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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

health committee

health inequalities

THURsday 22 May 2008

PROFESSOR ALAN MARYON DAVIES, PROFESSOR JULIAN LE GRAND
and DR SUSAN JEBB

MR PAUL JENKINS, MS SARANJIT SIHOTA and MS DEBORAH ARNOTT

Evidence heard in Public Questions 411 - 533

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 22 May 2008

Members present

Mr Kevin Barron, in the Chair

Jim Dowd

Sandra Gidley

Dr Howard Stoate

Dr Richard Taylor

________________

Witnesses: Professor Alan Maryon Davies, President, Faculty of Public Health, Professor Julian Le Grand, Chair, Health England, and Dr Susan Jebb, Foresight Obesity Project, gave evidence.

Q411 Chairman: For the sake of the record, could I ask you to introduce yourselves and state the position you hold, please.

Dr Jebb: I am Dr Susan Jebb. I am a scientist with the Medical Research Council Human Nutrition Research Unit in Cambridge. I was the science adviser to the Foresight Obesity Project and I currently chair the expert advisory group on obesity for the cross-government obesity team.

Professor Davies: I am Professor Alan Maryon Davies. I am the President of the UK Faculty of Public Health, which is a faculty of the Royal Colleges of Physicians of London, Edinburgh and Glasgow. I am an ex Director of Public Health in the inner city in London and I have a long interest in health improvement.

Professor Le Grand: I am Professor Julian Le Grand from the London School of Economics. I am Chair of Health England, which is an advisory board for ministers.

Q412 Chairman: Thank you. As you are probably aware, some of our members are evidence‑taking in Crewe and Nantwich today, so we are a little bit thin on the ground, but we should be able to see this session through all right. Could I ask an open question to all three of you: what three interventions would you prioritise to reduce health inequalities and what evidence base would you have for each of them?

Professor Davies: I would focus upon some of the key determinants which make a huge difference to health inequalities, and I would have to put at the top of my list smoking, which continues to be the big one. If you look at the differences between smokers and non-smokers in terms of health outcomes over a period of, say, 20 or 30 years, there are far greater differences than there are between the haves and the have-nots in terms of disadvantage, although there are important factors there as well. There are other important health areas where health inequalities really count for an awful lot. Obesity is another classic where the determinants are very largely around the social determinants of health and the environmental determinants of health as well. I think I would put those two as pretty key elements. We are talking here about disadvantage, so we have tended to focus on inequalities in terms of health outcomes, and of course the NHS is predominantly concerned with health outcomes, but I think we should really shift the magnifying glass and focus more on health inequities, on unfairness, on disadvantages. If we can reduce the many disadvantages then we will reduce health inequalities.

Professor Le Grand: I would strongly go along with that. If you look at the international comparisons on health inequalities, internationally England does not do too badly. Oddly enough, places like Scandinavia have the greatest health inequalities. That is largely because the distribution of risk factors, like smoking and, indeed, obesity, is very unequal there. In other countries, where all social classes smoke, so to speak, you get much more equality of health. It illustrates, in a way, the importance of focusing on risk factors like smoking, like obesity, for dealing with addressing the health inequalities problem. On your second question about what works, that is more difficult, of course. Working out ways of stopping the poor smoking is very difficult. The extra point I would make on obesity is that, so far as I can see, most of the evidence is not so much that people are overeating - there is not a great deal of evidence that there is a great increase in calorie intake - but there is evidence for a fall in calorie output and calorie expenditure through exercise. There is a fairly dramatic fall in that, and that is probably the area we should focus on.

Dr Jebb: I totally concur with the importance of addressing smoking, but since my expertise is primarily obesity I shall focus in on that. We have to recognise the importance of the wider environment as a determinant of individual behaviour. We have spent much of our time focusing on work in relation to reducing health inequalities, focusing on individuals who experience some of the most significant difficulties. There is a growing acceptance that if we change some of the wider environmental determinants we will have a disproportionately bigger impact. There are two specific examples I would give you where I think perhaps we could make substantial progress. The first I choose not because it is necessarily the most important but because it is the one where we are on the verge of a breakthrough, and that is in relation to front-of-pack labelling in foods. I have been taken aback at the striking impact it has had on purchasing habits, regardless of which scheme is used - certainly far greater than I have seen in interventions done by health professionals. Interestingly the research done by the Food Standards Agency to compare different schemes showed very clearly that, although, on average, both schemes currently in use improve understanding, the benefits for people in the less advantaged groups was significantly greater if we used the colour-coded multiple traffic light scheme. It seems to me that is a specific example where we could have a much clearer emphasis on a specific policy that did not disadvantage anybody but particularly offered benefits for people who suffered the greatest inequalities. On the physical activity side of things, building on my environmental determinants theme, we do need to do more to develop active transport policies. Too often on physical activity in relation to obesity there has been an emphasis on sport, gym memberships, and all these sorts of things which we know are taken up by people with higher incomes, from a higher social class. If we turned our attention more firmly to the active transport issues we would perhaps see some contribution to widening inequalities.

Q413 Chairman: The Government have taken on issues about getting individuals to go to the gym and weight-loss programmes and things like that. Do you think that is one of the reasons, with it being done on that basis, that we are not seeing a closing of health inequalities in the UK? Does that not work?

Dr Jebb: First, the level of investment there has been in individual-focused interventions has still been far too little in relation to the scale of the problem. One of the reasons it is not working is that we are not putting sufficient resources into it. That is particularly true if one considers the effort put into tackling obesity in those people who have an established weight problem. However, I think it is also fair to say that when you have a problem which affects so many people, the scale of coverage that is necessary really argues very strongly for moving towards a much greater focus on environmental determinants.

Professor Davies: Labelling is a very important point. The GDA labelling system is discriminatory: it actively disadvantages people who are less able to interpret it. It is very complex. It has another fundamental fault: it only applies to the average adult. How many of us are the average adult? All the children are not average adults, for a start, so almost on a trade description basis it is a falsity. On the active travel point: crucially, we should be trying to encourage the mass of the people to be more active, but that means we would have to put more money into buses and trains, into public transport, as well as encouraging walking and cycling. We would have to make walking and cycling safer, through all sorts of mechanisms, but we would also have to encourage public transport. That will mean macro decisions around third runways and the whole business about reducing end travel, so I think it goes very wide indeed.

Professor Le Grand: I would slightly disagree with my colleagues here, not so much on the specifics of what they are saying but because I think there is something of a danger of focusing too heavily upon the social environmental determinants of health inequalities. The danger is that it makes the problem look so large that it almost inspires a kind of nihilism, in which you say, "Oh, my God, there's nothing we can do short of a massive revolution in the way we organise society." Both Susan and Alan have mentioned highly specific ideas, many of which I would support, but there is a slight danger that if we construct the problem as a massive social and environmental problem we take our eye off the ball about some specific measures that really could change things, even if they are focused more on the individual than they are upon society.

Q414 Chairman: Do you think individual behaviour does work or should work?

Professor Le Grand: Yes, I do. I think you can change individual behaviour. The classic case is price rises. Taxes on cigarettes we know work. There are problems, there are problems of regressivity and so on, but we do know that that kind of incentive structures work. Some of the work we are doing in Health England, which is this ministerial board advising ministers, is looking at some direct economic incentives for encouraging people to take up preventive care of various kinds, with vouchers for good food and so on, and the evidence tends to be that it does work.

Professor Davies: It is not either or, is it? We have to cover all these bases. Quite a useful model, I find, is what I call the three-Es model. You have to engage with people. That is the first E: engagement, on an individual basis as well as a population basis. You engage people: you get them to be aware of the problem, to understand the issues, to understand the risks they may be running, and to take on board the messages about improving health. Then you have to empower people as well. That is the second E: empowerment. You give people the life skills so that they can make these choices. They know where to go, they know how to speak the language, they can make use of what is out there, they have the skills to take advantage of their engagement and their knowledge. The third thing, as Susan has been saying, is the environmental impacts. That is the third E: environmental impacts - not just the physical environment but the social environment, the economic environment, the cultural environment. I think you really need to tackle those three Es in order to get a grip on health inequalities.

Q415 Chairman: Susan, I hear what you have said about labelling. Some of my parliamentary colleagues are looking for going after food a lot more than just front-of-pack labelling. You will have seen a private Member's bill that was tabled just a few weeks ago to cut back on the advertising of what is deemed to be junk food. Julian mentioned tobacco taxes. Do you think clamping down on the promotion or marketing of so-called junk food is something that ought to be done as an upstream measure as opposed to waiting for everybody to change their individual habits?

Dr Jebb: It is certainly part of an overall strategy. On its own, it would be wildly optimistic to imagine that restrictions on advertising are going to make the nation slim, but it is a critical element in a broader package of measures. When Foresight was considering what a strategy to tackle obesity might look like, we talked about three kinds of initiatives. There are very focused interventions, where you just go in and change something: transforming school food, for example. There are enabling initiatives, where you essentially empower people, through examples like labelling, where people can make those changes for themselves. Thirdly, there are what we have described as amplifying initiatives, and that is where things like the restriction of advertising to children comes in. These begin to change the social and the cultural norms in which people are acting and making decisions. It is part of an overall strategy. Within obesity the one thing we have learned is not too put too much weight on any individual component: what matters is the synergistic package.

Professor Le Grand: When I was working in Number 10, I was amused at the stream of advertising agencies that would come through desperate to persuade us not to ban the promotion of junk food, saying, really, that advertising does not make any difference, and then next line would be: "But we could help you with a good health promotion campaign." They never seemed to be quite aware of the contradiction between advertising being very effective at health promotion but totally ineffective at producing damaging health behaviour. The best evidence we could find was that the ban on advertising tobacco reduced consumption between 2% and 5%. That does not sound very much but is not trivial. I would have thought that a ban on the promotion of junk food would produce a reduction of that kind. It would not be the total answer, of course, but it is something worth considering.

Professor Davies: I think there are real practical difficulties. It is a nice idea in theory but there are real practical difficulties in making that work. Possibly we could extend the traffic light scheme to menu labelling as well, so that people who are eating out in various food outlets would see at a glance what is in the meal they are having. So much food is now eaten outside the home or brought back and eaten in the home that it is crucial really to be able know what is in the food. That is one example. On the social marketing theme, it is not just advertising, of course. Social marketing these days adopts a much more aggressive approach. It starts from where the person is at, gets into the culture of the people and gets into their heads in terms of what is in it for them, as it were, and becomes a much more comprehensive science, working with communities as well as simply directing advertising. It has a part to play, therefore, but nothing like the part that is needed to change the fundamental social determinants of health.

Dr Jebb: On the subject of food, the best example of the balance between individual and environmental is over whether you encourage people to choose lower fat foods - in which case we know there is a disproportionate uptake of that in the more advantaged groups - or encourage manufacturers to reformulate to reduce the fat content of foods across the board? Using a similar model, we have seen the impact you can have with salt. That has been tremendously beneficial. It is continuing to improve and it has been across the population. That is perhaps the best example of what can be achieved by interventions which do not rely solely on individuals making active choices to change their own behaviour. Clearly, as we have said earlier, it is not either/or, and encouraging and motivating consumers to look out for those lower fat, lower sugar, lower salt varieties, is going to be part of the overall mix, but reformulation has been key to reducing salt intake.

Q416 Dr Stoate: I have a couple of points for clarification from Susan. First of all, I agree entirely with the traffic light scheme, which I believe may explain why some of our larger supermarkets and food manufacturers are so reluctant to accept it. That is a point worth putting on the record. My main concern is on something Julian raised, this idea that there is no evidence that calorie intake has increased. My understanding is that because so much food now is eaten outside the home, by people snacking on their way to and from school, et cetera, an awful lot of the research up to now has not been that accurate and in fact calorie intakes are going up. I think this point needs clarifying.

Dr Jebb: It is extremely difficult to clarify it because the evidence which we have is so weak. It is incredibly hard to get accurate information on what people currently consume. The evidence is that, since a peak in the 1970s or so, energy intakes have declined a little, but there is also evidence that people are increasingly likely to underreport their food intake as they become more weight conscious and, indeed, as more people become overweight. We know that overweight people underreport to a greater extent than lean people. I do not think we should be reducing this down to individual calorie balance. If we try to tackle obesity either by diet or physical activity, essentially we are tying one hand behind our backs. The relative importance is going to vary for different individuals and we should tackle both at once. It would be wrong to take food out of the equation because we have not seen any substantial increase. Also, it is not just about total calories; we are talking about the overall balance of the diet. Poor diet contributes to obesity but it also contributes to coronary heart disease and cancer through mechanisms independent of weight, so diet quality matters too. Where people are getting those calories from is critical.

Professor Le Grand: The data is extremely difficult to interpret. It is often self-reported consumption. There is also data on food production and that gives slightly different messages, but, on the whole, it tends to be best applying the fat that is in the calorie intake - which is also in the United States, surprisingly. Of course that does not mean that one should not focus on diet. If we have exercise falling/calorie output falling, then if we are not going to get an increase in obesity we need to have calorie input falling too pari passu. Ideally we would like to focus that exercise back up again, but if we are not going to be able to then we have to focus on diet.

Dr Jebb: Exercise is not continuing to fall. Exercise has fallen substantially, physical activity, but it has almost certainly plateaued out and may even be increasing slightly because, to be honest, we could not get any less active than we were!

Q417 Dr Stoate: Speak for yourself.

Dr Jebb: As a nation. There are fewer manual jobs, lots of cars, we reward ourselves for a hard day's work by sitting in front of the television. We could not go much slower. The messages about being physically active are beginning to be taken up by sub-groups within the proposal and I think those are beginning to affect the overall average. We have seen a discord between changes in diet, changes in physical activity and the two add up together in rather complex ways which are hard to measure to give us the burden of obesity and, indeed, other chronic diseases that we see today.

Q418 Jim Dowd: To follow that up, both Dr Jebb and Professor Le Grand have mentioned the paucity of evidence. When we did the obesity inquiry, it was not just about whether there was a paucity of evidence but the different interpretations that were put upon the same evidence. Perhaps I could ask Dr Jebb this question. I read a summary of a risk report the other day, and you are an expert in this field - had I known it was going to come up in this form, I would have brought it with me. It was looking into childhood obesity in particular and it said that, the level of activity amongst children across the piece, whether from well-off backgrounds or less well-off backgrounds, was virtually identical and yet the propensity for obesity was very much towards the lower end. Surely that indicates that you can virtually take the activity factor out and it is not just about calorie intake but the balance of diet towards the lower end of social background.

Dr Jebb: I would caution against taking physical activity out of it completely because of the real difficulties in measuring this, but you are absolutely right: using the techniques that we have, overall physical activity levels do appear to be rather similar in children, particularly in young children, because of their natural, innate activity. What is clear is that the nature of activity is very different. Children from higher social class backgrounds are more likely to be driven to a physical activity, where they go off and do their football or rugby or ballet or whatever, whereas children from lower social class backgrounds are more likely to be playing and in much more unstructured play. Therefore the nature of physical activity is different, but you are absolutely right that overall differences in physical activity do not appear to be the major determinant of difference in childhood obesity.

Q419 Dr Taylor: My questions are really for Alan, for the moment, concentrating on public health. I think we have all seen more and more combined appointments of directors of public health between local authorities and PCTs. What is the evidence of the effectiveness of this sort of joint appointment?

Professor Davies: It is a very difficult to answer that in terms of effectiveness. Where those joint appointments are happening, we can say that it is crucial they are sitting at the top table, as it were, on both sides of that equation. I am disappointed to see that some directors of public health who have been appointed to joint posts with local authorities are not reporting directly into the chief executive, and are not of a sufficiently senior level in the local authorities to be able to talk to the other directors of the other parts of the local authority and therefore do not have the clout to do that joining up. The crucial role of directors of public health is in terms of making those joins across the system, not just within the NHS and the local authority of course - both of whom have huge impacts on our health inequalities or health equity - but also linking in with the voluntary sector, which plays a crucial part in this in helping disadvantaged people, and the commercial sector as well, which can put in resources and has large workforces which can be brought to bear. I think that joining-up function is fundamental. It is probably too early to say yet how well that is working. You could hark back to pre-1974, in the old days, when of course the equivalent of the director of public health was the old MOH (medical officer of health) employed directly by local government, and a lot of people think back to the golden days. Well, times have changed, the world moves on, but I think if you can get back to a position where directors of public health do have real clout across the system, we will see some real effects there. Quite a lot of money is going into prevention and into health improvement and health promotion. We want much more - I say that straight away - but it will not be effective unless you have proper co‑ordination and proper joining up. That is when you need effective directors of public health and solid, well-resourced teams to back them up.

Q420 Dr Taylor: One of the worries when we lost the medical officers of health was that the new directors, because they were executive directors of various bodies, were going to lose some of their independence. Has that been borne out or are they still able to represent the needs of the public health of the people powerfully?

Professor Davies: I think it would be useful to try to enshrine the role of providing an independent report on the health of the people in law. It is written in various reports and White Papers, but how firmly is it enshrined, I am not sure. My understanding is that it is not very firmly enshrined. One thing we might get on to at some stage is the notion of perhaps having a new Public Health Act, one of the measures of which could be to firmly enshrine that role of a local director of public health to produce an independent report. The difficulty is always, of course, that you are also a servant of two masters: you are reporting to a chief executive who is meant to be delivering on what you are being critical about and there are real conflicts in there. It does need looking at and resolving.

Q421 Dr Taylor: In an ideal world you would want somebody with a lot of clout right at the top and maintaining a degree of independence somehow.

Professor Davies: Somehow. Is that feasible? I do not know. Both those functions need to be done. We need to find a mechanism whereby both those things happen.

Dr Taylor: I do not know how widespread it is but certainly non-medical directors of public health are being appointed. Are these sorts of people as good, better, or not as good? Or different?

Q422 Dr Stoate: They are certainly different.

Professor Davies: Well, they are different and not different. They have to demonstrate their competencies. Whatever background they come from, be it medical, nursing, pharmacy, health economy - you name it - in order to be a director of public health they have to demonstrate their competencies at certain levels. This is something in which the Faculty of Public Health is particularly involved. They are demonstrably competent at the role which they are given - at least, that is the theory. It may be that for some reason or other a medical background is required for specific functions within that, but just to be a director of public health you do not need to come from a medical or even a clinical background. As long as you know where to go for that advice and you can have that advice applied to your role, then that is fine. In other words, you may not know yourself but you know somebody who does.

Q423 Dr Taylor: Is thee any evidence to say they are as competent, as effective?

Professor Davies: That work has not yet been done. We did apply for some funding to try to do that sort of analysis and we are still awaiting to see whether or not we get that funding.

Professor Le Grand: The real question about the power of the public health professional is not so much their training but whether or not they hold a budget. Basically, they do not hold a budget - or they hold a diffuse budget in some cases. I am becoming increasingly of the view that you have to either ring-fence some form of public health spending or engage in an explicit incentive mechanism to encourage PCTs or local authorities to spend on public health measures. We have been looking at ideas such as matching grants, for which the Department of Health holds back some money and then offers a matching grant to PCTs to engage in public health programmes of various kinds. I think we have to consider that kind of thing; otherwise, public health monies will always get swallowed up by the acute sector in a way that has happened historically.

Professor Davies: The Faculty of Public Health has conducted surveys of its senior workforce. Over the last several years there has been a drifting away, a loss of senior people with a lot of experience in public health, which is a tragic waste. We have to reverse that trend. Part of that is being caused by the repeated reorganisations and, of course, all the turmoil in the system and people losing confidence and morale, but if we can have a relatively steady state and if we can build up capacity to what is required, particularly in terms of the supporting teams that Julian has mentioned, then you can ask the question how effective are these Directors of Public Health, and they are only as effective as the resources they have to do stuff.

Q424 Dr Stoate: Alan, you have suggested that public health spending has fallen in the last few years. What evidence is there for that? What effect do you think it has had?

Professor Davies: The figures we have were based on the figures of the Choosing Health investments of two or three years ago now, where, of course, if you remember, there was a crisis in the NHS, there was a massive deficit, and there was a bit of panic in the system. Inevitably, the first things to get chopped, to put it bluntly, are these preventive health promotion soft targets really. You can wave the shroud around heart disease or heart disease services or cancer services or any kind of patient care. It is more difficult to wave the shroud in terms of prevention and health promotion and these initiatives tend to get the chop. We do have hard figures that show a lot of the Choosing Health monies, in particular, simply disappeared.

Q425 Dr Stoate: Assuming that is put right - and hopefully it will be - how will you ensure that the extra investment will make a difference?

Professor Davies: This is where the Healthcare Commission and its successor body should be important. You have to look at what those monies are invested in and how they work through the entire potential workforce. We need to train up a lot of health visitors, nurses, doctors, pharmacists, all sorts of frontline workers, to have the sort of mindset that speaks in terms of prevention and health promotion, so that they think, "What can I do in my job? What are the barriers facing this person sitting in front of me to achieve health and access to health care? What can I do to reduce or remove the health barriers that this person sitting in front of me has to get through for better health?" We have to deal with that mindset. We need to deal not just with the problem that is sitting there but with what is behind the problem.

Professor Le Grand: On the figures, the last time the UK estimated how much money we were spending on preventive health measures of various kinds was in 1999, when we submitted a record of this to the OECD. One of Health England's tasks is to try and work out exactly how much we are spending - it is not easy - and to start increasing our reporting to the OECD. Other countries manage it. A second part of the task is to work out whether we are spending it on the right things and, if not, to try to prioritise what we should be spending it on. We are due to report at the end of this year on that, when hopefully we will get a bit further on that.

Q426 Jim Dowd: Why do you think the acute sector has so much more ability to lever in public money - whether it is growing, diminishing, or on a plateau - than the public health sector?

Professor Davies: People immediately think in terms of: they have a health problem, they need it to be fixed, and the services have to be there to deal with that. That is crucial. It is harder to lever money into the preventive services, but we are recognising that. There have been successive government reports that recognise there has to be a shift of resources into the primary care and pre-primary care health promotion type services. That has been recognised: Our Health, our care, our say for instance. The reality is lagging behind that and that is partly because of the payment-by-results approach, the whole choice agenda in terms of people choosing acute services. The whole of the financial system is geared to rewarding hospitals for doing work, and there is a drag in the system, if you like, in terms of trying to shift the emphasis and shift the resources into the primary care prevention agenda. I think that is something that has to happen. I would hope the Darzi Report will do a lot to try to address that - I will be very disappointed if it does not - but it is really hard to pull resources out of acute services. That becomes very difficult indeed.

Dr Jebb: It also reflects a public mandate. Alan referred to that a little bit in terms of a public priority on acute services. Also, if we think more specifically within the health promotion/public health arena, the people who are the most vocal in that perhaps have the least to gain from the public health measures. That is very pertinent for this particular inquiry into health inequalities, in that the people who may gain most from the health promotion benefits are perhaps the least vocal in getting that attention.

Q427 Jim Dowd: Is it also the case, across the piece, that with public expenditure generally - not just in health but right across the sector - everybody believes in the notion that prevention is better than cure, but that is not the way public administration works and that is not the way the public judges it. If you try to show a negative (namely, that we have stopped so many people getting heart disease) that does not impact in the same way as the first heart transplant or the latest technology. Can you help us with that particular conundrum? How much of it is to do with the way the medical profession itself is organised and sets its own priorities?

Professor Le Grand: There is a kind of structural problem which is not easy to resolve. The benefits from most public health interventions accrue a long time in the future, whereas the costs are immediate. For instance, when you are a PCT and trying to decide whether to engage in some resource-intensive public health programme that is going to pay off with reduced heart disease and so on in 20 years time, versus bailing out your local acute trust that is in difficulties, it is pretty easy to see which decision you will make. If you get down to the level of the individual making the decision, he or she will not be in their job in 20 years time, or the PCT may not be in existence in 20 years time. The immediacy of the benefits from engaging in acute provision militate against investment in much longer term pay-offs and benefits. I am not sure there is an easy resolution of that, but it suggests that we ought to be trying to think of ways of bringing the benefits forward so that they impact directly on the relevant decision-makers now.

Professor Davies: Something which might count at the ballot box - which is germane - is the notion of there being some value in well-being, in the feeling of well-being, in feeling good. We are not very good at that in this country. The Californians seem to be hooked on that. Although MPs have been elected simply on the basis of whether or not they support or are against the closure of a local hospital, increasingly there will be something in the whole notion of creating a society which feels good about itself, feels good about life and feels vibrant. We just have to find a way of valuing that, so that it is an immediate factor when people are there deciding who they are going to vote for or what policies they are going to put in place nationally and locally. It is a difficult thing.

Q428 Jim Dowd: Somebody being elected just over a local hospital? I find that difficult to believe!

Dr Jebb: On a slightly different point, but relevant to the health equality issue: the tensions we are discussing in the healthcare system are really just one of the reasons why tackling inequalities by just putting all the emphasis on the role of the Department of Health or the NHS is going to constrain our ability to make progress. It is only when we move beyond the NHS that you can start to address it more comprehensibly. The fact of the matter, as we have heard, is that the NHS picks up most of the costs but has very few of the levers for change if one starts to think about the underlying determinants of some of these risky behaviours and look at the inequalities in health.

Q429 Jim Dowd: Professor Davies, you stated in your submission to us that health promotion and preventive ... Why is it not preventative?

Professor Davies: I can answer that. The noun is "prevention" not preventation; so the adjective is "preventive".

Q430 Jim Dowd: Professor Davies, you are making the mistake of taking my questions literally and seriously! Anyway, you say, "health promotion and preventive efforts in the community, many of which are channelled through primary care, require a massive investment to be effective". I presume "massive investment" means a lot of money.

Professor Davies: Yes.

Q431 Jim Dowd: Do you think such an investment would be cost-effective? How would you measure the benefits?

Professor Davies: The whole business of measuring cost-effectiveness is extremely complex. One answer to that, which is a slightly evasive answer, is that we need to look hard at the research agenda in this country. We need to look hard at where we are putting our money around research. A key element we need to build into the research programme is looking at these prevention and health promotion services per se, because those tend to be ignored, but specifically putting money into looking at the cost-effectiveness and the cost benefits of those interventions, particularly in terms of complex systems, because, as Susan and Julian have been saying, these things do not work in isolation; they are part of a complex approach which hits in many ways: encouragement, empowerment, environmentally. It is coming at people from all angles. To study the effectiveness of those rather global systems is really difficult but we have to do that if we want to see whether these approaches work. I would say that we really need to shift the research agenda and make sure that we look into these complex systems, and, within that, put much more research into social anthropology, the anthropology of choice, how people make decisions about their life. There is precious little research going into that sort of area and I think we need to build that up.

Dr Jebb: I am no economist, but my reading of the Wanless Report was that there was an economic case for investing in prevention and public health at a much more fundamental level than we are doing at present.

Q432 Jim Dowd: Is the problem with it not a structural one? Is it not all jam tomorrow?

Professor Davies: Yes, but tomorrow becomes today fairly soon. Historically, if we had put money into prevention over the years, we would be reaping the benefits now.

Dr Jebb: We also have to consider the costs of inaction. If we think of the burden of, for example, obesity, but also smoking-related diseases on the NHS, if we fail to take action to prevent that now, those costs are going to simply become unsustainable in relation to the National Health Service. So there is a cost of inaction which we cannot afford to miss.

Professor Le Grand: On this point about jam tomorrow, we tend to measure inequalities by the relative differences between the disadvantaged and the advantaged by definition. Of course, if all the effort put into the social determinants and the health determinants is working - and there is masses going in - then we are shifting people from being disadvantaged to being advantaged (or whatever the opposite is) and, therefore, when we try to measure an improvement, we are not measuring the same thing, because people have moved from one category into another. That is an inherent problem. I know in previous sessions you have looked at the targets and the indicators and whether we are measuring the right thing, but that is something we have to think about.

Q433 Sandra Gidley: Health England is looking at the cost-effectiveness of preventive interventions. This may be echoing the first question you answered, but, at this stage, which interventions do you think are the most likely to be cost-effective when it comes to reducing health inequalities?

Professor Le Grand: I do not think we have a good answer to that question. The Chairman asked at the beginning for our three priorities. My three priorities are similar to those of the others: smoking, smoking and smoking. If we could stop the poor or the less well-off smoking, I think there would be a massive dent in health inequalities. Massive. Quite how we do that is difficult. There is raising taxes. There are two problems with that. One is the problem of smuggling, which is already a very considerable problem. The other is potential regressivity, in that it hits the poor more than the rich. Interestingly enough, that may be a red herring. There was some evidence in the 1990s that if you raise taxes on cigarettes - and it is a kind of caricature - the poor stop smoking and the rich carry on. Oddly enough, the tax increase is progressive not regressive: it hits the rich more than the poor. By raising taxes, it might be quite effective in stopping smoking, if we can cope with the smuggling problem.

Professor Davies: I do not have the figures to hand, but another area where we can get very high levels of cost-effectiveness - and smoking is obviously crucial - is in our work with mothers and babies and young children. The inputs are expensive and they will have to be focused on disadvantaged people but the benefits accrue over a lifetime. They are hard to measure and it is hard to get the data because of the sheer length of the issues, but we can be fairly confident that those benefits really do mount up and far, far outweigh the costs in terms of the input.

Q434 Sandra Gidley: I am slightly confused. Health England is looking at the cost-effectiveness of preventive interventions, but I thought NICE had a public health remit now and was looking at some of this as well. Why do we need Health England?

Professor Le Grand: We are working with NICE. The Chief Executive of NICE is on Health England. Health England's task is not to work out cost-effectiveness. Our task is, first, to try to assemble all the relevant evidence, including that produced by NICE, about what is cost-effective and what is not, and, second, to prioritise the various interventions, which NICE does not do. Our third task - which, again, NICE does not do - is to try to keep going back to work out ways of incentivisng the relevant people to undertake the necessary behaviours. That stems from PCTs to employers to individuals themselves, in relation to how we change behaviour to engage in preventive activities of various kinds. All of that is well beyond the remit of NICE.

Q435 Dr Stoate: Professor Le Grand, you quote the Eurothine project, stating that co-payments will increase inequalities. Should we not abolish all co-payments therefore?

Professor Le Grand: Co-payments is an issue that a colleague of mine from Canada, Bob Evans, calls a "zombie": it is an idea that has been effectively killed but nonetheless comes back time and time again, year after year, to haunt the think-tank streets. Wales and Scotland of course have moved to abolish prescription charges. As it is, in England, about 85% of all prescriptions are exemption of prescription charges. The only people who pay prescription charges are people like me: white, male and middle-class.

Q436 Sandra Gidley: That is rubbish.

Professor Le Grand: I think there is probably a strong case for getting rid of them, yes, on general grounds and probably on health inequality grounds as well

Q437 Dr Stoate: You would advocate getting rid of them, basically.

Professor Le Grand: Yes.

Q438 Dr Stoate: That is very helpful.

Professor Le Grand: They will then come back to haunt me.

Q439 Dr Stoate: Exactly. Do not worry. We will make sure it does: we will not cease to quote you on this in the future. Just to move to another controversial area, the private sector's involvement: do you think the private sector to provide NHS services can have an effect on health inequalities?

Professor Le Grand: Not directly, in the sense that this is a provision issue. The reason for introducing the private sector is to promote incentives of various kinds to try to encourage greater efficiency and responsiveness throughout the system. Wearing my LSE hat, we have been doing a little work recently about waiting times - although I do not have published data on this yet. It used to be the case that essentially the middle-class waited less time than the poor, but, since the introduction of various market reforms, including Chase and payment by results and the introduction of the private sector, it looks as though that has flipped, so that it is now the less well-off who are waiting less time. Before that comes back to haunt me, let me say that this is very preliminary and we are not quite there yet. Intrinsically, I cannot see any reason why these kinds of market-oriented reforms would not benefit the less well-off, and, indeed, there is probably some evidence to suggest that they are.

Q440 Dr Stoate: You are saying, therefore, that investment in the private sector is reducing inequalities. Is that what you are saying?

Professor Le Grand: In combination with all these other changes that are going on, there are preliminary suggestions - and I need to be very careful here - that, yes, equity is improving.

Dr Stoate: That is very helpful.. Thank you.

Q441 Dr Taylor: There is quite a lot of pressure from some of the press that people who could afford it should be allowed to contribute towards their health care by paying for specific drugs. Is there any way that that extra money could be harnessed without increasing inequalities?

Professor Le Grand: No.

Q442 Dr Taylor: That is what I thought you would say. Moving on to choice: what is the evidence that choice helps to reduce health inequalities? Is there any?

Professor Le Grand: There is quite a lot of evidence that choice is preferred by the less well-off. It is interesting that there have been lots of studies looking at the various groups in society as to their attitude towards choice, both in health care and education. It comes back time and time again that, although in all groups there is a majority who want choice, the majorities are larger among the less well-off. It is the poor who tend to want choice. This is true in England, the United States, Finland, New Zealand. There is a very strong result.

Q443 Dr Taylor: Is this just because they feel they do not have it in any case; whereas the better-off have that choice?

Professor Le Grand: I think it is partly that. It is more related to the fact that on the whole the middle classes are quite good at manipulating ... perhaps that is a little strong .... at persuading non-choice systems or bureaucratic or professional systems to get what they want. We all know a doctor or a nurse or a manager and if we have a health problem - as, indeed, I have one at the moment - I ring up the relevant people and find out who is the best person and I try to make sure that I get there. The less well-off, the less powerful, see choice - indeed, as you have just said - as a means of trying to get the things that in many cases the middle-classes are getting already.

Q444 Dr Taylor: What you have said should reduce inequalities.

Professor Le Grand: It should. There is beginning to be some evidence that it is.

Q445 Dr Taylor: If you are going to have choice, you have to have increased capacity and you have to have proven supply of capacity to take it on, so what about cost?

Professor Le Grand: There is a question there. We are very effective in using our capacity as it is. Some interesting research looked at the year 2000, well before choice, and it found that something like 90% of the population was living within an hour's travel time of 100 available and unoccupied NHS beds and about 75% of the population was living within an hour's travel of 500 available and unoccupied NHS beds. This was at a time when there were massive waiting lists. It was extraordinary. We are not very effective in using existing capacity and when they introduced the choice pilots in some of the key areas, it led to a much better use of capacity. There was this surplus capacity not being used by the non-choice system very effectively, and so choice enabled a better slotting in of that. I am saying that choice systems can probably do better than non-choice systems as an effective use of capacity, but it is true that you will require a little bit extra capacity to allow choice to work.

Professor Davies: I think choice can introduce inequalities. I have one particular idea in mind. Where you have a city where you have a number of providers that can provide that service, you can have an effective choice arrangement. But in parts of the country there is very often only one or perhaps two feasible providers and there the choice menu is so much more limited. I think there are problems in terms of an urban versus rural disadvantage. We have not talked about that much. We have tended to talk about socio-economic status, poverty, et cetera, but there are all sorts of dimensions of disadvantage and urban/rural is an important one. I think that is particularly germane when it comes to choice.

Q446 Dr Taylor: So people living in large urban areas have more choice than people outside.

Professor Davies: Yes. There it should reduce inequalities in their situation but I think there may be problems in terms of rural communities.

Q447 Dr Taylor: By and large, in towns the capacity is there to absorb choice.

Professor Davies: I would say so.

Q448 Dr Taylor: Is it fair to say that choice is a social experiment based on inadequate piloting and wishful thinking?

Professor Davies: Is that a leading question?

Professor Le Grand: No, it is a social experiment based on adequate piloting and upon a strong intellectual foundation in terms of its theory.

Q449 Dr Taylor: Where was it piloted?

Professor Le Grand: We had several choice pilots. There was the cardiac choice pilot. There were the London choice pilots. I cannot remember the total. They were piloted and they were evaluated. There was a substantial evaluation programme undertaken by the Picker Institute and others.

Q450 Dr Taylor: I think it was Nick Timmins of the Financial Times who was one of the first people to recognise that really we had choice years and years ago and it is not anything new in fact.

Professor Le Grand: That is a different point. Indeed, in the old days, prior to 1991, GPs could refer to anyone they chose. But there was a crucial difference: the money did not follow the choice. The key thing under payment-by-results and choice cover-paid is that the money follows the choice. That is what gives it the incentive effect, to encourage the hospitals and providers more generally to respond to the choice decisions.

Dr Taylor: Thank you.

Q451 Jim Dowd: Professor Le Grand, could I clarify this question of co-payments of prescription payments. One of your priorities is to give the best part of half a billion pounds of NHS expenditure to the richest 15% of the population. Is that right?

Professor Le Grand: It would be a regressive move but .... There are some very interesting discussions about the effect of charges on whether it prevents people from receiving care that they need. The best evidence, from the Rand experiments in the 1970s, tends to suggest half in half: half of the use, they discovered, is frivolous, but half is really needed care. Yes, it would benefit the well-off in terms of money but it would also benefit the needy in terms of health care.

Q452 Jim Dowd: Is the second part through the fabled trickle-down theory?

Professor Le Grand: No. It is because some of the well-off are deterred from getting the care they need by the charges.

Q453 Jim Dowd: Really?

Professor Le Grand: That is what the evidence tends to suggest.

Q454 Jim Dowd: You submitted some data suggesting that total expenditure on public health and prevention in England is low compared to Canada, the Netherlands and the US.

Professor Le Grand: That was the 1999 data, yes.

Q455 Jim Dowd: Unfortunately, as soon as you include the US in almost any health data of any kind, it becomes completely skewed. Those countries generally, except for the US, have much worse health inequalities than we do in this country - even Canada, in some areas, and the Netherlands. Why do you think simply expending more is going to be beneficial when clearly those who are spending more than we are still have worse inequalities in many areas?

Professor Le Grand: I do not. Indeed, towards the end of our submission we make the point that health promotion or disease prevention and dealing with that is not the same as dealing with health inequalities. One of the problems is that many health promotion interventions and many disease prevention interventions worsen health inequalities. The classic case, of course, are the health education programmes of various kinds.

Q456 Jim Dowd: When you say worsen, is that because the more socially advantaged are the first people to take advantage of them?

Professor Le Grand: Yes.

Q457 Jim Dowd: But you cannot possibly be saying that no intervention is better than some.

Professor Le Grand: No, I am not. I am saying there may well be a trade-off between raising the average health of the population and widening health inequalities. That is not an argument, in my judgment, for not engaging with the programmes to raise average health. I think it is very important. I think there is a way through this, if I might say so. There does seem a real dilemma there, a real trade-off. One of the things that is a mistake, is to focus on health inequalities. One should focus on the absolute level of ill-health of the poor. One of the pieces of advice I gave the Government a very long time ago was that setting a target in health inequalities is almost certainly a mistake, because almost certainly you will miss it - and, indeed, that is exactly what has happened - because of the kind of phenomenon we have just been talking about. We should be targeting the absolute health of the poor, trying to drive on programmes that will improve the health of the poor, not worry if, as a result of those programmes, the health of the rich gets even better - because on the whole people are not going to fuss about that. We ought not to worry too much if we do get a widening of health inequalities, but we need to be sure that we are raising the level at the bottom.

Q458 Jim Dowd: It is a parallel with the idea about relative poverty. We live in times when the rich are getting much richer. The generality of the problem is that everybody is moving up, but it is just that the people at the top are moving up much faster.

Professor Le Grand: Relative poverty is different in some sense from relative health. There are real psychological issues about being at the bottom of the heap in terms of the income distribution which suggest that reducing the incomes of the rich might make people better off at the bottom psychologically and in various other ways. I do not think there will be a strong demand in this country for saying we need to reduce the health of the rich.

Q459 Jim Dowd: Presumably not amongst the rich anyway.

Professor Le Grand: Not among the rich. Which is why I think concentrating on absolute levels is probably more important in this context than income distribution.

Professor Davies: I think we should not be preoccupied with, as it were, the upper part of the curve. We are talking about the inequalities between the most disadvantaged and the median, and that is the key thing. We want to shift the health of the bulk of the population, in simple terms, but I agree with Julian that we have to focus on the absolute, on making absolute improvements, and not just for the poorest, because, as I mentioned before, we are looking at numbers of different types of disadvantage. We want to reduce disadvantage in all its forms and that means tackling the barriers and trying to close that gap. Inevitably, we will fail to close the gap, because people who understand the system and know which buttons to push and which levers to press will automatically do better - it is a target which is always running away from us - but if you focus on the most disadvantaged people and try to remove those barriers then we might get somewhere.

Q460 Jim Dowd: The whole premise of this inquiry that we are undertaking is completely misplaced.

Professor Davies: It has an unfortunate title, yes.

Q461 Jim Dowd: Smoking has been mentioned many, many times, for obvious reasons. Is not the difficulty - and you are all health professionals - that there is no direct link between smoking and ill-health and it is all based on epidemiology. You cannot say to somebody who is smoking, "You're going to die early definitely. You're going to get lung disease or heart disease or whatever" because not everybody who smokes does get that. Equally, people who have never smoked do get it. The epidemiology is sound - I do not dispute that - but the point is it is not individualised.

Professor Davies: It is on probabilities across populations.

Q462 Jim Dowd: The problem with that is that you cannot address the fact that my Uncle Bert smoked 100 a day and died aged 146, whereas Auntie Ethel never smoked and died at the age of 42.

Professor Davies: Yes, but you have not mentioned your other uncle who smoked like crazy and died of lung cancer at the age of 43. I am trying to say that if you look across the population, there are clear health disbenefits to smoking. Even on an individual, one-to-one basis, any GP will know when they are facing someone who is a smoker: they can hear in the way they breathe that they have the beginnings of chronic bronchitis, emphysema. You can hear it in the fruitiness of the way they clear their throat as they are talking to you. You can see that ill-health and that death happening in front of you, as it were. It can be very highly individualised.

Professor Le Grand: Not everyone dies from gun shots but it is a good idea to avoid being shot.

Q463 Jim Dowd: Let me make a note of that!

Professor Davies: During this hiatus, perhaps I could go back to the point made about the effectiveness on public health or public health specialists at the local level. It is important to grasp the concept that public health or prevention is not done by directors of public health or done by public health specialists. It is done by every frontline person, including the doctor facing the patient who is smoking. It is done by teachers in schools, by the town planners, by people trying to find jobs. It is a very broad church. The directors of public health and the public health specialist workforce are key players in helping to co‑ordinate all that work and join that all up and try to make sure that whatever investment does go into that, right across the board, is spent in an effective way.

Dr Jebb: I concur with the comments about focusing on increasing the health in an absolute sense, but that does not mean to say that when we are thinking about our interventions that we should not perhaps be at least considering the potential impact on health inequalities, and, as I said at the beginning, prioritising those which may have differential effects. That remains an important issue. My final comment is on the role of the NHS as an employer. The NHS employs more than three million people and the opportunity it has there to consider what its role and responsibilities are in relation to health inequalities is not being particularly addressed.

Q464 Sandra Gidley: I was supposed be asking questions on Eurothine data, but, as everybody else has indulged themselves on co-payments, I am going to briefly as well. Can we disabuse ourselves of this notion that it is the 15% richest who pay prescription charges. The 15% who do not pay relates to the total number of prescriptions, so if you think that the disproportionate number of prescriptions go to the elderly, a lot go to children, and take those out of the equation, a much more useful figure to be bandying around would be the proportion or the working population who pay charges. Rant over. Back to Eurothine data. Eurothine data suggests that relative inequalities in obesity in England are relatively low but relative inequalities in smoking are amongst the highest in all the countries reviews. I am not sure whether the absolute inequalities reflect the same pattern. Is anybody able to reflect on that?

Professor Le Grand: That is a good question. It is very important to draw attention to the distinction between the absolute and the relative inequalities. One of the reasons why Swedish and Norwegian data on health inequalities looks so bad is because when you take the relative numbers they are very good but the absolute gaps between mortality in Sweden are probably much less than the absolute gaps in the UK. That is a good question on the relative gaps in smoking. We will take it back and have a look.

Q465 Sandra Gidley: That is fine. Smoking and obesity were highlighted as two of the things that could be tackled the most. As we are looking at the relative inequalities, there is such a difference between smoking and obesity. What does that tell us, if anything, about the relative importance of which one we should tackle first? It is lies, damn lies and statistics, really.

Professor Davies: They both need tackling. I would not like to see us say, "Let's focus all our efforts in terms of health inequalities on smoking." I think that would be a huge mistake. We have to go for all these things. This becomes a practical issue when you look at, say, the QOF payments and what is the balance of QOF points in terms of smoking versus obesity or high blood pressure or diabetes. That is when you do have to start making some hard decisions about what weight you give things, so it is a germane question. I would not like to say. I do not know what the answer to that would be but it clearly needs looking at and a very careful judgment needs to be made as to how much we incentivise primary care, for instance, to put effort into tackling smoking or tackling obesity.

Dr Jebb: It is also important to recognise that many of the high-risk health behaviours cluster in individuals. People who smoke may also have a poorer diet and be less likely to be physically active. It may be that some of the interventions that are required to encourage and motivate and empower them to engage in more health promoting behaviours may be common across all of those risk factors. It may not be about specific information to stop smoking or eat more fruit and vegetables, it may be that a much more subtle approach is required which looks at much more attitudinal approaches to health and, in a way, the value people put on health and the extent to which they are prepared to take decisions today which are only going to have long-term consequences. Certainly we see this with parents in relation to feeding their children. The emphasis is very much on having a quiet life today rather than thinking about the long-term health consequences. That came out very clearly in some of the work the Department of Health are doing on their social marketing.

Professor Davies: Many diseases are multi-causal, and many causes, as it were, are multi-diseasal, so you have to have a comprehensive approach.

Chairman: I understand, Julian, that you have to leave at this stage. We have further questions to ask but they are not specific to you, so if you would like to leave that is not a problem. Thank you very much for your attendance.

Q466 Dr Stoate: The Foresight Report states that "tackling obesity requires a system-wide approach". How good is the Government in terms of cross-departmental working? Do you think that needs to be looked at?

Dr Jebb: Howard, you are better placed to comment on that than I am, but I think it is well accepted. The National Audit Office, the Health Select Committee report on obesity, successive reports, have criticised the lack of joined-up, cross-government working on obesity. Saying there was a problem I do not think was very revolutionary. What has been important is that Foresight, through its very complex system map, has really brought home to people the huge breadth of this problem and I am encouraged by the early signs and structures which have been put in place to facilitate some cross-government working at least in relation to obesity. My hope is that we can build on that, consolidate that, get some real progress, and it might then set a model which is also relevant for other areas of public health.

Q467 Dr Stoate: You are quite optimistic that the Government really can work together if it wants to.

Dr Jebb: I am more optimistic than I have ever been before in my career.

Dr Stoate: That is a careful answer.

Q468 Jim Dowd: That might not have been very much.

Dr Jebb: I think we have got to base camp. There is a much better acknowledgement of what needs to be done, both in terms of cross-government but also the scale of what is required. I think there has been too much emphasis on isolated initiatives in the past without recognising they need to be joined up and implemented consistently and over a long period of time. But doing it is an enormous challenge.

Professor Davies: There are still silos there and there does need to be a lot more cross-government working but there are some important synergies. One synergy to mention in terms of obesity is the synergy with the climate change agenda, where encouraging physical activity is also going to help the planet, or, indeed, encouraging people to eat more fruit and vegetables and which plants to grow, and perhaps playing down the eating of meat, which is a highly resource-intensive food, will help to save the planet. That is just one example but there are examples of synergies which can help to bring those departments together in a common cause.

Q469 Dr Stoate: Do you think it would help to have a minister of public health at Cabinet level rather than buried in the Department of Health?

Dr Jebb: Yes.

Professor Davies: Yes.

Dr Stoate: Good. You both agree. That is something for which I have been pushing for some time.

Q470 Sandra Gidley: This is a question for Dr Jebb. The Foresight report has been widely praised. Has any action actually been taken since its publication?

Dr Jebb: Absolutely. I think the setting up of the cross-government unit on obesity is very much in direct response to the Foresight report, the setting up of an expert advisory group on obesity, which I am delighted to chair and which calls heavily on the expertise which was assembled by Foresight in order to continue providing that evidence in to government. Indeed, the Healthy Weight, Healthy Life strategy maps very closely on to essentially what I would describe as the Foresight vision, which has now been populated in terms of the Healthy Weight, Healthy Life strategy. So I think it has been very influential. In government one of the interesting issues for me is the extent to which it has been taken up by other stakeholders. It was very well received and I have spent a lot of time going and talking to very diverse groups in all sectors of society, but I think other sectors are perhaps finding it harder to see how they can engage as part of his overall strategy, and that is something which we really need to work on because, as we said earlier, most of the levers for change are not within the Department of Health; they are in other bits of government, but they are also very often in the private sector too.

Q471 Sandra Gidley: What do you think were the three most important conclusions?

Dr Jebb: A higher priority for the prevention of obesity rather than just tackling it. That was absolutely vital. The need for joined-up government action and high-level representation. I think those are absolutely critical. Those are very structural but until you get those structural issues in place, it is very difficult to start making any progress on specific initiatives and, again, it is vital that individual initiatives are co-ordinated, and that requires a structure to do it. So I think the structural changes are vital.

Professor Davies: Yes, and I think one of the crucial things is how that translates down to local level. This is where we are talking about working across the system. The local authority has a very important part to play in that, as do local schools. We are talking about transport policies, planning, making sure what goes on in schools is all part of that process, the work with mothers and young children, getting things started at a very early age, and then of course the work in primary care and in hospitals. The whole thing has to join together. It is all very well having these national strategies but, unless they go down to local level and are well co-ordinated by people such as directors of public health, we are not going to see real action on the ground.

Dr Jebb: That is a very valid point. If I were to be critical of the Foresight report, it is that we spent a lot of time thinking about central government and perhaps did not do as much as we might have done in terms of thinking about how action was going to be delivered on the ground.

Q472 Sandra Gidley: It all sounds very positive so far but we have seen all too many reports and initiatives come and go that were not fully implemented. What do you think is least likely to happen?

Dr Jebb: That is difficult. Clearly, there is a timescale to some of this and some of these initiatives will take longer to implement than others. There are also issues in relation to absolute resources. The big environmental infrastructure, rebuilding things, clearly are a lot more costly than front-of-pack labelling. It is a question of when they are going to happen. I think it is too early to say which are going to be the most difficult.

Q473 Sandra Gidley: You tend to think the cheap and easy things will be done but other than that, the things that require a bit more joining up, a bit more strategy, will possibly not happen.

Dr Jebb: We are only four months on from publishing the strategy, so I think is really too early to start saying that this or that will or will not happen. What I think is absolutely vital is that within the strategy was built in an annual, publicly accountable, progress report. I think that is vital because then we can start to judge where progress is being made and where progress is not being made. Accountability in the system is critical.

Q474 Dr Taylor: One time when I was catching the train to come down here, I saw one of the station staff picking up fag ends and he said to me, "It is very easy to change policies, it is very difficult to change behaviour." For that sort of person to have come up with that I thought was absolutely brilliant. So changing behaviour is awfully difficult. Is there any research going on into how you make people change behaviour, thinking of obesity particularly?

Dr Jebb: I think there is a growing body of research in doing that but it is growing from a very low base. If we think of research in obesity, it has been very focused on the biomedical model of the causes. We know a great deal about the causes of obesity but we know much less about the solutions, and one of the biggest unknown areas is how to change behaviour. It is not specific to obesity-relevant behaviours. It is the same with smoking and many other things: drug taking, safe sex; there is a whole range of health behaviours, but it is an area where we are seeing research expanding enormously. The UKCRC has recently set up a number of centres of excellence in public health, which are very focused on some of these big topics - smoking, diet, physical activity and so forth. We certainly have one in Cambridge, and changing behaviour is a critical element in our work.

Professor Davies: As I mentioned before, looking at the anthropology of choice, understanding why people make decisions about their lives and their lifestyles, getting inside their heads, looking at the psychology as well, we need more research into that area, and looking across the complex systems, the total system, which is a difficult form of analysis but it has to be done if you want to see how the real world changes things rather than just controlled experiments, which are not necessarily reflecting the real world. We just need to beef up the amount of research input into some of those things.

Dr Jebb: Aside from research - again, a note of optimism. Maybe I am a naturally optimistic person - is that the understanding across all sectors of society, the public, industry, government, of the need to do something, the need to make change, is greater than it has ever been before. So whereas in the past I think there was really not a good understanding of the scale of the problem and the severity of the consequences, so there was a rather half-hearted approach to whether we really needed to change behaviour, I think now there is a much greater acceptance of the need to do something, and that has to be the first step towards actually getting people to change. The consistency of messaging I think is absolutely vital. If people are being asked to do 50 different things, it becomes very hard for them to change behaviour. So we need a clear focus and consistency in what we want people to do.

Professor Davies: Can I add a rider to that in terms of changing behaviour? It is not just about changing the behaviour of the public. I think in terms of three Ps: yes, it is the public but we also want to change the behaviour of the professionals or the persuaders, the people who are at the front line and who have a direct influence on the public. We need to change their behaviour and their mindset as well, as I mentioned earlier on. Then the third P are the policymakers, yourselves, government, government at national level and government at local level. We need to work on the behaviour, to change the behaviour of all three of those Ps: the public, the professionals or the persuaders and the policymakers.

Dr Jebb: I would add another one: the private sector as well, which, of course is very influential.

Q475 Dr Taylor: So we have four Ps, and you have three Es: empowerment, encouragement and environment. Do you have any more of these?

Professor Davies: I have these three hemispheres, or are they "trispheres"?

Dr Taylor: I think "Eurothine" is one of the worst of the acronyms that you could possibly think of, is it not? It is nice to have simple things, four Ps and three Es. Thank you very much.

Chairman: Thank you very much for the four Ps and three Es, and also for this morning's evidence session. I have found that very enlightening and I am sure the Committee has as well. Thank you very much indeed.

Witnesses: Mr Paul Jenkins, Chief Executive, Rethink; Ms Saranjit Sihota, Head of Public Policy, Diabetes UK; and Ms Deborah Arnott, Director, ASH, gave evidence.

Q476 Chairman: Good morning. Thank you for attending this morning. I wonder if I could ask you to introduce yourselves and the position you hold for the sake of the record, please.

Ms Arnott: I am Deborah Arnott, Director of Action on Smoking and Health, an organisation working to reduce the harm caused by tobacco which was set up in 1971 by the Royal College of Physicians. I myself have been a member of the NICE Programme Development Group looking at developing guidance on smoking cessation, and I am also a member of the Royal College of Physicians' Tobacco Advisory Group.

Mr Jenkins: I am Paul Jenkins, Chief Executive of the mental health charity Rethink. We work with everybody affected by severe mental illness, both in a campaigning role and as a provider of services.

Ms Sihota: My name is Saranjit Sihota. I am Head of Public Policy with Diabetes UK. We are a charity, one of the largest in Europe, working with people with diabetes.

Q477 Chairman: Thank you. I suppose I have an interest to declare in terms of ASH. I am a member of your Council. I do not think this is something that has been a hidden secret in my years in Parliament. Could I start with a question to you, Paul? What are the most important aspects of health inequalities relating to mental health? For example, what is the relative importance of income, education, ethnicity and gender? What is the best way to reduce health inequalities in these areas?

Mr Jenkins: Our starting point was that we were involved in some work that the former Disability Rights Commission did a couple of years ago, looking at the physical health inequalities experienced both by people with severe mental illness and also with learning disabilities. That came up with a very shocking evidence base about the scale of difference in life expectancy, in outcomes of common diseases, and on people's experience of accessing physical health care. One of my first points is the need, where there is an evidence base of that kind, to have a very discrete focus within an overall health inequality strategy looking at particular disability groups. In terms of what you can do about it, there are perhaps four things. First of all, there are some very interesting patterns of disease which I think need some further investigation and research. For instance, if you have schizophrenia, why is it that you have a 90% greater chance of getting bowel cancer or a 42% greater chance of getting breast cancer? The second thing is that there is a very significant issue about tooling up primary care to provide a much more personalised and accessible service for people with severe mental illness in accessing physical health care. Then I think there is a need to integrate physical health care much more extensively into the provision of mental health services that can see somebody's physical health care needs as an important component of their overall recovery plan from the impact of their mental illness. Within that, recognising that there are some particular issues around health promotion which are there in that population, as they are in the general population, but may need some more targeted responses which take account of the background that somebody's mental health problems bring, and sometimes also some of the issues of stigma and discrimination in wider society that make it harder for people to participate in things like exercise and other things.

Ms Arnott: Could I just add to that? One of the things we need to recognise as well, and it is something that ASH has done quite a lot of work on, is that if you look at smoking rates, they are very linked to disadvantage and they are very strongly linked to mental health status. For example, if you have serious depression or psychotic illness, your smoking rates are likely to be above 70%. It is not that mentally ill smokers do not want to quit but they tend to be more heavily addicted, find it much harder to do so. Smoking has been endemic in psychiatric premises, and I think the fact that all psychiatric premises are going smoke-free on 1 July 2008, a year after the legislation was implemented, is a major opportunity. However, for it to be fully realised, we need to do more to help people with mental health problems to quit. They live very difficult lives, they are under enormous stress and smoking is a response to stress, and also just to the boredom of being in psychiatric premises. So we need to ensure that when the legislation comes in there is better access to stop smoking services and to stop smoking medications, which often are not on the list of medications that can be prescribed in mental health premises, both in psychiatric settings but also in the community. There is a very interesting project which Quit are running on trying to give better smoking cessation help and advice and support to people with mental health problems that I think will give us some good ideas about how that can be better implemented. We also need training for psychiatric staff in brief interventions and referral, and we need to tailor interventions to individual needs. For example, my brother is a psychiatrist. He set up a mental health unit which was smoke-free from the beginning, but actually, if you stop smoking and you are on antipsychotic medications, it affects the amount of antipsychotic medication that you need to take. That is actually a really positive thing because you can reduce the amount of antipsychotic medications people are taking, but some health care professionals are worried about what the impact is, and they need to have the education and advice about how to do this and how to work with their patients. There is strong evidence that one of the reasons why people smoke, particularly people with mental health problems in psychiatric premises, is that their life is boring and it is a responsibility really to do something about that. We need structured activities, we need to provide diversion for mentally ill patients so they do not just think "What am I going to do next? I will light up a cigarette."

Q478 Dr Stoate: I would like to ask Ms Sihota a similar sort of question really, and that is what are the most important aspects of health inequalities in relation to diabetes? Is it age, gender, ethnicity? What are the most important health inequality areas?

Ms Sihota: Just to begin, there are two types of diabetes, as I am sure you are aware. There is type 1 and type 2 and the greatest increase is being seen in type 2 diabetes.

Q479 Dr Stoate: Yes, type 2 diabetes is most related to public health issues.

Ms Sihota: Sure. A number of things. Certainly obesity. I actually got the latest results from the diabetes prevalence model, and this is showing that by 2025 approximately 43% of the increase in diabetes prevalence will be due to ageing population. The other 57% will be down to increasing obesity. With that said, we also know that people from those lower socio-economic groups are 2.5 times much more likely to be at risk of diabetes.

Q480 Dr Stoate: Do you mean even with equivalent weights?

Ms Sihota: No, not necessarily. What do you mean?

Q481 Dr Stoate: Are people more likely per se to have diabetes or is it because of their obesity that they are more likely to get diabetes?

Ms Sihota: This is the problem with type 2 diabetes. It is so difficult to understand how much of it is lifestyle and how much of it is a genetic component. We do know that if there is a family history of type 2 diabetes, the risk of a child or a sibling getting diabetes also increases. Lifestyle certainly has a large part to play. Just to complicate the matter a little bit, if you take the South Asian population, yes, they are five to six times more likely to get diabetes. However, the interesting thing about that population is that, regardless of environment, in the sense that regardless of whether they are in India, Pakistan, the US or the UK, they always seem to have higher rates of diabetes compared to the other populations.

Q482 Dr Stoate: Is that independent of weight or is that related to the fact that there is more likely to be obesity in those populations?

Ms Sihota: Exactly, and again, it is very difficult at the moment. Researchers are finding it very difficult to disassociate the genetic and the lifestyle, and how much of it is genetic and how much of it is lifestyle, what the link is and which is triggering which really. I would suggest, general reading around the situation, that, given the risk factors, if you have a larger waist size you are more likely to incur diabetes, and that is if you are over 40 in the white population, and it is much earlier if you are in the south Asian and black population.

Q483 Dr Stoate: You are saying basically there are a lot of unknowns but you are saying quite clearly that obesity is probably the most important determinant.

Ms Sihota: Yes. Your weight management or lack of it is a significant factor.

Q484 Jim Dowd: This is principally the same question to Ms Arnott in relation to smoking, although I take what you said about those suffering from mental health in particular, but generally smoking across the piece in relation to income, education, ethnicity, age, gender, any other characteristics that make people more or less likely?

Ms Arnott: What we know is that almost any indicator of deprivation and disadvantage is independently linked to higher smoking rates, so whether it is mental health status, if you are a single parent on benefit, if you are homeless, if you are in prison - almost anything that one can link as being about disadvantage. Living in rented housing, for example, is independently linked to higher rates of smoking. What we have seen is over the last 30 to 50 years, and we are in the advance on this, and that is one of the main reasons why inequalities have increased, because something like half the differential in death rates between the poorest and the least well-off in society is down to smoking. It is because we have seen this decline in smoking amongst the most affluent in society, which has not been followed by a decline in the least affluent. A good example is, if you look at smoking rates among doctors in Eastern Europe, they are actually higher than the general population. That is not what we see here. So we are further along that route, and that is why we have seen widening health inequalities. Over the last ten years we have seen a comprehensive strategy to tackle smoking and I would not want to see that stop; in fact, I would want to see it continue. The Government is about to consult on a new national tobacco control strategy but what we want to do is, within that, focus on how we can reduce smoking rates amongst the most disadvantaged in society. I would like to just point to the research in Renfrew and Paisley, which was longitudinal research over about 15,000 people, so quite good quality research. What it showed was that the least affluent never-smokers have much better survival than even the most affluent smokers, but if you take smoking out of the equation, the differences in survival between the best and least well off are relatively small, especially amongst women, and that even if the socio-economic circumstances of less well off smokers are improved, their health gain is likely to be minimal unless you can actually stop them from smoking; if they carry on smoking, it will not help them being better off. So to tackle health inequalities, reducing the differential in smoking is going to be absolutely crucial, but we can actually do something about it. Around 70% of smokers want to quit, and I know Michael Marmot said to this Committee that if you are less well off, smoking is not important to you, but if you actually look at the statistics and the evidence, it does not matter where you come from in society; if you are a smoker, around 70% of smokers want to quit. So people want to quit; it is just that the more disadvantaged they are, the more heavily addicted they are, the more difficult it is for them to quit. So we have to target measures on helping the most disadvantaged in society to quit. On top of this comprehensive strategy, which has been very successful in generally driving down rates of smoking, actually over the last year we have seen a decline in smoking amongst routine and manual workers as well, and I think the smoke-free legislation - and this Committee was central to ensuring that the legislation did not have a differential effect by ensuring that it covered pubs and bars that did not serve food as well as pubs and bars generally, because we knew that pubs and bars that do not serve food are concentrated in poorer areas, so that was absolutely crucial but we need to do more. I think there are three things we can do that would actually target health inequalities, and smoking and health inequalities, more effectively: more effective targeting of smoking cessation services. We know they are more effective with poorer smokers; because they were set up in health action zones first of all, they have always tried to target the most disadvantaged smokers, but because the quit rate is less successful, you have to do even more to target disadvantaged smokers to have a differential effect. Tackling tobacco smuggling: I think it was Julian Le Grand who talked about the price incentive, and yes, we know that the price incentive to quit is stronger amongst poorer and younger smokers, but the fact that smuggling went up dramatically in the 1990s and is still at significant levels is a real problem. We have just done research - and this is literally hot off the press today because we have just got the results - which shows that one in five poorer smokers buy smuggled tobacco - and we are talking about cigarettes at half the price you pay in the shops - compared to only one in 20 of the most affluent in society. There is also an age link; the people most likely to buy smuggled cigarettes are the young, 16 to 24, and something like one in three 16 to 24-year-olds say they buy smuggled tobacco or tobacco from illicit sources. Thirdly, I think we need a harm reduction approach, because it is the smoke that kills you, not the nicotine. It is the nicotine you are addicted to, and the more heavily addicted you are, the more important the nicotine is. So we would like to see smokers being given access to safe forms of medicinal nicotine for long-term use, because as long as you can stop smoking, just using nicotine replacement therapy is not going to kill you. The problem is that nicotine replacement therapy is currently formulated for short-term use and is not competitive with cigarettes in terms of the amount of nicotine it delivers.

Q485 Jim Dowd: We have covered a great deal of ground here. I know one of my colleagues is going to come on to the issues of tobacco smuggling in more detail in a moment but, of course, the 1990s did also coincide with the access to cheaper tobacco, in particular, with the abolition of the customs restrictions, et cetera, the agreement in the EU for personal use. There were famous cases where Customs, as they were then, tried to stop people bringing back thousands for personal use and they were unsuccessful in that. So the accessibility to tobacco has to be factored in, apart from the rise in the cost in the UK of cigarettes, surely.

Ms Arnott: That is true, but if you actually look at cheap tobacco coming into this country, far more significant than duty-frees or cheaper cigarettes being imported over the boundary is large-scale smuggling through container fraud. That is about 80% of the total. Really, it is much more down to not just avoiding the level of tax we get in this country but smuggling, which undermines the whole basis of a taxation structure.

Q486 Jim Dowd: The reduction rates in recent years have - I will not say quite plateaued but I think there were huge falls originally. Now it is becoming much more difficult incrementally. Are we in a position essentially of diminishing return insofar as it is costing more and more to get a smaller and smaller reduction?

Ms Arnott: I do not think that is the case actually. What is interesting is Smoking Kills, the smoking White Paper, was published at the end of 1998 and the measures in it were implemented in 1999-2000. The decline in smoking prevalence had plateaued in the late 1990s. At the beginning of 2000 it began to decline again and we have seen an average rate of decline of 0.4 percentage points of the population, so that is a significant number of people giving up smoking since then. We think, with a more comprehensive strategy and a more focused strategy, that we could increase that rate of decline and double it. The encouraging thing about smoking is we know what works, we have implemented strategies along the lines of what we know works, and they have had an effect and, if anything, if we did more of what we have already been doing, and introduced a new strategy, which would be a harm reduction strategy, we could drive down smoking even more, and I think really cracking down on smuggling is absolutely crucial. We are really concerned about the new Borders Agency taking over responsibility for tackling tobacco smuggling because clearly their priority is going to be immigration. Tobacco smuggling is not going to be a priority for them, and in fact, the targets for reducing tobacco smuggling disappeared at the end of last year, so there are no targets at the moment for how it should be reduced, and responsibility has switched from the Treasury and Revenue and Customs to the Home Office and the Borders Agency in terms of implementing it. There are very real concerns that our effectiveness in reducing smuggling could go down in the future, and that is going to be absolutely crucial, and particularly crucial to reducing health inequalities.

Q487 Dr Taylor: I would like to continue on the smuggling issue. I am very grateful to you for raising the severity of the problem because certainly I personally had not realised that they were half the price and so many of the poorer smokers were using these. You have given us a lot of detail in your written submission. Firstly, it appears that we are alone in Europe in not signing up with Philip Morris and JTI for an anti-smuggling agreement. Why have we not done that?

Ms Arnott: I have asked this on a number of occasions and I have not had a good answer. The only thing I can guess is it is a "not invented here" policy. We are the only Member State in the EU that has not signed up to the agreement. First of all, with Philip Morris, they said "Oh, well, Philip Morris only has a small market share so it is not relevant." Well, JTI, Japan Tobacco, now owns Gallaher, which has a 40% market share in the UK, so that does not hold water. They also said they thought it would conflict with the Finance Act legislation which was brought in a year or so ago, which enables them to take companies to court if they appear not to be controlling smuggling effectively, but actually, again, I have sought legal opinion on that and the good thing about the agreement is you do not have to take the companies to court; if their product is found to be smuggled, there are seizure payments which are just implemented unilaterally. That makes life a lot easier because, as we know, taking tobacco companies to court is not an easy thing to do. So I really find it very hard to understand. The National Audit Office got the Government to say they could have perhaps got seizure payments just on Philip Morris of about £1 million, but that is not very significant. Well, that is £1 million one year but if you are getting £1 million, that is going to help with your cracking down on smuggling, and with Gallaher, Gallaher's cigarettes have been amongst the most highly smuggled over the last few years. We worked out with the amount of Gallaher product smuggled just on 2004-2005 they would have got seizure payments of nearly £100 million. Obviously, now Gallaher is in the agreement I am sure they are cracking down very heavily on ensuring that their product is not smuggled back into the UK or into Europe, but still it shows you the sort of scale of the benefit that the Government could potentially get from this. I would very much like to see the Health Select Committee have the Home Office and the Treasury come and talk to you about smuggling, how crucial smuggling is to tackling health inequalities, and what they are going to do to ensure that their strategy to tackle smuggling remains effective and is increased in its effectiveness in the years to come.

Q488 Dr Taylor: You have certainly written one of our recommendations for us if at the end of this week we agree with that, just to get the Government to sign up. It is so obvious, is it not? What about penalties for tobacco smuggling? Are they high? Are they serious?

Ms Arnott: That is an interesting question. For tobacco smuggling it is a penalty of up to seven years' imprisonment and confiscation of any benefit gained, compared to 14 years for class B and C drugs and life for class A drugs. I have heard it said that, because the penalties are lower, enforcement officers take tobacco smuggling less seriously and also that smugglers switch to smuggling tobacco because it is lucrative and less risky. I do not necessarily think that just increasing the penalty would decrease smuggling. I think what is more important is that there are tough targets set for the relevant agencies to reduce smuggling and that we improve and develop a tackling tobacco strategy going forward to include better international collaboration and tougher measures to require the tobacco industry to control the supply chain. I would like to see licensing of the whole supply chain. That is actually in the WHO Framework Convention on Tobacco Control template for an Illicit Trade Protocol, which is currently being negotiated and which I think will see much better international collaboration on tackling smuggling. Smuggling is a global problem. If you try and stop it in one place... It used to be Andorra with cigarettes. Enough British cigarettes were being exported to Andorra that every man, woman and child could smoke 40 a day or something, but once it was cracked down on in Andorra, it moved to Cyprus, Eastern Europe. You need a global strategy to tackle tobacco smuggling, and that is what we are seeing being developed.

Q489 Dr Taylor: The police are very aware of drug peddling. Are the police aware of the importance of tobacco peddling? Where does it actually happen? Where do kids buy these half-price cigarettes?

Ms Arnott: A number of places. The research that we have done and the research done by others on a qualitative levels shows that people are buying them from fag houses on council estates, in pubs, on the street - I heard someone say that you could buy cheap cigarettes at a bus stop in East London, where someone would just turn up and start handing them round - markets, car boot sales, but also employers; there are a lot of employers who have someone there who is accessing cheap tobacco and selling it on the premises. There are all sorts of different ways people can get hold of it, and no, it is not seen as particularly serious by the police. They do not really crack down on it.

Q490 Dr Taylor: Cigarettes are much bulkier to carry than little tiny packets of drugs.

Ms Arnott: They are, but it is not seen as a crime in the same way.

Dr Taylor: That is very helpful. Thank you.

Q491 Dr Stoate: I am deeply suspicious of any initiative where we do a new voluntary agreement with the tobacco industry.

Ms Arnott: It is not a voluntary agreement. That is a key point.

Q492 Dr Stoate: Anything we sign with the tobacco industry is likely to fall flat on its face. We tried it on sports sponsorship, we tried it on advertising, and we got nowhere. In the end we had to legislate. When we did an inquiry when I was on a previous Health Select Committee into the whole problem of tobacco, we found some incredible things. We were given evidence that the tobacco companies are actually complicit in smuggling. They call it DNP, even in their own papers, duty not paid. We were even given papers where DNP tobacco was taken across national borders in order to avoid the need to pay duty, so I am deeply suspicious. The Americans in the end had to use the Master Settlement Agreement, a $125 billion agreement, to force the tobacco companies even to get round the same table in terms of tobacco control. So whether or not we sign agreements with the tobacco industry I think is likely to be of limited benefit.

Ms Arnott: We have agreements with the tobacco industry in this country. We have memoranda of understanding which are completely voluntary and they can pull out of at any time.

Q493 Dr Stoate: That is only because they do not work.

Ms Arnott: Yes. The difference about the EU agreements is that they are agreements made in settlement of litigation in the States for collusion with smuggling and facilitating smuggling under the RICO legislation, and so they are not voluntary agreements and they are actually backed up under the New York Agreement. The EU can take the companies to court if they do not fulfil the agreements, but the agreements are actually very strong because they were in settlement of litigation, and so they cover the tobacco industry being forced to check its supply chain. They have to know everything about the first purchaser, who they are, what they are, what their criminal background is, and if they are found to be diverting cigarettes to the illicit supply chain, they have to be struck off. Plus there are these seizure payments, which are a good enforcement, because basically, if your cigarettes are seized above a certain amount - and it is quite a small quantity - then you have to pay significant financial penalties.

Q494 Dr Stoate: I shall remain deeply cynical because I know the way tobacco companies work, and they do not do anything that is not to their own advantage and, if they are doing something like this, it is only because they see no alternative to it.

Ms Arnott: The alternative was litigation.

Q495 Dr Stoate: I remain to be convinced.

Ms Arnott: It is also why the WHO Illicit Trade Protocol is going to be so crucial, because what it will do is take some of the best elements of the EU agreements and other things like better enforcement measures across boundaries and everything, and impose that on the tobacco industry. That is what we would like to see.

Q496 Dr Stoate: We will see what happens. I want to direct my question to Paul. In your written submission you expressed your disappointment that the NHS did not heed the advice of the Disability Rights Commission about measuring health outcomes by disability. Why do you think that was, and what do you think we should now do about it?

Mr Jenkins: We were very disappointed about it, because I think there is a very discrete set of disadvantages experienced both by people with severe mental illness and, as the DRC report, people with learning disabilities, which have some specific things that can be done to address them. If you do not measure it, you will lose that in the general issues. I think part of it is just that the paradigm of health inequalities has been a socio-demographic one, which is not to decry that those factors are not critical in understanding health inequalities, but also there is a case here that you can see this through a different light. There is a penny that needs to drop here. We sat on the inquiry panel, and one of the people also on the panel was David Haslam, the then President of the Royal College of General Practitioners. One of the quotes the report captures is him saying "I had a real road to Damascus experience here. I had been used to seeing health inequalities in my surgery and generally in terms of race, in terms of social deprivation. I had never seen quite how dreadful an experience and such dreadful outcomes this group of patients had had." So I think there is a penny to drop but if it was one of the things that this Committee would recommend it would be adding weight to a debate that we have been trying to push.

Q497 Dr Stoate: How would you prioritise the idea of reducing health inequalities amongst mental ill health sufferers?

Mr Jenkins: Once you have highlighted the scale of the issue, you can begin to tackle it. There are a number of things, as I say, that you can do. There are aspects of people's experience that do relate to by-products of people's mental health treatment. So we know there is a connection between antipsychotic medication and conditions like diabetes and obesity. Although we think that the introduction of the physical health check for people with severe mental illness in QOF is a good thing, I think at the moment there is a danger that it is not specific enough, and there are some concerns about the variable quality of that. For instance, if there were a requirement to look at glucose intolerance for all people with severe mental illness, given that you have that background of a much higher incidence, that would be one very specific measure. There is a whole set of issues about how primary care interacts with people with severe mental illness. Some of it is about access. If somebody has a severe mental illness, a psychotic illness, often a by-product of medication may be that they are not at their best in the mornings, so some of the systems we have that you have to get up at the crack of dawn to access an urgent appointment can be very off-putting.

Q498 Dr Stoate: The QOF actually asks GPs to send at least three invitations on a yearly basis to people with severe mental illness for their annual check. The problem is take-up is disappointingly low. How would you address that, the fact that you can send three invitations, you really do your best, but if you get a negative or no response at all, what do you do then?

Mr Jenkins: I think it is about trying to personalise your service. People with severe mental illness do see their GP.

Q499 Dr Stoate: But disproportionately not very often, if you see what I mean?

Mr Jenkins: Yes, but they see them often for their mental health care.

Q500 Dr Stoate: Sadly, that is not necessarily the case actually. I am still a general practitioner and, actually, we do not see people with mental health problems as frequently as frequently as we would like to. It is quite difficult. They do get prescriptions but quite often that is all.

Mr Jenkins: There are various points. There is the point of registration, sitting down with somebody and discussing some of their access issues, explaining, for instance, what the rationale of them being on a severe mental illness or register is, what the benefits of that might be, some particular efforts to just do something that is a little bit more tailored around that individual's circumstances rather than just putting them through the more general systems that people use to access primary care. One of the things we have done is develop a guide to reasonable adjustments in primary care, which we have done jointly with the Royal College of General Practitioners. We are going to publish that next month. It gives service users, carers, GPs and practice staff some basis on which to address those issues.

Dr Stoate: That is helpful. Thank you.

Q501 Sandra Gidley: This is a question for Saranjit Sihota. What specific action should be taken to target groups at high risk of type 2 diabetes? I am particularly thinking of the ethnic minority population but there may be others as well.

Ms Sihota: Diabetes UK has quite a longstanding recommendation about the early identification of people with type 2 diabetes, and that means screening. It is known that people can have type 2 diabetes and not have it diagnosed for up to nine to 12 years, by which time 50% of them actually have signs of complications, heart disease, et cetera. We have always advocated screening and targeting. We know who the at risk groups are, for instance, the South Asian population is one example, and people with a certain waist size, et cetera. The next question is exactly how you reach them. We have heard time and time again about personalising services and about understanding. There are examples that are available of where people have been targeted: a very successful one is, for instance, Slough back in 2004. That was a very visible way of doing it. You get a double-decker bus, you go to the places where people congregate, where people tend to get together, and you reach them in that way with information and with education. Many people were screened; I think it was an increase of 30% of people that went in to access services.

Q502 Sandra Gidley: Screening and identification are obviously very important but should we not be trying to go back a stage from that so that you reduce the likelihood?

Ms Sihota: Certainly, we would support that and we do say that. That is about the information and awareness of diabetes in the context of how much your lifestyle can affect your risks and chances of getting it. We come back to some of the debate we had earlier with the other witnesses around food, exercise, where the facilities are and how to access them, around food and weight management. Yes, we would endorse that absolutely. The issue is about how you do it. As we heard this morning, there is a real paucity of evidence around what effective interventions are. I saw the very recent work done by the King's Fund. I cannot remember the criteria that they used but they used certain criteria to find studies which were about behavioural interventions and what worked and what did not work. In the end, they identified 17 case studies, out of which they identified nine that did show a real benefit through direct behavioural interventions, which were primarily about providing people with information. When it comes to people from lower socio-economic groups, because it is generally that their information base and knowledge of conditions, of good health, is poorer, when you do provide them with information about risk and consequences, they were able to take that on board and start to change their behaviour but, as I said, I think they only identified two studies that were able to show that change, and they do recommend, as everyone said this morning, that we need further evidence.

Q503 Chairman: You mentioned Slough. Are there others similar to that that have been done in different communities up and down the UK?

Ms Sihota: There are. I know that one best, but certainly, regardless of diabetes, there are lots of efforts within health to actually target particular groups, and using vehicles, using buses, et cetera is a common way. We do that. We do a roadshow which goes out every year across the country to both inform and educate people about diabetes, and there are lots of other examples around. One of the problems is that lack of information available in any one place about which ones are working, which ones are not and which ones are most effective. That is information and awareness. There are other examples where, once you have diabetes, about how you manage it and ensure that your blood glucose levels are at recommended levels. There is a piece of work that was done in Scotland - again, this was targeted at the South Asian population - where structured patient education, which is typically available in English, was then tailored and repackaged in a very different way to be able to talk to people with a different set of languages. They managed to show over six months a reduction in people's blood glucose levels and a greater knowledge and awareness of how to manage their condition.

Q504 Chairman: Do you have a reasonable idea how Diabetes UK engages with local PCTs in relation to this type of work? Is your bus welcomed in some areas and ignored in others?

Ms Sihota: No, I think we are welcomed quite widely. I joined Diabetes UK in the summer of last year and I have consistently heard the argument that we find it very difficult to engage with PCTs. That is the common thread across all of Diabetes UK. Given the world-class commissioning and the requirement for world-class commissioning, and the competencies that world-class commissioning is about, hopefully that is an opportunity, and certainly I hope to see that that will change around how to design services for your local population and their needs. That is key. We also have our Year of Care work that we are doing with the Department of Health and the National Diabetes Support Team, looking precisely at how to commission services for local populations in the context of choice and personalisation and what is possible, working for the patient at a micro level, to how you might be able to commission at a macro level. We hope to be able to use that information to work in world-class commissioning.

Q505 Chairman: If at any time you could share some of that information with us, we would greatly appreciate that.

Ms Sihota: The first evaluation comes out in June, I believe. I am not entirely sure but I think so.

Chairman: If you could share that with us, I would appreciate having a look at it.

Q506 Jim Dowd: We bandy terms around fairly freely here. Can we just add a definition to what "south Asian" means? Principally, obviously, in population terms it would be Indian, Pakistani subcontinent, Sri Lankan, et cetera. Does it extend further east than that?

Ms Sihota: You mean does it incorporate Chinese?

Q507 Jim Dowd: Chinese, Malaysian.

Ms Sihota: I think invariably it does not. I understand what you are saying. I have the same tension or problem when I am reading the literature as to exactly who it is including and who it is not including. My understanding is it is Indian, Pakistani, Bangladeshi. The other problem with that term is that, because everyone is lumped together, I do not know whether we are talking about first generation or second-generation. I think there is a difference between how people's behaviours and lifestyles are changing in the first generation of migrants and those that have been born and raised here, and now the third. That certainly needs looking at.

Q508 Jim Dowd: Has the work not been done generationally to see if there is any change?

Ms Sihota: I previously worked around race and ethnicity issues. Generally, the research is not that sophisticated. I am not saying there is not any; there is, but I generally know it is not as sophisticated as that, and when you are looking at an issue like diabetes, I consistently see that yes, south Asians are more at risk. I do not know at this stage whether poorer south Asians or richer south Asians or all of them at the same time, first generation, second generation. I do not know. We need to go there.

Q509 Jim Dowd: I think you were here earlier when we heard about front-of-pack food labelling and the importance of that. Does Diabetes UK have an attitude towards that?

Ms Sihota: Yes. We are part of the coalition that supports banning junk food advertising. We also support very much the FSA recommendation about the traffic light labelling system because of what their research shows, and not only that most consumers like it but particularly that those in lower socio-economic groups understand it better than the guideline daily amounts, and because it has shown some evidence that food manufacturers are in some instances reformulating their products.

Q510 Jim Dowd: I would just say that I initiated an Adjournment Debate on front-of-pack food labelling in the House last year. I realise you may not be entirely qualified to answer this, but given your involvement in the subject, why do you think the food processors in particular - and I include Tesco in this, because although they are a retailer, they are as much a food processor these days as a food retailer - are so adamantly opposed to including traffic light labelling on packs and insist on sticking to GDAs, even though the FSA, for example, have said, "Do both"? They will not countenance the traffic light system.

Ms Sihota: I can give my view. I do not know that Diabetes UK has a view on that. It makes me wonder what their motivation is around that. If the evidence shows that certain people find the traffic light labelling much more accessible and the GDA less accessible, and this more processed food, I imagine, would perhaps lead to traffic light labelling exposing more clearly that this is high fat, high salt or high sugar. I would suggest that is probably one of the reasons for that.

Q511 Jim Dowd: You would not be so rash as to say they do not want people to know what is in it, but I would. Just moving on, Sandra touched on this a moment ago, about improved screening in NHS care of patients. Both yourself and Mr Jenkins included that in the submissions that you advocate. The Government are attempting to introduce perhaps the most comprehensive screening programme ever, and yet this is running into considerable opposition from GPs, who essentially are try to describe it as simply wasting time on well people. Do you agree with that? How do you think these changes should be introduced in the system?

Mr Jenkins: If I may go first, I think the clear thing we would advocate for is imaginative access to screening where you have a proven higher rate of incidence. The examples I quoted around, say, bowel cancer, people with schizophrenia, the link with diabetes and antipsychotic medication. There is a really clear evidence base there that people should get access to regular testing or screening. My argument would be that it needs to be targeted, and there is some very strong evidence for targeting some of the groups that we represent.

Ms Sihota: I would echo some of that in the sense that we have never advocated wholesale screening of, say, people over 40. The age range is 40 to 75. We have always said it needs to be very targeted on the populations that we know are likely to have certain risk factors. The 40 to 75 denies, again to use the south Asian example, people at risk of diabetes at a much earlier age. Those people are not included in the 40 to 75.

Q512 Jim Dowd: Is not part of the objective of a broader and more comprehensive screening programme to find people that you would not find through any other identifier?

Ms Sihota: Absolutely, but it fails on the south Asian and black population. Again, we are a part of that debate that the National Screening Committee is obviously having with us and all the other organisations. It is about how you reach the hardest to reach, basically, and how we are going to do that. Obviously, organisations like ours are probably better equipped than the Department of Health and the National Screening Committee in terms of reaching those populations, or we have a role to play in that.

Mr Jenkins: If your argument is about the prioritisation of resources, it has to make sense to prioritise those where there is a proven link. In some ways, that question of finding the people who are hard to reach, in our case - and this echoes the point that Howard made - it may not be one of universality of screening but actually more imagination and how you deliver screening programmes, where you take those screening programmes rather than necessarily expecting everybody to come to the GP practice to have them delivered. Taking out screening programmes to supported accommodation, to community services that engage with people with severe mental illness, may be the sort of thing that you ought to be doing in those areas where, as I say, there is a heightened risk of developing those particular conditions.

Ms Sihota: This is our experience; this is what we do when we do our roadshows, the number of people we screen who do not go to the surgery.

Ms Arnott: Can I pick up on that, because actually asking people whether they smoke or not is a form of early screening, given that half of all smokers will die long term from their habit, losing many years of life. The problem is that although that happens in primary care, a lot of points are awarded - in fact, most points are awarded on the QOF on smoking just asking people whether they smoke or not. What happens with that? Not enough does happen, because, basically, the evidence is that either doctors are not giving advice to smokers to quit or, when they do give advice to smokers to quit, it is not as effective as it should be. The BMA recognizes this. In a recent report they said research suggests that smoking cessation advice is not provided in the majority of GP consultations with smokers. What is the point of asking people about their smoking if you do not do anything about it? At the moment advice is only given to people with pre-existing disease. We would like to see the QOF rebalanced - and we have recommended this on a number of occasions but it h