Uncorrected Evidence 422

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Oral Evidence

Taken before the Health Committee

on Thursday 5 June 2008

Members present

Sandra Gidley

Mr Lee Scott

Dr Howard Stoate

Mr Robert Syms

Dr Richard Taylor

In the absence of the Chairman, Dr Howard Stoate was called to the Chair

________________

Witnesses: Dr Hamish Meldrum, Chairman of Council, British Medical Association, Professor Martin Roland, Director, National Primary Care Research and Development Centre and Dr Julian Tudor Hart, retired GP and Research Fellow, University of Wales, gave evidence.

Q534 Dr Stoate: Good morning, everybody, and welcome to today's session of the Health Select Committee and our inquiry on health inequalities. I would like to start by apologising on behalf of the Chair, Kevin Barron, who unfortunately cannot be with us due to a family bereavement. I would like to place on record the Committee's sincere condolences to Kevin, and hope he can make a speedy return to his Parliamentary duties. He is certainly missed very greatly and our thoughts are with him at this time. I would also like to place a declaration of interest on the record, and that is I am a member of the BMA, a practising general practitioner; I also chair the All-Party Group on Men's Health, which is supported by the Men's Health Forum. All these things are well-known and in the declarations of interest, but I thought I would place them on the record just for any sake of ambiguity. Could I now start by inviting our three witnesses to introduce themselves for the record.

Dr Meldrum: Hamish Meldrum, I am a GP in East Yorkshire one day a week, and for the rest of the time, I am Chairman of BMA Council, at the British Medical Association.

Dr Tudor Hart: I am Julian Tudor Hart; for 35 years I was a GP in the South Wales Valleys, and now I am a research fellow in the University in Swansea.

Professor Roland: I am Martin Roland, Director of the National Primary Care Research and Development Centre, which is based in the University of Manchester, and I am a part-time GP in Central Manchester.

Q535 Dr Stoate: Thank you very much. I would like to start with you, Dr Tudor Hart, and that is: your submission describes a model of anticipatory care which I think has gained an enormous amount of respect within and without the medical profession. How do you think that your model can help tackle health inequalities?

Dr Tudor Hart: Well, it can, if we have the staff and the continuity to deliver it. But it cannot be delivered in boxes that people can tick.

Q536 Dr Stoate: That is a good answer. Do you want to expand a bit further? We know that you have an extraordinary track record of achieving a lot in the area where you worked, and in the community that you served, but what I am concerned about is: is that model possible in other scenarios across the country, or is it really quite specific to an area like yours?

Dr Tudor Hart: Well, it obviously was specific at the time that I did it, because other people did not do it. I think the things that tend to get overlooked are first of all that I measured everything from the very beginning, and other people were not doing that, because I came out of epidemiology into primary care. Secondly, I accepted about half the net income that GPs were expected to receive and that went on until my retirement. Since then, I have never been paid for anything I have done. That is not a reproducible scenario. I got to knackering myself with overwork; by 1974, I had published enough that the MRC thought I was respectable, and they funded a research registrar post, so that as well as being a trainer, I had additional skilled labour from an extra doctor, and also whatever research team we had for whatever project we were doing at the time. We did a whole lot of projects for the MRC, pilot studies. Of course, what we did was to misuse that, if you can call it that, to provide better service, we just did more things for more people, and recorded what we did. So the whole model needs to be looked at, to see how to make it reproducible now, and I think they are waking up to that in Scotland. It has to move from rhetoric to reality.

Q537 Dr Stoate: Obviously you describe some severe problems and barriers you went through, and obviously, I do not think you can expect that to be a universal model as it is. Do you see any fundamental barriers to the type of care you provided, or do you think it is purely a matter of resourcing and adequate staffing?

Dr Tudor Hart: It is resourcing and staffing primarily. The political background that you would need to get that resourcing and staffing would imply a different situation than we are now in. But in the situation we are now in, what was a high morale community has gone through a long period of demoralisation and is now somehow or other staggering to its feet again, but in very different circumstances, so I do not think I am the right person to ask. I think the right people to ask are people in Glasgow, like Graham Watt and people round him, who are trying to do this, I think with considerable success, but they have not solved the problem that the GPs throughout the country, throughout the UK, are as if in a swimming pool, with a shallow end and a deep end. The deep end are the industrial or post-industrial areas where the GPs and their staff cannot even get their feet on the bottom of the pool, they have to swim all the time in order to avoid drowning, and they also have the task of stopping the patients drowning. They tend to save themselves first, which is understandable, because they will not save any patients if they do not. At the other end of the pool, I would not say life is easy, I think all GPs work hard, and the golf course GP is on the whole a myth, but they can put their feet on the bottom when they need to, and their patients do not drown very much. What we have called equality in the past is that all the people in the swimming pool get the same, if they are lucky, the people at the shallow end and the people at the deep end. Well, that is not equality.

Q538 Dr Stoate: So you would like to see an more equitable distribution of resources?

Dr Tudor Hart: I want to see resources directed to where there is greatest need, and there is a very simple way to measure it, either with standardised mortality rates, which reflect very accurately what is happening, even on quite a small area basis, or you could look at the estate agents and see what has happened to house prices, because the house values also reflect, I think, very accurately what is going on.

Q539 Dr Stoate: Is there any evidence that deprivation payments for GPs make much difference?

Dr Tudor Hart: Well, I am not sure that there is very good evidence, or that there can be very good evidence that putting more money into GPs' pockets has any predictable result. I mean, there will be a tendency for them to buy more cars and to have longer holidays, and there will also be a tendency for them to invest in their practice and help their patients more; profoundly influenced, for the investment in practice, by whether it is likely to be an appreciating investment or pouring money down the tube. I think it is a very inefficient way to fund primary care, and I do not think primary care funded that way is taken seriously. That is why I would be in favour of a salaried GP service if I had any confidence that any authorities exist who could be the employers and in whom GPs could have confidence. I think we are getting that in a way, also I think we are getting it in Scotland, I do not know about Northern Ireland, I have no confidence at all in England, and I could not possibly recommend any of my colleagues to seek salaried employment, either by their colleagues, who have always been very bad employers, or by government, which does not seem to be interested in providing healthcare.

Q540 Dr Stoate: Thank you very much. It is probably the only bit you agree with Dr Meldrum on, because I want to move on --

Dr Meldrum: I agreed with quite a bit of that.

Q541 Dr Stoate: I am very pleased to hear it. I wanted to ask you, Dr Meldrum, about QOF. Do you think there have been sufficient incentives within QOF to target disadvantage, or do you think QOF has actually missed the point in terms of inequalities and disadvantage?

Dr Meldrum: I do not think it has missed the point but it is certainly not the whole answer. If I use the experience in my own practice, I mean, I think we were doing quite a lot of the quality work that QOF covers already. I think QOF though made us better at doing it, certainly the 10% of the more difficult or the most difficult to reach patients, I think it did encourage us to try and reach out to them and to try and look at them, but in the disease areas that are covered by QOF, which I freely admit are not anything like all the areas that general practice covers. But that is because QOF was designed only to be used where there was a good evidence base, also where there is good evidence that actually interventions in primary care made a difference; and also that you could measure it. Martin is much more of an expert on this than I am, but that does limit the areas in which it can work. Of course, one has to say at the outset, and I know this is probably taken as read in this situation, that health inequalities go much wider than just what the health service does, or even what one small part of the health service, or one small part of one small part, which is what QOF is; it is about much wider social and economic situations, and unless you address them, this is where I do disagree a little bit with Julian, then just throwing money at the areas of greatest need, unless that money is targeted into very specific means of trying to address the specific health inequalities, I do not think it will work.

Q542 Dr Stoate: That is actually helpful, but what we are looking at in this inquiry is the extent to which the health service can redress inequalities, which we know are far wider than health. What we want to see is what influence the Department of Health specifically could have on those inequalities. Perhaps I will ask Professor Roland the same thing: do you think QOF has been in any way helpful in terms of reducing inequalities, and if not, is there any way QOF could be modified to change that?

Professor Roland: I think it has. While accepting there are many causes of health inequalities, I believe that actually, the healthcare system is a powerful lever for addressing those. It may not get at the root causes. You can look at that across a range of different countries, that a good healthcare system does make people more equal in terms of their health outcomes. Well, QOF does it partly, is the answer. If you look at the difference in mortality between deprived and affluent areas, then 60% of that difference is due to conditions which are addressed in QOF. Some are addressed quite well, although Julian might not agree, heart disease; and some of them are addressed pretty poorly, cancer; but nonetheless, you have the major conditions that are the cause of health inequalities in the QOF to, as it were, do something about. My surprise in a sense is how well GPs in deprived areas have done. I was involved in advising negotiating teams originally when QOF was developed, and I argued that the QOF points should be deprivation weighted; in other words, it was going to be harder work to achieve points in deprived areas than not. What we have actually seen is that the difference in scores between affluent and deprived areas is astonishingly small, and it has narrowed in the first three years of the QOF. So rather like when cervical cytology was introduced, the financial incentives, perhaps surprisingly, appear to have had the effect of reducing inequalities. Now there may still be an argument for deprivation weighting, in that the GPs that achieve those things in deprived areas may be struggling, drowning, barely swimming, but nonetheless the fact is they have achieved what to many people was a surprising result.

Dr Stoate: Richard, do you want to take over from there?

Q543 Dr Taylor: Thank you, Howard. Like you, I should declare I am a member of the BMA and a Fellow of the College of Physicians. Firstly, really, an absolutely basic question: why was QOF needed at all? Were not the good practices actually doing it before QOF came in, and that was why they achieved the payments more quickly than the practices in deprived areas? So why did we actually need it?

Dr Meldrum: I would put forward two reasons: one, I think the good practices were doing some of it, but I do not think they were all doing it in a terribly structured or even a very evidence-based way. I think the first time it was done on a UK-wide basis, people really did look at the evidence for what things made a difference, and actually excluded all the other stuff in a way that did not really seem to make much difference and concentrated on those that did. As I say, I think the discipline of QOF did help practices, even the good practices, actually try to apply that discipline to that small group of patients, or in some practices quite a large group of patients, who have always been quite difficult to reach. It made us more pro-active in seeking out conditions and addressing them, rather than just being fairly reactive as a lot of us were. Not completely, but --

Q544 Dr Taylor: So within a practice with a very mixed population, it would have made you look for the people who do not normally attend, the more deprived people.

Dr Meldrum: I think it certainly encouraged that. The person who you knew was hypertensive but had not appeared for a year to have their blood pressure and various other things checked, you made jolly sure you tried to get them and chivvy them up, so I think it did. I know where you are coming from in the sense that why should you need some sort of financial incentive to actually practise good medicine, and it is something we all struggled with, but getting back in a way to Julian's earlier point, you have to pay GPs, it seems to me not unreasonable to use some of the payment system to actually encourage and incentivise good practice.

Q545 Dr Taylor: Martin, do you want to add anything?

Professor Roland: The five years after QOF were characterised by a whole raft of Government initiatives to improve quality of care, so there were national service frameworks, audits, feedback, all sorts of things. I do not think Government believed they were working, whereas we now know very clearly from our research that actually they were, and so quality of care, particularly for measurable things like heart disease and so forth, was actually improving pretty rapidly before QOF, and that was not realised at the time. QOF has made a difference in terms of a modest increase in the rate at which quality is improving, but it is not a staggering increase, simply because care was already improving pretty rapidly. So you could say that at that time, in 2003, the Government made two quite expensive mistakes: they believed that GP care was generally poor, which it was not, and they believed that consultants were generally lazy, which they were not. Both have proved to be rather expensive mistakes.

Q546 Dr Taylor: Thanks.

Professor Roland: Yourself excluded, of course.

Q547 Dr Taylor: Certainly I know most of them work hard. Is it possible that putting this money into QOF could take it away from other almost more needed areas?

Professor Roland: Well, I mean, there is a total sum of money, and it is up to the BMA to negotiate what goes to what. So yes, there is an opportunity cost of funding anything, and so, for example, one of the things which we now know from research is that continuity of care has got less good in the last five years, and that might be partly related to QOF, more nurses, more disease-specific clinics and practices. So you can argue whether that matters or not, but it is very unlikely that if you put money into one area of the healthcare system, you will not have some impact on others.

Dr Meldrum: Just to add to that, we argued actually quite strongly that not as much money as went into QOF should have gone in. We actually wanted significantly less money in QOF and more money into funding what I would call basic services, trying to improve staffing levels in the poorer practices and suchlike, so there was more of a balance; the idea of the way you funded basic services and QOF was to have a balance between the two, so that actually practices in the more deprived, difficult areas would get bigger and better basic funding, those in the wealthier areas would get a bit less but would actually find it easier to earn the money from QOF. Now because of what I have to call political interference, that balance was never achieved, and that is why we ended up with things like the minimum practice income guarantee, and also the bigger than anticipated overspend when GPs so-called overperformed because -- well, I do not think they overperformed, I think they performed as we expected, but because there was so much more money in the Quality and Outcomes Framework, it cost a lot more.

Q548 Dr Taylor: I would like to go back to Martin's paper, when you pick up under-reporting of prevalence in section 12, I think. That rather ties up with Julian's comments at the beginning, that we should be looking at redistribution, and Julian, I think, suggested according to house price, according to mortality rates, because what you are implying, Martin, is if prevalence is under-reported, particularly in the more deprived areas, that is doing them down on the actual amount of money that they get. Have I understood that right?

Professor Roland: That is right, there has been persistent concern that practices in deprived areas simply do not either recognise or code on their computers or in some other way report the true prevalence of disease. I must say, we have tried hard to look at this, and it is extremely difficult to do, because there is not really a good gold standard as to how many people with asthma or whatever there actually are in an area. We cannot find evidence of widespread under-reporting; there probably is patchy under-reporting. But in a sense, that leads to a problem, and it is a technicality of the payment formula which means there is actually a disincentive for practices in deprived areas to go out and case find, because they get relatively less additional money for doing that than practices in affluent areas with lower prevalence. So in a sense, the incentives are the wrong way round there, you need to be encouraging practices who are likely to have high prevalences to be going out and looking for people.

Q549 Dr Taylor: What would you think of Julian's suggestion that you should redistribute according to mortality rates and house price?

Professor Roland: Well, to some extent, we distribute in relation to mortality, in that some of the MPIG relates back to Jarman, which is an index of socio-economic deprivation, so we do have a distribution mechanism. The question is whether it is right, fair, et cetera; it would have been very much better if we had not got into the MPIG mess.

Dr Tudor Hart: But that is a distribution of GP income, it is not a distribution of investment. I want primary care to be taken seriously, which I think at present it is still not. Its full capacity is not used; its full capacity, for example, includes mobilising patients to do something about things, and that is not happening at all, through these very fragmenting mechanisms. I really detest piece rates; piece rates have predictable effects on producing everything else. If you are not producing a standard product, they are very dangerous. What is it that people do less of if they do more of the things that they tick the boxes of? Well, in my personal experience, they do less visiting of patients dying at home. How do you balance these two? Health economists do not have an answer to that, and cannot have an answer to it. In the end, it still comes down to professional judgment of people who actually know their populations, and live in them, and share the schools and buildings and so on that they use, know their lives. It is about life stories, it is not about a whole lot of sort of punctuation marks in their lives that represent taking parts of them out and so on. It is about the whole life. If the primary care staff get really involved in patients' lives, I really do not think they need these incentives or disincentives. All my life, I was struggling, as far as the practice economy went, to get enough staff, and get enough time, it was about time. You start off with six minutes per patient, when we first measured it; we ended up with nine, approaching ten minutes per patient for the doctor. We never succeeded in measuring what the nurses did, but it was getting more and more, because they did not really believe in measuring things. But I find that nearly all the discourse on this issue is off the point because it is always about putting more money or less money into the GPs' pockets, more or less to spend at their discretion; well, that can have good and bad results, but I just do not think it is taking things seriously. Everybody else is paid to do their work; you have enough to live on, live well, without worrying about things, and then the rest of your work is about the most interesting job in the world, looking after people's lives.

Q550 Dr Taylor: I am terribly much afraid that you, like me, may be sort of labelled as a bit of a medical dinosaur, which is rather hard, really. Hamish, do you want to --

Dr Tudor Hart: How many million years did they last?

Q551 Dr Stoate: Good answer. Robert, do you want to say anything?

Dr Meldrum: Heaven forbid I ever talk about dinosaurs.

Q552 Mr Syms: Still on QOFs, we have received numerous suggestions about how QOF targets could be revised or new targets introduced to better tackle certain conditions. We know GPs are very busy, finite time and everything else we have just discussed. What would you add or subtract from the QOF process, particularly to reduce health inequalities? Perhaps if I start with you, Professor Roland.

Professor Roland: Well, there has been what I think is a very good process of having an academic team who have taken evidence from a wide range of patient groups and produced suggestions for what should be in QOF, and how it should be changed. It seems to me a good process which has not been able to deliver fully because the negotiations got tied up with all sorts of other things that were not strictly related. So I think that there are certainly areas that we could do better in, so vascular disease and osteoporosis are two examples that have been suggested and may be funded in other ways, but it seemed to me that the Government had produced actually quite a good method for seeing how we can continuously improve QOF. There is no question that it should be, there was never any suggestion it would not need continuous change, continuous improvement. Use that mechanism.

Dr Meldrum: I would agree with that. I think though it is wrong just to concentrate on QOF, there are other ways of trying to resource, incentivise and encourage the various types of enhanced services where actually you can -- QOF, I think, quite rightly, remains a national scheme, and I think there would be dangers in having lots and lots of little local QOFs. There is no reason why you cannot, if you have a local problem, devise something that has quality built into it, but it does not necessarily need to form part of QOF, and there are various local enhanced services and suchlike that can be used to tackle asylum seekers, people with ethnic problems, lots of things that might actually better target the resources at addressing health inequalities, rather than putting something into a national framework, which to some extent, getting back to Julian's swimming pool, would help the people with their feet on the bottom just as much as those who are struggling to keep afloat.

Q553 Mr Syms: I think it was once said all politics is local, and from what Dr Tudor Hart has been saying, his experience is that actually it is related to the communities where a GP actually works, so perhaps, Dr Tudor Hart, if you would like to comment, do you think -- I mean, your view basically would be to scrap the lot and move to a different system, but do you think if we move the QOF system to something much more related to a locality, such as the one you operated in, that you could get more value out of the system?

Dr Tudor Hart: No, I do not think so. I think realistically, at the moment, we have many more innovative practices and innovative people working in primary care, not only doctors, many, many more than we had 20 years ago, no comparison. Medical science, all the health sciences, move forward, however much governments try to move everything backwards. So that creates some rather deceptive consequences. You know, advances can be attributed to things that actually are not their advances at all. I think we really have very good social motivation in most health workers of all grades, and I do not think at the moment in England there is much confidence among almost any of them that there is available any kind of Government agency that would give them a real sense of direction and real leadership. So if there is any leadership at the moment, it tends to come from within the profession, but that is a very weak position for tackling health inequalities, because obviously, the difficulties are very much greater in the high morbidity/low income areas, and they are going to get a lot worse now with the collision between prices and wages and so on, it is a terrifying prospect. So I am sorry, I cannot be very constructive about this, but I do not think that breaking everything we do up into fragments and paying for it is a sensible way to do anything, and it gets in the way of these progressive thoughtful intelligent people who just want to get on with the job. They do not want to be having to tick a box all the time or worry about whether there is a box for them to do the ticking. There is no other subject on which I find such unanimity now. I mean, it must be telling us something, but I think I would be right in saying that at one time, I was an extremely peripheral member of the BMA in ways, quite a lot of people would not talk to me, because the last time I gave evidence to this Committee was about private consulting practice and its effect on waiting lists, so quite a lot of people never spoke to me again. Now, a week ago, the BMA in Wales convened a policy meeting, how to respond to our Welsh Ministers' excellent proposals for getting the purchase-provider split out of the NHS, I was invited to introduce the whole day, and allowed to say whatever I liked, and when I sent the most inflammatory statement in for their approval, because I did not really want to rock the boat too much, they said, "Wonderful". Something extraordinary has happened.

Dr Meldrum: I am glad to hear it, Julian.

Q554 Dr Stoate: It is probably not as bad as you think, Julian. One thing I did not put on the record is you and I are both members of the Socialist Health Association, so it cannot be all bad. I think there is some recognition that some of the work you are doing is well valued by a large number of people. I just wanted to add a quick supplementary to Professor Roland actually, that is about smoking. You talked about how valuable QOF has been, I think QOF has been valuable, but half the available points from QOF on smoking are simply for recording the fact of whether anyone smokes or not. We do know that intervention in general practice can actually make a significant difference to smoking rates. So why is it that it gives half the points just to record smoking?

Professor Roland: That is one of the things that needs sorting. Clearly it is a criticism of QOF that a whole lot of stuff may just be paid for because it is recorded, that was recorded in different ways before. Am I allowed just to come back on the previous question? As you will realise, I am slightly more keen on measurement than Julian, I am also slightly more keen on localisation than Hamish. Hamish is absolutely right, QOF is not the only mechanism, there are all sorts of mechanisms for paying for things, and my own view is that there is quite a lot of opportunity for localisation. So if you take, for example, the patch I work in, major needs relate to drug abuse and relate to mental health problems of ethnic minorities. Actually, I can think of some very, very straightforward tick boxes that would really help in my practice, and that is just whether an interpreter is ever available or not, so some fairly straightforward things. But if there is going to be localisation, I believe very strongly, and things are going to be measured, that they should be things that come from a national menu, as it were. So if Manchester chooses to pay GPs for something to do with mental health for ethnic minorities, it should be done in such a way that what goes on can be compared with what goes on in other places.

Q555 Dr Stoate: Dr Meldrum, I just want to ask you whether you agree with the point on smoking and QOF, and whether you think that needs adjusting or not; what is the BMA's position on that?

Dr Meldrum: Yes, certainly there has been some adjustment and there will be more. Obviously, recording and finding out who are the at risk is important, and one should not knock that. Equally, there are some things, yes, smoking is one, where there is some evidence that actually interventions in the practice itself are good, but actually, a lot of evidence that smoking cessation clinics, which use a wider group and are perhaps held above a practice level, can be equally if not more effective. Same applies for drug and alcohol problems; there may be one or two practices who have the expertise to properly tackle them, but in most places, you need a better range of services than most practices can have in terms of testing, in terms of other help, counselling and various other strategies. So it gets back to whether or not the QOF -- one should not rely on the QOF for addressing all health inequalities, because it really applies to things that can and are being done in general practice or can be done, and you have to look at areas outside that. But I perfectly agree with Martin that even these areas outside, there should be national accreditation, if you want, of those, so that they are properly evidence-based and you get some consistency. Just one point on Julian's, he was mentioning ideology of GPs being salaried, but then talked about innovation on that; I believe it is the independent contractor status that helps with the innovative side of general practice, and there are ways in which, you know, we have seen recently, with restrictions on money for premises, for increased staffing, that these innovative tendencies have been hampered.

Q556 Sandra Gidley: Question to Professor Roland: in your evidence, you say that deprived and affluent sections of the community mostly access primary care equally once need has been adjusted for. We hear quite a lot about the lower proportion of GPs in underprivileged areas or deprived areas, and the Government has some plans to put more GPs in. Are they doing enough, or is it not just a case of increasing the number of GPs?

Professor Roland: No, they are certainly not, because the first thing you mentioned is just crudely numbers of consultations. You are absolutely right, there are fewer GPs in deprived areas, and so one of the consequences is they are rattling through patients faster, patients who themselves have greater need. But we have looked at the inequality and distribution of GPs across the country over the last 30 or 35 years: it got better and better from 1974 up until the early 1990s, and then it stabilised out, and since the early 1990s, the inequality in distribution has got progressively worse year on year, up to when we last looked, which was 2005. So the inequality in distribution of GPs has been getting worse.

Q557 Sandra Gidley: Is this linked to the colour of the Government at the time? As a Liberal Democrat, I am neutral here.

Dr Meldrum: It may have been linked to the fact that they got rid of something called the Medical Practice Committee, that actually looked at the overall distribution --

Professor Roland: That was not until 2003.

Dr Meldrum: I think it was the late 1990s.

Professor Roland: So there is definitely a problem, and since 2005, there have been a number of initiatives to try and bring more doctors into deprived areas, and we do not know the effect of that, but we have looked at the effect of schemes trying to do that in other countries, because every country faces this problem, how to get doctors to go to places that are not very congenial to practice.

Q558 Sandra Gidley: But do doctors actually need to do different things in deprived areas? Do GPs have a different approach in deprived areas, or is it just a question of time?

Professor Roland: I do not think fundamentally they need to be all that different, because as I said earlier, the big causes of death in deprived areas, over and above those in affluent areas, are heart disease, chronic suppurative lung disease, cancer.

Q559 Sandra Gidley: You also mention in your evidence that the access to secondary care is different; in deprived areas, there is less access to secondary care. I am slightly confused what is happening here, because extra money does go into deprived areas, and it seems it does not go into primary care, so the assumption is that perhaps it goes into secondary care, so do they have better services that they are not accessing?

Professor Roland: Well, the figure that you are trying to interpret is that patients in deprived areas, and this again is seen across many countries, see less specialists. That is not quite the same as having less access to specialists. You might think, why do they see less specialists? Of course, it could arise from a whole range of things. We have done a study, for example, of patients with coronary heart disease in Toxteth in Liverpool, who had apparently not had the investigations that they should have had. A substantial part of that was people being very fatalistic about their health, and believing they were going to die young like their dad and granddad, and there was nothing they could do about it. So it may be partly to do with patients. Of course, it may be to do with the GPs, who may not appropriately refer people who could benefit from specialist investigation. My inclination is to think it is perhaps more to do with those than the actual availability of the specialists, which as you say is not obviously less.

Q560 Sandra Gidley: So to some extent, it is a cultural thing, which greater primary care input could have that knock-on effect on secondary care?

Professor Roland: I mean, the key there is to make sure that the people who will benefit from referral get referred. Although a lot of the NHS is currently concerned with how to deal with overreferral, I think that this ignores the problem of underreferral. Overreferral is expensive, but underreferral is more likely to be damaging to patients' health.

Sandra Gidley: So it is not just the worried well that are skewing the figures, there is a definite underreferral. Okay, thanks.

Q561 Dr Taylor: I am coming on to two fairly controversial areas: Alternative Provider Medical Services and polyclinics. Hamish, in your executive summary, the BMA remain very concerned that the new APMS practices may end up delivering a potentially second class service to areas of the country that already have significant health inequalities. Can you expand on that?

Dr Meldrum: Yes, I think the word potentially is important because it is probably too early to have lots of evidence, but there is some evidence in terms of what we have seen from some of the private companies who have had a succession of shorter term locum type doctors rather than the longer term continuity that you tend to get with what I call more traditional general practice. Certainly one has seen it a bit in pharmacy, a move from the smaller local pharmacist to the larger companies, where the continuity aspects of care are less well addressed. There is also evidence, in terms of size, that actually, although bigger practices may have a bigger range of services and suchlike, in terms of quality and in terms of patient perception of whether they like them, actually smaller practices often do better and certainly do better on continuity. I think the other worry is that if you only use the APMS contract and do not use the other more traditional contracts, you do tend to discourage perhaps traditional GPs from taking these on. The APMS contracts tend to be shorter term contracts, therefore more risk attached, and people with access to limited resources are less likely to want to invest in something where they do not necessarily see a long-term future and would have anxieties about investment for the longer term.

Q562 Dr Taylor: So continuity, size, short-termism, any other --

Dr Meldrum: If we are talking about polyclinics, and everybody has their own view of what that word means, I think the idea that in certain areas, you get rid of lots of small practices and move them into one big place, have outreach facilities from the hospital, well, there are some aspects of that that are quite good, but in some ways actually you are taking primary care further away from what the majority of patients want, because the majority of patients do not necessarily need access to these enhanced services, and therefore, if developing polyclinics means not investing or even worse closing down the smaller practices, you actually might make the problem of access, particularly for those who find access quite difficult, with transport and other problems, make it worse.

Q563 Dr Taylor: So you implied there were some good things about polyclinics possibly in some places.

Dr Meldrum: We have never said that we are against polyclinics per se, and certainly, I for a long time have talked about perhaps more the sort of hub and spoke model, where a number of practices may feed into a community resource. You might actually call it a community hospital, because we have had them around for quite a bit of time, and consultants may come in there, you would have other things like dietetics, physiotherapy, work advisors, various other things. So there is scope for that sort of development, but I think at the moment one is concerned that there is this almost fixation that polyclinics are the new nirvana, they are the answer, and they will solve all the problems. They will not, for two reasons, because first of all, they are certainly not the answer everywhere, and secondly, they are not the answer for all the various problems we have.

Q564 Dr Taylor: Anything to add?

Professor Roland: I think APMS arrives to some extent out of frustration by Government that certainly in some parts of the country, general practice has been very resistant to change. I think this is a particular problem at places which have real problems of quality. Certainly I have experienced this personally as a member of the Manchester Performance Panel, in visiting practices which have come to the notice of the Panel, through being at the bottom end of performance. Actually, there are really very few levers to try and persuade practices that really need to change a lot to change. So I think that APMS to some extent comes out of that frustration, and I think the two interesting questions are, if you introduce other types of provider into the system, will they improve things -- supposing you want to extend hours, to have surgery starting at 7.00 in the morning. Do you improve them by having to cover the population with such a facility, or do you introduce it by putting one thing in there, and the surrounding local practitioners look at the competition and then change their behaviour? I do not think anybody knows the answer to that. Except possibly Professor Maynard, but he is not allowed to talk.

Dr Stoate: We will ask him later.

Q565 Dr Taylor: So they could be good in some areas. What about the risks that are feared that bringing polyclinics in will increase the risk of commercialisation?

Professor Roland: Well, they are not inherently tied up together, in that polyclinics do not have to be run by commercial organisations, but it is clear that commercial organisations appear to have significant advantages in bidding for such things over and above local practitioners. I think in terms of polyclinics, there are two broad aims for a polyclinic. One is to bring practices together in the way Hamish describes, and there, the benefits are principally that it is an opportunity to have radical improvement of the estate, which is very poor in some places; and then you have the attendant disadvantages of reducing access, reducing choice, potentially reducing continuity of care. So my view in terms of whether practices should be corralled into polyclinics is that it is an appropriate strategy where the local estate is poor, and it really is a means of improving it substantially, and probably not appropriate for many parts of the country where the local practices operate from quite good premises.

Dr Tudor Hart: I think we are losing sight of the big picture. Back in the 1970s, when the NHS was indisputably more cost-effective than any other national care system, there was general agreement, a consensus view, that this was attributable, first of all, to the existence of a primary care system that included everybody, and secondly, that it had a gateway function, that access to secondary care, to specialist care, was always via a primary generalist. It was such a good system that it even worked better than other people's systems, in spite of having quite a lot of really not very good doctors working in primary care. But even so, it was better than not having anyone or, worst of all, direct access to specialists for customers who just decided for themselves what they could afford and what they wanted. We now have the situation where, starting in America, but naturally it will happen here, we even have direct-to-consumer advertising of coronary artery stents. Can you imagine? But that is actually happening now. Of course, the polyclinics are already in the pipeline in Haringey now, and are displacing practices that were very innovative and had big plans to expand and to diversify and so on, but these things are coming in. I think members of all parties need to think ten times before doing any further damage to the gateway function of primary care. We really need primary generalists. We have to have basic human biologists who really understand, take the human mind and body really seriously. Being a GP, a good GP, is more difficult than any other speciality, it is more demanding, because you have a wider area of responsibility, and it always includes everybody, not just some people, within your territory, and in that territory, you do not just have a verbal commitment to the human race, they have names and addresses and telephone numbers. So if you say it, you have to mean it. Now we must hang on to that and build on that and stop destroying it, and at the moment, we are destroying it. The polyclinic idea, which used to be a Soviet threat, then we went through a phrase where the Cubans had it, they discarded it, they dropped polyclinics, and where did they come to find what to do instead? Us. They came here and remodelled their primary care system on GPs, on family doctors. They have polyclinics, but they are in the right place, that is they are a kind of outpatients, and they really function pretty much the same as our outpatients departments do. So I think it is very important that we do not get lost in the trees, and not see the wood that we have staggered into.

Q566 Sandra Gidley: Just a very quick question really, it strikes me that with your GP, there is somebody who knows their patients fairly well; there are some they know too well, because they are there every week, and there are some they hardly see. One of the advantages of a GP is that they will often make a judgment based on knowing the individual, as to what is necessary. I do not know if that is a fair assessment or not. So is there a possibility that with larger polyclinics, more anonymity, but potentially probably less guarantee you will see the same person or somebody who knows you, is there any evidence to show that this will ultimately be more expensive, there will be more tests ordered, medicine will be practised more defensively, because you simply do not have that basic knowledge of the person? Or is this a fairytale myth put out by the BMA?

Dr Tudor Hart: I think on the whole what we have to look for is not evidence, if we are using the term responsibly, it is experience. If you wait for the evidence, it means you have to create them, and actually have a control group and so on. Well, no government so far seems to have been prepared to do that about anything.

Q567 Sandra Gidley: I would not want to be part of that experiment.

Dr Tudor Hart: But you have to set it up as an experiment, and so far, none of the steps that have been taken, for example, to weaken the gated function, none of that has been subjected to controlled experiment, so we have to look at experience, and the experience of the kind of polyclinics that seem to be being talked about mainly comes from the United States, where absolutely none of them actually are totally socially inclusive. That is very important: to get from the station here to get into this building, you probably had to walk past one or two people who will certainly be missed out of virtually all systems, and yet they concentrate a great deal of illness. So I think we have to look suspiciously at things that look to me like shopping malls. I think that is the idea that is present in the minds of some politicians, certainly in the minds of a lot of potential patients, and the BBC and the media and so on, that is the way they think, that people are going to go in and shop around, and they will go direct to the specialist that they think they need. Now there are all sorts of modifications of that: if you have an insurance-run model, as the Americans have, where really, insurance companies are in charge of strategies, not the clinicians, you will get a different result than if you have large bowel cancer surgeons, but it is a funny place to go for a redesign of primary care.

Q568 Dr Taylor: I am going on, trying to search for any possible advantages of polyclinics. As we are unlikely to abolish the purchaser-provider split in this country, is there any way that polyclinics could lead to a merging of primary and secondary care?

Professor Roland: The answer to that is yes, and if you know about some of the problems, you can also mitigate them. Just returning to Mr Syms' question, if continuity of care is a problem, you could incentivise it in a QOF, you could actually incentivise it quite easily, and I would do so, personally. The issues, apart from getting GPs all to move together, is whether you get specialists to move in, relating in some ways to the GPs. What is pretty clear from the previous evidence is just to move specialists from doing what they do now to doing it in a different place in the community is of modest benefit in most urban areas. They are less efficient, they see fewer patients, and it is probably not a brilliant idea, but what there is a lot of discussion about at the moment is specialists moving out to work differently, and to work in a much more integrated way with their GP colleagues, and looking at whether it is -- pathways to care and developing practice-based admission in a way that has people working together rather differently, I think there are a lot of opportunities there, because although Julian is absolutely right, that the rigid primary/secondary split is something that has kept our costs down, and I certainly would not advocate direct access to specialists, I think we could do a lot better if we had much better communication between GPs and specialists.

Dr Meldrum: I think we can easily get bogged down in buildings and structures, and that is part of the problem with a polyclinic, rather than actually services and how they are provided. I have sort of almost gone full circle where I practise on the East Coast of Yorkshire. When I first went there, community hospital, we were very much involved, ran a minor injuries unit, did clinical assistance sessions, worked with consultants. Through time, we were pushed out, our practices got busier, for something, we were no longer thought fit to do these sort of things, and now they are trying to encourage us back. I am hopefully not as pessimistic as you, Richard, about the purchaser-provider split being here forever, in all areas. I think there is probably not a bad case for it in terms of one-off episodes of elective care. I am actually not convinced that the arguments of increased efficiency and driving down costs outweigh the transaction costs that are involved, and the fact that it does tend to put purchaser against provider, and inhibits collaboration, so I would still like to see what is happening in places like Wales and Scotland, and perhaps learn from them, and say that actually, maybe the market and the purchaser-provider split is not the answer to everything in healthcare. Just to follow on one other thing, something that Sandra was talking about, I think there is always -- the important thing is the trust and relationship between the doctor and the patient, and there is always going to be a balance in that. It is not just whether it is a good doctor, it is how much the patient trusts that doctor, so that when I say, "You have got a headache, you do not need a brain scan", they will accept that, rather than saying, "Well, I want one", sort of thing. And where that balance lies between who has the power in that relationship will change depending on the condition, depending on the patient, depending on a whole series of things. There is also the balance too between what one would traditionally call a patient and what one would call a customer. Again, there are lots of arguments about where the balance -- and in certain conditions, if somebody has a hernia that they need doing, they will behave more like a customer, in a way that they will want to know a lot about the hospital and the way it is going; if it is a much more complex situation, they will prefer to be more like a traditional patient, who will accept the advice of a trusted healthcare professional. So it is quite a complex mechanism but that relationship between the doctor and the patient, or not just the doctor but the patient and the health professional, is absolutely vital. I think that is what one worries about, when you talk about continuity issues.

Q569 Dr Taylor: Finally, out of hours care, how do polyclinics affect out of hours care?

Professor Roland: Well, I am not sure they do, in the sense they are just a building.

Q570 Dr Taylor: Sorry, the service provided by polyclinics, because they are going to remain open, I think, until 8.00 pm; are they going to --

Professor Roland: There are clearly problems in provision of out of hours care, and some of them, but by no means all of them, would be addressed by nice buildings that people could get to easily and park. I do not think they are critical to the argument really.

Q571 Mr Robert Syms: How can Primary Care Trusts be incentivised to be more active in reducing health inequalities, say by commissioning nurse practitioners where it is underdoctored, or would you say they are irrelevant?

Professor Roland: No, absolutely not, because to the extent, as we have discussed earlier, that some of the problems of health inequality extend well outside the healthcare system, then PCTs are in a position to do certain things. For example, as a GP, I do not terribly want to be incentivised in relation to the teenage pregnancy rate of my 16 year old girls. You could argue I should be, but if you look at PCT level, then the PCTs do have a responsibility to be talking to the local education authority, to social services, and providing other types of clinic; then clearly, those broader things, which might be outside healthcare, are within the remit of the PCT, but they are not necessarily within the remit of a practitioner, so absolutely, yes.

Dr Meldrum: I would say that PCTs are vital. I know the BMA is always accused of being negative, but recently, we have produced a series of documents about where we think you could make positive approaches, and it sort of gets back to what I was talking earlier to Sandra about, in terms of this partnership between patient and public; not just on an individual basis but at a community level as well, I think we feel that PCTs, within certain constraints, and you need to have national standards that they have to conform, but they need much more flexibility to adapt and decide how best for themselves to deliver healthcare to that population, and that can only be done where there is a partnership between the managers of the PCT, the public and professionals. I mean, commissioning in too many people's language is about buying healthcare; commissioning is much wider than that. Commissioning is about assessing the health needs of the population and deciding how best in the local circumstances you are going to address these healthcare needs, and at the end actually seeing whether you have done it. I think at the moment commissioning is still very poorly carried out in many areas in terms of accurately assessing health needs and then letting local communities realistically decide how they are going to deliver them.

Dr Tudor Hart: Well, I am in Wales. I think we are moving to a situation where we all agree in Wales that you do not trust anything called a Trust. It implies some kind of standalone institution which cannot be dis-elected, is not elected in the first place, you cannot get rid of it, full of people who have unknown expertise, that makes them able to take bold, brave decisions that apply to other people but not themselves. So I am just against them, I suppose.

Q572 Dr Stoate: You have made that clear, I think.

Dr Tudor Hart: But more important than what I think, I think what is happening in Wales, it is not just a matter of getting rid of the purchaser-provider split, you have to think about what happens when you do not have the split any more. The whole point about the purchaser-provider split is that it divides the people who plan the job from the people who do the job. The people who do the job are not just doctors, and they are not only doctors and nurses, they are patients. The purpose of a consultation, which is the point of production in medicine, is that it brings together the evidence from the patient and the evidence from the doctors, so they are working in it. We do not want the planners and managers to be a completely separate body of people from the people who actually do things, implement things, and I think we can get back to that, I think they are probably further ahead with it in Scotland actually, because there is a much stronger profession in Scotland, but the internal disputes in England, I just cannot engage with it.

Q573 Mr Syms: GP practices, sometimes in deprived areas, can be of poor quality. Should there be a licensing of practices' fitness to provide care to their local population, should that be a way we go, and how rigorous should it be, if you supported that proposition?

Professor Roland: Well, there are currently detailed discussions going on and piloting of a system of practice accreditation which in a sense is not exactly the same as licensing, but has quite a bit in common with it, in that there are a set of core standards that practices have to reach and then a set of other types of standards that people pick from and gradually improve year on year. I think that we have, over the last five or ten years, got much better at recognising poor performing practices that maybe really should not be in business, but we still, although the National Clinical Assessment Service has done a very good job, as I alluded earlier, there are actually still real problems in addressing a very small number of practices.

Dr Meldrum: I would agree, there is a lot of work, my colleagues in the GPs' committee at the BMA are working very closely with colleagues at the Royal College of GPs developing the practice accreditation system. It is going to be piloted, so I think it might help to address some of the issues. I agree with Martin too, I have often said that one of the real things we need to tackle in the health service is unacceptable variability in quality; that is not just in doctors but in Trust managers, whoever. At the moment, I do not think the systems are terribly good, I have often sort of said that we seem to have a system that actually upsets, I will put it politely, the majority of people who are really trying hard and doing quite a good job, and does not adequately deal with the small minority who are not. There have been some improvements in that, but I think we have to go further in addressing unacceptable variability.

Dr Tudor Hart: I do not think I can add anything to that, I agree with that.

Q574 Sandra Gidley: Question to all of you really, back to practice-based commissioning: how can it be used to tackle health inequalities, and is there actually any evidence that it is having any impact whatsoever yet? We have heard it is not really getting off the ground in some places. How would it best be used, given -- and actually, are GPs being given the flexibility, because it is called practice-based commissioning, but the Trusts that are not trusted seem to be interfering quite a lot in what some of the GPs are coming up with, I am told.

Professor Roland: Practice-based commissioning is a slight misnomer, because in almost all parts of the country, it is actually consortia of practices, it is really consortium-based commissioning. The simple answer to your question is yes, since it is a mechanism for looking at the health needs of our population, it absolutely is in a position to address inequalities. Received wisdom is that it has had little impact yet.

Dr Meldrum: Partly it is back to what I was saying earlier about the definition of commissioning, I think commissioning still seems to be often concentrated on actually buying services, rather than the much wider. Now I agree with Martin, I think in most cases, the practice is probably too small a unit. Practices are good, in that they do have defined populations, the registered list is very helpful, but I think in many ways, they are too small a unit to base the sort of wider public health or health of the public type issues. I think it has been poorly resourced in many areas, the managerial support has not been good; certainly data, both in terms of quantity and quality, is poor in many areas too. Although you do not want this to become a bureaucratic nightmare, unless you have reasonable and effective and speedy flows of information, then it is very difficult to judge how well or how badly you are doing, and to actually have effective commissioning.

Dr Tudor Hart: I think the thing that stands out a mile is that the redistribution of investment in primary care which logically follows from there being much greater needs in some areas and much higher workloads in some areas than others, that has never really taken place. I cannot remember the name of the committee in Scotland, the report that -- it was not Goodenough, but it was something with a G in it. They put a tremendous amount of work into this, and it was a very well-intentioned report that is well worth reading, but it only succeeded in actually shifting, I think, about 1% more resources to the areas of high need. The same thing applied in Wales, where Jane Hutt spent an awful lot of money in an assessment of need in all the different Welsh localities, and there is a barely perceptible actual real shift of resources, once all the different vested interests, local interests, have had their say, and the various elected people have looked at what might happen to them if they allowed a real shift to take place. If you ever suggest that some areas should have more of something, then a tremendous howl goes up, and we are told that we want levelling up, not levelling down. Now I do not know what the hell that means, when you really think about it. At some point, people who are relatively better off are going to have to slow up a bit. If we are in an expanding system, that is really not too difficult, because you can have preferential expansion where it is needed. The test, I would have thought, is very crude. Do we have more doctors for the same population in the poor areas, where there is not only much higher morbidity and mortality, but much greater difficulty in delivering the care and sustaining the care and so on, for all sorts of reasons. The swimming pool analogy, stick with it, because it is a global problem. Poverty in an area and demoralisation in an area now, we do not have the old kind of poverty, with high industrial morale but low incomes; now we have low incomes and demoralisation, and it is so multi-factorial that it is better not to try to be precise because it never gives you a satisfactory answer. It is about drowning. I think we really have to look at 5 and 10% shifts, not less than 1% shifts. It should primarily be in staff, so that you have more time to listen to people and write down what they think and pick up the telephone and melt the wires with somebody. It is complex. The terribly simplified pathways that people devise to work out their boxes for ticking do not have any meaning to most of us who are experienced in this field. I think Hamish would agree.

Professor Roland: Can I just make one comment? In terms of workforce planning, in some respects, the PCT is too small a unit, because experience from other countries shows that if you have a PCT which is very deprived, it puts in some sort of incentive package to get people to work in that patch. They do not actually come and work from the leafy shire over there, they move from the almost as deprived area next door, so what you get is just selective shuffling around within the deprived areas, and that does need a broader approach to workforce planning, so you do not just shuffle people around within deprived areas.

Q575 Sandra Gidley: I think a recent inquiry showed there was no such thing as workforce planning.

Professor Roland: Not in this country. There is in other countries.

Q576 Sandra Gidley: Perhaps that is a little cynical. Just a quick final question: would it be fair to say that tackling health inequalities per se is really not on the radar of commissioners? Is that fair or unfair? If it is unfair, is there any difference between spearhead PCTs, which are supposed to have a greater attention to this problem? Would anybody like to answer that? I see some shrugs of the shoulders.

Dr Meldrum: I think it would be a little unfair to say it is not on the radar, but I do not think it is a very big blip on the radar.

Q577 Sandra Gidley: A blipette then.

Dr Taylor: Really just coming back to something totally different, out of hours care: is there any suggestion that removing out of hours care out of the GP contract has had any effect on inequalities?

Dr Tudor Hart: Made it worse.

Q578 Dr Taylor: That is the gut feeling, but is there any actual hard evidence coming out to that effect?

Dr Meldrum: I think it is quite difficult, because obviously the change in pattern of out of hours care was happening long before the GP contract. It started in the early 1990s, that fewer and fewer practices were doing solely their own out of hours care, they were getting together in co-ops, but actually even before the contract, there were problems with some of the co-ops actually being able to attract enough people. In some ways, people blamed the GP contract, and of course I was one of the people who helped negotiate it, so I would say this, wouldn't I, for the cause of the problems, but in fact, some of the things in the contract were an answer to the problems; the fact that there were more women going into general practice who would be put off by the out of hours commitment. I think too the answer is to look at much better co-ordination and integration of care out of hours. We still tend to put it into silos: that is the GP bit, there is the ambulance, there is A&E. I think unless you have a more co-ordinated approach, then you are probably not going to address some of the inequality issues with people turning up frequently at casualty or problems that they really should not be going there with, and are not addressing the longer term issues that they have, they are just quick sticking plasters rather than actually addressing their longer term health issues.

Q579 Dr Taylor: However do you co-ordinate it, if you have the GP practice on one hand, and the out of hours run by some huge consortium from somewhere else?

Dr Meldrum: You do it by effective commissioning, which we do not have.

Q580 Dr Stoate: I would like to ask a supplementary actually, particularly to Julian, just because we have a few minutes spare before the end of this session, and we do not normally have that. You have not taken the polyclinic idea very well, but I want just to discuss something with you, and that is slightly philosophical. You and I go back quite a way in general practice, and we remember the days when GPs were nothing more than people who could not make it in a hospital lab, or at least that was the theory put around by hospital consultants. I remember having a debate with a consultant who was patronising me rather badly, and I said to him --

Dr Tudor Hart: I missed the last bit you said.

Q581 Dr Stoate: I said some consultants were rather patronising about GPs, and I remember having a rather angry exchange with a consultant who was being patronising, saying, "You are only a GP", and I said, "Listen, mate, I am the patient's doctor, and you are my expert assistant, and don't you forget it". But those were the days when GPs had a pretty poor reputation. It has radically improved since then, but surely the idea of polyclinics puts primary care specialists, which I believe we are, back in the driving seat, instead of having to pass the patient on to a specialist and effectively losing all control over that patient until the consultant deems it fit to send them back to us. The polyclinic model allows the GP to stay in complete control of the process right up until almost tertiary level, because if we are trading directly with consultants in the same building, effectively able to do joint consultations with a specialist in a particular area, surely that keeps the GP effectively overseeing the entire process, rather than the patient disappearing into a black hole.

Dr Tudor Hart: I do not quite see it this way.

Q582 Dr Stoate: Hamish does not either, by the sound of it.

Dr Tudor Hart: This is a very doctor-centred discussion. I saw enough of the outgoing cohort of GP surgeons and sort of GP specialoids to have a great fear of any return of that kind of thing, and even people excising apparently harmless bits of skin which then turn out to be melanomas and so on, I think we have seen some retreats from -- I think we have moved backwards for some things.

Q583 Dr Stoate: But surely the best way of solving that problem is to make sure that the biopsy is done with the dermatologist in the building at the same time.

Dr Tudor Hart: I am trying to get away from that kind of example. I mean, all right, biopsies and taking the guts out and so on, and giving them a new hip and so on, of course it is very important, but people like talking about those things because they are items that can be specified, and you can build a theory of economics around them, but I am talking about life care. I should think the number one worry of most people now, if you asked them, is how the last few years of their lives are going to be spent. Is it going to be sitting in a row watching television with crap on it? It is about life. I think that the definition of a primary care doctor is going to have to change. It is going to need an enormous upgrading and it is not going to be an upgrading towards an homme tradiciene, somebody who can do everything. That was a ridiculous idea; of course you cannot. Although I think that quite a lot of specialists, the more primitive kind of specialists do think that; they think that a really good GP is one who is a master of all the specialties. That is crazy. I think that we need a human biologist which would include brains; it includes an understanding of sociology because human beings are social animals. It is more demanding because it is wider than any other part of medicine but, in that, clinical medicine is actually a subset of public health instead of the other way round. It demands a huge revolution in thinking. I think that this is beginning to happen in our medical schools which are wonderful; the improvement is fantastic since 1952 when I qualified; those were the dark ages. We have wonderful people coming. I am not so sure about the society they are going to serve. We have beautifully trained people with very generous imaginative ideas, but I am not sure that the service they then go into really matches that. No, I do not see polyclinics as a place to maintain expertise or to help us in the struggle for power over the patient. The tug-of-war, "he is my patient, keep away", is rubbish. I also do not think that the patient should be left in sole charge of their own care as a consumer/customer. That is ridiculous. I am full of all sorts of diseases because I am 81. I am afraid that at the moment I am the only person who pulls them altogether; it is fortunate for me that I am a doctor. I do not really have anyone acting as my generalist. I am in a very easily doctored part of the world in the Gower Peninsula where every doctor would like to work. The doctor whom I regularly see is a nurse. I had a choice between two or three nurses but I have settled on one who I like. She is my GP now. I do not think that she thinks physiologically and I do not think that she knows any pharmacology, but a good many GPs do not know those things and actually I meet specialists too who stopped reading their journals a long time ago.

Dr Stoate: Thank you very much for that. I would like to thank the three witnesses for giving us that excellent session this morning. Thank you very much for your time.

Witnesses: Professor James Nazroo, Professor of Sociology, University of Manchester; Ms Margit Physant, Health Policy Adviser, Age Concern; and Mr Peter Baker, Chief Executive, Men's Health Forum, gave evidence.

Q584 Dr Stoate: I welcome our three witnesses to the second session of this morning's meeting and I ask all three of you to introduce yourselves for the record.

Mr Baker: I am Peter Baker, Chief Executive of the Men's Health Forum.

Ms Physant: I am Margit Physant, I am Health Policy Adviser at Age Concern England.

Professor Nazroo: I am James Nazroo, Professor of Sociology at the University of Manchester.

Q585 Dr Stoate: I shall begin with you, Margit, and ask you: what are the main aspects of health inequalities in relation to age?

Ms Physant: There is age discrimination in health service provision today. There are still services that are restricted by age. In mental health care, when people reach the age of 65, they sometimes have to transfer to another service even if it is not determined by their clinical need at that time. There are also age limitations on screening. At the moment, screening for breast cancer and screening for bowel cancer, where the risk increases as you age, there are still upper limits on that which we are not convinced are the optimal levels at which people can still benefit from screening, although they have increased recently.

Q586 Dr Stoate: One of the theories behind that surely is that, as you almost pointed out there, there is a clinical reason why some screening programmes are simply more effective at some ages than others. Is that not reasonable?

Ms Physant: The risk of having these cancers increase with age and there is a point at which, yes, there is an upper limit where you might not benefit from treatment or discovery, but we are not convinced that 73 as the upper limit is that age and we have not seen any public justification for that particular age.

Q587 Sandra Gidley: Is there not some evidence that, particularly with women and breast cancer, as they are not screened anymore, they think they are not at such a great risk, so it is almost counterproductive?

Ms Physant: I have heard that as well, yes.

Q588 Dr Stoate: What three interventions would you prioritise to tackle age discrimination within the health service?

Ms Physant: The first priority would be to eradicate age discrimination in the NHS and we believe that if the NHS had a duty imposed on it to promote age equality in its services and as an employer - the NHS is of course our biggest employer and employs about 5% of the labour force, so it can have an impact in that sense as well - then we would go some way towards it.

Q589 Dr Stoate: Are there any other priorities that you would take? Obviously that is the main one but what else would you do?

Ms Physant: Health inequalities are determined by very many factors outside the NHS but the NHS has a role. It is part of local partnerships that can use, say, local area agreements to redress those inequalities. It can also do something directly in that it can help alleviate poverty. We have just carried out some research into using healthcare settings for welfare benefits advice for older people which has shown that it can be very successful. It is taken up by people and people who participate benefit from it by improved mental health services and less worrying, health professionals like it and it also supports the local economy because it tends to be spent locally. People spend the money on things like additional food, heating and practical help in the home. So, this is another aspect where the NHS can do something directly. In terms of worklessness which we know is very bad for health, it is terribly important that people, particularly the 50-plus age group, stay in work, so the NHS can support people to remain in work with long-term conditions or, if you are off sick from work, you can be rehabilitated and get back to work. There is a very high risk that almost week by week that you stay out of work, the risk of never working again increases dramatically in a very short time. We would say thirdly that the NHS can support vulnerable groups in old age, groups like carers and they can support people around the trigger points where people might become vulnerable to poorer health; it may be around bereavement, retirement, transferring to a care home, those sorts of points where health can deteriorate.

Q590 Sandra Gidley: Staying with age for a moment, you have mentioned some of the groups which you say in your submission receive insufficient support from GP services such as older carers and even people living in care homes which is quite surprising, and those suffering from depression. Do you know what the reason for this is? Why are these people effectively written off?

Ms Physant: There are probably slightly different reasons for the different groups. If you take carers, carers do have poorer health than other people, both physical health and mental health, and it may be very difficult for them to get to the surgery to be seen for their own health and take part in any sort of preventative measures that could improve their own health because they have this caring responsibility and GP services are not amenable to having home visits for social reasons, it may be that they are more determined by people's physical need. We did some research with older carers and one of the things that came up was that they found it very difficult to get a GP to come and visit them or the practicalities of getting to a surgery.

Q591 Sandra Gidley: Was it that they did not like to ask because they did not feel their problem was bad enough, or is there any evidence that GPs are not making as many visits?

Ms Physant: From the research, it would appear that it was not possible for them to get home visits for their own physical needs.

Q592 Sandra Gidley: Surely you would expect people in care homes to be better provided for than almost anybody. What is the reason that they seem to be missing out?

Ms Physant: They are indeed amongst the frailest members of our society and they are, by definition, in a care home and it is not so much if somebody is sick that they cannot call the GP out ... There are local arrangements in some areas where things are working well, but there is not really any national direction in that there is not a national system that can provide that clinical leadership in that you may need somebody to tell the care home to have arrangements for falls prevention or having the community pharmacist to come out and do medicines used reviews or having somebody to help the care home with infection control. We know that clostridium difficile is raising its ugly head again. There is not a national system of addressing this need.

Q593 Sandra Gidley: Do you think that some of that will be helped when the regulators change? I am not quite sure whether CSCI is not doing their job with some of the things that you have mentioned or whether they could be doing more to make sure these things happen. The things you have mentioned such as pharmacists going in to medication reviews should happen, it is part of what a good care home should be doing, but we know that they are not.

Ms Physant: Yes.

Q594 Sandra Gidley: What evidence-based incentives do you think could be used to make sure that some of these groups receive improved care?

Ms Physant: We believe that GPs should be incentivised to look after these groups but we do not have ---

Q595 Sandra Gidley: Does this mean paying them more?

Ms Physant: We are not particularly about which incentive it is but that there are incentives.

Q596 Dr Taylor: Professor Nazroo, I thank you for your memorandum because it helped understand the differences in various ethnic groups. My question is, before we come on to ethnicity, previous witnesses here and in our trip abroad have emphasised that class, income and educational status are really the major deciders about health inequalities. Would you agree with that and can you separate them? Which do you think is the most important?

Professor Nazroo: I agree with that kind of broad conclusion. If we are thinking of older people, I think that we also need to consider wealth over and above income as an important marker because of the way in which people ---

Q597 Dr Taylor: In older people it is wealth?

Professor Nazroo: Wealth is particularly important in older people because of the relationship between work, income, retirement and resources that people have to spend, so wealth is particularly important for older people, but I would agree with the broad characterisation that it is class, education, income and I would add wealth to that. The question of which is the most important I think depends upon how you see those being related to each other and what they broadly characterise. From my perspective, they broadly characterise economic location and also social status. If you think of the relationship between education, class and income, we can see that they flow from each other rather than being separate elements that one might contribute more or less. So you see people like me doing research in an attempt to see which one has the greatest effect, but in fact you cannot understand them as separately, you have to understand them as causally related to each other. That is important because then you can think about policy in relation to where long-term and short-term interventions might become important, so education is clearly a precursor to many other things, and investments in education in the long-term are perhaps the most important thing. In the short term of course, income may be very important.

Q598 Dr Taylor: So they all together.

Professor Nazroo: Yes.

Q599 Mr Syms: My question overlaps a little and is to Professor Nazroo. How do you summarise the impact of characteristics such as race, ethnicity, culture and faith and how far are ethnic inequalities caused by social and economic inequalities?

Professor Nazroo: My research has suggested - and I think there is now a very broad body of research that suggests - that the primary driver of inequalities associated with ethnicity, race, culture and religion - and I would not want to characterise particular groups within our population - is social and economic inequalities.

Q600 Mr Syms: In your evidence, you set out that making income comparisons between different ethnic groups is a very complex subject. How robust is the data in this area, where does it come from and what further data research needs to be done in order that we can better understand this problem and improve the situation?

Professor Nazroo: We have increasingly good data on social and economic inequalities across different ethnic or race groups. In broad social surveys, there have been studies like the fourth national survey of ethnic minorities which I use for a lot of my research which characterised in some detail economic and social differences across different groups. The problem we have with a lot of health research is that those social and economic inequalities are characterised very crudely. So, using an area deprivation score, using a measure of occupational class or something like that and, as I indicated in my memo, they fail to capture the complexity and the depth of the disadvantage across many domains faced by some ethnic minority people.

Q601 Mr Syms: Is there evidence of inter-generational mobility among ethnic groups? I fought a seat in Walsall in the 1990s and it was a scenario of father came in to drive a bus, and ended up owning a shop and the son was driving a BMW. People were moving, the usual immigrant story.

Professor Nazroo: There has been some very interesting research done using linked census data which shows variable social mobility amongst different ethnic groups. Some segments of the Indian population seem to have made fairly marked social mobility from migrant to post-migrant generations. Others such as Pakistanis have not. Of course, you can potentially understand that by thinking about the resources that people bring with them in terms of human capital and so on and also where they are located geographically and in relation to the industries that are there. It is variable but there is some evidence of social mobility. I think what is particularly important is that many of those studies do not compare social mobility within ethnic minorities in comparison with social mobility in the general population and that step really needs to be taken as well because of course seeing social mobility in the Indian population, you cannot actually estimate how much of that contributes to a repositioning in class unless you see what is happening with the white population as well. The other thing that we have very little of is evidence of inter-generational change in health. The small pieces of evidence that I have seen suggest that there are not improvements in health across generations.

Q602 Mr Syms: We have undertaken one or two overseas visits and one of things that came up was status within communities. So, if you were better off in a relatively poor area but your status was higher, you actually sometimes had better health outcomes. Is that something which you have looked into?

Professor Nazroo: It is not something that I have looked into but there is literature on relative status and how important relative status is. Richard Wilkinson particularly has undertaken a lot of work in that area and has argued that in areas where there are less social inequalities, there are fewer health inequalities, and the implication is of course that, if you are fairly high up in the hierarchy, then you will do well. Professor Sir Michael Marmot has done work looking at how people evaluate their status and how that relates to their health and again has shown the same kind of thing. So, you can imagine that location within a community is important. Location within a community is important also because of the protective effects that a community can bring to you in terms of providing you with the location in society. I have undertaken a little bit of work which shows that people living in deprived areas sometimes value those areas more highly than you would expect and it seems that they do that because of the investments that they and other people in their community have made in those areas and what those areas mean to them.

Q603 Sandra Gidley: I have another question for Professor Nazroo. On the basis of effectiveness and cost-effectiveness, if you were to be able to implement three interventions, what would you prioritise if you are trying to tackle some of the health inequalities related to ethnicity?

Professor Nazroo: Three interventions within the health service or ...?

Q604 Sandra Gidley: It does not have to be confined to the health service.

Professor Nazroo: I think that education is crucial, as I mentioned earlier, and I think that investments in education are central to reducing inequalities in our society.

Q605 Sandra Gidley: Do some ethnic groups not perform better educationally? Some of the Asian statistics for school kids are very, very good, so presumably there is high education but still health inequalities. Is this an historical time lapse?

Professor Nazroo: That is a very important and very interesting question. The Indian success in schools is not reflected for Pakistani and Bangladeshi children, which is interesting of course, and why that might be so when you think about where geographically Indian populations are located in comparison with Pakistani and Bangladeshi children. I mentioned the issue of social mobility and there is evidence of social mobility for the Indian population, but how that translates into differences in health we are not yet sure about, but the evidence at the moment does not look particularly good. The other important issue of course is that these children who are achieving well at school are not necessarily achieving well in further education and there is a big literature which suggests that they do less well than expected in higher education.

Q606 Sandra Gidley: So, it is education across the piece really?

Professor Nazroo: Yes, but also I would stress the point about where Indian people are located in terms of the schooling opportunities available to them and where investments in education might need to take place.

Q607 Sandra Gidley: And your other two are ...?

Professor Nazroo: I think that, in the short term, we need to think very seriously about employment and welfare benefits and the very low rates of income in certain ethnic groups and households should be a major cause for concern. So, welfare in terms of efforts to address income inequality and employment.

Q608 Sandra Gidley: Is it that the take-up of benefits is poorer in ethnic communities or that they disproportionately are in receipt of benefits and the benefits are not good enough whoever the individual is?

Professor Nazroo: Disproportionately in receipt of low incomes from employment and disproportionately in receipt of benefits.

Q609 Sandra Gidley: And your third is ...?

Professor Nazroo: Another one?

Q610 Sandra Gidley: I thought that was two! They are combined. Okay, I will let you off!

Professor Nazroo: I will give you a third one if you like.

Q611 Dr Taylor: Still with Professor Nazroo, with regard to mental health in ethnic groups you have raised some quite puzzling things. The black Caribbean people here are three to five times more likely to be admitted to a psychiatric hospital with a first diagnosis of psychosis and yet the same does not happen at home in the Caribbean. Have I read that right?

Professor Nazroo: You have read that correctly, yes.

Q612 Dr Taylor: Could you expand on your explanations because your next paragraph gives I think three partial explanations. Could you explain those to us, please.

Professor Nazroo: I am sorry that I was not entirely clear in terms of explanations but that is because the evidence is really difficult to interpret. I have perhaps a particular view on the evidence but I know that there are problems with the evidence. The key issues in the evidence are, as you say, high rates of admission and low rates of illness in the Caribbean and, when we have undertaken community surveys, low rates of illness in the community. The correspondence between the low rates in the community and the high rates of admission I think requires very care investigation. It could be that the low rates in the community are a consequence of ill people already being out of the community in hospital or in prison. There are very high rates of mental illness in prison of course. It could be that there is an overrepresentation of people with schizophrenia from black backgrounds in comparison with people with schizophrenia from white backgrounds in hospital, and I indicate that there are some mechanisms by which this might be happening in terms of the process of appearing in hospital. I think that most importantly of course is the possibility that these high rates of illness are real and represent real social problems amongst the Caribbean population. Personally, I feel that we are very short of evidence in this area. There has been a deal of research but the research is very difficult to do and very difficult to do at high quality including the research that I have done. I think that there are real problems with the quality.

Q613 Dr Taylor: Assuming that the feelings are right, what can we do about it?

Professor Nazroo: As I say, I am not sure that we know enough to do much about it. I think what we need to do is really to investigate how far we are seeing an over-representation of Caribbean people in psychiatric institutions.

Q614 Dr Taylor: Your third possibility is social adversity faced by ethnic minority people in the UK.

Professor Nazroo: Yes.

Q615 Dr Taylor: How do we tackle that?

Professor Nazroo: I think that this relates to my broader comments around social and economic inequalities. There is some evidence to suggest that there are high rates of psychosis amongst many minority groups, not just the black Caribbean population though I would stress caution in interpreting that evidence. There is evidence which shows links between psychiatric illness and experiences of racism and discrimination and evidence showing links between experiences of psychiatric illness and poverty and so on.

Q616 Sandra Gidley: I am confused now because you have just said that there is some evidence that there is increased psychosis but, in your evidence to us, you say that surveys in the UK indicate that the prevalence of psychosis in the community is not particularly high in the Caribbean population, not higher for young Caribbean men and not higher for second generation young Caribbean men. You seem to be saying two conflicting things.

Professor Nazroo: That point has to be read in relation to the one above which shows that there are very high rates of admission to hospital ---

Q617 Sandra Gidley: I appreciate that but you said earlier that there were higher rates of psychosis. You did not say higher rates of admission, you said higher rates of psychosis. I would be grateful if you could clarify that.

Professor Nazroo: I meant in terms of studies of people receiving treatment.

Q618 Sandra Gidley: So, when you made your point earlier, you were not talking about the underlying base rate.

Professor Nazroo: That is right. The community surveys do show relatively low rates. There are problems with the community surveys as I said earlier.

Q619 Dr Taylor: Which are the other groups that are affected?

Professor Nazroo: My recollection from the piece of research is that it included African people, Irish people and I think Indian people.

Q620 Sandra Gidley: May I come back to the Afro-Caribbeans because I find this particularly interesting and I do apologise for banging on about it. Dr Taylor reflected the three possible reasons that you suggested might reflect the difference in admission rates. Is it possible that there is a fourth reason? I just put it to you that institutional racism is mentioned but could it be a lack of cultural understanding? This may seem an odd thing to say but I was told by an Afro-Caribbean woman that many of that population are assiduous attenders of quite Evangelical churches and anybody who has been to one of those churches will know they speak in tongues and there is some behaviour which is not quite British in some respects. Therefore, this slightly more flamboyant expression of religious belief raises alarm bells in people who do not understand the culture. So, it is not racism as such but a lack of cultural understanding. Is there any investigation that has been carried out into that because I found that a particularly interesting idea?

Professor Nazroo: The investigations which have been carried out have tried to address this question by using standardised assessments of people's mental health and those investigations have suggested that this is not the problem and that people actually really are ill, if we accept that these standardised assessments operate equally across the cultural groups and I think that broadly they do.

Sandra Gidley: So I can discount her theory.

Q621 Dr Stoate: I would like to bring Peter Baker from the Men's Health Forum in now and ask a similar question. What are the main aspects of health inequalities in relation to gender?

Mr Baker: I think that there are many. I think that virtually whatever health issue you look at there is a gender issue there; there are clear gender differences. A point I would like to make first of all is that gender is consistently overlooked even today in terms of policy and practice in health. We are seeing some changes in the right direction at a national level in terms of Department of Health policy and its approach to looking at gender as one of the inequality strands, but it is still not consistent across all areas of policy within the Department. At local level in terms of what the NHS is doing, it is extremely patchy indeed and there are very few signs at a local level that gender is taken seriously as an inequality issue. Having said that, I think that inequality issues are extremely clear and they relate also to social class and ethnicity and age and all the other equality issues as well. If you look at an issue like suicide, for example, you cannot understand suicide properly unless you also look at social class because the highest rate of suicides is in social groups four and five and it is predominantly a problem for young men, or men in general but young men in particular. So, we have to look at both gender and class to understand an issue like suicide properly. Looking at other issues more broadly, there are clear differences in life expectancy between men and women - these are well established - and it is particularly acute in the lower social classes. If you are a baby boy born today in Manchester, your chances of reaching the age of 75 are 50/50, just 50/50 and that is a pretty extraordinary statistic and that is the area which has the lowest male life expectancy in England. There are big differences in terms of the major killers. For heart disease, men are more likely to develop heart disease at a younger age than women, about 10 to 15 years earlier on average. For cancer, men are more likely to develop and die from cancer of any kind. If you look at the ten most common cancers that both men and women can develop, men are about twice as likely to develop one of those cancers and about twice as likely to die. So, there is a fairly staggering difference there. Obesity is another issue where there are quite clear gender differences with men much more likely to be overweight than women. Obesity is an interesting example because it is largely seen as a women's issue but in fact, in terms of the statistics, it is a much greater problem for men. In terms of lifestyle and behaviour, we know that men are more likely to take risks with their health in terms of smoking, drinking, protecting themselves from the effects of the sun, pretty much any area you care to look at. The only area where they do better than women is in the area of physical activity; they are more likely to be physically active but again not at levels which generally bring benefits to their health. The other key issue is use of services. We know that in general men make less effective use of health services, particularly primary care where they are less likely to go to the GP, but it is not just about the GP, it is true of pharmacy and dentistry as well and I think that this suggests that the difference between men and women is not just accounted for by younger women being more likely to go to the GP for reproductive health issues. It is a problem across most of the age ranges in general practice, but it is also a problem in preventive dentistry as well where men are much less likely to go for check-ups. I think what we are seeing is a reluctance by men to seek help and a failure of those services to actually market themselves effectively to men.

Q622 Dr Stoate: I would like to ask a question which might be a little unfair because there might not be an answer to it, but can you quantify the relative effects of gender for example against social class, ethnicity or age? Is there any research out there that can say that genders have a greater or a lesser effect than social class? In other words, if you are a woman born in a rich area, how much better off are you than a bloke in a poor area or a bloke in a rich area? In other words, is there any way that you can separate out gender differences with class differences or economic differences?

Mr Baker: There may well be research on that; I am not sure that I can give you the answer to that question now but it is something that I could take away and have a look at if you would like me to. In terms of the particular question you asked about life expectancy, yes, you can show that very clearly. We know - and I have the information here - that if you are a man born in an affluent area, then you are much more likely to have a longer life. The highest probability for survival to the age of 75 for men is in East Dorset for example where 78% of men are likely to reach the age of 75 compared to Manchester where it is about 52%. So, you can show that there is a clear difference there which is related to gender, but of course it is clearly bound with social class and disentangling them is quite a complex issue.

Q623 Dr Stoate: What I am trying to get at is, in terms of policy, you have made it quite clear that gender has not seen the policy direction that it ought to have done in the last ten years and obviously we will aim to look at that in our report. What I want to try and get a handle on is how big a problem is simply a gender issue compared with the other big inequalities facing us.

Mr Baker: All I can say in answer to that is that it is a very large problem that has hitherto been unrecognised and we have not actually taken action to tackle this effectively yet. We know that you can now take action effectively in the area of men's health to improve men's outcomes. We know that you can make a difference to men's health by approaching problems, by delivering services in a different way. We know that you can make a difference, but I cannot answer your question in exactly the way you have answered it and I think that is something which I will have to take away and have a look at.

Q624 Dr Stoate: It is a pretty unfair question but, if there is any research on it, we would very much like to see it because obviously it gives us more ammunition if we are able to say that gender is even more important or as important as ethnicity, age or other things. What three interventions would you prioritise to try and tackle the problems you have raised?

Mr Baker: First of all, I would like to say that I think we know that you can make a difference in this area. I think that there has been a lot of fatalism about men's health believing that mean are either doomed to die early because of their white chromosome or that they will not take any notice of anything you say anyway. We do know that you can make a difference. For example, the work on public awareness around testicular cancer which has been going on for quite a long time now I think has been reflected in the fact that tumours are now being detected at an earlier stage and the reason for that is that young men are detecting the lumps sooner and going to their doctor sooner, so we know that you can make a difference and it can lead to a very clear outcome. I would also highlight the work of the National Chlamydia Screening Programme which at the outset was very poor at actually getting men to take part in the screening programme and the proportion of men screened was actually extremely small. Partly through the work of the Men's Health Forum where we demonstrated that you can engage men in this, the screening programme now has a men strategy and the proportion of men screened is going up considerably and there are now some local screening offices which are achieving about a 50/50 split in screens between men and women. So, it is clearly possible to engage with men in a way that previously was not thought possible. In terms of specific interventions, I think that part of this is about going to where men are and not passively waiting and hoping that men are going to turn up at the GP surgery because men are reluctant users of those services and would tend to put them off until they are either in pain or they realise that they have a really severe problem. I think that we need to do more in terms of outreach work, going to the workplace and engaging with men in environments where they feel more comfortable about using services and taking part in health improvement programmes. I think that pharmacy has an enormous potential here as the kind of service that men would be more likely to use because of the ease of access to those services if it was marketed in a different way or if men were encouraged to use pharmacy or educated about the role of pharmacy in a way that is simply not happening at the moment. I think that we could do much more in terms of producing health information which is designed in ways that men find attractive and useful to them. There are some 60,000 providers of health information in the UK and only a handful of those providers are producing information which is aimed at men. I am pleased to say that the Men's Health Forum is one of that small handful and we have had some success in producing health information which is designed in the format of care maintenance manuals because we know that for some men, not all men, this fits with the way in which they see their bodies and understand the quite mechanistic way of thinking about their health. This is not necessarily something we should encourage but we know that it works. The final intervention that I would say which is a much longer term piece of work is about education. I think that we are very poor in delivering health education in schools particularly and I think that is particularly true of boys. I think that we need to do more to equip boys and young men with information about how the health system works such as really basic simple things such as how you register with a GP, how you make an appointment with a GP and which service might it be appropriate to use, so that you do not get everybody going to A&E for example when they could go to a pharmacy, a walk-in centre or somewhere else.

Dr Stoate: That was very helpful. Thank you.

Q625 Sandra Gidley: I think that my question has mostly been covered because you have mentioned the risk taking behaviour, but I do not know if that has been quantified in any way, and you mentioned that men are less likely to use primary care service. How can we actually change this? There is one extra point that I wanted to bring up and that is that you were talking about taking services to where men are but, in your evidence, you mention issues like the working hours being incompatible with getting to a doctor's surgery not being helpful. Have you any evidence that the reduction in the hours that a surgery is open has actually made that problem worse?

Mr Baker: We do not have any hard evidence of that. We suspect that it may well be the case but we cannot demonstrate that. What we do know from some very small studies that are not particularly robust is that where GP surgeries have opened in the evening, they do see a high proportion of men in their evening sessions. We also know that walk-in centres which are open for longer and are much easier to access do tend to see a higher proportion of men than normal GP services. There is some good evidence that extending opening hours and making access easier reduce the barriers and make it easier for men to attend. It will be interesting to see the outcome of the much wider scale extended opening hours for surgeries that the Government are implementing over the next few years. I think that there is a critical problem with GPs because it is important to develop services that do go to where men are but I think that we do need to tackle the problem of GPs in particular and make them more accessible to men. I think that there we have some small studies which suggest that it can be done but we actually need some properly evaluated pilots which help us to understand how we can do that better than is happening at the moment.

Q626 Sandra Gidley: Who is going to do this because we have a primary care system where the GPs stay in their surgery more or less and everybody is expected to go to them. You are saying that that does not work for men and we have to spoon feed them and go to the chaps. Who is going to deliver this service? I am not quite clear. I obviously want men to have better health but there is a resource implication here. It is very easy to say but who is going to deliver this service?

Mr Baker: I think that it needs to be delivered by a number of different providers. Employers for example is one area where I think there is huge potential for improving men's health. The Royal Mail, which is one of the organisations which has been in the lead in doing this work, has brought in GPs to run sessions in some of their sorting offices with considerable impact. The men will use the GP service that is provided. It is not done consistently but, where they have done it, it seems to work. We know that running health improvement programmes aimed primarily at men through the workplace also can have a significant impact. We undertook some work with British Telecom a couple of years ago, a programme called Work Fit, which actually succeeded in signing up and engaging very large numbers of men in a programme to improve their diet and physical activity. British Telecom is a company which has a mostly male workforce. We got 16,000 staff signed up to this programme and the proportion of men signed up was exactly in proportion to the numbers in the workforce. So, you can engage men in that kind of programme through a workplace campaign that is properly marketed and the evaluation showed that it made an impact. I think that, with a little imagination, there are ways in which these services can be delivered in a range of settings.

Q627 Sandra Gidley: To come back to the risk-taking behaviour, how can that be changed? Obviously there is an education possibility with going to men in the workplace.

Mr Baker: Yes.

Q628 Sandra Gidley: You can do so much at school but one suspects that messages are not taken in then, so how that be addressed?

Mr Baker: I think that it is an enormous challenge and that there is no one answer to this obviously because there are a wide number of factors that influence risk. I think that risk taking is part of how men, if you like, prove their masculinity to themselves and to other men.

Q629 Sandra Gidley: It does not impress the girls though.

Mr Baker: They think it is does. They think that it impresses each other. To address that is a huge project in itself. We know that we can change men's risk-taking behaviour through programmes like the one in BT that I mentioned where we made a real difference to men's diet and lifestyle. Other projects like the Pit Stop Project that was run in Knowsley PCT found that by offering men MOT-type health checks, doing very simple health checks and giving them health information and advice, actually led to lifestyle improvements as well, less smoking, less drinking and better diet. I think that there are therefore a number of ways in which you can tackle risk taking. The other risk that men take is by not using services and I think that there are ways in which we can improve men's use of services and the example I gave about testicular cancer is one of them and if we can actually improve men's awareness of symptoms and make clear that there are advantages to early presentation and diagnosis, we can actually get them to reduce the risk they run by not presenting to services early enough.

Q630 Sandra Gidley: Is there a role for the media here? Women are very influenced by (a) women's magazines and (b) the number of TV programmes aimed at women that get some of these messages across. Are we missing a trick for men or would they just not watch or read or listen?

Mr Baker: I think that we are missing a trick. I am always staggered by the number of magazines that are available to teenage girls that address all sorts of emotional and physical health issues, sometimes badly but sometimes very well. There is absolutely nothing available to teenage boys apart from magazine like Zoo or Nuts. If you follow the advice in those magazines, you would be dead within a week! I think that we have to ask the question of the media about why men's health issues are so clearly neglected. They are not addressed at all. There have been some attempts which the Department of Health has sponsored. There was a magazine aimed at young men called Fit, which were produced for PCTs to distribute. That tried to ape magazines like Zoo or Nuts; it was using that kind of format to deliver health information to young men.

Q631 Sandra Gidley: They did not put it in doctors' surgeries where men do not go, did they?

Mr Baker: This is the problem. We do not really know how flexibly it was distributed or what the impact of that was. I think that we should look at how we can make a difference with those sorts of publications. Also, they need to be consistent. Just doing that kind of thing as a one-off is not going to get the message across and I think that that is one of the problems we have with health programmes that have been developed for men. When I said before that local activity is extremely patchy, it is not only patchy, it is also very short term and we constantly find that, in men's health, there is a lot of reinventing of wheels because projects start, then they stop and somebody with a particular enthusiasm starts them again somewhere else and it is like going back to the starting block all over again. I think what we are lacking is the NHS taking a strategic approach to gender inequality and to men's health in particular and trying to get this mainstreamed and that should be happening. A gender equality duty actually imposes an obligation on the NHS to tackle these issues but that is not happening and that is why the Equality in Human Rights Commission wrote in March to strategic health authorities pointing out that 27 PCTs still had not taken the basic step of producing a gender equality scheme and the EHRC pointed out that virtually all, if not all, the gender equality schemes that did exist were pretty useless in that they almost entirely focused on process - what committee would look at this when - rather than actually focusing on outcomes like, how do we increase men's uptake of weight management programmes or smoking cessation services.

Q632 Mr Syms: Is there any evidence between men who live alone, single/divorced, and men in a relationship because it usually takes a woman two weeks of nagging before I go to see a doctor? If I am ill, I soldier on and it is usually somebody else who says, "You've really got to go; I've made an appointment for you; you have to turn up" and eventually I give in and I go.

Mr Baker: There is unfortunately some truth in that. We know that relationships are actually good for men. Men who are in a relationship with a woman tend to take fewer risks with their health and have better outcomes. Unfortunately, the reverse is the case for women who tend to do worse if they live with a man. Single men, particularly older single men, do particularly badly. We cannot load the responsibility for a health promotion strategy for men on women. Not only is it in a sense not fair on women but it is also not going to reach all those men who are not in relationships with women for whatever reason and I think that what we have to do is to develop an approach that actually succeeds in engaging with men and getting men interested in looking after themselves rather than waiting for somebody else to do it for them.

Q633 Dr Stoate: That is a really good point. Something you said earlier made me smile was that blokes come along when they are in sufficient pain. I saw a chap recently who came in because he finally could not put up with the pain of his thrombosed external pile any longer. He was in absolute agony and he made it completely clear by saying, "I would not be here if I wasn't in absolute agony and I couldn't think of anything else to do". What he had done was gone on the Internet and made a diagnosis which turned out to be completely correct, so he had done everything possible to be done in my surgery but realised that, even though he had made his own diagnosis, he could not actually cure himself, so he had to come to me. Having said that, he was massively overweight with very high cholesterol, extremely high blood pressure with and with totally uncontrolled lifestyle and I said to him, "This is probably the least of your problems", but it took something very dramatic to get him over the threshold. As a GP, my problem is, what can we do to address chaps like him because he is going to go two ways: he is either going to go down the route of being dead by the age of 45 literally or down the route of sorting himself out and actually having a normal lifespan. What do we do?

Mr Baker: I think that GPs are in a difficult position because they have enough to do already with the people who are already coming through the door. On the other hand, I would make the argument that, if you could see men sooner ... If you had seen this guy earlier, perhaps you could have done yourself a favour as well by treating some of his problems before they became so difficult to treat and more expensive for the NHS. I think that we have to think about creative ways of getting men to use the GP service and other health services more effectively. I have said before that we need to pilot some ways of doing this in primary care. One method that has worked in one or two practices where it has been tried is simply writing to men - it does not cost a lot - and saying, "Why don't you come in and have a health check-up?" That seems to bring in men who have not been seen for quite some time who may have these problems but feel, for whatever reason, inhibited about making an appointment. It actually does seem to help men break through some kind of psychological barrier and picking up the phone and coming in. The other point - and I hesitate to bring this up - is about QOF. Some of your previous witnesses were asked about inequality issues in relation to QOF and I think it would be worth looking at whether some of the QOF indicators could be linked to gender because there are some marked gender differences in the area of obesity for example or weight generally and also smoking and blood pressure. These are gendered issues and I think that rather than giving GPs points for simply reaching a certain proportion of their patient population, you could look at rewarding them if they reach those targets as broken down by gender as well and maybe by ethnicity, social class, age and other inequality factors.

Q634 Dr