sector and the private sector. They have got a role to play, as we all have. When you put all that together, all of that should be working to reduce inequalities. Yes, I would accept that some of the policies have been more concentrated on secondary care to date, but there is no reason why certainly for practice-based commissioning on choice for example that they cannot play a significant role in supporting our endeavours.

Q82 Dr Taylor: Are the others as optimistic?

Dr Adshead: On the choice issue, I understand why it may seem counterintuitive that more deprived communities would have trouble perhaps expressing choice, but international evidence from New Zealand, America and Finland shows the same thing, and part of the explanation behind that may well be that people who are more able to express themselves through voice influencing the system are less concerned about choice, whereas when you put something into place like a choice-based system that systematises it for people and gives people the opportunities. The London pilot, which gave people support to make the choices, showed that by factors like ethnicity, gender and social class there was very little variation in people's ability to make choice. It is like many things - it is about how you implement it and understanding that the system we have often does not promote people to make those choices without formalising it.

Q83 Dr Taylor: Have you anything to add, Una?

Ms O'Brien: Simply to say I do not think any of these reforms are an end in themselves. They are absolutely a means to an end and they sit there as tools, incentives and enablers to help local communities to address their particular problems. If I could simply draw one example which I find quite inspiring and that is the work they are doing on the health and well-being partnership in the City of Birmingham. Two things: they have commissioned a social enterprise, Gateway Family Services, to help them develop targeted support for men over 40 at risk of heart disease. They realised that there was a whole group in the population that they are simply not reaching and by engaging a social enterprise they could have people recruited from different communities who could help to work in and alongside whether it is in faith groups, whether it is in local social clubs or in workplaces, so that is about the flexibility of a PCT to contract differently. That is one example. Interestingly, in that same place they are working with Lloyd's Pharmacy in two neighbourhoods within the city again in order to try and tackle this particular problem. That is one example, a health and inequalities problem, a social enterprise and private sector company coming together in partnership with the PCT to look at new and innovative ways. I think that would be the way in which we would see the reforms playing out, not as ends in themselves but as a means to tackle the problem. Just to conclude our challenge now is to seize those examples to understand what works and to try and replicate and allow for that to be more systematised across the country because it is not good enough to have it happening, if you like, in pockets and I really do think that that is one of the key jobs we have to do in the strategy refresh looking to the future.

Dr Taylor: We have had previous inquiries where the first session has been very optimistic and the following ones have been just the opposite, so I am hoping that this inquiry will maintain this same sense of optimism throughout. Thank you.

Q84 Chairman: Do NHS prescription charges and dental and optical charges contribute to health inequalities? Who wants to try that question? It is quite interesting if you do not know because my next question was going to be, do you measure it?

Dr Adshead: As you know, the way in which health systems are financed and whether you have co-payments is something that has been looked at across the system and that is why there are exclusions obviously on prescription charges for the most vulnerable. That would be my broad level response to that.

Q85 Chairman: When we did our inquiry on NHS charges in 2006, we had evidence from professional bodies and individuals which you could say was anecdotal but I think it was a bit more than that, that some people presented at the pharmacist with three prescriptions and only had the money to take two away and would ask the pharmacist which one they should not have, which was quite disturbing from the point of view of patient care never mind all the other levers there. Does the Department ever look at these issues? Do they ever measure if this does take place and the effect it may have on health inequalities?

Ms O'Brien: I think it is a good question and it is something that we should look at. As we know with prescriptions, only a relatively small number of people actually pay for prescriptions, so I think that needs to be taken on board, and also the amounts that are paid are often out of all proportion to the cost of the drug, so looked at as a whole and comparatively with what is available in other countries, it is a system that we can be proud off. At the same time I think that society is always changing, the needs of people are changing, and it is the right thing that periodically we should be looking to make sure that we are not unintentionally exacerbating inequalities by our own policies.

Dr Adshead: One of the things that the national support team is looking at is a medication review, particularly for chronic diseases, and trying to push that effectively. We are looking as part of our work on the communities collaborative on cardiovascular disease at the barriers that people face so if that is a major problem it is the kind of thing we will flag up, but I think it is an important point, as Una said.

Q86 Chairman: Thank you very much indeed for coming along this morning to help us in this first evidence session on our inquiry. It may be that one or two of you may be back again at some stage and we are more than happy to welcome you back. Thank you very much indeed.

Dr Adshead: We look forward to that.