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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

HEALTH INEQUALITIES

Thursday 3 April 2008

DR JACKY CHAMBERS, MS ALWEN WILLIAMS and MR DAVID STOUT

DR PAULA GREY, MR ANDY HULL and MR JAMIE RENTOUL

Evidence heard in Public Questions 197 - 316

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 3 April 2008

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Jim Dowd

Sandra Gidley

Stephen Hesford

Dr Doug Naysmith

Dr Howard Stoate

Dr Richard Taylor

________________

Witnesses: Dr Jacky Chambers, Director of Public Health, Heart of Birmingham Teaching PCT, Ms Alwen Williams, Chief Executive, Tower Hamlets PCT, and Mr David Stout, Director of PCT Network, NHS Confederation, gave evidence.

Q197 Chairman: Good morning. Could I welcome you to what is our third evidence session on our inquiry into health inequalities. For the record, could I ask you to introduce yourselves and the position you hold.

Ms Williams: My name is Alwen Williams and I am the Chief Executive of Tower Hamlets Primary Care Trust.

Dr Chambers: Good morning. My name is Dr Jacky Chambers and I am Director of Public Health for the Heart of Birmingham Teaching Primary Care Trust.

Mr Stout: Good morning. I am David Stout, Director of the Primary Care Trust Network in the NHS Confederation, which represents NHS bodies across the country.

Q198 Chairman: Welcome and thank you very much for coming along. My question is aimed initially at Alwen and Jacky. What significant differences have you made to health inequalities in your areas and how have you made those differences? Are you on track to deliver the Government's health inequalities targets?

Dr Chambers: I think it is a mixed picture. If we look at our area, we have made a significant difference in my view to death rates under the age of 75 for circulatory disorders. The decline we have seen is steeper than the Birmingham average and we do look as though we are closing the gap in terms of premature deaths from heart disease, strokes and generally the vascular diseases. We are on target in terms of the Spearhead adjusted target that has been given to us by the Strategic Health Authority. I think in terms of the way we have achieved that, obviously we have built on the work that was done previously by the Birmingham Health Authority which was particularly strong around helping people to give up smoking, and promoting access to Stop Smoking Services; but we have also majored in terms of the contribution that the NHS can make on trying to improve the management of people that are on chronic disease registers through primary care; and also making sure that we are giving feedback and auditing the doctors in our area in terms of the management of those chronic diseases. More recently, as I think we will come onto in terms of the evidence, we have commissioned a major screening programme for men over 40, which is going very well and I think is a signal in terms of Government policy that in areas like ours this is an important and wanted thing that will help bring those rates down even further. That is the good news. In terms of Birmingham as a whole and where our Primary Care Trust sits, the bad news is if you look at our life expectancy target we are not on track as a city, which is curious in terms of the very rapid decline we are seeing in deaths under 75; and one of the things I think we consider when you look at why Birmingham is different from other areas is that infant mortality is a major player in that life expectancy picture that we see. 14% of the gap between our city and the rest of the Spearhead areas is attributable to the very high number of babies that die in the first year of life. I can explain some of the reasons for that if you want to pursue that.

Ms Williams: I am from Tower Hamlets and we are in east London, as you know. We are one of the Spearhead Group PCT areas, and in terms of meeting targets we are currently on track to meet the life expectancy target by 2010 and envisage a reduction in terms of gaps in life expectancy for both men and women. Currently we have a reduction in infant mortality and, indeed, our rates are currently below national average, which is quite interesting given the area we are in. In terms of what we are doing, I would say we have three key areas of focus: firstly, tackling the wider determinants of health inequalities, and that is very much building and sustaining very effective partnerships locally, with local government, with the third sector, and indeed with local people and local communities. Secondly, we have made strenuous efforts in the last few years to improve the quality of primary care service and, indeed, improve access and the capacity and the quality of primary care services; so that, for example, we are not an under-doctored area in Tower Hamlets, so we have been recruiting GPs; we have been dealing with poor performance; we have been improving extended hours in general practice. One of our key challenges ahead is to ensure people who absolutely need good access to primary care have that at all times; what we would call "case finding". People we think are at risk, for example, of diabetes and other long-term health conditions are actually connected effectively with our services. Thirdly, the focus on increasing substantially what I would call the range of healthy living services: so that is Stop Smoking Services; access to physical activity and nutritional advice; and, in all of that, building good connectivity with our local communities in perhaps more sophisticated ways than we have done in the past.

Q199 Chairman: We will probably pursue one or two of those matters later on this morning. Obviously you will have seen the status report published last month, do you think, given Primary Care Trusts or the National Health Service in general is not dealing with all the issues that create and sustain health inequalities, that it is fair to set the targeting in the way they have done? It seems the targets have not been met and people may say it is an unfair summary of what is happening in the status report, but it does look like we have met all these departmental commitments but not met the targets; and setting targets for 2010 we had a session last week with people suggesting perhaps this is something that will be delivered in decades as opposed to a few years. Is it unfair to set targets in the way they are at the moment and expect the National Health Service or PCTs in particular to be responsible for meeting them?

Dr Chambers: I believe it has been very useful to have national targets. Certainly when I served on the Atchison Committee we were very concerned that there should be something measurable that would set the framework for trying to close the gap around health inequalities. The missing bit for me, certainly in Birmingham, is that the Department of Health and Government have tried to drive these targets largely through the NHS and, in a sense, I think we have only had half a system, certainly in Birmingham, in terms of the engagement and understanding of the local authority about what they can do to actually create the conditions in which people can be healthy; as opposed to doing what the NHS is good at, which is trying to deal with individual risk as it comes through the door, either in general practice or in hospital. The new development around partnership working, the local area agreement certainly has been a real catalyst for trying to move this agenda forward. The Neighbourhood Renewal Fund that has come with some of that has enabled us to jointly work with other Primary Care Trusts and, to a certain extent, with the voluntary sector to actually move the targets on. I hope national targets and health inequalities will be reset perhaps slightly differently in the way they are framed. With regard to the regulation and accountability of local authorities - having very clear delivery plans for the things they can do around wellbeing, trying to create better living conditions, and taking very simple measures like decent school kitchens that provide fresh food, decent play areas and regenerating local neighbourhoods - I hope there are going to be very clear accountabilities around their responsibilities regarding health inequalities in the future. Half a system I would say at the moment.

Q200 Chairman: Would it be fair to say the wider partners, as it were, are probably not as focussed as the National Health Service is at the moment in terms of health inequalities?

Dr Chambers: I have looked at how the index of multiple deprivation has moved in Birmingham over the last five years and compared the most recent one with previously, and the only thing that has actually improved in our area, which is the most deprived part of Birmingham, are the crime figures. You can understand, in a sense, why something has happened there, because a lot of the regeneration and money that has gone has gone to what was called the "Clean and Safe Programme" and they have delivered in relation to moving that on; but other areas, like income, living environment, barriers to services and houses, all of those, including employment, appear to have got worse. Something has not happened in relation to the areas which are most in need of regeneration, that that money has not been applied in Birmingham in that way.

Q201 Chairman: Is your experience the same?

Ms Williams: No, I would certainly emphasise the need for wider partnerships. Certainly my experience in Tower Hamlets is that we have had a very strong input from our local authority, indeed we have a very strong local strategic partnership. We have a Local Area Agreement which incorporates many of these health inequality targets; we have a joint strategy in Tower Hamlets for health and wellbeing that is owned by the local strategic partnership. I think the focus and the relationships locally for me are all-important. Indeed, because we are now looking to problem-solve together we are able to look, for example, at the impact of improvement in education, which there indeed has been in Tower Hamlets, and how that is starting to make a difference in terms of us thinking differently about employment together, and the impact employment has on poverty and health inequalities. My experience is that it is those wider partnerships. The NHS clearly has a very important contribution and often leads in some areas those partnership arrangements - for example in our tobacco control alliance we lead - but the inclusivity is absolutely critical, and the focus is really very, very important. I think it is about all partners contributing all that they can in a way that then delivers on a whole range of very complex factors that are not just about health inequalities but also about socio-economic inequality that then leads to health inequality.

Mr Stout: In terms of the national targets, I guess targets make sense when they are derived from a sense of policy about how they will be delivered; if a target appears like it is being plucked slightly randomly out of the air I am not sure how helpful that is; but a target that is linked to a plan and a strategy that is likely to deliver it I think has been helpful in this area. I think there are some difficulties when you translate the national target to local targets, not least issues like life expectancy can be significantly changed by movement of residents in and out of your particular local area. If you are in an area where there is a large turnover of the population you could be doing lots of very sensible initiatives and the actual benefit in terms of life expectancy, one, is quite long-term and, two, may actually exist in a different area, so there are some technical issues associated with it. I think the key, as both Jacky and Alwen have said, is that targets around this should be set locally, agreed locally between health, local government and the wider local strategic partnerships and then they are going to be much more meaningful. Taking a formulaic approach might not work desperately well in these sorts of areas and so with some of the performance PCT by PCT it is quite hard to interpret what the root causes of those are at a national level.

Q202 Chairman: Would you agree with that? Do you think there ought to be some sort of refined targeting that would be more set at a local level on the basis of local need?

Ms Williams: I am interested in how we set ambition and how we get targets to support that ambition. It is also about the culture of how we deliver targets. What we would want to do is set very ambitious targets for our population. If we were then to meet to 80% of those targets that was seen as success rather than failure. I think there is some culture currently that we are fairly risk-averse. The view we have taken with our local authority is we want to be very ambitious in our Local Area Agreement targets. We have just been refreshing our LAA targets and have actually concentrated on some really difficult targets within the menu we were able to choose from. I suspect if you wanted an easy life you could pick slightly easier targets and be seen to delivering. I think there has to be a challenge; there has to be a measure of ambition; but also the culture of how we are rewarded and acknowledged for success and improvement I think is key.

Dr Chambers: I think it is important to have an indicator that you can track what is happening to deprivation and health at a number of different levels. In my view the common index that everybody understands across partners is the index of multiple deprivation. You can actually classify areas at a number of different levels right up to national level to compare how areas are doing. In terms of where people live and the delivery side of that, having that perspective in terms of the deprivation quintiles and the way you can organise areas into looking at health indicators that is probably the most robust approach we could adopt in the future. I would caution against abandoning a national drive around tackling health inequalities between areas.

Q203 Stephen Hesford: The Chairman is talking about partnerships, the NHS and other partners, local government etc. How key in coordinating the partnerships, and talking about Local Area Agreements and the like, is the Director of Public Health in leading that?

Ms Williams: We have a Joint Director of Public Health across the local authority and PCT, and I think that is a very important role. The Director of Public Health sits across both - the PCT and local authority - as do the Associate Directors of Public Health, who each take a particular focus, whether that be children, adults, environmental health etc. In terms of public health expert advice and focus particularly with local government members, we have found it very, very helpful.

Dr Chambers: Birmingham is complicated in that it now has three primary care trusts and one local authority, and the strategic thrust of policy both at the political and officer level is still very central around Birmingham. Obviously in the days of one health authority it was easier to try and management some of the leadership influencing processes with chief officers and so on. I think now in terms of the Birmingham Health and Wellbeing Partnership, clearly the Directors of Public Health from each of the three PCTs play an important part in framing the way in which the Local Area Agreement is now being refreshed. They are proposing now in Birmingham to have a dedicated Director of Public Health working just for the city council to try and ensure that the different departments within the city council are very much more focussed on health. I have to say, the political dimension of approaching health inequalities and the way in which members and councils play into that, perhaps one of the challenges is that it is not just like having a national target the NHS is driving; you have to very much work with those personal relationships and win the trust of the members as well as that they need to work within a framework of accountability too.

Q204 Stephen Hesford: You have to be tough and focussed?

Dr Chambers: Yes, you do.

Q205 Stephen Hesford: And bully them a bit!

Dr Chambers: Yes.

Mr Stout: The majority of PCTs now do have joint posts. It is also important that they are properly resourced. As Alwen said, simply having a joint post, unless there is an underpinning capacity within the council and the PCT to actually do something and influence, a joint post on its own will not work.

Q206 Stephen Hesford: Would that not come through your properly functioning Local Area Agreement that the Director then tries to draft with others? Is that not where the resource would come?

Ms Williams: If we are talking about the expert public health resource, I think clearly PCTs with local government need to invest. I would agree with David, it is not just investing in one individual, but it is investing in a team of public health experts that therefore work within that area.

Mr Stout: The driver will be the joint Strategic Needs Assessment, which is done across both health and local government. That should indeed inform and influence the Local Area Agreement and what is captured within it.

Q207 Stephen Hesford: Are you saying as a discrete function within the PCT or the health setting the public health function is not properly resourced to do the job? Is that what you are saying?

Mr Stout: No, we are saying to work effectively it needs to be properly resourced. It will vary from place to place, to be honest. There will be some areas that need more investment; others have got this worked out.

Dr Chambers: I think you need a public health function within the city council as well if you are working across a big city likes ours. You can be tough with members from the outside but you have also got to need your own officers giving you tough advice from the inside as well, which is why the joint posts and having people that carry the brief around health within the city council is absolutely key because they do look to their own officers very much for that advice.

Q208 Stephen Hesford: Is it rather like the old-fashioned pre1974?

Dr Chambers: Yes, in a sense. I am not suggesting we go back to that, but if local authorities like Birmingham are going to take this seriously they need some capacity within their own organisations and they need people with identified job descriptions whose job it is to work on this brief as well.

Q209 Charlotte Atkins: Government targets are very much based around socio-economic inequalities. Do you think there are other areas of inequality that perhaps ought to be focussed on as well? I am talking about things like gender, race and age? Do you think to some extent this particular government target distracts the focus from other areas which might also be worthy of some sort of focus and effort?

Mr Stout: I think there is quite a lot of evidence around issues such as people with mental health problems having poor physical health; and the same with people with learning disabilities; and clearly issues of ethnicity as well. There are a whole range of inequalities the national targets do not specifically monitor but I would expect and indeed PCTs do pick up on those sorts of issues in their local plans, which is why we should not only be driven by national targets. If you only do that you might miss significant factors in your local patch which are as important.

Q210 Charlotte Atkins: In terms of the PCTs, do you find you have key local drivers which you focus on in addition to the Government socio-economic targets?

Ms Williams: For us, given our population, issues of ethnicity are key. One of the challenges the NHS has is: how do we measure, so we can measure the impact of what we are doing in relation to the different population groups within our communities? We have implemented, for example, patient profiling in our general practices so that we are starting now to measure ethnicity in a much more comprehensive way. That will help us ensure we can then measure equity of access, equity of health outcomes in relation to some of those factors that are part and parcel of our population make-up. We are not doing that because that has been a target set for us: that is because we understand that for us to be successful in what we are trying to do around health improvement that is a key component - for us to be able to understand and measure our achievements and successes in future years. I think it is still a struggle; my sense is it is a challenge across all NHS services; and I think we need to challenge ourselves more but not just in terms of general practice but looking at ethnicity and other equity audits across a whole range of services, not just primary care but looking at some of our specialist services as well.

Q211 Charlotte Atkins: In terms of equity audits, which groups would you say are doing the worst or the best in terms of meeting those health inequalities? Obviously we are talking about the elderly or disabled; are they missing out on the drive towards reducing health inequalities?

Ms Williams: Certainly from our perspective in Tower Hamlets the area where we have been particularly focussing on looking at issues of equality is in particular in relation to our ethnic populations. We are slightly unusual in that we have a very young population. I think probably in other areas issues of the elderly population will clearly be key; we are obviously taking all of that into account and doing a lot of work looking at vulnerable elderly and ensuring their health and their wellbeing is catered for within jointly developed services; and monitoring, for example, their use of unplanned care so we can make sure we have got more systematic management of patient care. Our particular focus has been on ethnicity. If you were to ask me what group would I have particular concerns about - we have got a very high dominance of Bangladeshi population in Tower Hamlets, and a Somali population, and I think we have got to do a lot more than we are currently doing to ensure we can put our hand on our heart and say we are offering comprehensive equitable access to all segments of our population at all ages. That is a key challenge but one that we are very much aware of and are addressing.

Dr Chambers: Certainly in our PCT where seven out of ten of our people are non-white ethnicity is the dominant issue we are looking at in terms of the different health experience of those groups. In terms of the most recent concerns we have about access to good primary care and the kind of ways in which we are responding in the NHS, the new migrant communities that have arrived in Birmingham are probably almost certainly the least well served in terms of the way we have constructed our services and in the way that they feel able to access them at present. We have particularly seen this in relation to antenatal care and the way in which our midwifery services have traditionally been used.

Q212 Charlotte Atkins: Which groups are you talking about in that respect?

Dr Chambers: I am talking about the Somali community in particular. At the last census there were 500 Somalis in Birmingham recorded; the latest estimates suggest there may be around 20,000 now; many of them have settled in our part of the city, so a completely new and large population we knew very little about and have yet to catch up in terms of providing good, flexible and accessible care which is appropriate for them, and little understanding of what their rights are in terms of primary care in this country.

Q213 Charlotte Atkins: What about gender inequalities? Clearly what we are seeing, particularly among women, is that the inequalities are actually increasing more than among men. Are there any particular issues around gender which you are focussing on?

Ms Williams: We are certainly looking at particular issues. If we look at the way in which we are segmenting age and gender, there are clearly big issues in terms of not just what can we do in the short-term, which we have touched on, but in terms of the longer term agenda around health and, in particular, looking at young people and working with schools. What we have picked up as an example is that young women now are smoking more, for example, than they used to. We are doing some social marketing work currently now in schools to address the issue of what it is that is making girls take up smoking; and what the interventions that would particularly work with the young people living in Tower Hamlets. It is that kind of analysis we now have to get into. Similarly with issues around teenage pregnancy, where we have done relatively well but we have plateaued in the last year or so, and we know what we now need to do and are doing is actually focussing on subsets of our population in parts of the borough where that is a particular issue and do some very targeted work.

Q214 Charlotte Atkins: I think that issue is coming up a little later on the whole teenage pregnancy question.

Mr Stout: Jacky mentioned earlier, and it is not solely about women, infant mortality is the other area where there are wide variations and there are interventions (and Jacky is probably better placed to talk about then I am) you can make as a PCT around maternity services, how they are accessed and how much of the problems derive from late presentations. This idea of social marketing, which is segmenting the population and finding ways of messaging what we are doing more effectively to the different audiences, is really important; so we get health messages across in different ways to different groups in the population and do not just imagine they all are the same and a single message will work with everyone. Those sorts of approaches work and it is not just a gender issue but across all sorts of areas in health.

Q215 Charlotte Atkins: Obviously income will be an important factor right across the board. Have either of the two PCTs experimented with providing, say, welfare rights advice in a PCT setting to encourage people to take up added income via the benefit system?

Dr Chambers: Yes, that element is part of our new model for providing maternity care and putting services into children's centres for the under fives. So benefits advice offered through the voluntary sector, who have a lot of experience of working and reaching our new migrant communities and other ethnic communities, is an integral part of that and obviously they are very focussed on helping women as part of the family support we offer in those areas. We basically have completely rewritten our model of maternity care and under-fives provision in the areas and are now delivering those from children's centres, of which we have 17; and that, in terms of offering women not only income advice and support on benefits, but also starting them thinking about their own aspirations as women in terms of career and learning more about literacy and education, is integral to the model we are trying to put in place.

Q216 Charlotte Atkins: Has that been delivered by a Sure Start and the Children's Centres or via the PCT, or both?

Dr Chambers: It has been a mixture of Sure Start funding, as was originally, which has now been mainstreamed, and the funding we have put in through mainstream Primary Care Trust money as well as the Neighbourhood Renewal Funding we have put into our infant mortality programme. It has come from a number of different sources, but we are mainstreaming that in terms of the pick-up next year.

Ms Williams: We share a similar experience. We have commissioned welfare benefits advice services in our general practices for a number of years and actually very positive in terms of the evaluation in terms of the take-up of benefits by local people. The GPs themselves very positive in terms of having that kind of expertise based within the general practice. In some practices we are now looking to extend this employment advisory service as well so we are trying to make the link in terms of supporting people back into social activity and, indeed, employment if that is feasible. For us that works very well with the recent Dame Carol Black report and working with practices in terms of occupational health services and encouraging people not to remain on invalidity benefit but, where feasible, to move back into employment. As an example of wider partnerships, the other partnerships that are being developed are certainly with the business sector and the voluntary sector. We have some interesting examples in Tower Hamlets of micro-credit and helping women in particular think about an income for their families; and again the coalition between health, local government, business sector and third sector thinking a little bit differently about how we make progress in supporting people in terms of their own improvement of their economic positions as families.

Q217 Jim Dowd: Briefly, I wanted to look at Tower Hamlets in particular. The most recent wave of immigrants, if you like, into Tower Hamlets has been the very wealthy occupants down in Docklands and around the area. Has that skewed the position? My impression is that would tend to improve your figures without actually doing anything on the ground. Has it skewed the picture in Tower Hamlets?

Ms Williams: I think it is probably too early to say because the housing developments are only just starting to be occupied. My guess is that over the next few years that clearly will do.

Q218 Jim Dowd: One of the shortest cuts to improve inequality is to move out poor people and move in rich people!

Ms Williams: Exactly! What I was going to say, we are certainly not complacent and we are not saying, "We'll sit back and therefore it's not a problem in Tower Hamlets", because we can do our calculations and realise we are going to be on-track because of those sorts of factors. What we are increasingly doing - and I guess many PCTs and local authorities are having to do this - is look at the inequalities within a borough; and if we look within the Borough of Tower Hamlets that is where we get the most disparities in health inequalities. We can do the comparison of Tower Hamlets versus other PCTS in our Spearhead group over the rest of the country, but actually if we look at men living in Bethnal Green and men living in Millwall, there is a difference of eight years in terms of life expectancy. There are some interesting statistics and we are looking a bit more at this; but looking at Spitalfields, which is predominantly a Bangladeshi community, the life expectancy there for women is higher than the national average; so we have actually got some unexpected statistics. It is that driving down below borough level and really working at a very local level, as David said, around social marketing, working with a third sector and local community groups, is what is absolutely critical. I think there is something about how we are measuring progress; and it is about looking at individual communities rather than necessarily just looking at the borough as a whole.

Mr Stout: That was the sort of thing I was alluding to earlier. If you simply look at a single local authority or PCT, taking the national target and deriving it locally you may miss exactly that sort of phenomenon of change in population; therefore you really do need, and PCTs should and do have, an understanding of what is going on at a much more micro level, and then set their objectives against that rather than doing it mechanistically.

Dr Chambers: Certainly on the question of migration, we believe that inward migration is a very important factor in terms of the infant mortality figures we are seeing. We persistently have one of the most dreadful rates of perinatal and infant deaths. One in three of the births that we have in Birmingham now are to women who are first generation migrants; that is, they have been born overseas. So it is an enormous number of women who are coming in, and they are part of the generation of mothers for whom we have to provide constantly changing services, educate and so on. That is a challenge in terms of: how do you set figures when you have got this migration phenomenon going on all the time, especially if you only have a census once every ten years? On the question of ethnicity and how do we track health in our ethnic groups, it has been around a long time, this question of ethnicity and death certification, and we still have not got yet the ability to look at death certification by ethnicity at a local level. I know ONS have been looking at the feasibility of doing that, but until we get that a key marker of how long people are living and what they are dying from is not open to us to examine in a systematic way. We can look at service delivery and improve ethnic monitoring but we still cannot monitor ethnic mortality.

Q219 Dr Stoate: SHORN(?) and QOF now does ask GPs to code for ethnicity, so will that not improve things?

Dr Chambers: It could and we have got some data now but it is not perfect and does not capture death.

Q220 Sandra Gidley: We are frequently told that "world class commissioning" is going to be the answer to life, the universe and everything! Will it help tackle the health inequalities at a PCT level? How helpful is what has been coming out of the Department's PCTs?

Mr Stout: World class commissioning itself is just a concept and a concept on its own does not change anything. What I think is helpful about it is it sets health inequalities very explicitly within the objectives of commissioning. You would be forgiven for thinking previous policies may have paid lip service to health inequalities but did not really follow it through. I think it is really helpful that the whole objective of commissioning is set out more explicitly, and absolutely fundamentally includes health inequalities within it. Then it sets out a series of capacity competencies that would underpin a successful commissioning organisation to deliver those objectives. As you probably know now the next phase is an assurance framework which will then test PCTs against this whole device. What I think is useful is that it sets a clearer ambition; it sets stronger and probably more challenging measurements of PCT capacity; and I think it will help energise PCTs in delivering those objectives. Ultimately it is PCTs themselves who are doing the commissioning; and PCTs themselves who will have to meet the challenges underpinning world class commissioning. The framework is just a framework and it is important to bear that in mind.

Q221 Sandra Gidley: Is there not an arm of the world class commissioning initiative that is supposed to be putting a bit more help and support into PCTs so the commissioning as a whole does not fail, because with some PCTs the expertise has been variable, shall we say?

Mr Stout: There is a debate at the moment about how exactly support and development for PCTs will be put in place; but there is a recognition that you will not achieve change simply by setting a vision and measuring it; there does need to be access to new skills and, indeed, new resources. Amongst other things there is the framework for external support for the commissioning of ESC, as it is known, which is a device to help PCTs hopefully more rapidly be able to commission external support where there are skills and competencies gaps in the local organisation. I would not underestimate the challenge that PCTs will face. The skills we need are going to have to be learnt as well as brought in. I do not simply buying in expertise is going to be the whole story. I think there is a whole development programme - Alwen and I were chatting about it earlier - that PCTs are working up themselves as to, "How are we going to work collectively to drive this forward, as well work individually?"

Q222 Sandra Gidley: On a practical level for the PCTs, is it going to be helpful? Do you currently have the capacity to commission effectively to tackle health inequalities?

Dr Chambers: I think the answer is, no. If you really aspire to the principles that are set out in world class commissioning, there are two areas where we have not yet got the capacity: one is around partnership working across a complex system; and the other is really around public engagement as a real driver in terms of that notion of engaging with our communities to drive health and choice, and drive up the standards of service and the expectation of those services. We have got the basics in place, but if we are going to aspire to the excellence that is set out there we are going to need more capacity to do that.

Ms Williams: I think it comes back to my earlier point about ambition. I think world class commissioning ultimately is about ensuring that we do set an ambition for improving health. I think part of the world class commissioning framework is a focus on health outcomes and, as David says, that is clearly going to combine to bring about improvements in health and a reduction in health inequalities. What I would say though is, it is about world class commissioning in the context of the wider partnerships. I think it is helpful that there is a systematic, transparent and very clear set of expectations for commissioning and PCTS. How we conduct that and undertake that in those wider partnerships locally are going to be real measures of our competence and part of the competency framework because that is what is going to really make some of the differences on the ground.

Q223 Sandra Gidley: At a more practical level, are you able to give a couple of examples of effective and efficient interventions that commissioners can actually employ to tackle some of the inequalities; perhaps tell us one of your success stories?

Dr Chambers: I would like to tell you one. I would like to tell you about commissioning primary care and the way in which we have used and contracted with the private sector to introduce what we have called "active patient management systems". We believe for good preventive care if you are going to make the best use of population registers that you need system support in order to enable practices to deliver good population coverage. If you look at the evidence we provided in terms of the immunisation rates we now have of 94% for MMR, the flu vaccination rate topping the country at 80%, and more recently in terms of the circulatory audit and screening we have introduced that has been through having a call centre, a database and a scheduling process that means we can actually follow-up people who do not attend, and we can support practices with real delivery of good population coverage. I believe that sort of mainstream element, in terms of where primary care needs to go to tackling health inequalities, of the principle of active patient management and the way in which we have used the flexibilities you get with the private sector by contracting with them alongside our independent contracts, is a really important strand that needs to be taken forward and applied generally across the nation.

Q224 Sandra Gidley: Who actually does this work? I have a vision of people in a call centre ringing people up and pestering them to go along for something? Is this at a surgery level?

Dr Chambers: No, this is at a Primary Care Trust level. It is a commercial organisation staffed by local people, many of whom speak three or four languages. They work out of hours so they work in the evenings and at weekends. Yes, they do pester people in the sense that they ring them up; but actually what we have found is that people are delighted to be rung up and do feel that the NHS is starting to look after them. They are ringing on behalf of their doctor and this is when they would like to come for this particular appointment, and they actually schedule the appointments as well.

Q225 Sandra Gidley: Are the people who ring medically qualified? I am just wondering how much access to individual health data they have; or are they just given a task list and they ring up and try and get people to do X, Y and Z?

Dr Chambers: Basically they pull the information, obviously with the permission of the local doctors, from the practice registers and they draw up a schedule of calling from those registers and then they call the patients who have got telephone numbers. It is more difficult if the telephone numbers are not there, and quite a lot of our practices do not keep accurate telephone numbers. Where they do have telephone numbers they are getting a 70% response on average to those invitations to go for preventive care. It really does work and much better than the old systems of writing to people and just hoping that they walk through the door.

Ms Williams: We have introduced what is called a "balance scorecard" across general practice which measures some very key targets local at practice level; and again that has been very successful.

Q226 Sandra Gidley: What sort of things does it measure?

Ms Williams: Things like blood pressure, cholesterol, diabetic control, screening rates and immunisation rates. That is shared amongst all practices. We have agreed with our NMC that will be in the public domain shortly. There is a lot of good clinical leadership really where we have got very highly performing practices supporting other practices to improve their effective management of patients in that way. The second example is that we have commissioned, and indeed are developing, a wide-ranging health trainers' programme in Tower Hamlets, and we have commissioned that through four voluntary sector organisations. What is interesting is that the majority of recruits are from the local community; and when we did the analysis a lot of the people who pressed into our health trainers' programme were from the NEET category - Not in Education, Employment or Training - the 16-24 year olds. Not only are we commissioning services in terms of being able to provide support to individuals to help them maintain and improve their own health lifestyles, but the people helping those individuals are now in active employment. I have no doubt we and the NHS can think then about their own career development. Those are just a couple of examples.

Q227 Dr Stoate: Dr Chambers, you obviously have to make priority decisions on whether you put money directly into the delivery of healthcare or if you put money into things further upstream in order to tackle inequalities. What evidence base do you have for making those decisions?

Dr Chambers: We have a good evidence base around primary and secondary prevention of coronary heart disease, and that is where we have put a lot of our effort. We have a good evidence base certainly around smoking as a behaviour that is the single most important behavioural determinant of the health inequalities that we see; and we have put a large investment in that and are proposing to increase it even further. We have taken some views without much evidence that we need to put a large investment into tackling childhood obesity. We have put a large investment into working with schools and parents, under 5s, nurseries and with Aston Villa Football Club to actually provide a whole generation of children with a completely different environment in their schools and experience around physical activity and nutrition. We do not know necessarily that that is going to work because there is not much evidence around obesity, but we have got to do something in terms of the rising trends we are seeing in obesity and doing it on a large scale.

Q228 Dr Stoate: Obviously you have got to make difficult decisions about whether to put money, for example, into developing a new practice, or whether to put money into teenage pregnancies in schools, whatever it might be. How do you base that decision? What do you do to come to a decision as to where that money ought to go?

Dr Chambers: We have a process of prioritisation which I as the Director of Public Health am part of in terms of what needs to happen.

Q229 Dr Stoate: I appreciate you have got a process of prioritisation, but what evidence do you base it on? All businesses must prioritise, of course they must; that is what every decision is based on. What evidence do you use to decide whether the money goes into direct practice care or whether it goes into preventive care in schools, or whatever it might be?

Dr Chambers: We have been fortunate, we have been in a growth situation in terms of the money that has been coming; so a lot of the growth and development we have obviously put in according to the profile that we have of health needs - the things that are getting worse that we need to tackle and we actually need to address; the evidence that we have around what works and what we can actually take as simple measures to improve upon. Around teenage conceptions, for example, easily accessible contraception services for young people delivered out of youth-friendly environments we know is a success. We have also put money into the Healthy Schools Award in trying to increase the number of schools that provide good personal, sex and relationships education. There is evidence, in terms of the whole range of programmes of health inequalities, that has come from NICE, and before that the Health Education Authority, and before that the Department of Health. There is an evidence base around the things that we have put our money into; and the question of how it competes and takes its place against the acute sector and primary care. We have worked that through in terms of seeing it as an integral part of the shift we want to make from out of hospital into developing primary care.

Q230 Dr Stoate: Are you talking about your own evidence base or a nationally published body of literature that helps make the decisions? Where do you get the information from?

Dr Chambers: We have our evidence based around the local health profiles. We have our own evidence based around the research we have done into our own communities, and we have done a lot of focus group work; we have done a lot of qualitative as well as quantitative research work around what local people think and want. We know that health information and lack of health information is one thing they really are concerned about. We obviously use national evidence in terms of things like chronic disease management to say, "How do we stack up in primary care at the moment against what we know is going to effect and bring about improvement?" We know that people on the disease registers, if we want to make a really quick impact, getting those properly managed and knowing where we are in relation to actually managing those well is a key area for us to invest in.

Q231 Dr Stoate: Do either of you have anything briefly to add to that, about you base your evidence or does that roughly cover it for all of you?

Ms Williams: I think that is accurate. I think increasingly we are looking at comparator information; that is becoming increasingly another source of intelligence if there is something we need to particularly look at and then determine how that gets prioritised.

Mr Stout: It is local judgment, is it not? There is evidence and then you have to use local judgment to compare. The evidence you have described will give you are lot of alternative choices.

Q232 Dr Stoate: I do not like the sound of "local judgment", because you are talking about very, very large sums of public money and you are saying, "Well, we thought it might be a bit of that and we might try and bit of that and see what happens". I am not very happy with that.

Mr Stout: Based on what your strategy is. Local judgment based on what you are trying to achieve, I suppose.

Q233 Dr Stoate: I am trying to decide what you are trying to achieve and whether you have got any scientific base to it whatsoever, or whether it is just pure guesswork?

Dr Chambers: There are a number of tools now that one can use. The programme budgeting tool is one, so we have looked at our spend and outlays against other Primary Care Trusts that are in the same cluster, like Tower Hamlets. We have looked at the health inequalities tool kit in terms of how is the gap explained, and where are the big gaps that we see which would account for our poor life expectancy track record.

Q234 Dr Stoate: In know what the inequalities are, I am just trying to get to how you actually work out whether one intervention is scientifically evaluated as being better than a different intervention, or is it just purely "We thought we'd try some of this and see what happened"?

Dr Chambers: The quality of evidence does vary around different interventions. One has to make judgments, and so a big thrust in relation to what I have said is that smoking is our number one and we have got to get that right, and there is a very good evidence base around that.

Ms Williams: There are judgments we do need to take that have not necessarily got an evidence base. I am looking for the year ahead at investing considerably in improving the population's awareness of diabetes on an industrial scale. I think it is acknowledging we do take risk in terms of the judgments we have to take about what we are trying to achieve, the longer term impact that will have and what investment we put into that. I guess what we are going to have to do increasingly as PCTs is share some of that together so we are learning. I think it is fair to say we are, to some extent, in new territory in trying to bring about some new creative ways of doing these things and we have not necessarily got the body of research or evidence behind it.

Mr Stout: The important thing is to be transparent about how you are doing; so be clear when you are using it, and be transparent where you are exercising judgment which, as Alwen says, is based on hunch rather than hugely scientific facts.

Q235 Stephen Hesford: Alwen, your evidence says you have spent time and money improving access to primary care. In terms of other evidence that we have heard access to primary care does not really affect tackling health inequalities. My question is: how much does it cost for you to secure your extra GP appointments; and have you any evidence that this in fact gets to deprived groups?

Ms Williams: I would not agree with the fact that access does not have an impact on tackling inequalities. I think our experience would be that ensuring good equitable access to high quality primary care services is critical in tackling health inequalities. If we look at our population we have invested in more GPs, we have invested in more community nursing and specialist roles within primary care. We have also had to tackle poor performance. We have negotiated with our general practices extended hours of opening and we are doing a very in-depth piece of work to absolutely ensure that satisfaction with general practice services improves in Tower Hamlets because we are very conscious that in the recent MORI poll many of our Bangladeshi population were still expressing dissatisfaction in terms of accessing services. I think our tenet is that you need to ensure there are no barriers to access because what you want is your population to be able to see their GP or health professional about getting good advice to stay healthy, or to prevent any onset of any long-term health condition, or indeed to effectively manage with that individual their long-term health conditions. I think access is very, very important.

Q236 Stephen Hesford: How much does it cost?

Ms Williams: I cannot tell you an entire cost off the top of my head.

Q237 Stephen Hesford: Could you write to us?

Ms Williams: I can let you know what we have invested in each of those.

Q238 Chairman: Alwen, you were one of the first users of the alternative provider medical services which effectively is the introduction of the private sector in terms of delivering at local level. It is not without its critics. We have had evidence certainly by one of the professional organisations that says there is an issue about quality of service in relation to that. Do you think in any way that this is diminishing the quality of service?

Ms Williams: This is a practice serving predominantly Bangladeshi population of 10,000 so a large practice. The specification upon which the procurement was based was a much higher quality of service than those patients have certainly enjoyed in the past. The practice not only is open from eight in the morning to eight o'clock in the evening, but it is also nine to five on Saturday, and is offering a much wider range of services. The new provider only took up provision of the services at the end of January, so clearly it is early days, but we are already getting good feedback from patients who are now unsurprisingly being able to access and get an appointment because there are now more appointments in the system for them to access, but also enjoying a much wider access to a whole range of services closer to home. I think the contract requirements are stringent. What goes with a very good specification is clearly a responsibility on our part as the commissioner to monitor that contract. Indeed there are penalties built into the contract should there be any diminution of quality over the next few years. We are very confident that will not be the case.

Q239 Chairman: Why do you think organisations write to us saying they have serious concerns about quality then? Do you think it is ideological?

Ms Williams: Certainly what we have experienced in Tower Hamlets is a lot of concern from our local GP community about the introduction of another independent provider. There have been concerns expressed about issues such as continuity of care; so a concern that maybe a private company would not employ permanent staff but perhaps would employ local staff on a rotational basis. Again, that is specified in the contract that they need to be permanent staff deployed within the practice. The relationships continue to be productive, and indeed our local practices and others are now working well with the new provider.

Mr Stout: It is also worth point out APMS is actually open to all types of practices; it is not restricted to the independent sector. An existing practice can equally compete in the tender. Clearly there are some groups who are ideologically opposed to widening the type of independent contractor providing primary care.

Q240 Dr Taylor: Going on exploring the quality issue, one of the things the NHS probably can do to improve inequalities is to improve the variation in quality of service. We have talked about access but actually quality of service. I would be very interested to see that balance scorecard because that seems as if you are really getting to grips with tackling the practices that are not providing the best service. Going on to secondary care, Alwen, you have said the solutions for identifying undiagnosed disease cannot rest with primary care alone and will need strong partnerships with new trusts. What can the acute trusts do stimulated by you as commissioners to tackle health inequalities?

Ms Williams: There are a number of things I can do. As a commissioner, as a key leader in the local health economy, I think it is incumbent on commissioners to put health inequalities on the list of important things strategically. When we meet the joint board to board meetings of the acute trust we review health inequalities and what we are doing strategically together. An example would be employment. Our acute trust, and it happens to be a major teaching hospital based in the middle of the borough, is a very significant employer. Thinking about the wider role of the NHS organisation in terms of employment and development of skills is a key factor, as part of the wider regeneration and economic agenda. At another level through the contractor requirements with acute trusts, we are now requiring what we would call brief interventions, so that we are training and putting some resource into the acute trust to train frontline staff to be able to talk to patients about maybe Stop Smoking or Lose Weight. There is the Stop Before the Op initiative, where we are encouraging people through their interface with acute clinicians. Opportunistic public health advice, acknowledging that when we talk to clinical staff about that people are often concerned about how they do that in a way that does not look as if they are preaching. The way in which that is communicated is critical, so doing some training with frontline staff in terms of how that can be done in a productive way. There are some interesting examples where patients with lung cancer have said, "Actually we went through the NHS system and nobody did talk to us about Stop Smoking". Really getting this high on everyone's agenda strategically at board level, but also critically in terms of the frontline delivery of services we think is very important.

Q241 Dr Taylor: If you had concerns about the quality of care being delivered in a particular department or a particular hospital what could you do about it, or has that not occurred?

Ms Williams: There are very clear quality standards and quality metrics. We have now got a national contract, as you know, for example with acute services. There are national quality standards but we also have built in local quality standards. For example, an area of great concern to our public has been maternity care. We have quite specifically been undertaking a joint review of those services with the acute trust colleagues with our local population, and that has led to the implementation of some clarity about quality standards and helping improve that service.

Q242 Dr Taylor: Jacky, if you were dissatisfied with something at Solihull or Heartlands what could you do as commissioner?

Dr Chambers: We have regular meetings with our acute trust and, separate to the actual financial negotiations on the contractual side, we also have clinical governance meetings too. Those issues in terms of quality and any concerns we have are raised at that level as well. In terms of your question about acute trusts' role in tackling health inequalities, I just want to flag up that what we are trying to do is move a lot of hospital care out of hospitals much closer to where people live in terms of the areas we serve. We know that transport and costs of transport and difficulties of getting on a bus, perhaps two bus journeys, to get to hospital care is a real barrier to people maintaining their out-patient appointments and so on. What we have got is a major programme to shift about £40 million worth of revenue and activity into local diagnostic and treatment centres and into our bigger health centres as well. From a commissioning point of view it is really important for us to try and deliver the out of hospital care.

Q243 Dr Taylor: You may have a closer control on them when they are under you directly?

Dr Chambers: In terms of who provides them they are still providing them, but it is a different model of care; it is more accessible and it gives time for a lot of the brief interventions and self-care and education work to go on in a more community environment with language support and other staff playing into that sort of service model of delivery, which is very different in terms of what patients experience at the moment.

Q244 Dr Taylor: David, in your paper one of your bullet points that health inequality covers, inequalities in the outcomes from healthcare, can you expand on that? How far have you got with measuring outcomes and being able to compare them between different providers?

Mr Stout: If you look at some of the work going on, it is not all done by the Confederation, I confess, but the work going on with the Department of Health around Vital Signs, for example, which you might have come across which are the outcome indicators that have been developed as an assessment tool of the commissioners, that starts to breakdown relative performance and is a sort of evidence. Howard was asking about where we can look at relative performance between commissioners. You can then equally use similar data around relative performance of providers as your question implies. By and large you do not use contractual devices to solve these sorts of problems because they are a bit crude and they are not necessarily that effective, but having a contract that allows local quality standards to be set, as Alwen said, and having contractual threats sitting over your shoulder is one means of creating an environment which leads to improvement; equally providing incentives, which is another set of initiatives, for example, in the North-West. The PCTS in the Strategic Health Authority are experimenting with a quality incentive system for hospital care, which does not exactly look like QOF in general practice but has some comparisons in terms of the thinking behind it. We are starting to develop new ways of both incentivising improvement on the one hand and dealing with problems as they come up as commissioners. The other point I would quickly make is around mental health providers, because you asked about the key providers. I think there is also a role for mental health trusts, most obviously in relation to people with long-term serious and enduring mental health problems whose physical health, as I alluded earlier, is often a lot worse than the average citizen. I think there is certainly a role around the new care programme. Approach guidance came our recently that emphasises the importance of coordinating physical care as well as mental health care for those patients. Again, there are roles for all sorts of different parties. The other point I would make is the duty of partnership that is being built into the guidance for all NHS organisations about partnerships working within the framework of the local strategic partnership, and that ties in the wider provider community as well as the commissioners. While I do not think it has been tested as to exactly how that would operate, it is quite important potentially that it is set in the regulations.

Q245 Dr Taylor: Could we have a note about the quality incentives for hospitals?

Mr Stout: Sure.

Q246 Dr Naysmith: We have talked about commissioning primary care services and commissioning other National Health services like the acute trusts and mental health trusts. Can we turn for a minute or two to commissioning directly public health services, and bearing in mind the need for an evidence base and value for money and so on, the actions recommended by the Government to tackle inequalities in infant mortality are much broader than those for life expectancy and, as you know, they include things like reducing infant mortality, reducing the prevalence of obesity in the routine and manual group, reducing smoking in pregnancy from 23% to 15%, reducing sudden unexplained deaths in infancy by persuading one in ten women in the routine and manual group to avoid sharing a bed with a baby and so on, and the teenage pregnancy strategy that we have talked about already. Some of these are pretty broad; how can PCTs meet such broad public health targets? Jacky, you have talked about infant mortality already and it is obviously a big problem in your area, so how does that match on to the broader targets that are being set?

Dr Chambers: The starting point in terms of understanding how to commission in order to address infant mortality has been the work that the West Midlands Perinatal Institute has done and the information that it has gathered, both in terms of the demographic factors that are playing into that and also some of the service factors. They have done some audits around midwifery and obstetric care, and also some of the modelling, picking up Dr Stoate's point about the kind of ways in which we use evidence, through what the impact of different interventions would be, whether it was smoking or trying to reduce, in our case, in the Pakistani community the prevalence of first-cousin marriage and consanguinity, so we have a sense of the importance of some of those drivers. In the south of the city we know that smoking in low-income mothers is certainly a bigger driver for them than consanguinity is in our community. That is the starting point in terms of the commissioning plan, and we have an infant mortality action plan that has a number of deliverables and objectives set out for that. The net result of all of that in terms of how best to deliver a range of both social as well as clinical interventions that are going to impact on infant mortality is that we chose as the delivery route to remodel the whole way in which ante-natal care was provided out of children's centres, which would provide a much wider range of different agencies that could help work with women and manage some of the risks, like domestic violence and income poverty and so on. We have worked from the basis of the demography, the need, the modelling, and we have come to the conclusion that the delivery route of the public health programme is to be our redesign of maternity care, and we are still working that through in terms of trying to get real change on the ground to happen.

Q247 Dr Naysmith: Clearly that is an important area for you to explore in your PCT because it is a big problem in your area, but, say, we are talking about some leafy suburb in Surrey or somewhere, some of these things would not really apply in exactly the same sort of way so they would have to make judgments. How would they do that, how would they judge one of these things against another, or does it bring us back to the local commissioning again and knowing what your locality needs most?

Dr Chambers: If you are living in a leafy suburb and your infant death rate is not above the national average, it probably would not feature as a very high priority, unless you go down to the small areas and start to look at the within area differences. Of course the national target which is set around social class is not measurable at local level so the only way in which you can start to work that through locally is by looking at an area focus using IMD scores and so on, so it is not easy to translate that and the evidence base around infant mortality is not as definite in many of these areas as it is for life expectancy and cardiovascular disease, and so on. I do not work in a leafy suburb but I guess if you were thinking about the babies that are dying, you would also be thinking about the babies that are born disabled, and you might be looking at the way in which you do that.

Q248 Dr Naysmith: You might also be thinking that reducing obesity might be a good target in itself unrelated to infant mortality?

Dr Chambers: Yes.

Q249 Dr Naysmith: It might even be more important in a leafy suburb in some respects?

Dr Chambers: It may be, and infertility treatment may be equally important in terms of playing into the levels that you might be seeing, so you have to look at your own area and decide which are the most important factors that are playing in. In relation to obesity, we have found that our maternity units operate very different policies in terms of BMI cut-offs and we are trying now to make sure that we get consistency built into the way in which we contract for those services and the interventions that are offered.

Q250 Dr Naysmith: Do you think that the public health function in your own area and elsewhere is rising to meet these challenges that the Government have set? I know we have talked about this a little bit already, but bearing into mind specifically what I said at the start about value for money and an evidence base, is it these broad targets versus locality and is it value for money?

Dr Chambers: Is this question just in relation to infant mortality or generally?

Q251 Dr Naysmith: No, in setting the broad targets that public health requires.

Dr Chambers: I have been in public health for a long time now, and I am getting towards the end of my career, and I think in terms of the last few years that the opportunities that we have now in terms of the funding, the drivers and the accountability are stronger than I have ever seen in my lifetime of working in the NHS, so I do think that we are in a very different position than we were, say, ten or 15 years ago. Whether or not we have risen to the challenge as a profession, I think you work within a context locally and nationally, and there is no doubt that in terms of our positioning, my view is that in the NHS the more that we can move across to work and engage with the local authority that that is going to be an absolutely key development for us as a profession, and the capacity of the teams to work with those organisations that we will be leading and working and influencing is absolutely central to making this work in the future. Obviously in terms of other key players like chief executives and directors of commissioning, and raising awareness about what can be done and the commitment to do that, that is certainly taking off, and I think there is more support on a corporate level than there has been because of the centrality of the health inequalities agenda that has been driven through PCTs.

Q252 Dr Naysmith: Do either of the other two want to add anything?

Mr Stout: I think the critical challenge for public health is to move from an analysis function to one that drives decision-making, and I absolutely agree that is the opportunity. It is early days in terms of the sorts of changes that Jacky is referring to, but I think the opportunities are really there.

Q253 Dr Naysmith: It is interesting you say early days; public health has been going for 150 years.

Mr Stout: Early days in the context of the policy shift with the emphasis on health inequalities and the world-class commissioning agenda we referred to earlier; health inequalities and health outcomes are absolutely fundamentally within it and I think it is a huge opportunity.

Ms Williams: The only thing to add is the alignment of public health with practice-based commissioning so that as local decisions are being taken they are well-informed by good public health information and expertise, and I think that is another very valuable opportunity going forward.

Q254 Jim Dowd: I know that any organisation could always do with more resources, but do you regard your PCTs as having sufficient resources to be effective in addressing health inequalities?

Dr Chambers: We currently have a surplus and that is quite deliberate in some respects because of this big shift that we are trying to make to out-of-hospital care of which public health programmes of self-care services will all be part. I think the difficulty that we have as primary care trusts, and this does not apply now to foundation trusts or indeed to local authorities, is that we are not able to carry over that surplus and plan long term financially for the sorts of investments that we need to make in a strategy to tackle health inequalities, and I think if there was one thing in terms of flexibilities that nationally we ought to be able to secure it is that freedom to carry over these surpluses and bank them in the way that foundation trusts and local authorities are able to. We work on an annual financial ---

Q255 Jim Dowd: Surely the imperative there then is for you to aspire to foundation trust status?

Dr Chambers: I am not sure that is within the frame really in terms of ---

Q256 Jim Dowd: If you readily accept that you cannot deploy the surplus, what is the point of generating it?

Dr Chambers: The issue is if you have got long-term strategic plans to try and make things move from hospitals into better primary care - new buildings for primary care and the revenue to support new health centres - those things have a lead time in the way that they are actually rolled out and you need to ensure that you have a long-term financial investment plan so that when you have surpluses, and you know the kind of fluidity of some of the allocations that we have had in the NHS and clawing money back from surpluses, it is that ability to actually carry over some of those surpluses and use them in a more long-term investment way.

Q257 Jim Dowd: Sure and we understand that. The next point I was going to raise is rather redundant. I was going to say if you were given more resources how would you have used them, but clearly you do not need them! What then on the other side of the coin - and I leave it for others to judge which is more likely - if there was a reduction in resources available, what would you cut from the work on health and inequalities first?

Dr Chambers: Could I answer the question in terms of if there was more money to be spent, and obviously our latest local delivery plan has got more investment in a whole range of self-care lifestyle services and partnership work around obesity and commissioning in the voluntary sector around mental health services, so those are the things that we are planning with the development money that we have. In terms of what would one cut, I guess ---

Q258 Jim Dowd: I suppose I am asking you indirectly what is the least effective activity in this area, in your view?

Ms Williams: Could I answer it slightly differently because I think that there is a risk that we see public health as having a separate set of resources and being slightly to one side. I think the issue for us all is how we mainstream public health, as we said earlier, into our entire commissioning and delivery of NHS services. There are particular healthy lifestyle services that clearly we need to be investing in, and smoking cessation is the obvious example. Certainly the DH report is suggesting we should double our services if we are going to eradicate smoking, and we know that smoking has the largest impact on health inequalities.

Q259 Jim Dowd: We have known that for 30 years or 50 years.

Ms Williams: There are certain very dedicated public health services that indeed we would want to be expanding massively, in the same way as I mentioned diabetes education, but I think the key challenge is how do we use effectively the totality of our resource so that it is all lined up as best it can be to improving the health of the population, which for us I think does go back to how do we deploy the resource that we are allocating to our major acute provider, so it is not just looking at care but quality and public health interventions.

Mr Stout: If you accept that analysis, which I think is right, then in the circumstance of shrinking resource you would be making decisions across your whole spend as to relative effectiveness of everything. It is back to Dr Stoate's questions earlier which is how do you make those decisions because they are the same challenge but in the opposite direction so how do you decide what to disinvest in is a similar.

Q260 Jim Dowd: I appreciate that but that was not the question I asked. Nonetheless we will press on. How valuable has the Spearhead status that you both enjoy been and what would happen if it were withdrawn?

Dr Chambers: We have been working as part of Birmingham as local authority Spearhead status so very much we have been working in partnership with the other primary care trusts and the city council under that banner. We have obviously received support from the National Support Team and that has been helpful. That came quite late on in terms of our local area agreement but it was a helpful visit and feedback and there has been some funding from Communities for Health that has come into the city council, which I have to say has not been particularly significant and has not played a particularly large part in terms of what we have done. I think the awareness of Spearhead and the extent to which it has got a profile in the city is probably quite low, if I am honest, in terms of it as a vehicle, and although the Spearhead local authority is a network and the conference that kick-started that, I think the reality is that in terms of the kinds of support that we have received by way of sharing good practice and networking has not really had all that much in the way of impact. We have basically got on with it. We have enjoyed having that status and we have enjoyed having the National Support Team visit but other than that I cannot say that it has really added much.

Q261 Jim Dowd: So it has only really been a marginal consideration?

Dr Chambers: The most significant thing I think is the local area agreement and the way in which neighbourhood renewable funds within that will apply to deliver the floor target action plan and our ability to commission within that agreement new ways of working and pump-prime some mainstream service change.

Q262 Jim Dowd: Ms Williams, is your experience similar?

Ms Williams: I think pretty similar. Looking back the more than couple of years since we were designated, sometimes it is useful to throw a spotlight on an issue, and I think it did that at the outset and helped me galvanise the organisation and our director of public health agenda. If we did not have it any longer I do not think we would be doing anything differently, we would continue to focus on the things that we need to focus on to reduce health inequalities in our population.

Chairman: Could I thank all three of you very much indeed for coming along and assisting us with this inquiry; it has been a very useful evidence session. I have to say that after 25 years in politics, I am finding it very difficult to adjust to the situation where people who work in the public sector say that they are adequately resourced but ---

Q263 Jim Dowd: It is ten years of a Labour Government, Chairman!

Ms Williams: Can I say we are finding it difficult as well

Chairman: Thank you very much anyway.

Witnesses: Dr Paula Grey, Joint Director of Public Health, Liverpool PCT/Liverpool City Council, Mr Andy Hull, Divisional Manager, Public Protection and Regeneration, Liverpool City Council; and Mr Jamie Rentoul, Head of Strategy, Healthcare Commission, gave evidence.

Q264 Chairman: Could I first of all welcome you and could I ask you to introduce yourselves and the positions that you hold for the sake of the record, please.

Mr Hull: I am Andy Hull and I am the Divisional Manager for Public Protection for the City Council of Liverpool.

Dr Grey: I am Paula Grey and I am the Director of Public Health in Liverpool. It is a joint post between the city council and the PCT.

Mr Rentoul: I am Jamie Rentoul and I am Head of Strategy at the Healthcare Commission.

Q265 Chairman: Thank you again for coming along to help us. It is the third session of our inquiry into health inequalities. I have known personally for quite a while that the big issue in Liverpool is the SmokeFree Liverpool initiative. As a joint initiative that we assume has been successful, why has it been successful and what impact has it had to date on health inequalities in Liverpool?

Dr Grey: Our focus on smoking goes back a long time but the decision to look towards a smoke-free Liverpool came about in about 2003. It was before Choosing Health came out and I think the defining moment was saying that in Liverpool we have so many pressing health issues but smoking had to be our number one priority and from that time we were going to focus on it. We set ourselves a very ambitious target of making Liverpool smoke-free by 2008 and at that time we did not have any idea how we would get there, we did not know what was going to come in terms of legislation. Setting that ambitious target at that time was very important in galvanising support behind us. Over the next two years what we did do was get engagement across the city and in leadership at all levels across the city to support the idea of a smoke-free Liverpool and really get through to people the understanding of the significance of smoking for the health of the population. I think those were the significant first steps which actually got us on to the track of saying that SmokeFree Liverpool was something that everyone could sign up to and would have a significant improvement in health for the people of the city.

Mr Hull: From my perspective I chaired the SmokeFree Liverpool Group. It was a decision of the local strategic partnership sub-group for health and they defined this as their single top priority and it was a combination of me volunteering and being appointed as the chair. I am obviously not a PCT employee and I am not a smoking cessation specialist; I am a public health practitioner working within a local authority, and we looked for the most cogent way of trying to drive down smoking prevalence, and the viewpoint we came to was that, yes, we would as a partnership massively invest in smoking cessation, as has been touched on, and there was virtually at that stage a blank cheque given by the PCT to increase smoking cessation services, and that is still the case and they have massively increased. We will refer to that in the health inequalities bit. We then looked at what international best practice was, and it came from California and from what they had done with their smoke-free legislation. Professor Stanton Glantz, from the University of San Francisco, came over to visit us, inspired all of us, and made us believe, along with Ireland who were already on the track by that stage, and then obviously Scotland as it became and Wales and ourselves, that we were able to start really agitating and moving for that. We feel entirely vindicated by taking that approach. The written evidence we have submitted does show a very significant drop in smoking prevalence. Liverpool had the unenviable title of having the highest adult smoking prevalence in England and all the things that go with that such as the highest lung cancer rates. I am sad to say it still has because all of the rest of England has reduced as well but we have made an enormous impact. We have reduced smoking prevalence from 35% to 30% in the adult population in a little over two and a half years subsequent to the campaign, and most of that has been achieved ahead of the implementation of the legislation, and obviously in my day job I am charged with the implementation of the actual legislation itself. It has had a massive impact but I would just say that the thing that happened (and I was listening to the previous evidence here) is that the PCT used its uplift money and used its leverage in the local strategic partnership to follow through what its strategic decision was on this. So often the disconnect comes between making a strategic decision and then properly resourcing that strategic decision and, and again referring back to what you have just heard, notwithstanding whatever turbulence might happen in budgets actually carrying that through to its final conclusion.

Q266 Chairman: Andy, in Liverpool you were advocating issues around a smoke-free Liverpool well before legislation was brought there and implemented through Parliament and that debate in here was predicated on this issue of the nanny state. Were there any debates about the nanny state in Liverpool prior to February 2006 when the decision was taken in Westminster?

Mr Hull: Do you know, there were, but we go back a period of time here and we still have at the moment a Liberal Democrat administration and you will have experienced in the Houses here that many of the members of that party have a mind-set that this is against personal freedom. We took a very practical approach of actually briefing individual members and the committees in advance and going through all the arguments with them. The vehicle for it was we looked at all the legal mechanisms and we went through a very big sifting process. We thought about whether we could use local licensing or the Health and Safety at Work Act because it had previously been thought that that was essentially a piece of legislation that would affect workplaces. When we came down to the final analysis, the best way forward was to propose our own private legislation. That legislation actually went into the House of Lords and went through the second reading stage, as members may be aware. What that did back in Liverpool is it meant that it had to go through the city council as a resolution to take that forward. That presented us - and there is a key in this for other things we have done since - with a vital opportunity to have those dialogues and have that discussion with members in a very open way, to actually acknowledge their concerns but also to confront those concerns and tell them what we were about and where this would lead us ultimately and what was at stake here. That was a very important part. There was a cross-party consensus. I have referred to the Liberal Democrat administration but we briefed all members on this, and there were concerns from the Liberals and the Labour Group as well, and we dealt with all of those. It was an overwhelming majority in the city council which at the time had 99 seats. Of those, 90 members voted in favour when the vote came through, so there was a massive cross-party vote in favour of this in Liverpool and that level of consensus carries us forward to today. It is not just a consensus within the city council chamber; it is a consensus amongst the whole partnership, and not just in the PCT but the other people around that partnership table who have helped us make it successful.

Dr Grey: It is a public protection issue; it is about protecting people, and it is the tobacco companies which are manipulating us to smoke more, and I think it is about turning it around and showing that it is not about us being nannies but being there to protect people. We had all-partner support including organisations like trade unions that supported that approach of a smoke-free Liverpool.

Q267 Chairman: Would you be comfortable to do that type of thing with other areas, maybe on food or whatever, where the same argument about the nanny state has taken over? I am quite interested how you manage this within a city and getting the support of people in the city.

Dr Grey: I think there is a real role for regulation and perhaps we do not use it enough. It is not always about legislation but about regulating some of the things people can do. We had a very interesting talk from Sir Kenneth Calman yesterday talking about stewardship and the role of public authorities in terms of being stewards, so in a liberal state you do not want to be too prescriptive, but in terms of the public good and protecting people, there is a real role for stewardship and balancing that against individual rights but also the rights of communities to live safe and healthy lives. It is a delicate balance but we are certainly discussing other things in Liverpool at the moment but more around the issue of young people starting smoking, where we think this same kind of approach is legitimate and we can justify, in terms of children being a vulnerable group, having to take action at a communal level to protect (with an evidence base) young people against harm. The issue we are picking up at the moment is the issue of smoking in movies. We understand from the evidence that about 50% of young people who start to smoke do so because of seeing it in the movies. That is an area where we think we should be trying to take action, because something like 1,700 children in Liverpool alone are starting to smoke each year because of this effect. That is another area where we are seriously considering this kind of regulation as something we would like to support.

Q268 Chairman: It has been successful but it is a single issue that you have looked at. Health inequalities go across a lot wider than any one single issue. Do you think that single issues is a way to approach health inequalities in communities?

Mr Hull: I think there is an inspirational thing here because it is that idea of how do you eat an elephant or how do you change anybody's life? - it is one thing at once. We mentioned here the prioritisation issue of, if you had to drop everything else what would you still do, and smoking is still the biggest single preventable cause of ill-health and health inequality across the city. The smoking prevalence figures across the various areas of the city still show that and still pay testimony to it in terms of the effects that that has in terms of heart disease, cancer and all the rest of it, so we would pick that out. Stepping back just a second into other areas where regulation can help, regulation can definitely help in the area of alcohol. I do not mean by putting more police on the streets; I mean by doing things like having a better presence in dealing with under-age sales in trading standards and dealing with illegal imports through closer work with Customs, and these all form part of our programmes on-going as far as this is concerned. It is part of the public health/public protection agenda. Local authorities were developed as nannies, were they not? They were developed as the nanny state; they were developed to look after people in the first place; they were developed to deliver public health improvements. That is why they were made in the first place. Many of those things they did originally were regulatory things, they were putting in sewers, they were putting in roads, and they were doing away with poor housing. We will introduce a new scheme which will very much drive forward a Healthy Homes programme in Liverpool which is utilising what is already on the statute book. The Housing Act gives local authorities enormous control of housing conditions in the private sector. Most local authorities have (like Liverpool) divested themselves of all of their own property and put it into the private sector. Who is now regulating? Are local authorities properly resourced to regulate not just the single landlords but the new huge super landlords, and are we staying on their case to make sure they deliver the improvements that they are all now funded for? Housing and health is still a huge structural issue and it is one which we should not lose sight of in terms of all the other lifestyle issues. There are still some very important structural things that only local authorities can deal with and only strategic partnerships with PCTs at the moment can help fund and drive forward.

Dr Grey: I think coalitions around a single issue can be very effective. I think you have to pick and choose them. We cannot have a coalition around everything, but on something like smoking it was an obvious one and one where we had a very focused agenda, and the coalition was able over two or three years to really make an impact.

Q269 Sandra Gidley: Moving on to teenage pregnancy from smoking, it looks as though you are doing a fairly good job and you are pretty much on track, but you say you are not on track to deliver the Government's targets for tackling health inequalities. I am curious as to why you are succeeding with one and not the other or are there different challenges for the different health inequalities?

Dr Grey: There are different challenges and our success in teenage pregnancy has come from a package of things, it is not one silver bullet, it is a package of things that we have done. I think that has been partly due to the investment we have made in a lot of young people's services, particularly third sector, so we invest a lot in Brook services and we have got very good access to services for young people in Liverpool. I think also the fact that educational attainment in Liverpool is improving is a factor because we know as young people have more aspirations and have better qualifications then teenage pregnancies are likely to be lower on their agenda. I think there is a range of issues around teenage pregnancy and we cannot pick out one thing as to why we are succeeding, but we have used a range of opportunities that have been available to us, for example morning-after pills from pharmacies and some of those interventions to really make an impact on teenage pregnancy. I think the issue of life expectancy and mortality in general is more complicated and we are still living to some extent with a legacy of Liverpool that goes back a long way and issues around unemployment and poor housing which go back 20 or 30 or more years. It is a very complex picture and it needs complex answers and it is a range of different things we need to do. Teenage pregnancy on its own, yes, we are making improvements (although we need to do more) but life expectancy in general is a more complex issue that we need to deal with.

Q270 Sandra Gidley: It is quite interesting you have talked about education and housing as things that will improve which are obviously not directly health. Would you say that they are a bigger part of the picture perhaps than anything you can do in the direct health sphere?

Dr Grey: Speaking from a public health perspective, I would say yes, that unless we can get really good educational achievement and good housing and raise people out of poverty in Liverpool, then all our efforts for health will have a marginal effect but we will not really bring Liverpool up to the health age that we should expect unless we can address those issues as well.

Q271 Sandra Gidley: I do not want to lead you but you mentioned that better education might already be having an impact on teenage pregnancy, so would it be fair or unfair to assume or think perhaps that in the longer term that education could actually make a difference on some of the other health outcomes, maternal mortality for example?

Dr Grey: Yes, and I think the big question mark over that is whether the things we are doing are sustainable, and if we can do them in the longer term then I truly believe that that will have an impact on health. I think our experience in the past is we have had, as everywhere in the country has had, lots of good initiatives, lots of project work which has not been done on a scale which is big enough or long term enough to really see the difference. I still have confidence that working with children in the early years, Surestart and those kinds of initiatives, will give us a healthier population long term.

Q272 Sandra Gidley: So you would say that joint working is absolutely key to delivering all of this?

Dr Grey: Absolutely key and of course at the same time we must not the forget people of middle age, we cannot wait ---

Q273 Sandra Gidley: What is middle age?

Dr Grey: Up to about 65! We cannot just address issues around childhood; we have to address people who are currently at risk and who have early signs of heart disease and whatever. Primary and secondary prevention is also very important in the adult population but it seems to me children in early years is a real key issue.

Mr Hull: We do have a very strong (as many areas do) Healthy Schools programme, but the partnership has levered other things from the local authority and some of those levers are not regulatory, they are actually things you can doing as a local authority. A couple of years ago the administration introduced free leisure passes for under 16s on the back of our Active City programme. That has a number of positive effects. It has a massive effect on distraction activities for young people during the summer when they are away from school, and the crime and community safety impact is across the piece. It has had a huge impact and we think it is part of the picture about why our obesity levels in the up to 11 age group are actually levelling off, it is not a decrease at the moment, but it is a real impact, and that is something that the local authority has done uptake rates on and the output measures we would use are through the roof for those groups.

Sandra Gidley: Excellent

Q274 Chairman: Could I just ask you about health education. Could you call health education in schools, both at primary and secondary level, comprehensive in Liverpool?

Dr Grey: I would say it is comprehensive in that there has been an enormous interest and enthusiasm particularly around physical activity in schools. Every school now has enormous opportunities not just for the pupils but for the extended schools, families and communities to participate. We could not say we have had a comprehensive health education policy with regard to school food and that is something we are looking at really seriously. We have standards now around school food but we believe in Liverpool we should be going further than that. Even more patchy probably are issues around sex education and alcohol and drug misuse. There is good work going on but I am sure, again, that a lot more could be done.

Q275 Chairman: Do you think we should do more as a nation in terms of education in sexual health particularly in schools? Should it be more comprehensive than it is? My own experience is that it seems to happen where there happen to be educationalists there who are quite prepared to take these issues on, but in other schools where there are not such educationalists these things do not happen. Do you think there should be a more comprehensive approach to issues around that and maybe the use of alcohol, smoking and drugs as well and the potential effect on somebody's life?

Dr Grey: Again some of the evidence is a bit limited around what just having education in schools can do, so I do not think we should go the whole hog in assuming that if we put health education into alcohols it is going to resolve issues. I think some of this is about going back earlier than that. I do not think giving kids a few lectures in secondary schools is going to help. I think it goes back to a lot of the early years stuff. I do think we could do things more systematically on a bigger scale. I think it is about not just telling kids what to do but if we provide them with a better culture and atmosphere around school and food and making school lunchtimes more of an event kids that can enjoy rather than try to avoid, I think it is some of that cultural change rather than just preaching at kids about what they should be doing. I think food is a good example of where we could get a lot more skills for kids, not directly related to health, but cooking skills for example, which is a big issue and issues such as that are related to health. I think a more comprehensive joined-up view about what kids should be doing in schools is very important.

Mr Hull: There are two things for me that go with that. One is underneath the issues that you mentioned there is very much the taboo about some of those things and talking to young children about them yet they are going to happen, teenage pregnancies are going to happen if you do not talk to young people about sex at a very early age. We need to be a lot more open about some of those things. Equally so, one of the programmes in support of the smoke-free status is a very strong youth advocacy programme, and I think it is young people talking to other young people about those things rather than it coming through the formal education routes that is really very powerful in our experience, and we have a lot of anecdotal evidence and evaluation coming through on that.

Q276 Dr Taylor: Jamie, your first chance so you do not feel too left out! The Commission has got experience of assessing PCTs; have you seen notable progress towards joined-up working? Could you tell us something about your impression of that?

Mr Rentoul: I think first of all the regulator should be modest in its use of time not least because the people driving and leading change locally are on my right. In terms of our assessment of PCTs and the extent to which partnership working has developed, I think it is important to recognise the amount of change in PCTs in the last year of assessment that we have published. There has been big structural change which obviously affects partnerships and the ability to do good partnership working. I think it is very much work in progress, both in terms of what is happening locally but also in terms of what the regulator and the assessment system is doing to assess it well. One of the things that was discussed earlier was the local area agreements and what is being developed now is a comprehensive area assessment process with the Audit Commission, Ofsted, the Healthcare Commission and the new regulator in due course coming together to form a view about risk to delivery of outcomes for local people, and I think that mechanism should allow a better route in to testing partnership working and being able to follow up where there are concerns that it is not working well. You look at the outcomes first for the local area and where you spot risks you can do some more work.

Q277 Dr Taylor: So it is very early days following the reorganisation?

Mr Rentoul: Yes.

Q278 Dr Taylor: Have you any idea about the number of places where there are shared directors of public health appointments? Is this still pretty rare or is it coming forward?

Mr Rentoul: I think a lot of PCTs have got joint public health appointments. There are issues about, as we heard earlier in Birmingham, having one local authority with three PCTs and so on, but I do not have an exact figure about the proportion.

Dr Grey: Certainly in the North West the vast majority of posts are now joint posts, and I understand nationally as well.

Q279 Dr Taylor: Right. Can the Healthcare Commission do anything about the proliferation of acronyms?

Mr Rentoul: We are responsible for some of them.

Dr Taylor: At least you did not use the acronym, you used the full words, thank goodness. JSNA completely defeats me although I have got it here!

Q280 Dr Naysmith: Dr Grey, in Liverpool's submission to us you mentioned the need to strengthen local commissioning particularly around knowledge management and needs assessment. Can you tell us just a little bit more about what 'knowledge management' means and how you intend to achieve these two things?

Dr Grey: We are data rich and information poor, if you like, and I think that is still probably the case. We have got lots of data, it comes from a range of sources, and I think perhaps what we need to be clever at is harnessing that together to make some intelligence out of it really and a focus moving from what we have had in the NHS in the past, which has been very much based on inputs, into outcomes of public health programmes and also obviously clinical outcomes as well, so knowledge management is trying to bring some of that together. For example we have recently employed a health economist in the PCT to try and bring some of that economic evaluation into the work we do as well. It is bringing that together and also then making that relevant to people actually working in public health programmes because often we have these very high-level targets around all-cause all-age mortality and it is quite difficult for people in public health programmes working on the ground to understand how they are contributing to that. In terms of knowledge management it is trying to link how some of this work on the ground, which is sometimes at a very local level, is actually contributing to these bigger goals that we are trying to achieve and feeding back to people how that works in terms of what they are doing, and by doing more of that or evaluating it better, we can end up improving the health of the population.

Q281 Dr Naysmith: Would asking the right questions to start with help?

Dr Grey: Yes it would.

Q282 Dr Naysmith: Because we accumulate all sorts of data which is often filed away and never used if you do not ask some of these questions or ask the right questions, so presumably that is what you are planning to do more of?

Dr Grey: Exactly, and often it is the same with evaluation in that we do not think of the evaluation until our programme is halfway completed, and it is bringing some of those ideas forward so we know exactly what we are trying to aim at. It is getting slightly easier because I must say over the last two years or so the range of indicators we have had is starting to line up better now. They are not perfect, they are not complete, but we are starting to see a lot more congruity between the indicators coming from different places, which is moving us towards the same priorities and in the same direction.

Mr Hull: I just want to say it is about how you use the information as well. The information that you gather like this should not just be, in my opinion at least, the purview of the health professionals, who will go away and read the evaluation and make tweaking adjustments to their own system and then go back to the communities and do some more intervention. This is about shareware, it is about the engagement process from the beginning, and one of the things we have learned from SmokeFree Liverpool has been about when you are successful, when you want to move a campaign on, when you want to make success, you share the results with people, and that creates ambition in communities when they know they are doing the right thing and it is having a positive effect. Too often that information does not get back to them in any shape or form and so there is no positive reinforcement cycle and we need to use this intelligence to help provide and feed into the social marketing. Social marketing is not just pushing initial ideas out, it is the whole cycle of working with that. A private company would not use marketing in a single, one-off way. Private companies learn from the marketing and each campaign builds on the last one, and that is what ours needs to do.

Dr Grey: Just one other thing, a particular issue with me at the moment is we constantly take snapshots of health in either wards or cities or whatever and we do not follow up individual people. As populations become more mobile and move a lot, it is very difficult; we do not follow a child in Liverpool and say have our interventions, have the things that have happened to that child improved their health into adulthood? I think having some longitudinal data would be really important to follow up life paths for people and how health can improve through intervention.

Q283 Dr Naysmith: The other thing I was going to pick up from your submission is that you stress the importance of personal relationships in forging good partnerships between PCTs and local authorities. Clearly you have demonstrated today that that is no problem in Liverpool, you may be had to work at it many years ago but you have got a really good relationship now. What happens in places where the PCTs and the local authorities do not have nearly so much of a good relationship? You must hear about that on the grapevine.

Dr Grey: I do not think we should take too much credit in Liverpool because whilst obviously smoking has been a great partnership, forging a similar partnership around alcohol is more difficult because there are a lot of other competing priorities around the alcohol agenda, around regeneration and business interests and those kinds of things, so in some ways smoking turned out to be the easy partnership to manage, and some of the partnerships now are more complex.

Q284 Dr Naysmith: Are you having a little bit more difficulty?

Dr Grey: I think the issue is it takes a lot of time to develop. I think it is about getting the focus which everybody can sign up to, understanding that there will be different competing interests, commercial interests and other things, that we have to manage within the partnership, but it does not get away from the fact that the individual relationships within that partnership are very important and the fact that the chief executive of the city council and the PCT do talk to each other regularly.

Q285 Dr Naysmith: How do you arrange for this to happen? Do you meet socially or have bonding sessions? How do you do it?

Mr Hull: It is part of joint working. Joint working is what it says on the tin really. It is not having a nine to five relationship over things that are important. If you become very focused on things you want to achieve then you become very focused and you do things in a different way, but that manifests itself in not just, as has been said, a token joint director of public health at the management table in a local authority and the PCT; you have a really active, as we have, director of health and adult social care as a joint post in the social services set-up. You have, as we have, a joint post in children's services at a strategic level who commissions children's services, so this is a commissioning arrangement in children's services, it is not a casual arrangement. The way this will go and the way it is going is that the PCT is increasingly formalising that commissioning arrangement on a range of public health issues as well, so it is not just limited to those very big picture things which we quite rightly highlighted in children's services and social care. Everybody focuses on those and they have been acknowledged to be the big hitters in terms of that, and we would say they still are, to a point, but there are lots of other things which we have been touching on which local authorities in the context of the partnership can and should be jointly commissioned to do by the partnership, so it is not just left to the local authority of its own accord but it is the whole partnership which is saying that.

Mr Rentoul: Can I add just a little bit to that.

Q286 Dr Naysmith: Do not worry, there are a lot of questions coming your way in a minute, but if you have got something to add it will be useful.

Mr Rentoul: Clearly personal relationships and the leadership of the organisations are critical to these things, but I think you would have to recognise that the funding streams and accountabilities can pull in different directions, so I think there is also something around the goals being set for the organisations and the system. It comes back to what I was saying and what was said earlier this morning about the local strategic partnerships, and once you get that sense of common purpose around goals, then that aligns people in the organisations, and people can be held to account for what they are achieving together. Certainly within the health side of things, relationships between PCTs and provider trusts are not always sweetness and light and we have sought where possible to share our assessments and progress for these particularly goals between the two, and we have done that in other areas looking at drug action teams and so on. You are holding the local public services to account for delivery together.

Q287 Jim Dowd: That was a U trailer advertising an X certificate because we come to Mr Rentoul now. In your experience of assisting PCTs, what progress has been made in promoting health as opposed to just treating illness and how much progress are we making in tackling health inequalities?

Mr Rentoul: I think, as we said in our submission to you, when you look at progress against the big killers, quite significant progress has been made. When you then look at some of the contributing factors such as smoking, substance misuse, mental health issues, sexual health, it starts to get a bit patchier really I think. If you look overall at some of the Government targets for 2010, they may not be met. I think we said in our note that is not necessarily a failure, there are good things about setting ambitious targets, as the Chief Executive of Tower Hamlets said earlier, and they have certainly incentivised action. While saying there has been progress on particular things like the big killers, the inequalities gaps have not necessarily narrowed, so there we come back to some of the earlier discussions about what it is right to be holding the NHS to account for and what is a wider determinant of the health inequalities issue that you need that wider effort across local public services and indeed national government to be addressing.

Q288 Jim Dowd: When you mentioned the areas where progress is more patchy, as you describe it, is it that in different areas they do some things well and other things not so well or is there one particular area of the catalogue you have outlined that everybody has difficulty with?

Mr Rentoul: It tends to be patchier on different things according to local priority choosing, so if you look at the work we did on tobacco control, the more deprived PCTs were tending to do pretty well in the assessment we did of it. If you look at something like teenage pregnancy where there is more consistent progress across the country, again deprived areas showed greater improvement. If you look across our assessment against public health targets in the annual health check, the Spearhead PCTs tended to do better than the non-Spearhead PCTs, and again that may be symptomatic of it has got a stronger focus there of being part of the club if you like and it has got that drive.

Q289 Jim Dowd: On tobacco control, certainly it is popularly believed that we have virtually plateau-ed on that now. We are down to the almost irreducible one in four who we cannot get to give up, either through price mechanisms or other things, apart from at the margins. Is that the picture? People have been giving up smoking ever since Sir Walter Raleigh but some people give up anyway. What evidence do you have that direct action has changed those figures?

Mr Rentoul: It is right that the pace of change has slowed. The national prevalence figures are two-yearly and if you look at 2004 compared to 2006, you still get a couple of percentage points reduction in the adult smoking rate for manual workers and 3% for non-manual workers, so it still seems to be declining. It will be interesting to see for the 2008 figures whether the smoking in public places legislation as part of that wider strategy is going to shift that along further because the overall cultural shift is changing. What we measure in the annual health check is a four-week smoking quitting rate, which has its detractors as to whether it is a good enough measure, but you do not have prevalence level data across the country at a local level and it has certainly again galvanised action. However, the progress on that was in the wrong direction last year over the year before so when we did our tobacco control review, one of the things we said was we should not be complacent about this, it still needs continued drive and effort.

Dr Grey: Compared with somewhere like California their smoking prevalence is something like 12% so we have quite a long way to go, and not just around cessation, it is young people being recruited to smoking now where we need to focus on trying to make further reductions.

Q290 Jim Dowd: I think the ban on smoking in enclosed public spaces may have a doubly beneficial effect because it seems to be putting large numbers of pubs out of business as well, so perhaps it will address alcohol at the same time! You mentioned the 2010 target which was going to be my concluding question, could you just say a bit more, was it just unrealistic to start with? I think you said it was an ambitious target; what is the difference between ambitious and unrealistic?

Mr Rentoul: To come at that question in a slightly round about way, we are doing a bit of work with the Audit Commission at the moment looking at progress across the Choosing Health agenda and looking at various components contributing to that target on smoking, substance misuse, obesity, et cetera. Again it is not rocket science that for the things that have done well like teenage pregnancy you have clear measurable objectives and a consistent focus across the NHS and local government, good information to track progress with, a good evidence base on what works, decent resources and capability development and support, and decent local public accountability for progress, and that does not apply across all those contributory factors to the target. When these targets get developed they do a lot of modelling on what the trend lines are and what the evidence base is, and if you look at the 2007 Status Report from Marmot, it has got bar charts showing what extra intervention would get you to deliver the target. Again, those are not unrealistic but they are ambitious.

Q291 Sandra Gidley: Jamie again, do you think the Commission has prioritised health inequalities sufficiently within its current regulatory status?

Mr Rentoul: If I can explain very quickly what we do. In terms of our statutory role we have to provide a performance assessment of every healthcare organisation, which includes PCTs and provider trusts as well as independent healthcare regulation, and in the assessment of the NHS the statute requires us to take account of the standards issued by the Government, which include the seven domains of safety, clinical effectiveness, patient focus and public health, which is the seventh domain, so within our assessments, in Orwellian speak, all standards are equal, there are 24 standards, and we assess against them all, and in the assessment we then also assess progress against a range of targets, again reflecting the Government's operating framework priorities for the NHS. PCTs have got a strong public health and health inequality focus so that is the bread and butter of our assessment system. We then do more in-depth review work where we have got particular concerns about performance, and we have done a lot of work in public health and health inequality issues on that on tobacco control, unintentional injury with the Audit Commission, obesity with the Audit Commission and the NAO, sexual health services, a maternity services review, which got published recently where we were doing a variations report looking at ethnicity, disability, deprivation factors in the results we are seeing there. We do weave it through our work. Could we do more? I am sure we could.

Q292 Sandra Gidle