Uncorrected Evidence 422

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Oral Evidence

Taken before the Health Committee

on Wednesday 30 April 2008

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Mr Peter Bone

Sandra Gidley

Dr Doug Naysmith

Dr Howard Stoate

Mr Robert Syms

Dr Richard Taylor

________________

Witnesses: Professor Ken Judge, University of Bath, Professor Mike Kelly, Director, Centre for Public Health Excellence, NICE, and Professor Sally Macintyre, Director, MRC Social and Public Health Sciences Unit, gave evidence.

Q317 Chairman: Good morning. Could I welcome you to what is the fourth evidence session of our inquiry into health inequalities. I wonder if I could ask you to introduce yourselves and the positions you hold, for the record.

Professor Kelly: I am Professor Mike Kelly. I am the Director of the Centre for Public Health Excellence at NICE.

Professor Macintyre: I am Sally Macintyre. I am Director of the MRC Social and Public Health Sciences Unit in Glasgow, Scotland.

Professor Judge: I am Ken Judge, Dean of the School for Health at the University of Bath.

Q318 Chairman: Could I ask a question for Mike Kelly and Sally Macintyre. What three evidence-based interventions would you each recommend as being most likely to reduce health inequalities? That is a nice easy one.

Professor Kelly: Shall I go first?

Q319 Chairman: Yes.

Professor Kelly: The three that I would select are all ones that have been through the NICE process of considering the evidence and looking at the cost-effectiveness. One, I would make sure that we continue to advise all women to take 400mg of folic acid daily before pregnancy and during the first 12 weeks of pregnancy and advise them also to take a suitable supplement, such as the Healthy Start vitamins. That is a universal intervention, but is particularly important if we are to reach young women and girls in the more disadvantaged sections of society. That is one. Secondly, I would support all new mothers to breastfeed. Again, there are considerable differences and variations in the rates of breastfeeding across the social spectrum and breastfeeding is one of the best starts that we can give to children and mums at their start in life. It is not just about advice, it is taking forward and allowing the child not just to get to the breast first-off but to continue so to do, continuation of breastfeeding rather than just initiation. Then I would provide tailored advice on counselling and support for smoking cessation particularly targeted at the most disadvantaged groups in our society, what are sometimes called the hard-to-reach groups. All three of those things are cost-effective interventions and I have chosen them because, one, they pick on the issue of child and maternal development and, two, smoking is there because that accounts for the largest slice of the rates of health inequalities in our society presently.

Professor Macintyre: First of all I would like to say that one of the problems in this area, and I am sure other witnesses have told you this, is we actually do not know a lot about what cost-effective interventions are that reduce inequalities as opposed to interventions that work. There are interventions that might work but we often do not know whether they work to reduce inequalities. Quite often, the well meaning interventions designed or expected to reduce inequalities may not actually have that effect or we do not have the measures. It is actually a very difficult question. Mike is in a better position than I because, coming from NICE, his organisation has been to look at very specific interventions. I would probably move up a level from what Mike has said and suggest that some of the most cost-effective interventions may, in fact, be major structural ones. Some of these are more historic, Clean Air Acts, smoking bans in public places, and of course universal free to access public services. However, there have not been very detailed cost-effectiveness studies of those sorts of major interventions in the way there might have been in terms of things like folic acid and breastfeeding.

Q320 Chairman: Do we know what is being done that is not cost-effective?

Professor Kelly: Well, of all the interventions that we have looked at at NICE we have not found any that fall into that category, but we have only done a limited slice in at the moment. What I should say is those things that we have looked at, relatively speaking, compared to clinical interventions are highly cost-effective. The importance of that is two-fold. One is, given the overall cost-effectiveness, that means it is not just a good investment but given the health inequality dimension it is worth expending the extra effort and time on reaching those who are designated sometimes as hard-to-reach across the whole spectrum. We would like to see, and as we expand our work undoubtedly we will come across, interventions which would count as cost-ineffective in the way that we do the analysis. What I would say is to echo something Sally said a moment ago. We have to beware of the unintended consequences of some universal interventions because their cost-effectiveness varies across the social gradient. It can work both ways. It can sometimes mean that you get a bigger bang for your buck at the lower gradient, but it can also mean it is less cost-effective and it is easier to work the softer soil, so to speak. Presently, the public health interventions that we have examined offer extraordinarily good value for money. The caveat is we are the only organisation worldwide that is really doing a systematic analysis of this. When public health began at NICE in 2005 we were the first national agency anywhere in the world who were given the task of examining both effectiveness of public health interventions and their cost-effectiveness and in the three years we have only looked at a limited spectrum. It looks extremely promising.

Q321 Chairman: Sally, you have done a study on health inequalities in the West of Scotland. What practical lessons are we to learn from that?

Professor Macintyre: I think mainly to do with multi-pronged approaches. There is no single answer. Again, I am afraid you have heard this before and it may sound very negative, but it is true. There are a number of things that seem very attractive, like area-based approaches, for example urban regeneration. We have done reviews of urban regeneration and they show quite mixed findings. Billions of pounds have been spent since the Second World War in major programmes of urban regeneration and it is somehow assumed that if you target a poor area and pour money in good things will happen. Significantly, as you probably know, it is usually the same areas decade after decade that have the same interventions. One of the issues is that the people move out. You may create unaffordable housing so the original inhabitants cannot stay there and they move out. It is this thing that you may be able to create nicer neighbourhoods, but you are not necessarily targeting inequalities in health because the poor people may move out. It is partly this thing about looking at areas but also having to look at the individuals. Quite a lot of studies do not actually monitor the individuals to see whether they move out and whether the outcomes for them are worse. There were some early studies in the West of Scotland that actually showed adverse health effects for poor people of urban regeneration, mortality rose, and this was because of higher housing costs so families could spend less on food. Again, it is this integral thing about perverse outcomes, unintended outcomes, that need to be looked at.

Q322 Dr Naysmith: Professor Macintyre, in your written evidence you emphasise the importance of upstream factors, such as education, employment and income, in influencing health inequalities. We have just been talking in the first ten minutes or so about how difficult it is to know whether some of these specific public health actions actually work and are cost-effective and so on. Is there any conclusive evidence of fiscal policies having a positive impact on health inequalities?

Professor Macintyre: I am not aware of any. I think the emphasis on education, employment and income comes more from causal modelling about descriptive studies or explanatory studies which show you what might cause inequalities in health. We know that people who have poorer education have lower incomes, they are not in employment, have poorer health, and these things are likely to widen health inequalities. In this country we do not have a lot of evidence from interventions which have said, "Let's take people and give them more money". There are income supplementation trials in the States and we know also from the States a lot of early years interventions, and in your second session you are going to hear about early years interventions, have improved long-term outcomes. It is more that these are key gateways, that improving people's education allows them to get better jobs, to earn more, to cope with the world, better coping strategies, et cetera, take up health-promoting messages. It is quite difficult to do a randomised controlled trial of a whole society.

Q323 Dr Naysmith: It is kind of intuitive, is it not?

Professor Macintyre: The problem is sometimes intuitive things are wrong. I would regard those as best bets if you are going to put your money into major policies. You certainly want to make sure that education, employment and income are looked at.

Q324 Dr Naysmith: Sceptics sometimes say that giving poorer people more money means they will just spend more on smoking and alcohol. Now, without necessarily saying there is any validity to that, is there any real evidence that it does or does not happen?

Professor Macintyre: I do not know of any, but my colleagues might. I do know there are some trials going on at the moment in general practice, I think, which are helping people take up welfare benefits that they are entitled so, so it is welfare advice to give them access to benefits. I guess if they are being followed up to see how they spend money you might be able to answer that question.

Q325 Dr Naysmith: The Government is very keen in a number of areas on encouraging employment for very good reasons, but in terms of health the argument is often heard that getting people into work will improve health as well. Is there any evidence of that?

Professor Macintyre: I think from longitudinal studies there is evidence that getting people back into work does improve their health.

Q326 Dr Naysmith: That was my last question to you, but I was going to ask if either of the other two want to come in.

Professor Kelly: If I may come in on the employment question. Work and health are intrinsically linked in a positive sense in that generally speaking, as Sally has said, longitudinal data strongly points to the association between being in work and being in reasonable health.

Q327 Dr Naysmith: It could work the other way round, of course, that being healthy could mean you are much more likely to be in work than not.

Professor Kelly: There are two explanations that the data compete to explain. There is a drift hypothesis, or cause hypothesis as it were. The other thing, of course, is the obverse is true, that when people lose their jobs the decline in health is often very marked and very rapid, not just health but death rates, suicide rates and that sort of thing, so you see both of these relationships. The caveat that needs to be entered about work is that some work is intrinsically stressful beyond the limit that people can deal with and can have negative effects on mental health in particular too, but on balance a healthy society would be an employed society and in public health terms employment clearly is an important arm of the wider determinants which need to build into this picture.

Professor Macintyre: Can I just come in on your point about which way round it goes. The point about the longitudinal studies is that you can look at which comes first, so you can look at people with equal health status and then look at those who become unemployed or those who stay in work and see changes in health. It can be disentangled through British birth cohort studies and other longitudinal studies.

Professor Judge: Can I make two points. The first is in relation to economic activity. We are all familiar with the clear social gradient, for example, in smoking between professional groups and routine and manual groups where it is 15% amongst professional groups and 30% or so amongst routine and manual, but if you take routine and manual who are economically inactive the prevalence rate goes up to 60-65%. There is a huge additional impact of inactivity. The second thing is in relation to your question about the income elasticity of demand for unhealthy products, as it were, we expect there to be a price effect. If we raise the price of alcohol or smoking the assumption is that demand goes down. Logically, if you raise the income demand ought to go up, but that takes us down the wrong trail because in thinking about the income effect, raising incomes or improving the material position of disadvantaged people, I think you need to ask yourself questions about what amount of material change in circumstances do you make, over what time period and at what stages in people's lives to make judgments about what the likely impact could be rather than give somebody a fiver tomorrow and say what they do with it, which really is not very helpful.

Q328 Dr Stoate: I am interested in following on Professor Kelly's work with NICE. I would like to know what work you have done comparing the relative effectiveness and cost-effectiveness of various interventions. You have already mentioned some of the things in your statement, which was very helpful, but what areas have NICE looked at particularly comparing the relative and cost-effectiveness of interventions?

Professor Kelly: Let me just get my aide-m�moire, if I may, because it is quite a longish list. We started out by looking at smoking in primary care, what we could do to enhance rates of GPs working directly with patients. We looked at physical activity in primary care, the extent to which you get that moving along. We then moved on to consider the prevention of sexually transmitted infections and teenage conceptions using what the evidence was of our one-to-one interventions. Most recently, we have considered two educational based initiatives in this line of work, one looking at alcohol education in schools, primary schools in particular, and secondly on the promotion of mental wellbeing in primary education using both targeted approaches and universal approaches. In addition to those, what are called public health interventions, which is half of our work, and that is about looking at essentially downstream things, things which are done by frontline practitioners, whether they are GPs or doctors, in other sectors, teachers, people like that, downstream interventions that are done directly with members of the public. We have completed five programmes of work which are bigger looking at the bigger strategic picture and they are in the areas of health-related behaviour change, maternal and child nutrition, community engagement, smoking cessation services and my memory has gone for a moment on the last one. These are big programmes of work looking at the strategic elements that we are interested in.

Q329 Dr Stoate: Are there any areas that stand out as being spectacularly cost-effective or things that we should be taking forward or things that have not proven very much?

Professor Kelly: I must say it was one of the best moments of my research and academic career when we started doing the cost-effectiveness analysis because we did not really know what to expect in terms of the values that we would see. In the first ones that we looked at, which were the primary care smoking prevention, the QALY values that we were producing were around about �230, �250 for a five minute consultation with a GP. It rose a bit to about �500 if the consultation was longer. When we looked at promoting physical activity in primary care the figure that we came out with was �530 gained. For one-to-one counselling with respect to disadvantaged children and drugs I think it came out at about �3,000. The important point about those values is the typical threshold that NICE uses to determine whether something is cost-effective is �20,000 or between �20,000 and �30,000 for a clinical intervention, and above �30,000 NICE tends to say that is not a cost-effective way for the NHS to spend its money. Quite frankly, we were both gratified and to some extent surprised at the way the modelling produced these values. That was what was said about the overall cost-effectiveness. To date, all of them that we have looked at where we have run the cost-effectiveness modelling are falling well short of that �20,000 threshold. It looks like a good buy from the point of view of NHS resources and, indeed, broader public sector resources too.

Q330 Dr Stoate: That is a good downstream intervention. Very briefly, is there anything upstream that you think has been particularly cost-effective?

Professor Kelly: We have not done any of the big upstream things yet. The kinds of policies that Sally was referring to with respect to education, income distribution, physical policies relating to taxation on tobacco, alcohol and so on, would intuitively be where I would look first in terms of that kind of analysis. The opportunities which really a relatively slight shift in resources could bring about in terms of health gain cost-effectively look extremely promising.

Dr Stoate: Thank you very much.

Q331 Dr Taylor: Starting with Professor Kelly, can we focus on individual behaviour change, particularly with disadvantaged people. How do you aim to change their behaviours?

Professor Kelly: This is something we reviewed and published towards the end of 2007 in the Behaviour Change Guidance. First of all, there are very well developed technologies, if you like, about behaviour change based on what is called the principle of self-efficacy, which is essentially the generation in the individual of the belief that they can do it. We can put it in a more complex language than that, but that is essentially the heart of the argument. There are a series of steps. The first step is helping people to understand the short, medium and long-term impacts of their health behaviours. Binge drinking might give you a short-run hangover but it is the pattern of drinking over a lifetime that is really going to cause health damage to the liver, let us say. Secondly, when people begin to think about behaviour change they should plan it in easy steps. You do not change to alter your entire persona and personality overnight, it is about the little things, a bit at a time that can be mapped out towards, say, giving up smoking or taking more exercise or eating a different diet. Recognise how the social setting in which people live will affect their behaviour. That is particularly important to help people to plan the "what if" or "what then". That is the point at which someone who has successfully stopped smoking for 14 days finds themselves in a situation where other people are smoking: what are they going to do at that point? What you try to help them to do is rehearse how they will deal with that moment, because having rehearsed it, it is no easier, the cravings do not get less, but having thought it through there is psychological evidence that helps. Get them to make a commitment and share their goals with others. They are basic, general principles of behaviour change. If you are applying it across any of the areas with any given segment or group in the population you can map and build it around that. The big caveat to all of that, of course, is that if you simply talk about behaviour change without acknowledging the broader social circumstances, the social position in which people find themselves, you are whistling in the wind. Even of the 60% of smokers who Ken spoke about a moment ago who are economically active, if we asked them 95% probably would want to stop but it is much more difficult in that position to bring about the change. That is why when you read through the way that we looked at the Behaviour Change Guidance in general nearly all of the work we have done in NICE has determined the importance of tailoring and targeting interventions to particular needs and sensitivities of the different groups that we are talking about. That means getting right down, not talking in general terms about social class but about the local cultural settings and all that kind of stuff.

Q332 Dr Taylor: Have you evidence that you do actually change the behaviour of these disadvantaged people?

Professor Kelly: The evidence psychologically speaking says it would be possible, and there are examples where smoking cessation programmes have been successful and outreach programmes. They are pretty thin on the ground, it has to be said, because it is pretty tough to do.

Q333 Dr Taylor: Absolutely. Are there any incentives that can be used?

Professor Macintyre: The one that is on everyone's mind, I suppose, is whether cash incentives could be used. We have got that in the pipeline as something that NICE is going to look at or to see the degree to which it would be effective in these kinds of programmes. Although we have not looked at the evidence systematically at this stage, I must say the evidence coming from other societies, other countries, looks quite promising in that regard, but I would not put it any more strongly than that because we have not really tested it, at least in these kinds of things, in a setting in which medical care is free at the point of delivery, which might be a significant thing you would have to build into the equation. It is certainly something that deserves further detailed attention to see what we can learn from it. There are some other areas, drugs and things like that, where it has been shown to work.

Q334 Dr Taylor: Do you want to add anything?

Professor Macintyre: I was actually going to suggest that as Ken has done work on smoking cessation among disadvantaged groups he can probably answer on that.

Q335 Dr Taylor: We are going to come on to that. A specific thing we want to know is what is the most cost-effective way of getting people to stop smoking?

Professor Judge: I think all the evidence internationally is that if you want to reduce the rates of smoking in the population you need a comprehensive programme of tobacco control measures. Relying on a single instrument is unlikely to be effective. Whether you look at smoking prevalence rates between countries or, for example, between states within the United States or between European countries, the evidence is clear that those countries, regions or areas with the most comprehensive tobacco control measures tend to have the lowest rates of tobacco prevalence.

Q336 Dr Taylor: Can you list those measures that we should have that are comprehensive?

Professor Judge: They would include things like smoking in public places, treatment programmes like smoking cessation services, appropriate levels of taxation on tobacco products, anti-smuggling factors and control of advertising. There is a range of things like that and, in fact, I think the Department of Health have listed six or eight specific aspects of their tobacco control programme and they are consistent with established international practice about what you would be aiming for in this area. Where we have the clearest evidence, I think, is in relation to smoking cessation, but it is important to note that right from the very outset the provision of treatment services for motivated smokers - smoking cessation services are targeted at those individual smokers at a stage in the process that Mike Kelly just described where they are motivated and want to stop smoking - have been incredibly effective, much more effective than previous experience would suggest, in successfully reaching out and attracting and providing services to disadvantaged smokers. They have been much less successful at achieving the same levels of quit rates amongst most disadvantaged groups. I think the reason for that is pretty straightforward: disadvantaged smokers tend to be more addicted smokers and more addicted smokers find it harder to stop. Smoking cessation services, although they have grown and been delivered at a large scale very quickly and in that sense have been a great success and have contributed to reducing smoking prevalence rates in recent years, there is a kind of one-size-fits-all approach about that. More addicted smokers are, by definition, more needy smokers and need more intensive treatment. The challenge for services now is to think about more innovative ways of providing treatment services, and many of them are, it has to be said, more intensive services, better relapse prevention, better community supports. To give one specific example: in some areas, hiring disadvantaged women who are ex-smokers, training them to provide support to their peers, has shown to produce higher success rates amongst disadvantaged communities than other kinds of professions. There is enormous scope for innovation in the way in which we deliver these services to try and improve the rates.

Q337 Dr Taylor: Are there any ways of targeting the teenagers who are picking it up still remarkably frequently?

Professor Judge: That is not an area I am terribly familiar with. It is very, very difficult. Mike could probably add something.

Professor Kelly: If I could say firstly about innovation. Presently, NICE has got guidance out for consultation on precisely the question you have just asked, which is with a known effective technology, ie the smoking cessation services, how do we get them and the various innovations out to the most needy. Indeed, service configuration is quite important, the way we actually do it. Sometimes there is a feeling that it is a difficult problem for all the reasons that Ken has said and it saps morale a bit in terms of the services. The possibilities of these things are there and evidence-based to pursue. The other thing that we have got guidance on the stocks on is on the prevention of children taking up smoking, because it is children rather than teenagers, teenagers already are smokers, through our school-based programmes and community-based programmes, and we are looking at the evidence there and how that might work. We are trying to put in place a comprehensive and strategic set of interventions, guidance that will have gone through the NICE mincer, so to speak, that will give us some of those answers in the next six to nine months or so.

Professor Macintyre: Could I say something about the smoking bans? We have been involved in a comprehensive evaluation in Scotland of the effect of the smoking ban in public places because they have had a slightly longer lead-in, and there have been remarkable effects quite quickly. We need to look at how they last, so we have measured smoke quality inside bars, we have measured the respiratory health of bar workers, the attitude of bar workers, and there has been the use of routine data in Scotland to monitor admission rates for AMIs, for example. I do not know whether you have seen some of that work and I am not sure whether I actually believe a 17% reduction in admissions for AMI in the first year but, if that is true and it continues, that is something which is definitely worth monitoring and of course in England as well. The sort of pubs which had very high smoke concentrations were in deprived areas where deprived people went. Bar workers, seasonal workers, hospitality workers, certainly in Glasgow bars, are often in the lower social class, so there may be quite a big benefit. I do not know if anybody is measuring cost effectiveness but the cost effectiveness of having a law and having some people policing that is probably not very great compared to the benefits. That is why I think as well as the individually focused things there is some evidence about the effectiveness of larger structural changes. The other thing we have found from the West of Scotland is that children from lower social classes get their cigarettes on the black market, so it is not about the cost of cigarettes they buy in shops, and putting up the age at which you can buy cigarettes may not be effective because they are all buying singles or fives off the black market smuggled. So smuggling control may be extremely important to stop that up-take rather than a price effect.

Q338 Dr Taylor: The reduction in AMIs in Scotland mirrors that in Italy which happened earlier, does it not? It is very encouraging.

Professor Macintyre: Yes, it is.

Q339 Chairman: Ken, could I pick up on one thing you said about the more addicted, there is this debate at the moment about nicotine replacement therapy being a crucial part in smoking cessation, but what is on the market at the moment is not at the level of somebody who is on two or three packs a day, and it has been put to me that until you get that bigger hit, as it were, with nicotine replacement therapy it is going to be difficult to get some of those more addicted people on to programmes which may mean them eventually end up ceasing smoking altogether. What is your personal view on that?

Professor Judge: There are two things. First of all, I think new products are coming on to the market all the time which might provide that bigger hit. Also there is quite a controversial area of debate in the tobacco-control field about whether we should be adopting harm reduction strategies, whether it makes more sense to provide support to people, to change the products they use, to reduce their consumption of smoking - there is a traditional school of thought that we are only about quitting - and I think the jury is out on that. I cannot put my hand on my heart and say there is clear evidence which would guide me to inform you one way or another. In the context of Mike's more general remarks earlier, my guess is if you can help heavily addicted smokers in difficult social circumstances to move along this psychological chain which Mike talked about, which helps them get to the point where specific services can help them more effectively, we should not be ruling anything out, but it is a difficult area to give you a clear answer, I am afraid.

Q340 Chairman: Has anybody looked at the issue of oral tobacco patches which we banned in this country many years ago - "snus" I think it is called in Northern Europe - as a means of getting the bigger hit?

Professor Judge: This is what I was specifically relating to. There is a lot of interest in evaluations in Sweden at the moment.

Q341 Chairman: We are not doing any here in the UK on these bigger hit issues?

Professor Judge: No.

Q342 Mr Syms: A more general question, what is the minimum level to which inequalities can be reduced in a competitive society like ours? What would it cost?

Professor Judge: This is a question which really interests me because health inequalities are not a fixed thing. Take inequalities in infant mortality, which is a key headline target for English policy, it is possible to take the data on the social distribution of infant mortality rates and persuade yourself that the difference between the most advantaged group and the most disadvantaged group is 13%, a relative risk of 1.13. Or you can take the data and say the difference is three-fold. So at one moment in time, using different measures of health inequalities, you can persuade yourself that the problem is really rather small or as big as anything in the Third World. So before we can begin to address your question about how much change is feasible, we need more consensus about the measures we use to measure health inequalities. I have not heard anybody in all the years I have been engaged in this area talk seriously about the eradication of health inequalities, except governments in the United States at the most unpropitious moment when they did talk about eradicating health inequalities but did not appear to do anything about it. More generally people talk about tackling or reducing health inequalities. So I do not think we could reasonably say for health inequalities or income inequalities or education inequalities there is a precise fixed point that it is reasonable to aim for. Those people who are concerned about the unfairness of this situation want to improve the situation I think, and this then takes us into the question of whether it is sensible or not to set time-related targets for reducing health inequalities. There is a lot of difference of opinion, both in the United Kingdom and more broadly, about whether targets help. Certainly in England the view has been, and the pressure from the public health lobby on the Government at the time was, that the adoption of targets would help to focus efforts and drive through change-agendas which deliver more progress. There is little evidence that has been the case in the last seven or eight years, I am afraid.

Professor Macintyre: I think there is an important distinction between variation in health, which could be random or genetic or behavioural, and systematic structured persisting inequalities in health, for example between social groups. So quite a lot of the time we do not regard it - well, maybe some of you do - as unfair or unjust there is a life expectancy difference between men and women, but we do regard it as unfair and unjust that there is a life expectancy difference between the top and bottom of the social scale, and that is apparent from virtually before birth in terms of birth weight. These babies have not been smoking in the womb, they are born into a situation where they are born disadvantaged and their life expectancy and all sorts of life chances are damaged by that. So we would always expect to have variation in a society in terms of obesity, smoking rates, life expectancy, but it is the structured systematic way that happens where I think most societies, as a matter almost of social justice, would wish to see a reduction. What the precise social reduction is which is possible or desirable is a much harder question, but I think probably most people agree that increasing the gap is not an appropriate social goal; we want to reduce it. Whether it is possible to reduce it completely outside a society like Cuba or Kerala is difficult to know. I think in a market economy it is probably not. But we can certainly reduce it to less than it is at the moment if not to zero.

Professor Kelly: What I would like to add to that is in the United Kingdom we have a health gradient, which much of the evidence I am sure you have heard has described, and that gradient exists with mortality, with morbidity, it also exists with people's subjective feelings about their health and it is relatively smooth. One of the conundrums of public health has been that we have not been too bad about shifting that gradient up the way in absolute terms so the health of everybody is improving over time, and that is a legitimate goal I think for any society, improving the population's health overall. If you look back at the public health history of Britain since the middle of the 19^th century, that is something we have achieved, and it is something one can be proud of. The conundrum however is that sometimes the gradient begins to tilt in that direction, in the sense that the rate of improvement is greater among the well-to-do than the less well-to-do. That seems to have been an epidemiological trend which has been particularly notable in the last 50 years or so, notable in this country but not only in Great Britain, it is true equally in the United States and many other societies too. It is also true in some developing countries where any public health intervention, in infant health, things of that sort, seem to benefit the well-to-do more quickly. There is sometimes a catching-up effect but there is always a difference between the two. So the question is not, can you eradicate inequality, the question is, we should be trying to aim to get the gradient to shift in that kind of direction so it evens out, but that requires us to be more subtle and nuanced in the way we think about intervention. We have already mentioned things like targeting but rather than, as Ken said, a one-size-fits-all, it is about where we are dealing with particular groups, we need to think about their specific needs and understanding those groups in order to help to shift the gradient in that kind of direction. So it is about a purposive approach to policies at all levels rather than anything else. The other idea which is just worth mentioning is I think it is important to bear in mind there will always be health differences across a population because they reflect biological givens, as it were, but there are other things which reflect social and economic activities and are therefore technically within our power to do something about. If the differences have an element of injustice about them, it is worth considering what could be done.

Q343 Mr Bone: I am not entirely sure I follow your logic on that. If in society as a whole health care is getting much, much better but the well-off are doing better in relative terms than the bottom section, that does not make that wrong, that actually makes it good, because the whole of society is significantly improving. If you tilt the thing back to level things up, but are not increasingly dramatically the overall improvement in health, you are actually making things worse. Is this thing about health inequalities a fairness thing? Because what we are really talking about is improving the overall health of the whole population significantly and is that not more important?

Professor Kelly: If that were my logic, I would agree with you that I had got it wrong, but I do not think that is quite what I meant. When I talked about tilting the gradient, you want the overall level of improvement to keep going up but you try and get the relative disadvantages declining. In some areas it is quite legitimate to say that the immediate goal should be overall health improvement across the whole of the population regardless of the relative differences between them, and that is a genuinely important policy goal in some circumstances. In other circumstances, where one might argue there is a degree of unfairness in the way the pattern is evolving, I think the notion of trying to shift the gradient in a way that produces quicker improvement, although it will not happen automatically, would be the way I would want to argue it.

Professor Macintyre: I think this is a really important point because a lot of governments in Europe and the States and certainly in the UK are now saying we have twin goals to improve health and reduce health inequalities, and that is a good goal, but there is a tension between them, not in terms of pulling down the health of the well-off, flattening the gradient that way and making anybody worse off, but that it costs more to bring up the health of the poor. Let us take smoking, if you wanted to see England doing better in the international league tables on the overall prevalence of smoking, you might be better to put your money into helping the better off because they are going to get quicker gains. If you put your money into helping the poorest who smoke more, it will be harder work because of these things we have talked about - morbidity, addictions - so it will cost more. So I think the Government assumption quite often that they are the same thing, that reducing health inequalities will improve health overall, is not always quite correct, and I think we have to grasp that nettle. So what is more important? Is it the aggregate gain, or is it the flattening of the gradient? This is not about unfairness or pulling people down, everyone thinks you ought to level up, but it could cost more. If you will forgive me, Chairman, I want to come back to something Mike was talking about when he spoke about the cost effectiveness of various programmes. It depends how you value reducing inequalities in health, because a programme like folic acid for pregnant women might be cost effective overall but it might not reduce inequalities, and so you have to put into the equation how you value the outcome of reducing inequalities. We know quite a bit about the cost effectiveness of interventions overall but not about their cost effectiveness in reducing health inequalities. Forgive me if that sounds a bit obscure, I can amplify that, but it all comes back to Dr Stoate's question about cost effectiveness, it depends what you are talking about, overall cost effectiveness or cost effectiveness in reducing the gap.

Professor Judge: The term "strategies to reduce health inequalities" is not unproblematic in itself. Mike Kelly and a previous witness, Professor Hilary Graham, have pointed out that there are three common kinds of strategies which can be identified. One is simply to focus on the poorest themselves and say, "Our strategy is to improve the health of the poorest and ignore what is going on elsewhere". The second strategy is to say, "Define the top and the bottom in some way and adopt a strategy of closing the gap". The third strategy is to look at the distribution across the population as a whole between all social groups and flatten the gradient. To the best of my knowledge, no Government, no agency, anywhere, has explicitly adopted a strategy of flattening the gradient, most countries go for reducing the gap in some way. Interestingly in Scotland they have gone for the first strategy, their health inequality targets are specifically focused on improving the health of the poorest irrespective of what happens elsewhere, through an expert group which advised Scottish ministers told them to focus on the gap. This can produce some quite perverse changes over time. For example, one of the targets in Scotland is to reduce the rate of smoking in pregnancy amongst disadvantaged groups, those rates have gone down but they have gone down faster amongst the most advantaged groups, so while by measure number one in Scotland they are achieving their health inequality target, in terms of their expert advice about how to measure health inequalities, the health inequality is increasing. So you have to be clear about what your strategies and goals are to know whether you are having success or not.

Q344 Charlotte Atkins: I wanted to ask whether it is possible to calculate to what extent health inequalities are down to genetics, inherited inequality if you want, which inevitably you cannot do anything about, at the point of birth anyway?

Professor Macintyre: I do not think we have the evidence because we do not have enough genetic data at a population level to be able to identify any genetic differences. This often comes up, for example, in relation to ethnic differences in health. There might be epigenetic differences, which is something rather different, which is more to do with programming, so if you are born into a very poor environment there might be genes which get switched on but which do not get switched on if you were born into a better environment, so there might be some early life programming which is genetic as well as just constitutional. There is a lot of work going on now in terms of foetal and early origins of adult disease but we do not have a data set for the UK which says we can genotype everybody and apportion differences to genetics and environment.

Q345 Chairman: So we just apportion differences to social environment and the social class people are born into then, is that what you are saying?

Professor Macintyre: Yes.

Professor Kelly: That is where the data is currently available, so therefore the sorts of interests we have have, not surprisingly, followed that, and we have excellent information describing the problem in those terms. Undoubtedly there is a future research agenda exploring the complex interaction between genetics and social circumstances which will in 20 to 30 years' time offer us perhaps a rather different perspective on this, but what we should not lose sight of, of course, is that the big killers with respect to the big differences we see in mortality can to a very significant degree be located in social and environmental and economic terms rather than in genetic terms alone. But who knows what the future holds.

Q346 Chairman: There is nothing inevitable about the disadvantaged new born baby, providing the environment they grow up in is a bit different from what it has been in the past, is that what you are saying? They can avoid some of the outcomes of their risk, as it were, by having a different lifestyle?

Professor Macintyre: There is a study of twins growing up in different circumstances - I think they are identical twins - where there were then later differences in biological things like telemer lengths which actually suggest there is some influence again on people's biology from different circumstances irrespective of their original genetic make-up. So there is some evidence from twin studies and other studies about environment.

Professor Kelly: I think the best bet, as it were, at the moment is what is called lifecourse epidemiology, which takes us away from a rather static conception of inequalities, looking at a given moment in time, and if you like conceptualises our health almost as a bank account or a profit and loss account. So literally really from the moment of conception until we die, we are subject to a range of external phenomena of stimuli of one sort or another, some of which are beneficial and some of which are harmful. At critical points in the lifecourse, depending on your education, on your family background, the job you do, a whole range of factors, we come to forks in the road and go in different directions, some of which will be beneficial to us and some of which will be disadvantageous to us. So the overall approach to this, or the overall effect of this, is to think about inequalities in health as the consequence of that profit and loss account. The intriguing thing though is that it is not random, it does follow a set of, what Sally a moment ago referred to as, structured patterns across populations, where these different lifecourses of individuals cluster together in very striking ways. Insurance companies have known about this forever in the way they calculate premiums but it is the same sort of basic idea. It is very largely understandable with reference to broader social factors, as we have said. So it is not given at the moment of birth, but it does tend to follow certain well defined patterns nonetheless.

Q347 Mr Bone: I have got to move on to another area, but I think we could have spent a great deal more time on that particular point. What incentives are there for PCTs or practice based commissioners to implement NICE guidance?

Professor Kelly: In my view it operates at a couple of levels. First of all, when NICE public health guidance is produced it is part of the developmental standards. Presently the Healthcare Commission will test the local PCT, the local health economy when they go around to audit them to see the degree to which they are compliant with the NICE guidance. The way it then works is, of course, there are a series of different targets, public service agreements, local area agreements and local strategic partnerships with local authorities in which various targets that are relevant to public health come into play and the NICE guidance offers solutions and answers to those PCTs, local government and local authorities, of ways of achieving those targets. What we do not have at the moment in NICE's public health guidance are core standards, that is to say they are not "must do now" for the local PCTs. My view, and I think the view of NICE, is that it would be very helpful indeed if all of NICE's guidance, including its public health guidance, had the same "must do" quality about it in order to bring about these changes. The incentives presently reside within a complex structure of targets and so on at local level. What we should never lose sight of, of course, is that from the local PCT's point of view, and the local healthcare delivery system point of view, what NICE's guidance offers is the best way of providing either care or protection or health promotion for a population group. At another level the incentive is just about getting it right for the target group, the population group.

Q348 Mr Bone: Following up on that point, Chairman, my PCT has a lot of deprived areas within the county and we are the worst funded PCT in the country by the National Capitation Formula, it has never been met. How on earth is my PCT, which has got a hospital with a 92% ratio of C.Difficile, the worst ratio of C.Difficile in the country, going to concentrate on public health when there will be MPs jumping up and down, like myself, saying, "Why on earth aren't you sorting these other things out?"? In those sorts of hard pressed PCTs unless you ring-fence money how on earth are you going to get the right amount of money into it?

Professor Kelly: There is a good case for ring-fencing the money for public health because of the pressures that you are talking about and they are real. We understand that some of those pressures come from other aspects of NICE's work. The key argument is a cost-effectiveness one. If you look at the way the local healthcare economy makes its decisions, if those responsible for finance look at the kinds of benefits into the short and long-term, medium and long-term, which arise from some of the things that will come out of the public health guidance it makes economic sense but the trouble is, you are absolutely right, the micro-politics of it militate against it significantly. As a public health person, that is something which I regret but as a real-life political person too, I understand absolutely.

Q349 Mr Bone: It is short-sightedness, is it not, because as politicians we are only looking at what is happening tomorrow, not what is happening in five years' time, and that is the real problem. In reality, no PCT is going to not meet the Government's targets on waiting times to put more money into public health, though in the long-term that would be a better solution.

Professor Kelly: I am not sure I would call it short-sightedness, I think it is part of the realpolitik of the world in which people operate. The current set of incentives and regulation produce that response that you describe, which is why I said I think the case for ring-fencing local monies for public health is probably a fairly sound suggestion. In the overall picture, the benefits of taking the longer term perspective seem to me to be absolutely clear and given. The trouble is, of course, public health almost inevitably works on a canvas which is long-term. In many of the areas where health inequalities may be defined as being at their worse, this is not something which has happened overnight, we are dealing with ingrained inequalities which have historically existed for 100 years or more. Go to the centre of Tower Hamlets just down the road from here, health inequality there is not something which was discovered in the 1980s, it existed in the 1840s and much could be said about the patterns we see across the country. Therefore, when we are trying to bring about these kinds of changes we are in for a long haul. Some of these long hauls require smaller incremental movement now to build benefits for the future. The investment for the future is something which does seem to me to be a real possibility that we can work towards, but we need committees like yours to make this argument clearly and to say it often and to say it loudly.

Q350 Sandra Gidley: Other witnesses have placed great weight on the relative importance of ensuring that Early Years programmes tackle health inequalities and I wondered whether you agreed or disagreed and why that might be?

Professor Macintyre: I certainly agree, I think it is very important. Most studies show that there are huge differences from very early on, social class differences in all sorts of outcomes and behaviours and life circumstances and that these track forward into adult life. If you start early and try and change things then, I do not think that means you ignore the health of the middle aged or elderly or inequalities there, but an awful lot of these are generated in early life and I do think it is very important to try and change them there.

Professor Judge: I agree.

Professor Kelly: Absolutely and it is not without significance that when, along with colleagues in the Department of Health, we put together our first programme of work it included the big programme on maternal and child nutrition as one of the core pieces of our work. We have also done things relating to primary education and working with young people on drug misuse and teenage pregnancy, all that sort of thing. There is absolutely no doubt that the investment in Early Years and in the young mothers who go with the Early Years is a critically important thing. We have known this for 140 years with respect. This is not new. When Rathbone was going around Liverpool at the end of the 19^th century that was the conclusion then so we simply re-emphasise that.

Sandra Gidley: We will not speculate why it has taken so long to start addressing it.

Q351 Charlotte Atkins: We have been hearing, obviously, that the evidence is relatively thin for interventions to tackle health inequalities and that public health in general is relatively under researched. What would your three priorities for research be to fill in some of these gaps?

Professor Macintyre: I think a lot of interventions should be rolled out in more evaluatable ways. It is a natural tendency for governments to want to be seen to be doing things and to describe those in terms of inputs and how much we are spending, but I really think that a lot of interventions are rationed, Sure Start, HAZs, all sorts of interventions, only so many areas can get them. Randomise them so that you can genuinely compare those who get them with those who do not, you can use different waiting list designs because when you do not randomise them you reach real problems of the areas who shout the loudest, so have the most collective efficacy or the very poorest get them and the ones who are slightly less deprived do not get them. Any comparisons you then make about them, people can always say, "Oh, you weren't comparing like with like". You may hear more about this in the next session. I think there is no ethical problem. If they are rationed anyway, it is fairer to ration them randomly and then make sure, particularly if there might be harms, that you are comparing like with like. I think interventions and policies should be rolled out much more in a randomised way. The second one would be this issue about recognising that aggregate gain is not the same as reduction in health inequalities. That may mean you need larger studies because detecting differences between social groups requires bigger numbers. It also requires new ways of measuring things, the thing I mentioned about how do you value reducing health inequalities. You can value aggregate health outcomes but we do not yet know how to value the reduction you are making in health inequalities. The other issue about early life is, of course, you have got to allow it a long enough time span because the outcomes you are looking for may take several years and you may have to use intermediate outcomes. You may not detect a difference in child health but you may be able to detect a difference in maternal smoking in the home that you could hypothesise would affect child health. Those are my three. One is randomisation, the other is recognising the difference between aggregate gain and reducing inequalities, and then having sensible outcomes over a long enough time span.

Professor Judge: Over the last ten years or so I have been involved in the evaluation research activity associated with a number of complex community based interventions, smoking, Health Action Zones, Scottish health demonstration projects, New Deal for Communities. Most of these initiatives have been driven by people like yourselves with a clear recognition of the problems we face and a desire to do something about them, but these well-meaning intentions have got in the way of learning anything useful because we have raced into action too quickly. I agree absolutely with what Sally has just had to say. The key word for me, the single word I want to impress upon you in this area is evaluability. Design these interventions in a way that gives them some decent prospect of generating learning. It is daft that we pour hundreds of millions of pounds into complex community based interventions with quite sophisticated research designs and expect them to change the world in 18 months, it is not going to happen. All the things Sally has just said are absolutely true. If we did fewer things with more thought and more preparation, particularly for complex community interventions at the local level, engaging local communities of all kinds, all stakeholders, it takes time to win space, trust, resources, line people up, set things up in a feasible way, manage local expectations and enthusiasm in a way that we can learn something. I fear that over the last ten years or so, despite fantastically good expectations and intentions, we have wasted huge opportunities to learn and we have got to do better in the future.

Q352 Dr Naysmith: Chair, can I ask two very quick questions of Professor Macintyre and Professor Judge relating to what they have just said. Should there be pilots for everything before they are rolled out in a big way and, secondly, should this Committee absolutely recommend that nothing should be started unless there is a real programme for evaluating the outcomes over a proper period?

Professor Judge: The issue for me is not about evaluation, I think we have got well tried and tested methods of evaluating, it is about design and implementation. It is creating the space and the time to allow an intervention to be developed and implemented and embedded in a way that it can generate successful impacts. We do not give enough time to these interventions, we do not give enough time to people to set them up and we do not give enough time to see what the impacts are.

Q353 Dr Naysmith: Can you get useful information from the pilots, strictly controlled and evaluated, or not?

Professor Judge: You can get useful information from all sorts of things. I fear that what happens more often than not is we pour large amounts of money into these interventions and we end up with rich descriptions of what people are trying to do. These rich descriptions are then used as evidence of good practice because we do not have anything else and we slide inexorably from setting these things up essentially to the production of propaganda.

Professor Macintyre: A real problem with a lot of pilots is they are set up by the proponents and the enthusiasts. Somebody enthusiastic about a particular programme will say, "I've got this idea", set it up as a pilot, they evaluate it themselves, there is no independent evaluation and then whoever is organising it rolls out the next wave before you have got the results of the pilot. There are so many examples where the next wave gets rolled out before we have any information, particularly about outcomes.

Professor Kelly: I agree with what Ken and Sally have said about the higher level methodological stuff. One cannot overemphasize the importance of us doing a bit more "D" before we go into the "R" with the R&D. If you think about when a drug gets to market, there have been 10/15 years of development work before it is ever rolled into a trial, let alone the kind of trial we are talking about here. So often with public health interventions that element of development prior to going forward has not happened. It is a good idea, or it is a proponent of a good idea that takes it forward. As Ken has said, there are well defined mechanisms to allow us to plot the relationship between the intervention and the aspirations we have for it and its outcome. My specific research questions are at a lower level though, to echo where I began. I think if we knew the answer to what were the most effective ways of improving the nutritional status of pre-conceptual women and young children, particularly with reference to parents in low income groups, we would make a huge step forward. Secondly, if we knew the most effective way to prevent relapse from those who have successfully given up smoking we would really tackle that problem of the most addicted smokers. That is a very important research question. My third lower level but very important research question is what are the specific social and cultural contacts which help people adapt and change their behaviour. We struggle a bit to understand the detail of those once we get away from the generalities. What really is the issue for a Bangladeshi woman in Tower Hamlets or for someone growing up in a seaside town in Somerset or for someone living in Woking? The precise ways in which the social and cultural contact impacts on behaviour, surprising to say, perhaps, after 200 years of behavioural science looking at this, we are not terribly knowledgeable about those things. Incidentally, I would commend, the 2007 study that Sally led. That is one of the richest descriptions of that kind of thing within one particular cultural context, Western Scotland. We need more of that sort of thing if we are going to unravel these complicated problems.

Q354 Charlotte Atkins: You have all made passionate pleas for improving the evidence base and for setting up projects so that evidence can be evaluated from those projects before dashing to other new projects. Who do you think should be responsible for this? Who should provide the funding to make sure that this happens?

Professor Kelly: The same people who currently provide the funding; that is either through the NHS R&D programme or through the Research Councils or local funders of projects, individual PCTs and that sort of thing. The methodological precepts, the principles that Ken and Sally have outlined, are there in the behaviour change guidance. We have articulated as them clearly as we possibly can with, in this instance, guidance for research funders to do it. Presently the money is being spent. This is not new money; it is about using the money we already spend more effectively. The ways and means to do it are to hand; we are just not terribly good at making it happen.

Professor Judge: This is probably not a popular thing to say amongst my colleagues but I do not believe there is a lack of evaluation funding: it is money for properly defined interventions, to repeat the point. We have had hundreds of billions of pounds spent in this area and research monies associated with it. The Department of Health in particular, but other departments as well, have taken the message that for new interventions you need to have evaluation money put aside. There is a variety of ways in which this has been made available, but it has been badly spent money, because we have not designed and implemented the deed, as Mike said. When government departments rush to develop these new initiatives - the latest one would be in relation to obesity with the Foresight study: there is clearly a clamour for action, to do something about childhood obesity - let us stop and think about how to spend the money in a thoughtful way that might generate some real evidence. My advice would be to focus on the funding of the interventions more than the funding of the evaluations.

Professor McIntyre: I do not think it is the Department of Health or the research councils, because a lot of the initiatives or policies that might impact on inequalities of health and public health come from other government departments. Education, criminal justice, housing, communities, transport, and a lot of other government departments do fund. Sure Start is not funded by the Department of Health. There are funds in other government departments. It is an issue about communicating across government departments - which I know is difficult. I agree with Ken: the funds are probably there; it is how they are spent.

Q355 Chairman: You have mentioned the issue of a woman living in the East End of London and somebody living at the seaside and the differences there are in terms of culture. Social class, in my personal view, is best described as cultural. Why do you think there is a national answer to this, if the cultures that these people live in are so different, given that you are from a national institution that is looking at answers to these questions?

Professor Kelly: My reasoning is this: we are very well aware from many, many studies of what I described earlier on as the gradient between different groups across population. Conventionally, we use as a proxy measure for all of those differences, social class and socio-economic group. That works quite well at an aggregate level at helping us to see these things. Ever since the 1911 census, more or less, we have been able to plot this pretty accurately. To go back to the case of someone living in straitened circumstances in Tower Hamlets, the question is: What is the principal problem? Is it that she is a woman? Is it that she is living in poor housing in a borough which is poor? Is it that she is working in the unofficial labour market and not enjoying the protection that goes with that? Is it as a consequence of being Bangladeshi that she is a victim of racism? Or it is because it is a social class thing, to do with the position there? Of course it is all of those things and we do not know, either empirically or theoretically, how those different factors, all those things which make up the richness of the social diversity, interact with each other. Are they simply additives? Are they synergistic? How do they work? It is not so much looking for a national answer but looking to be able to describe how these things interact with each other. We know they do, but we do not really know how they do. Once we know that, the targeting and the specific things we need to do will be much easier for us to take forward.

Q356 Chairman: They may not be national, in terms of you need to do x and y in every community.

Professor Kelly: That is absolutely right.

Q357 Chairman: You may need to do x in some communities and y in others.

Professor Kelly: Exactly so,

Q358 Chairman: Btu we are not there yet.

Professor Kelly: We are far away from that. There is a big job to be done which will help to feed many of the kinds of interests that we have at NICE but also the things my colleagues have talked about this morning.

Chairman: We will move on a bit.

Q359 Sandra Gidley: Professor Judge, you have mentioned rushed initiatives and that brings us nicely to the subject of Health Action Zones. What, in your opinion, were the strengths and weaknesses of the design, implementation and evaluation? Obviously it is always easier with the benefit of hindsight, but how could they have been better designed and evaluated?

Professor Judge: Whenever I think about this, when I think about 1997 and Health Action Zones being formed, I think about Wordsworth's description of the French Revolution: "Bliss was it in that dawn to be alive" and all the rest of it. It is important to remember just how much enthusiasm there was in the late 1990s for an opportunity to invest resources in tackling these problems that had been decades or centuries long in standing. Even with hindsight, you can see why people were just desperate to do anything. There was enormous enthusiasm but really a desperation to make up for lost time and act quickly. Health Action Zones are best thought of as a mosaic. They generated certainly hundreds and possibly thousands of diverse activities. It is inconceivable to me that, getting motivated people, dealing with longstanding problems, given new resources and support, many good things did not happen - and they did - but there was a lack of strategic thinking about what it was realistic to expect these things to do. To try to give a short answer, I think the best thing that can be said about Health Action Zones is that they provided an important opportunity to develop the public health workforce and start to develop a more detailed understanding about engagement with local communities that could be taken forward.

Q360 Sandra Gidley: That is really reinforcing your earlier point about taking a bit of time to think about what might be better in the longer term rather than rushing headlong.

Professor Judge: Yes. You are the politicians, but this was supposed to be a seven-year initiative, launched by one secretary of state, dramatically changed by the next, abandoned by the third, subject to different parliamentary and political timetables, where guidance from the centre was not clear, megaphone, or contradictory. People competed with each other in terms of their aspirations. One of the Health Action Zones, which covered an entire conurbation and was given �4 million or �5 million a year, proposed to transform the life expectancy of the entire population such that it was in the top 10% for Western Europe in seven years. These things are simply not achievable.

Q361 Sandra Gidley: Should it have been abandoned when it was? Or did it come to the end of its natural life?

Professor Judge: I think it is best seen as a phase of learning.

Q362 Sandra Gidley: What was the cost of the programme?

Professor Judge: It is impossible to give a precise answer because, having established the Health Action Zones initiative, government piggy-backed a whole variety of other initiatives. Smoking cessation services started life within Health Action Zones, in the same way now that special initiatives often start life in Spearhead Group Local Authorities. It was some hundreds of millions of pounds, in the range less than �1 billion and more than �400 million.

Q363 Sandra Gidley: Are we making the same mistakes with the spearhead PCTs and local authority areas?

Professor Judge: I think it is for government to decide which portion of the population in relation to health inequalities it wants to make its assessments in relation to. It seems to me there is nothing wrong in principle, given the data that we have available, in pointing to the differences in all sorts of population health measures between the average rates in spearhead groups and others, in saying a legitimate aim of policy is to reduce the gap between spearhead groups and others. If that is the policy that we adopt, then the logical extension of that is to use the resources that you have available in as cost-effective a manner as possible to deliver interventions in the spearhead areas for reducing smoking, reducing infant mortality, whatever. I do not think it is necessarily wrong.

Q364 Dr Taylor: The overall message is much less speed in the form and much more planning and design.

Professor Judge: Yes.

Q365 Dr Taylor: We have heard about England and we have heard about Scotland. We have not heard anything about Wales. Is there anything encouraging coming from Wales?

Professor Judge: One of the encouraging things coming from Wales, in relation to their health inequality targets, for example, is that health inequality targets in relation to infant mortality and low birth weight are embedded in an all-Wales child poverty reduction strategy. They are very much placed alongside targets in relation to income, employment, education and the rest of it and they are not separated out. As I understand it, in Wales they are trying to take all these initiatives and, in particular, build upon the very good English experience of developing now, belatedly, a more clearly defined implementation plan to reduce infant mortality in England, alongside a clearly defined implementation plan across a broad spectrum of interventions to reduce child poverty.

Q366 Dr Taylor: Is it easier for them because they are smaller and they can cover the whole country more easily? Or could we do the same really?

Professor Judge: We could do the same really.

Q367 Chairman: What are your observations on New Deal for Communities?

Professor Judge: It is some years since I have had a detailed association with them and other people giving evidence to you will have more to say, but, certainly in the early years of New Deal for Communities, many of the general points that both Sally and I have made about intervention in general apply, and certainly I had New Deal for Communities in mind when I made my more general remarks.

Chairman: Could I thank all three of you very much indeed for coming along and helping us with this inquiry. Thank you.

Witnesses: Professor Edward Melhuish, University of London, Director, National Evaluation of Sure Start, Ms Pauline Naylor, Programme Manager, Sure Start Barkerend Children's Centre, Mr Richard Sharp, West Ham and Plaistow, New Deal for Communities, Ms Frances Rehal, Director/Chief Executive Officer, Sure Start Millmead Children's Centre, gave evidence.

Q368 Chairman: Good morning. Welcome to our fourth session in relation to health inequalities. Could I ask you to introduce yourselves for the record, please.

Professor Melhuish: I am Professor Melhuish, University of London. I am a Director of the National Evaluation of Sure Start.

Ms Naylor: I am Pauline Naylor. I am Programme Manager for Sure Start Barkerend Children's Centre in Bradford.

Mr Sharp: I am Richard Sharp. I am from West Ham and Plaistow New Deal for Communities and I am a neighbourhood coordinator.

Ms Rehal: I am Frances Rehal, I am the manager of Millmead Children's Centre which is now in the Social Enterprise.

Q369 Chairman: Thank you very much for coming. Pauline, my neighbour and colleague Terry Rooney spoke to me last night and said he was sorry he could not be here to listen to your evidence. I did question why he should want to come here when he has got you in Bradford, but there you are. Much of the evidence we have seen has placed great importance on early years provision. Could you outline for us the evidence that early years interventions such as Sure Start will contribute to reducing health inequalities as opposed to other issues?

Professor Melhuish: It depends how you define public health inequalities. If you define public health inequalities to include public mental health as well as public physical health then there is considerable evidence, because you do get a decrease in the incidence of behavioural problems, psychological disorders and special educational needs in children as they grow older where they have had good early years interventions. The payoff for these interventions usually does not show itself to adolescence. If you are talking about cost-benefit analyses, you need to collect the evidence through to adolescence before you see the payoff coming about. Although you could detect evidence of effectiveness earlier than that, the full costs do not become apparent until adolescence.

Q370 Chairman: That is an outcome that is measurable some time down the line. Are there any other outcomes where you could say health inequalities are helped by early years intervention?

Ms Rehal: We have some evidence from our programme. When we started our programme in 2000, 27% of mums breastfed their babies at birth; the figure now is around 57%. In teenage births within the Sure Start area over the past nine years, and that was four prior to Sure Start and five post Sure Start, we were able to evidence 65% reduction in teenage births. When we started out, 52% of our children failed to attend speech and language therapy sessions to which they had been referred. Now, after our programme funding research into the causes of non attendance, our figure is under 5% non attendance, and the speech and language therapists who have undertaken that research in our programme in partnership with the other Sure Start programme in Margate, have now taken these findings to other areas, and that approach has now been mainstreamed. We also have quite substantial evidence that the approach that we have taken to support women who have postnatal depression is very effective, and we have developed this and this has also been underpinned by some of the findings from NICE. We have a health visitor who co-ordinates two community workers, one across each of the Sure Start children centres, to provide an approach that enables mums and dads to express their views, and they will be listened to sympathetically and they will be supported. We also provide a structure for them to contact staff during times of stress.

Q371 Chairman: Pauline, would you like to add anything?

Ms Naylor: As an early learning teacher - I am an educationist and a health practitioner - I think there is a lot to be said for qualitative evidence as well; inasmuch as, with programmes which intensively work with families with young children, you can see a benefit from one child to the other, you can see a change for the whole family as the children develop. If you work with the family over a five-year period, there may be three young children in that household who have immediate access to the parents and carers. You are listening to their views, you are making a judgment about it, they are learning and understanding, they are engaging with you, so there is immediate evidence that they are gaining new experiences and understanding or changing their behaviour.

Q372 Chairman: Edward, do you have what you would call an ideal early years programme to reduce health inequalities? As an academic, could you say, "That's what you should do?" There is not an ideal programme, presumably.

Professor Melhuish: In our recent report on Sure Start programmes, we found evidence that Sure Start programmes overall were improving children's social behaviour and parenting in ways which are likely to lead to longer term improvement. But there was great variation in Sure Start programmes. Some are very effective and some are comparatively ineffective. There is a general tendency that those programmes with good integration of health services with the Sure Start programme are more likely to have effective outcomes. There is very good reason for this. The health services give you immediate access to parents in pregnancy and children at birth, and, therefore, the Sure Start programmes can get into contact with those families very early on. Where that integration of health services with Sure Start programmes does not take place, Sure Start programmes are often at a loss to know who has had a new baby in that area, whether that new family needs help or not. Any ideal services, I would suggest, would involve very close integration of the health services with Sure Start type programmes. Currently, this is very patchy across the country. Some programmes have excellent integration of health services; for example health visitors working closely with the Sure Start programmes. When they meet a young mother who is having difficulties with her parenting, they say, "Didn't you know there is a special mothers' group down the road which is helping with these sorts of problems? Why don't you go along there?" and they take them along and introduce them and they get integrated into the services straight away and help is brought to bear very early on. Where this does not happen, problems tend to get worse and worse as time goes on. I would have very good close integration of health services with Sure Start type programmes; I would expand the midwife and health visitor services so that those services could integrate more thoroughly with Sure Start programmes; and I would also improve the training of midwives and health visitors so that they have a better understanding of the factors affecting early child development and parenting. Currently, they are not as good at that as they could be. I would have cross-agency training for people who work in Sure Start programmes and health visitors and midwives, and maybe even some doctors as well: common training sessions, so that they learn to appreciate one of those perspectives. Interdisciplinary rivalry and miscommunication is rife and overcoming those sorts of problems is something which we could do something about relatively quickly and relatively easily.

Q373 Charlotte Atkins: Has your evaluation indicated that there is a clear link between Sure Start and reducing health inequalities?

Professor Melhuish: In our recent report we found an association between being in a Sure Start programme and reduced incidence of child accidents and an increased uptake of immunisations. Unfortunately, with our comparison group, the data was collected prior to the data collected in the Sure Start programme, so there was a time difference between the Sure Start and control data collections. We did see in our data some timing effects. Because the Sure Start data was collected later than the control data, we cannot rule out the possibility that the Sure Start effect we saw on accidents and immunisations could have been due to an incidental timing effect. I think it unlikely, but, adopting a cautious interpretation of our evidence, I cannot absolutely say that the evidence is unequivocal in terms of proving child accidents and immunisations.

Q374 Charlotte Atkins: You say there was a big variation in the outcomes of different Sure Starts. Was that related to how well embedded they were within the community? Which factors indicated where a Sure Start was going to be successful and where it was not?

Professor Melhuish: There was generally better empowerment of both parents and staff in areas in which both were more effective. Where the staff and parents both had a greater say in the nature of services being delivered, there was stronger leadership by programme managers, more clear leadership, more stable staffing, a much lower turnover of staff, better integration with health services, and generally a more enthusiastic, for want of a better word, participation of the local authority in the Sure Start programme.

Q375 Charlotte Atkins: Now that we are moving towards children's centres, have you any fears that once you get children's centres you might get more of a local authority direction of the programme rather than the empowerment of parents and other community organisations?

Professor Melhuish: Children's centres were brought about because there was evidence, partly from our evaluation and partly from other sources, that the early programmes were not working as effectively as they could do. Children's centres were brought about, to some extent, to introduce a change in the nature of the goals of the programmes and the guidelines for programmes so they would become more effective. It was also a political move, to put Sure Start programmes in an embedded slot within the organisational framework of our society, because up until 2004 they were like a free-floating entity which did not have a clear place in the hierarchy of organisations. Placing them in local authorities made sense in that regard. It had the unfortunate consequence that it made health services even less interested in children's centres than they were previously, because getting health trusts to become interested in children's centres is quite difficult. It works in some parts of the country and does not work in others. Stephen Ladyman, when he was the public health minister some years ago, wrote a letter to every PCT saying that they should regard the Sure Start programme as part of the health services of that area and, therefore, share information about new births with that programme. Many PCTs still refused, despite receiving that letter from Stephen Ladyman, to do so because they did not regard themselves as being thoroughly integrated with the Sure Start programme. They did not regard it as part of their responsibility and so on.

Q376 Charlotte Atkins: Have you also found in your research, in a situation where you have a children's centre, that some deprived families see going to the centre as being the fact that they are a problem family, that there is something wrong with their child and so on. In my experience, in my local area, that is what anecdotally has been said to me, that you either go there because it is cheap childcare, which the middleclasses tend to grab with both hands, or because it is perceived that there is a problem with their parenting. Are you finding that at all?

Professor Melhuish: I think that was an initial fear and one of the reasons why Sure Start programmes were set up, so that they were universal within their area rather than targeting within their area. By and large, I think that has been relatively successful. I do not think parents do feel stigmatised about using Sure Start services, although I think possibly our programme managers here might be better placed to voice opinions about that.

Ms Rehal: From our experience, because our programme and Sure Starts have been inclusive, they have included all the parents within a geographic area irrespective of income, that has helped for parents to see the programme as non-stigmatising. Also, including parents in the planning of services and the development of policies and procedures regarding the programme and the building has enabled parents to have a say, so they feel that it is theirs. I am speaking for our programme: parents feel that it is theirs. The challenge to our programme, as the other children's centres are established and the boundaries over time are not going to be as clearly defined, is how we enable our poorest families to access services as well as those parents who are much more highly educated, who have cars, who are able to seek out the best services. How do we also provide services to those parents from outside of our area who see us as a centre where they can access good quality provision?

Ms Naylor: The centre I work in was a Sure Start local programme for this particular neighbourhood and it is well embedded in this particular community. It is on a school site but it is seen as part of a universal service for that whole community. We have never really had a concern that people did not want to use that service because it was stigmatised. In terms of the clientele we would work with, there would probably be a group of people who would maybe think the social care family centre, which is not in the immediate area but works for that community, would suffer more stigmatisation. We have tried to work with them to develop services within our centre so that the parents were more able to engage because they did not feel stigmatised. We are in a fairly significantly deprived community, so it is catering for quite a large population within that social group. I would say we might have a desire to make that service far more inclusive but I would not imagine that people in our sort of district from the more affluent community would want to travel there to use that service. It is a community base, a neighbourhood base, it is not stigmatised, and it provides a universal service to people who need or want that service, but it is not necessarily a service that would be accessed by people who would not need some sort of help.

Q377 Charlotte Atkins: Edward, could I move back to your evaluation. Would you say that Sure Start has been value for money? Would you also suggest whether your research indicates that we should be doing anything differently in our early years provision at the present time.

Professor Melhuish: In terms of value for money, a lot of the full benefits of Sure Start programmes will not be seen until the children are older, so doing a proper cost-benefit analysis will require following through with the children until they are older. We have to look at the time frame. The very first Sure Start programme started in 1999. Our early work showed that they took three years to get up and running, so it really was not until 2002 that we saw fully functioning programmes of any kind. Then you had the phase of three years where they were rolling out across the country in a wider way, so we are talking about 2004 before you have a reasonably widespread fully functioning system of programmes. We are finding the children who are born around about 2003 and 2004 are now showing some improvement in their development where they have been in Sure Start programmes and parenting practices in Sure Start programme areas seem to be better. In that sense, they are having benefits. Are they value for money? Could we have spent the money in other ways which would have produced more benefits? That is still an open question, I think. There are ways they could be improved. I have already said the integration of health services is an issue that needs to be addressed. There needs to be further work on the development of language development in Sure Start programmes, because many Sure Start programmes' staff and other staff are still inadequately trained about what is it about environmental influence which causes and facilitates children's language development in particular, and we are not seeing the improvements there that we should be seeing. This is across the board and is partly the question of adequate training and staff development in Sure Start programmes and in the early years areas and the early health areas as well.

Q378 Charlotte Atkins: Would you explain the differences in the evaluation of the Sure Start programme, from the early evaluations, which were very critical, to the more recent evaluations? Would you say the Sure Start model has a future for the long term?

Professor Melhuish: Remember that prior to 2000 this was a policy desert. There was virtually nothing of this kind in this country before 2000. We were getting the first programmes functional from 2002 onwards, so really Sure Start is in a development phase. We are not yet seeing Sure Start programmes which are the fully developed model that we would want to be going forward into the longer term. They are developing over time and getting better and better over time.

Q379 Charlotte Atkins: They are based on Smart Start in the States, are they not?

Professor Melhuish: No. I think you are thinking of Head Start, not Smart Start. Head Start was one of the sources of evidence used to justify the Sure Start programmes, but Head Start is a radically different form of service to Sure Start. There is a dissociation between the evidence quoted to support Sure Start and the nature of Sure Start. They are in the process of developing. The early Sure Start programmes had rather weak guidelines. Provided an area had the money, they could more or less do what they liked with that money. They could make their own decisions about what they felt was the best way to spend the money, which led to a huge diversity around the country. That huge diversity led to very variable outcomes, with some having some effects and some not having very many effects at all. That led to a revision and a change over to the children's centres, which happened from about 2004 onwards, coincident with our early reports. Our early reports were in fact patchy, in the sense that we found some evidence of positive effects and some evidence of negative effects. As always happens in these situations, the press grabbed on the negative results and blew them up as if they were entirely negative, and in fact they were very mixed: there were some positive and some negative. It is interesting that we reported last month with a set of results which are much more detailed, which are largely positive, and the press largely ignored the evidence because it was not negative.

Q380 Charlotte Atkins: No surprise.

Professor Melhuish: Yes.

Q381 Dr Naysmith: If you are saying Sure Start was not based on the model in the United States, where did the idea come from? Where did the evidence come from?

Professor Melhuish: I could give you a book chapter which describes it.

Q382 Dr Naysmith: A quick answer would be fine. Was it totally new?

Professor Melhuish: In May 1997 Gordon Brown, the Chancellor of the Exchequer, decided he wanted to tackle the cycle of disadvantage. He gave one of his chief economists, Norman Glass, the task of looking at all the research evidence and saying, "How can we break the cycle of disadvantage?" Norman Glass came back with a report saying, "Unless we tackle the early years, we are wasting our time." That report was based upon the American evidence largely, like Head Start, which showed that early pre-school programmes of high quality produced lots of benefits for children and other forms of early intervention of that kind generally had longer-term benefits. With that evidence that intervention in the early years works, people justified putting up the money for Sure Start. When Sure Start was then instituted Norman Glass retired, Naomi Eisenstadt took over. Naomi Eisenstadt, who comes from a community development background, said, "We need to develop Sure Start programmes where they are embedded in the community" and, therefore, community control is a central feature. That is why communities had almost complete control at the start about how they delivered their programmes, which led to the enormous diversity we saw across the country in the early Sure Start programmes. There should have been published some guidelines about the kinds of services to be delivered at the early set up. Apparently those guidelines were written but did not get distributed to the programmes, and so there was this enormous diversity of set up.

Q383 Dr Naysmith: There is nowhere else in the world that has a model like this.

Professor Melhuish: There is nowhere else with quite the same model, no.

Ms Rehal: That flexibility enabled a level of responsiveness to local need that I had never experienced in the public sector in the past. As we are developing children centres and these are now the responsibility of local authorities, that flexibility is not there, and that responsiveness to local communities is not there to the extent that I think it ought to be if we are going to make a significant impact on outcomes.

Q384 Dr Stoate: I would like to ask Richard about New Deal for Communities. What do you think the interventions in New Deal for Communities will really make in terms of reducing inequalities of health?

Mr Sharp: From our point of view, we have been very successful in terms of integrating services that were not there formally; in other words, the area was characterised by a lack of facilities under one roof. There were not safer neighbourhood teams at the time, we had a lack of primary care facilities in areas, and there was a lack of community involvement, essentially, understanding what services were. We have invested within our community resource centres, one in Memorial Park - which was a park that people did not go into - and another one called The Hub which is in Star Lane. That has brought in improved childcare, employment, the police, pharmacy services, and health testing of cholesterol, blood pressure and that sort of thing, and so, in a way, our long-term legacy will be keeping those centres going and bringing in new partnerships from the new structures that we are setting up. Our funding, essentially, will end in two years' time, so we are in the business now of thinking very much about where neighbourhood renewal sits within the next step really. I think it has been very important bringing in services. When I first went into New Deal in 2001, the communities were not really talking to services that much. I think we have partly achieved that through bringing in services under one roof. Some of the things we have tried have not necessarily worked. Some of the things we have tried have worked very well and we will be able to take that best practice into new policy developments. For instance, where New Deal borders Canning Town and Custom House, which is a mixed communities initiative where there is going to be an awful lot of social housing being created, we are in discussions with the primary care trust about possibly a polyclinic and other social infrastructure facilities within that new build. We probably have the advantage of having experienced a lot with those partners. A lot of people have been through a lot of change in services with communities, so I think, long term, we can build on what has worked quite well. We have very good examples of some of those things. People who come into the area now can see the new GP surgery, they can see the new community resource centres, and they can see a community that is very involved. Not all the community are totally involved, but through training and getting people on the board and on the sub committees they have learned a lot. The matter of health inequalities is an extremely tough nut to crack within a regeneration context, within a local setting. The other thing is we have worked closely with Sure Start to put Sure Start in one of the community resource centres as well. There is a lot of community development work we have done as well, to try to encourage people who would not necessarily attend. I suppose it has been about linking local authority and third sector partners together.

Q385 Dr Stoate: I can see the benefit of that, as long as that is extremely welcome and improving services for the community generally, but is there any evidence of that reducing inequalities or does it just improve services across the board?

Mr Sharp: Certainly, through the MORI surveys which we have conducted every other year, there is evidence that people's low self-rated health has improved. We also have evaluation evidence that statistically there are some health gains in the area as well. I think the interventions in certain areas have worked quite well. Self-rated health is one where people are feeling better about their health in general when surveyed over time.

Q386 Dr Stoate: A lot of that, qualitatively, is not all that scientifically based. Have you any hard outcome measures that show that you have in any way reduced inequality?

Mr Sharp: I do not have them to hand but within the public health team we certainly have evidence, when we do our PMF exercises, that certain health inequalities that were a problem on our indicators have improved as well.

Q387 Dr Stoate: Can you give us any examples?

Mr Sharp: Not off the top of my head, no.

Q388 Dr Stoate: If you have any, it would be helpful if you would send them in, simply for us to work on.

Mr Sharp: Yes, we would do.

Q389 Dr Stoate: Obviously what you have listed is extremely welcome to the community, but our interest at the moment is to see whether that has any impact directly on inequalities and whether there is any sensible way we could measure that, because any recommendations we make need to be based as far as possible on evidence.

Mr Sharp: Yes. We have our PMF which we could forward.

Dr Stoate: Thank you very much.

Q390 Mr Bone: In my area, in the worst estate - drug ridden, lawlessness, an area nobody would want to go to - an initiative was started by a church - not a mainstream church - and they have built a community centre. That is expanding enormously. They have changed the area. The local pub, which had closed down, has now been taken over and converted. There is a transformation in that area and people want to go to that estate. That has been done not by the state but by a voluntary group, obviously with grants and things. That has transformed the area. I do not know how you measure whether that has improved health inequalities, but there is more than one way of doing that. Would that be a fair comment?

Mr Sharp: I think it is a completely fair assessment. In terms of third sector and faith organisations, our community resource centres are full of faith organisations and church group. Certainly within the regeneration area within Canning Town one of the very active and very good church organisations is planning their own development, because they have land, and they are also talking to us at the moment about health so that we are not duplicating. They are doing some fantastic work already, but they are looking at developing their land site as well, which would be developed alongside that mixed community, and that will add significant value as well. I do not think it is just NDC that has been responsible for work in that area but through ongoing discussion with partners you can bring an element of synergy to that process as well. One very good example, I suppose, is that a lot of youth providers in that area were working in isolation - some of those youth providers are doing drugs prevention work with young people - and we have got them together in the same group now talking to each other and doing joint commissioning. It is things like that where you can influence. Where NDC has been successful is that it has set up a model of getting organisations to work together and the impacts can be measured in that way. Sometimes that is quite tough to measure but, on a very crude level, if three years ago you did not have a childcare centre and you did not have an employment advisor and you did not have a pharmacist, and then three years on you have those things, and you have local residents within the board accessing that, to do an assessment on football is quite a good way of measuring that people are accessing it. Or if you have a fun day and one thousand people attend, that is good enough really I think.

Q391 Dr Taylor: Moving on from there, I have specific question to Frances, Richard and Pauline. Could you give us two examples each of projects that really work well and that have improved health inequalities. I will start with Frances, because your excellent paper gave us 11 examples of things that worked well. There is not time to go through 11, but can you pick out a couple of projects that have really worked to start with.

Ms Rehal: One of our most successful projects has been the development of our community worker role. These are, on the whole, parents from the estate and they have received training and supervision. They have been able to mobilise an extremely sceptical and cynical local population. Those have been the drivers for change. They have enabled parents. On occasions they have accompanied parents to health services that we have in the programme or speech and language groups for children or breastfeeding support groups. That has been part of our success. This role has been able to mobilise and engage the hardest-to-reach families and has enabled those parents to access services and to see our programme as a space for potential change.

Q392 Dr Taylor: They really give you the way into, as you put it, the cynical and sceptical population.

Ms Rehal: Yes.

Q393 Dr Taylor: Are they volunteers or are they paid?

Ms Rehal: They are paid staff. Our second programme - although this is not specifically for young children - is that we have now taken our integrated approach to teenagers. We have a whole child age group approach to developing services: our Sure Start parents from seven years ago now are encouraging their teenagers to come into our programme. I think that is a very significant development because some of the teenagers who are attending are those who are not attending school, who are cigarette smokers, and who are keen to change. They are requesting help from us on how to give up smoking and how to eat more healthily. Our integrated approach across the different age groups has been what has enabled us to deliver our outcomes.

Q394 Dr Taylor: You get them cooking and eating a meal together.

Ms Rehal: Yes, we have been doing that.

Mr Sharp: The two things that would stand would be our increasing physical activity programme which is run in conjunction with the local authority. That has worked in conjunction with residents and schools. We have had underused green space and alongside the increasing physical activity programmes we have managed to develop that green space to improve infrastructure, to encourage young people to take part in sport. That has been very successful, particularly with encouraging male participation in sport. A lot of the young people and the men that have been in that sport have been referred to other initiatives like employment programmes and health projects as well. That has been quite important. From a community cohesion point of view, sport has been very important to us in the NDC. The other programme or the other project, if you like, would be the community engagement team who work in the community resource centres. They have been particularly effective at not only engaging with the community board but they have also been very good at developing partnerships with organisations in the area as a reflection of that activity, as community resource centres have a lot of organisations from church groups to health activities operating under one roof and they are very skilled in their community involvement work. They also undertake a lot of training as well with the management committees of the centres and the boards as well. Those are the two projects I would highlight.

Q395 Dr Taylor: Do you get help from some of your local sports clubs?

Mr Sharp: Yes, we do. We are working very closely with West Ham Rugby Club. We are also developing the park, in terms of new sports pitches and a play orchard for children and a new pathway and a new lighting scheme. The rugby club have become very involved with us, yes, to encourage more people to take part in rugby.

Q396 Dr Taylor: Would you agree with one of our expert advisers who feels that the sort of picture of the aggressive, tough, risk-taking male is something that is bad for their health in the future and that you should be trying to get away from that?

Mr Sharp: There are ways that you could potentially turn that to a health advantage. I think role models could be looked at more, in terms of health, which make healthy risk-taking, if you like, attractive to young people. With young people risk is always part of the culture anyway, so you need to think about how you treat that, but certainly there is more that could be done. We have examples of role models we have used in the area that young people relate to but also give a healthy message.

Ms Naylor: We have been very fortunate at Barkerend, inasmuch as we have had the benefit of a team of health workers who have been integrated with the project, so we have been able to innovate quite a lot of different activities, whereby professionals and non professionals can work together with different groups of people in the community. Quite a lot of the various activities we have done have yielded quite a lot of good outcomes for people, but, in particular, professionals working with paraprofessionals (people who have been trained but do not necessarily hold professional qualifications) ----

Q397 Dr Taylor: Lay people who have been trained up, like Frances's community workers.

Ms Naylor: -- can go into family homes and other outreach settings and talk and work and engage with people, probably outside professional settings. That has also been beneficial because it has enabled those groups in the community to access services which they would not otherwise access, or enabled them to sustain intervention in different projects. That has been very beneficial but it has been resource intensive and expensive.

Q398 Mr Bone: My questions are really for Pauline, Richard and Frances. What are the major problems and barriers you have encountered in your work?

Ms Naylor: I have been involved in this particular project since inception, so I have seen the development of it and my role in it has changed in that time. I have seen the impact of a strategy which I personally have a lot of commitment to - because I do believe in the potential of working with children in the early years and the parents in the early years, particularly parents in need. It really has been a roller coaster of, "Here's the money, get this organised and have outcomes immediately." As managing supervisor in that, recruiting staff, training staff, embedding them, building a sustainable team, engaging with clients and creating major outcomes in a year/18months/two years has been a real challenge. It takes about two years to try something. If it does not work, rethink it, review it, try something else, and, if it does not work, try something else. We have not had the time to really make mistakes, try things and embed good practices, before we have been expected to change the strategy, change the targets and work towards different outcomes. I think that has been really challenging and it has resulted in quite a lot of waste of funds as well. If I could have done things differently, had the space and time to design and think about it and implement it, I think it would have been more cost effective than it has been. That has been a challenge. Also, we are expected to make radical changes for families - major, major changes. The sorts of inequalities that I see on a daily basis in this particular area of Bradford are enormous, are fundamental. Working with a two year old for six months or eight months I do not think is necessarily going to make a massive difference in a year or two years.

Q399 Mr Bone: I used to live in Pudsey. Do you have a breastfeeding group?

Ms Naylor: Yes, we do.

Q400 Mr Bone: What are the external barriers? My Sure Start in Wellingborough has a very good breastfeeding group but most of the major stores in my area do not have proper breastfeeding facilities. You can have a good unit - and it is exceptionally good in my Sure Start - but it can fall down by that standard, so are there external barriers?

Ms Naylor: There are: culturally, socially, environmentally. In Bradford in particular, Bradford Community Trust and Bradford PCT are adopting a friendly policy. They are trying to implement a universal policy across the whole district and, occasionally, we come together to information sessions and inform. We work together really to change the culture. We go around all the shops in our local area and talk to the owners and talk to them about what we are doing and why it is important. You have to do that. Just working with a group of parents in their home or in the centre is not going to enable them to go out down the street and get the kind of support that we might need to sustain the sort of activities we want them to do.

Mr Sharp: Certainly we have excellent NDC programmes that we were looking to mainstream. A particular one was with the PCT. The PCT were facing quite drastic cuts/overspend, however you want to word it, and are now having to prioritise their services, and, unfortunately, one of the health programmes we were looking to mainstream could not go ahead. That is sometimes quite frustrating because organisations have different priorities and, unfortunately, as much as we would like to think so, even with good evidence we are not always a priority in the overall scheme of things. That has been something that occasionally has been frustrating, not just in health but across other services as well. Also, sometimes you can build up a fantastic relationship with individuals in organisations. It is not always meant to be like that. Often you get a lot done and they leave, and then you have to start all over again. That can be quite difficult. Different organisational cultures and different perspectives and priorities are often quite difficult really. Sometimes you have to understand what the competing priorities are and get to the heart of that. Because we have also been there since 2000/2001, there has been a process of partnership development, so it easier now to have a common agendas and common aims. I think that has a lot to do with the work that is being developed. In the first two years it was quite difficult, because people did not know whether you were in New Deal or if you were part of a local authority and who you were working for. There was not any formal training for that, so you had new teams starting off, and, as my colleague said, there was a lot of time wasted. It has been identified that lessons can be learned from that. I am sure it has been picked up in the national evaluation that Sheffield Hallam has done as well. I think that still continues in developing new partnerships but you can look back on previous successes in the stakes and draw from those.

Ms Rehal: In the early days of our programme, it was flagged up as a particularly challenging programme at the department because of the differences of opinion among the partner agencies as to what Sure Start was. There were, I think it is accurate to say, quite fractious local politics on the estate, because the estate had been neglected for many decades and now there was funding coming down directly into the estate and partner agencies were having to agree on how much would be spent. So the early days of the programme were extremely challenging. At times it felt as though there were as many people who wanted the programme to succeed as there were who wanted it to fail. There was this constant tension. As we developed the programme and focused on developing quality services and engaging parents and the community, that aspect of it dissipated. It was clear that the programme was going to be around delivering services and improving outcomes. There were major challenges when we introduced a community worker role, because there had not been any such role in the district and I think the community organisations felt very threatened by this change. There were tensions in relation to how the programme wanted statutory agencies to change how they delivered services, so there were tensions between the different agencies, but that improved as it was clear that we were able to reach the local community. Over time we had 32 parents trained in parent breastfeeding support, so that voice was then being heard, and that was able to steer the programme and the voices of others who perhaps had been sceptical became quieter over time. It has not been easy; it has been very, very challenging. As we develop our services now for teenagers, those challenges are coming again, because that age group and the providers and the commissioners of that age group have not experienced the integrated approach that is in our programme in terms of the younger age group.

Q401 Mr Bone: The next question is about children centres and the health inequalities they are not able to address. In my area we have a really good, modern Sure Start. It is airy. You go in there and there is enthusiasm and it is successful - in fact, it is the first place MPs were invited to, it was the first visit I ever made, and it was very impressive. That is on one of my difficult estates. The children's centre has been tacked on to a school - it has taken a bit of playground - and there is not the same enthusiasm or sense when you go there. They tell me that they cannot reach the hard-to-reach people. The people who are using it are not the people we would be addressing as suffering from health inequalities. The Sure Start centre, however, is universal, but it is in an area where it manages to attract people from all social groups. How do children's centres deal with health inequalities and are the people they reach the people they are trying to reach?

Ms Naylor: For Bradford it will mean 33 children's centres, as opposed to eight Sure Start local programmes. It will mean that other parts of Bradford will get access to this funding where previously it was post-coded within the Sure Start Barkerend catchment. Bradford has a mixed economy of children's centres, so there will be children's centres based on Sure Start local programmes in a new build similar to the one that I am in, as well as attached to nursery schools, as well as attached to primary schools. I feel that there is the potential there for spreading good practice more widely across the Bradford district and for those various different organisations it will mean more opportunities to engage with more people in need in their local community.

Q402 Mr Bone: Where Sure Start was clearly successful. Some Sure Starts feel threatened by the children's centres programme but is it almost as if the Government is saying, "We are going to roll out these children's centre because that sounds like a good idea and it is going to reach the whole community," whereas it is probably not reaching the hard-to-reach people.

Ms Naylor: There is an emphasis on the hardest-to-reach. There is guidance centrally to support programmes, to look at how they need to engage with the hardest-to-reach. From a personal point of view, reaching the hardest-to-reach is very costly and very resource intensive. It requires a lot of bodies, it requires a lot of time and a lot of energy, and I fear that the level of resources will make that impossible. For an organisation like Barkerend, which has had the resources to work very closely with a number of health professionals and also had the resources to train and sustain a group of paraprofessionals who could go out to family homes and really engage with people, probably the sorts of people who were not likely on a regular basis to be walking into the centre, that will have to be reduced. That will have to be reshaped. I fear that in a community like ours that is going to be very challenging and I am balancing that against the fact that there may be another part of our district which probably has equally or slightly less inequalities and will have a little bit more resources to impact in that area. That is the strategy in B