House of Commons - Health Inequalities

Health Inequalities - Health Committee Contents

6 The role of the NHS in tackling health inequalities

171. This chapter considers the role the NHS should play in tackling health inequalities within its day to day activities, i.e. beyond the actions we have discussed in the previous chapter. The Secretary of State was clear in his evidence to us that NHS efforts to tackle health inequalities could not be simply an 'add-on' to mainstream NHS services, but instead must pervade everything the NHS does—from health promotion to primary care to more specialist services. The NHS can and should provide excellent services offering evidence-based, cost-effective interventions, accessible to all on the basis of need. In common with other areas of policy, the evidence base that exists to inform decisions on how the NHS should tackle health inequalities through its clinical interventions is incomplete, and it is not always clear how these should be best targeted to the most disadvantaged groups. This is discussed in more detail in the first section of this Chapter, on clinical interventions to tackle health inequalities. The rest of the chapter then discusses the different roles that can be played by different parts of the NHS, namely:

Strategic Health Authorities and Primary Care Trusts
Primary care teams
Secondary care and specialist services
Early years NHS services—maternity and health visiting.

Clinical interventions to tackle health inequalities

172. As we have described in Chapter 2, inequalities between different socio-economic groups are evident for almost all health outcomes. The interventions that NHS service providers can provide to tackle these inequalities fall into one of three categories:

Treatment - providing active management of acute and chronic conditions (such as diabetes and high blood pressure) with the aim of curing those conditions or stabilising them to prevent them worsening

Screening - providing proactive screening services with a particular focus on groups at highest risk of particular conditions

Health promotion - providing information, support and other incentives to promote healthier behaviour, particularly amongst those at highest risk of particular lifestyle risk factors or conditions.

CLINICAL EFFECTIVENESS AND COST EFFECTIVENESS

173. More evidence exists around the specific clinical interventions discussed in this chapter than for most other policies to tackle health inequalities that we cover in this report. For example, certain clinical treatments for conditions such as high blood pressure and high cholesterol, are proven to be effective at reducing the risk of coronary heart disease, which is the leading cause of premature death in the UK. For the first time, now, evidence exists that behavioural interventions such as smoking cessation clinics are effective in helping people quit smoking, and consequently reduce the health risks associated with it. It is because of this evidence that interventions such as these, which are discussed more fully below, are widely held up as the most effective ways of tackling health inequalities.

174. However, there is a difference between interventions being effective at improving health, and interventions being effective at improving health inequalities; an intervention which is effective at improving health will have no effect on health inequalities if all social groups benefit equally; it will actually increase them if the rich benefit more; and it will reduce them if the poor benefit more.

175. The major causes of ill-health and premature morbidity almost all reflect a social gradient, and so attempting to provide effective treatment, screening and health promotion to all those at risk of major preventable diseases such as coronary heart disease, in particular to those in lower socio-economic groups, appears sensible. However, there is limited evidence on how to ensure that those in lower socio-economic groups actually receive and benefit from these treatments.

176. Equally, debate still persists about the cost effectiveness of many of the interventions discussed below. Whilst NICE states that the behavioural interventions it recommends are cost effective, this is at a general level, rather than specifically for tackling health inequalities. The Government has argued for increased use of preventative treatments for coronary heart disease to tackle health inequalities (e.g. statins), but no evidence exists to support the cost effectiveness of this, and some academics even consider that current screening programmes, such as the breast cancer screening programme, are not cost effective at all.

TARGETED VS UNIVERSAL

177. Linked to these points is the ongoing debate about whether interventions should be introduced on a targeted or a universal basis—that is, whether they should be offered to the whole population, or just to specific targeted groups.

178. According to Professor Edward Melhuish, who led the national evaluation of Sure Start, a major problem with targeting deprived people is that of stigmatisation: "Families who need it most see themselves as picked out, picked upon, and therefore do not co-operate with the service or avoid the service."[132] Some degree of universal service is also needed to identify those families who are most in need. However, Professor Melhuish pointed out that conceptions of need may not be black and white, and so some degree of flexibility is necessary:

Who is in need is then not usually either/or: there are degrees of need. Some need a lot of help, some need an extra visit now and again, and some need just very light touch. The notion of progressive universalism is quite useful, where one has a universal service potentially available to all—at least in a very light touch way available to all—but the nature of the service becomes increasingly more intensive as the need is apparent.[133]

Professor Melhuish told us that in his view a 'progressively universalist' approach would be most cost-effective; however, he acknowledged the difficulties in prioritising spending in this way:

For a hard-to-reach family, as opposed to an ordinary disadvantaged family, it costs roughly five times as many resources to deliver. You are having to devote tremendously more resources to them than to other people. There comes a point at which you have to think: "Would I be better off delivering a service to a wider range of people, which will produce benefits for that wide range of people, versus focusing on just this group and using all my resources just this group." That is a dilemma which we have not come to terms with fully yet.[134]

TREATMENT

179. The causes of health inequalities that can be tackled by NHS service providers are those pre-disposing people to ill health and early death. Areas of importance which have been identified in 'causes' chapter include smoking, diet, alcohol and exercise. There is a growing evidence base informing the best way to treat the 'big killers', including cancer and coronary heart disease, and applying these optimum treatments consistently is the gold standard for using treatment to tackle health inequalities. NICE guidance now exists to inform the treatment of cancer, diabetes and coronary heart disease. In addition to this, the government's health inequalities intervention tool promotes two main treatments as effective options for tackling health inequalities.[135] These are:

Antihypertensive prescribing in people with previously undiagnosed/uncontrolled hypertension, but who do not have existing coronary heart disease or history of stroke
Statin prescribing in those people that are newly identified and have been treated with antihypertensive medication, but who do not have existing coronary heart disease or history of stroke

180. The main potential providers of these treatments are GPs. The impact of such treatments on health inequalities is dependent on them being effectively targeted towards those in lower socio-economic groups. Incentives for providers to do this are discussed more fully in the next section.

SCREENING

181. Effective treatment can only be commenced once affected individuals have been identified. Diseases, such as cancer and diabetes, and pre-disposing conditions, such as high blood pressure and cholesterol, can be latent for long periods, and therefore effective screening which reaches those most at risk can play an important role in tackling health inequalities. However, national screening programmes, which cover the whole population, have costs as well as benefits, including the costs of administering such a large scale intervention, and the other risks that can be associated with screening, including over-treatment arising from false positives. Currently, national screening programmes exist for breast, cervical and bowel cancer.

182. The National Screening Committee, which decides which screening tests are to be introduced on a population-wide basis, has always recommended against whole population screening for coronary heart disease, diabetes, high blood pressure, and the risk factors for stroke. However, in April 2008, following the recommendation of the National Screening Committee for the development of a vascular risk management programme, the Government announced its intention to introduce regular screening for all those aged between 40-74 for vascular disease.[136]

183. Vascular disease includes coronary heart disease, stroke, diabetes and kidney disease which are all linked by a common set of risk factors, including obesity, physical inactivity, smoking, high blood pressure, disordered blood fat levels (dyslipidaemia) and impaired glucose regulation (higher than normal blood glucose levels, but not as high as in diabetes). The Government estimates that it currently affects the lives of over 4 million people in England. It causes 36% of deaths (170,000 a year in England) and is responsible for a fifth of all hospital admissions. It is the largest single cause of long-term ill health and disability, impairing the quality of life for many people.

184. As the burden of these conditions falls disproportionately on people living in deprived circumstances and on particular ethnic groups, such as South Asians, and, according to Government accounts for the largest part of the health inequalities in our society, this screening test and the actions that will follow from it may have the potential to significantly affect health inequalities.

185. The screening will take the form of a single, universal, integrated check for all aged 40-74. It will measure risk of cardiovascular disease, diabetes and chronic kidney disease, and then classify people's risk as either low, moderate, high, or already having disease. For those who are at low risk, advice on how to reduce risk/maintain low risk will be given as part of a 'tailored package of prevention'. The screening will be repeated at 5 yearly intervals. For those who are at moderate risk, advice and assistance on reducing risk through lifestyle interventions will be given. These may include weight reduction class, exercise referral and smoking cessation clinics. Those at highest level of risk will be offered all of the above plus preventive statin medication, and, if necessary, blood pressure control and/ or intensive diabetes prevention.

186. The Government states that evidence confirms that this approach will be both clinically effective and cost effective, although we have not seen the evidence on which this is based. It is estimated that this programme will cost around £250 million per annum to administer.[137] It is not yet clear how the screening will be managed, administered or funded, but approaches are likely to be determined locally. The introduction of this screening programme could present an ideal opportunity to plan and introduce the model in such a way that permits rigorous evaluation, as outlined in Chapter 3. However, allowing PCTs to determine the implementation of this entirely locally risks ending up with very divergent approaches which may be difficult to evaluate. A preferable approach would be a national model which could be piloted and evaluated (for example in one SHA area) instead of national introduction of this but with 152 PCTs each adopting a different, and unevaluated, approach.

187. As with the treatments described in the previous section, the impact of these and other screening programmes on health inequalities depends on sufficient incentives being introduced for providers to actively target those from lower socio-economic groups.

HEALTH PROMOTION

188. As most health outcomes are linked to lifestyle factors—including smoking, alcohol intake, diet, exercise and sexual behaviour, and there is evidence that changing these lifestyle factors can have a positive effect on health outcomes. Therefore educating people about appropriate lifestyle changes is crucial. This can be done both locally—by clinicians discussing health promotion opportunistically as part of consultations about other things—and nationally—through, for example, national information campaigns.

Brief interventions and referral to specialist services

189. NICE has published public health intervention guidance on:

smoking cessation;

smoking cessation in the workplace;

physical activity;

sexually transmitted infections and teenage conceptions;

substance misuse

school-based alcohol interventions.[138]

190. With the exception of the school-based alcohol interventions guidance, which advocates a broader approach, the guidance recommends brief opportunistic health promotion advice by GPs and other health professionals, followed by referral to other specialist services (stop smoking services, exercise programmes) where appropriate.

191. NICE has assessed these behaviour change interventions to be very cost effective—where sufficient data for modelling purposes has been available, the estimated incremental costs of a QALY gained have been within a range well below the NICE acceptability threshold of £20,000-£30,000.[139]

192. However, this does not mean that such interventions are unproblematic. Smoking cessation interventions, although cost effective in terms of QALYs, achieve up to an 8% increase in the percentage of smokers abstinent for 6 months.[140] Moreover, achieving success with the most heavily addicted smokers, who tend to be from deprived groups, is far harder, and a more specific approach is needed.

193. The success of the NICE approach to changing health behaviour—brief, opportunistic interventions in primary or secondary care, followed by referral to specialist services—is dependent firstly on the primary and secondary care providers providing these interventions—which may be seen as 'add ons' to their existing workload—and secondly, on the availability of high quality specialist services to refer them to. The RCGP were amongst many to highlight shortcomings in this area, claiming that "doctors, nurses and other health professionals are still not trained to deliver smoking cessation interventions, and some do not see it as their job to do so."[141]

194. Beyond brief interventions, ASH argue that for smoking, the focus should not be solely on quitting, but on harm reduction—they advocate medicinal nicotine therapy as an important step on the way towards permanent smoking cessation.[142]

Social marketing

195. Traditionally, the approach taken by the NHS to changing health behaviour has been large scale public information campaigns providing health promotion messages. However, research suggests that, while general public information campaigns have a strong positive effect on those in higher socio-economic groups, they are far less effective in changing the behaviour of deprived groups. They can therefore actually increase health inequalities, as detailed by Professor Sally Macintyre:

More advantaged groups in society find it easier, because of better access to resources such as time, finance, and coping skills, to avail themselves of health promotion advice (e.g. to give up smoking, improve diet, use fluoride toothpaste etc.) and preventive services (e.g. immunisation, dental check ups and cervical screening). Disadvantaged groups tend to be harder to reach, and find it harder to change behaviour. A dental health education project in Scotland widened health inequalities in dental health because it was more successful among higher SES groups. A mass media campaign intended to reduce socio-economic differences in women's use of folic acid to prevent neural defects resulted in more marked social class differences in use than before the campaign

This suggests that interventions with more disadvantaged groups may need to be much more intensive and targeted than might be appropriate for more advantaged groups: information based approaches such as food labelling, pamphlets in doctors' surgeries, and mass media campaigns, or those which require people to take the initiative to sign up for, may be less effective among more disadvantaged groups.[143]

196. Much of our evidence argued for a new, more focused and tailored approach to providing information, under the banner of what is termed 'social marketing'. The National Consumer Council and the National Social Marketing Centre argue that:

Many of the models of public health promotion used to date are best characterised as message and information driven campaign models. Whilst raising awareness is valuable, these campaigns are often not proving effective at motivating behavioural change. Good customer focused and researched social marketing is helping to break the default position of communicating messages to people as the primary way to influence behaviour.[144]

197. They provide the following explanation of social marketing:

Social marketing is at its core a systematic planning system driven by user or target group insight. Social marketing draws on commercial marketing techniques and principles as well as the social sciences and behavioural research to develop insight based interventions to promote positive behaviours. It is not just a health promotion strategy, as it can be applied to any behavioural challenge, nor is it a re-badging of old style campaign models of health promotion or health communication.

Incentives for people to change their health behaviour

198. We were told of the possibility of using cash incentives to encourage behaviour change as well. Professor Julian Le Grand, Chairman of Health England, was optimistic about this and reported that Health England was currently examining economic incentives for encouraging people to take up preventive care of various kinds, with vouchers for good food and so on, and the evidence tends to be that it does work.[145] Professor Sally Macintyre also gave such schemes a cautious welcome, although she stressed the need for upcoming evaluation.[146] According to Dr Anna Dixon, Director of Policy at the King's Fund, a King's Fund review suggested that the evidence on actual behaviour change was 'limited':

The evidence is pretty limited and it is fairly focused on getting people to enrol in a programme. Where a financial incentive could be, for example, to sign up for a Weight Watchers programme or to join a Quit Smoking programme it has been quite successful, but it has no bearing on the success of then changing the behaviour. Where they have been applied, they have generally been applied for some very short-term and specific behaviour but, in terms of maintaining more complex behaviour changes over time, there is at the moment a lack of evidence to suggest that financial incentives can be used in that way.[147]

199. Margaret Whitehead, Professor of Public Health at the University of Liverpool, agreed with this view; she stated that recent research from Latin America suggested that financial incentives did encourage take up of programmes, but it was not clear whether the programmes themselves were actually causing behaviour change which was then improving outcomes, or whether outcomes were improving because families have more money to spend on their children and feel less stressed and therefore the family environment improves in those ways, as research from Mexico was beginning to suggest.[148]

CONCLUSION

200. Treatment, screening, and interventions to change health behaviours are the key tools available to the NHS for tackling health inequalities. Preventive prescribing of antihypertensive and cholesterol-reducing drugs have already been identified and promoted by the Government as an effective approach to tackling health inequalities, and the Government has also announced that a large-scale vascular screening programme will be introduced. However, whilst some evidence exists to support the clinical effectiveness of some of these interventions, less is known about their cost effectiveness, and in particular about how to ensure they are targeted towards those in the lowest socio-economic groups so that they actually have an impact on health inequalities. We urge the Government to plan the introduction of vascular checks with great care, and according to the steps outlined in Chapter 3, so that it does not waste another crucial opportunity to rigorously evaluate the effectiveness and cost effectiveness of this screening programme.

201. Changing health behaviour is widely acknowledged to be difficult, and evidence suggests that traditional public information campaigns are less successful with lower socio-economic or other hard-to-reach groups—in fact we were told that these interventions can actually widen health inequalities because richer groups respond to them so well. Social marketing is heralded as an approach that allows messages to be communicated in more tailored and evidence based ways. We have not seen firm evidence to support this claim, and we recommend that social marketing interventions are evaluated to ascertain their success. A sound evidence base does exist to support brief, opportunistic interventions in primary and secondary care, followed by referral to more specialist health promotion services. However, it seems that further steps are needed to ensure that the most heavily addicted smokers, who are often those from the lowest socio-economic groups, benefit fully from these interventions. This will have implications for the training of NHS staff and others.

Strategic Health Authorities and Primary Care Trusts

202. The NHS's capacity to tackle health inequalities encompasses not only those providing services—including primary and secondary care teams—but, crucially, SHAs and PCTs who are meant to provide a leadership role across local communities for health issues, both in terms of commissioning services and maintaining a focus on public health. Part of their responsibilities include planning services to meet the needs of local populations, to ensure good access. This section discusses PCTs' roles in:

Leadership and commissioning

Public health

Access to services.

LEADERSHIP AND COMMISSIONING

203. Primary Care Trusts have an important role in providing strategic leadership for health services at a local level, including commissioning primary and secondary care services, ensuring good access and high quality care, and retaining a responsibility for local needs assessment and public health. It is on PCTs that responsibility rests for delivering the Government's target to reduce health inequalities. Strategic Health Authorities have a role of strategic oversight at a regional level-which includes overseeing PCTs' performance in tackling health inequalities.

204. We were told by Mark Britnell, Director General for Commissioning and System Management at the Department of Health, that the Government's plans for 'World Class Commissioning' would ensure that health inequalities were at the heart of PCTs' commissioning activities, as well as developing PCTs' capacity to commission more effectively.[149] However, according to Dr Jacky Chambers, Director of Public Health at the Heart of Birmingham PCT, the reality of the situation is rather different from this:

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

Dr Chambers: I think the answer is, no. If you really aspire to the principles that are set out in world class commissioning, there are two areas where we have not yet got the capacity: one is around partnership working across a complex system; and the other is really around public engagement as a real driver in terms of that notion of engaging with our communities to drive health and choice, and drive up the standards of service and the expectation of those services. We have got the basics in place, but if we are going to aspire to the excellence that is set out there we are going to need more capacity to do that.[150]

PUBLIC HEALTH

205. Both PCTs and SHAs have public health functions. Their public health role differs from those providing NHS services, who bear chief responsibility for delivering public health interventions; instead their role should encompass providing leadership and strategic direction for NHS services, commissioning appropriate public health interventions, and leading in partnership working with local authorities, voluntary organisations, and other relevant local partners.

206. Public health as a specialty has struggled since the inception of the NHS, operating within a system which remains essentially focused on treatment of ill health rather than promotion of good health. While some SHAs and PCTs may have strong teams which are recognised to play a valued role in the local health community, others are less effective. Recent years have seen a reduction in the numbers of public health specialists, especially at a senior level, attributed by the Faculty of Public Health in part to the repeated reorganisations in the NHS.[151]

207. While we have not seen any evidence specifically supporting their effectiveness, it would appear that public health specialists working in the NHS have a potentially important role to play in co-ordinating efforts to tackle health inequalities, and it seems counter-intuitive for the NHS to be reducing their numbers at the same time as committing funding and priority to tackling health inequalities, and other public health initiatives.

208. In Chapter 4 we discussed funding issues, in particular problems with PCTs not distributing sufficient funding to public health priorities, such as tackling health inequalities, even when money had been specifically earmarked for this. One solution to this proposed by Peter Smith, Professor of Health Economics at the University of York, was moving responsibility for public health from PCTs to local authorities, which in his view would allow better prioritisation and integration:

… we should shift towards prevention, and many people in public health argue that case very passionately. But we do have very limited evidence on what really works on the ground, so I think you have to be a pretty brave PCT or other NHS organisation to divert resources towards prevention and public health. I think the NHS has a special problem in diverting resources, because the rest of its business is about urgency and manifest clinical need. It is for that reason that I have argued for some time that the public health element of promoting health would be better located in different organisations. In particular, my own view would be that the best local authorities would do a better job at promoting health than the PCT.[152]

ACCESS TO SERVICES

The contribution of poor access to health inequalities

209. A key responsibility of Primary Care Trusts and SHAs is to ensure good access to health services for the local populations they serve. Health services, both general practice, primary care and specialist secondary care, have not, historically, been located according to need. Many of today's NHS hospitals evolved from 19th century charitable foundations that were located in large urban centres, leading to over-provision in some areas and under-provision in others; more recent hospital development has seen hospitals relocated to brownfield sites on the edges of urban areas, which may also cause access problems. GP services have long suffered from what Julian Tudor Hart has famously described as the 'inverse care law'—deprived populations with high health needs tend to have fewer GP practices than wealthier areas, often because workload is higher and living conditions are less congenial in deprived areas, with few attendant compensations.

210. Several witnesses, including Dr Dixon, argued for the importance of the role of health care:

Health care has been shown in modern societies to be an important determinant of health status. Health care systems vary considerably in their performance as measured by the extent to which mortality amenable to medical care is addressed (Nolte and McKee 2003). It is therefore important that access to health services is equitably distributed if health inequalities are to be reduced (McKee 2002).[153]

211. According to Dr Dixon, international analysis suggests that on the whole the UK performs well in terms of equity of access to health care with rich and poor accessing GPs equitably having adjusted for need while access to specialists is pro-rich but less so than in other countries (van Doorslaer et al 2006).

212. Nothwithstanding this generally positive picture, one study found unemployed individuals and individuals with low income and educational qualifications used services less relative to need than their employed, more affluent or better educated counterparts (Dixon et al 2003). The same review found that most studies of specific services within the NHS reported that people in lower socio-economic groups use services less on average relative to need than those from higher socio-economic groups. These studies covered a range of treatments and conditions including cardiac, diagnostic and surgical care, elective procedures for hernia, gallstones, tonsillitis, hip replacements, and grommets, inpatient oral surgery, immunisation for diphtheria, pertussis, measles, mumps and rubella, and diabetes clinics and diabetes reviews. Some of the reasons identified for these inequalities in access included transport and lack of car ownership, ability to take time off to attend, communication skills and ability to navigate the system, beliefs and health seeking behaviours.

213. Age Concern argue also argue that the majority of chronic illnesses affecting the lives of older people can be either prevented or postponed, mainly through the adoption of healthy lifestyles, but that services and public health initiatives sometimes exclude older people. In their view, examples of this include the fact that the current national alcohol strategy does not mention drinking in later life, and breast and bowel cancer screening programmes are still not extended upwards to the maximum ages at which people can achieve health gains.[154] Age Concern also contend that some groups of older people with particularly significant health needs currently receive insufficient support from GP services, including older carers, those living in care homes, and those suffering from depression.

214. However, it is not clear how big a part access to health services plays in health inequalities, and most of those who submitted evidence to us seemed in agreement with Professor Whitehead that "inadequate access to health services is … only one of many determinants of the observed inequalities in health, and a relatively minor one at that".[155]

Access to primary care services

215. Bolstering primary care services in under-served areas has been a central plank of the Government policy in recent years, with claims that this will have a positive impact on health inequalities; the Secretary of State told us that 122 new GP practices are being introduced into the 20% of areas which have the fewest GPs per capita.

216. Notwithstanding the obvious benefits of introducing new GP services into under-doctored deprived areas, there are questions about where these new GPs will come from. As Professor Martin Roland, Director of the National Primary Care Research and Development Centre explained to us, it may not be a simple matter of redistributing resources from the less needy to the more needy:

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.[156]

217. Alongside this initiative, another policy to improve access to primary care services is the introduction of a new, larger primary care centre, now referred to as a 'GP led health centre', into every PCT in the country. Given the Secretary of State's assertions that tackling health inequalities must be part of every health policy decision taken, this may be rather a counter-intuitive departure, as clearly health needs and health service needs are different across England. Professor Roland feared that actually the advent of such centres could make access and continuity of care worse:

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, worse.

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.[157]

CONCLUSION

218. PCTs and SHAs should play a central role in informing and co-ordinating efforts to tackle health inequalities. However, our evidence has not suggested that they are currently providing the leadership that might be expected of them. We have been told that numbers of senior public health specialists working in these organisations are falling; while public health specialists clearly have not demonstrated progress in tackling health inequalities to date, and we have not seen evidence specifically supporting their effectiveness in this role, it is concerning that the section of the NHS workforce probably most able to provide good leadership for tackling health inequalities is in decline, and we recommend that the government monitor this trend closely. Nor did we see any evidence to suggest that the drive towards 'World Class Commissioning' is likely to have a measurable impact on health inequalities in the near future.

219. Access to high quality health services is an important responsibility of PCTs and SHAs, and the Government has advertised its drive to improve access to GP services as part of its policy to tackle health inequalities. The extra GPs that are to be introduced into deprived areas which are under-doctored are welcomed, unless they are being relocated from other deprived areas, which would simply move rather than solve the problem. However, most of our evidence suggests that while access to healthcare is important, it is not high on the list of priorities for tackling health inequalities; indeed research has said that England compares well to other countries in this regard. We are also concerned that the central edict for all PCTs to introduce a GP-led health centre has not involved due consideration of either need or inequalities, and that in fact centralising GP services may make access more difficult for lower socio-economic groups. We recommend that Sir Michael Marmot's review should examine the issue of access to healthcare closely, paying particular attention to claims of 'institutional ageism' and that access is worse for those suffering from mental health problems and learning disabilities.

220. We also recommend that wherever local primary care services are lost because of the introduction of GP-led health centres, the impact of this on the most needy and vulnerable groups should be carefully monitored by PCTs and steps taken, if necessary, to revert to traditional, more local patterns of service delivery.

Primary care services

221. Primary care medical services provided by general practitioners (GPs), nurses and other primary care clinicians were frequently identified in our evidence as having a crucial role to play in tackling health inequalities. GPs provide immunisation and screening services as part of national programmes (for example childhood immunisation, flu jabs and cervical screening). The 300 million plus consultations performed annually in general practice[158] also provide the opportunity to screen the population opportunistically, for example by measuring blood pressure or BMI, as well as to deliver face-to-face health promotion advice. Most secondary prevention—for example diagnosing and treating the risk factors that can lead to Coronary Heart Disease—and much of the management of chronic diseases that can contribute to lower life expectancy also takes place in general practice. Finally, GPs can refer patients to more specialist services, and therefore have a crucial role to play in ensuring good access to secondary care.

222. Dr Julian Tudor-Hart, a former GP in a very deprived part of Wales and researcher, described to us the differences in the challenges faced by GPs delivering care to deprived populations compared with those in more affluent parts of the country:

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.[159]

223. During our visit to Glasgow, we were told by Graham Watt, Professor of General Practice at the University of Glasgow, that his initial research in Glasgow showed that GPs in deprived areas had less time to spend with each patient; however it was not yet clear whether this was having any effect on health outcomes.

THE QUALITY AND OUTCOMES FRAMEWORK (QOF)

224. The Quality and Outcomes Framework (QOF) was introduced as part of the new GP contract in 2004, ushering in a radical new way of linking doctors' practice income to the quality of care they provided. No such scheme exists anywhere else in the NHS, although a scheme to link hospital funding to clinical outcomes has now been proposed. The first few years of the QOF's operation have seen a majority of GPs achieving continuously high scores, and the precise determination of QOF points is re-negotiated every year to ensure that the measures are sufficiently stretching and up-to-date. QOF points cannot feasibly cover the entirety of GPs' very broad area of practice, and therefore are necessarily limited in the conditions and treatments they measure. However, as with any incentive system that targets specific parts of an organisation's or individual's workload, there is the potential for unintended outcomes, through diverting resources away from other, equally valid activities.

225. Given this, it might be expected that GPs in more deprived areas would struggle to perform well under the QOF system. However, Professor Martin Roland, who has led the major research project into the impact of the new GP contract, concluded that, surprisingly, both GPs in deprived and non-deprived areas had performed very well:

My surprise in a sense is how well GPs in deprived areas have done. I was involved in advising the 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.[160]

226. Professor Roland told us that despite persistent concern that practices in deprived areas under-report the true disease prevalence in their areas, and significant efforts to investigate this, they had not found evidence of widespread under-reporting. However, as Professor Roland explained, there is in fact a disincentive built in to the GP contract funding formula for GPs in deprived areas to proactively identify those people in need:

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 prevalence to be going out and looking for people.[161]

227. The BMA reported that when the GP contract was originally being negotiated, they argued for measures which in their view would make the balance of effort and reward more equal between practices in deprived and more deprived areas:

We argued actually quite strongly [for] 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 …. because there was so much more money in the Quality and Outcomes Framework, it cost a lot more.[162]

228. The Secretary of State told us that the major changes that had been made this year to the GP contract that would support GPs in more deprived areas was a shift to the full prevalence adjustment and the removal of the Minimum Practice Income Guarantee.[163]

229. As discussed above, the QOF does not and cannot cover the full range of conditions treated and services provided in general practice. Providing GPs with financial incentives to provide certain interventions has a cost, and therefore cannot be added to indefinitely. Research into the early years of the implementation of QOF argued that much of the QOF was not evidence-based,[164] and in recognition of the need to improve this process, determining what goes into the QOF is now the responsibility of NICE. For interventions to be included in QOF they need to have a sound evidence base for their clinical effectiveness, and data collection in a GP setting needs to be feasible.

230. According to Professor Roland, the QOF has already made good progress in focusing GPs' efforts on tackling health inequalities as it covers the major causes of health inequalities:

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 … for example heart disease; and some of them are addressed pretty poorly, for example cancer; but nonetheless, you have the major conditions that are the cause of health inequalities in the QOF … [165]

231. However, while the QOF has had some positive impact on health inequalities, in the view of Professor Roland and his team, this good outcome should not be attributed to the design of QOF, which, in their view, has never been specifically designed to take account of health inequalities:

The basic problem is that QOF was never and is still not a vehicle at heart for addressing health inequalities in the way DH thinks …. the money, the public reporting and the other wider revalidation and accreditation agendas etc all paved the way for practices in more deprived areas to catch up.... but not the content of the indicators themselves. The 57 point change in 09 were made on clinical grounds and not to specifically address health inequalities.

The actual impact on inequalities (deprived areas catching up) … is really a side effect rather than a prime motivator behind QOF. Indeed, some of the literature argues that financial incentives might increase inequalities (patients in affluent areas easier to achieve targets on). The reverse of this has happened in QOF, as happened also a decade ago when financial incentives were introduced for immunization and cervical cytology. This is partly because quality indicators have been set at levels which are fairly easy to achieve in affluent areas, and partly because practices in deprived areas have worked hard to increase their levels of quality.[166]

232. Professor Roland identified vascular disease and osteoporosis as important areas for health inequalities that could be added to the QOF. The potential of GP smoking cessation interventions were also frequently cited to us in evidence. According to ASH:

The QOF currently awards 41 of the 74 points available for smoking for simply recording smoking status. The remaining 33 points are awarded for giving smoking cessation advice only to patients in specific disease categories by which time it may well be too late.[167]

233. Other candidates that were mentioned to us included Chronic Obstructive Pulmonary Disease (COPD) vascular disease and osteoporosis. We are not in a position to adjudicate on the validity of these claims, but it seems essential that in future the QOF decision making process should include explicit consideration of the likely impact on health inequalities.

BEYOND THE QOF - OTHER WAYS OF TACKLING INEQUALITIES THROUGH GP SERVICES

234. Evidence we took from individual PCTs identified a number of improvements made to local GP services with the aim of tacking health inequalities; in Birmingham, a major screening programme for men over the age of 40 has been commissioned.[168] They had made specific effort to achieve high take-up rate by using a privately contracted call centre to manage appointment scheduling for circulatory screening, and all eligible patients were contacted by telephone, achieving a 70% attendance rate where up-to-date telephone numbers were available for patients.[169]

CONCLUSION

235. General Practice is at the frontline of tackling health inequalities; evidence from QOF data suggests that those practices in deprived areas are performing well in difficult circumstances. QOF has made a start in tackling inequalities, covering most of its major causes but with modest targets. However, we were told that the fact that the performance of GPs in deprived areas had caught up with that of GPs in more affluent areas was actually a fortuitous 'side effect' of QOF, and that the QOF had not been designed to address health inequalities. We received many suggestions for additions to the QOF points system. It is clear that the QOF needs radical revision to fully take greater account of health inequalities and to improve its general focus on the product of patient health. We therefore recommend that tackling health inequalities should be an explicit objective during annual QOF negotiations and that this objective should have measurable characteristics which can be evaluated over time. The QOF should be adjusted so that less weight is placed on identifying smokers and more weight placed on incentives to stop smoking.

Secondary care and specialist services

236. Primary care services such as general practice and health visiting are clearly on the frontline of action necessary to reduce health inequalities. However, more specialist NHS services also have a crucial role to play, although little attention has been given to this by the Government. Specific concerns were raised about inequalities in maternity outcomes, and problems with mental health services; in addition to this, witnesses also described a lack of health promotion advice in secondary care services, in particularly around smoking.

MENTAL HEALTH SERVICES

237. As detailed in Chapter 2, people suffering from mental ill health have starkly increased risks of many physical health problems. In certain cases, this may be ascribable to side effects of medication for their mental health problem; in others, it may be because patients are ill-equipped to negotiate NHS services for the physical care they need; it may also be because their psychiatric condition pre-disposes them to high risk behaviour, for example smoking. Paul Jenkins, Chief Executive of Rethink Mental Health, told us that in his view secondary care mental health services were failing their patients by ignoring their physical health needs:

Mental health services have taken no responsibility for people's physical health, and seen that solely as the responsibility of primary care, which people may often be poorly in touch with.[170]

According to Rethink GPs may also be meeting the physical health needs of mental health patients inadequately.[171]

238. Mr Jenkins listed some specific areas for improvement for secondary care:

a) Improving standards of prescribing for psychiatric medication, to give patients more choice about the side-effects of medications, their impact on physical health, and the trade-offs that exist;

b) Ensuring routine follow up of patients' physical health when they are on particular medications that have an impact on physical health (for example, clozapine has a known link to diabetes and coronary heart disease)

c) Integrating routine physical health care into the provision of mental health services—not only because it minimises the risk of patients not attending for physical health check ups, but also because for some patients, engaging with their own physical health can be an important part of their recovery from mental illness.

d) Health promotion, in particular around smoking cessation; support needs to be specific to mental health because stopping smoking can alter patients' medication needs.[172]

REFERRAL TO SMOKING CESSATION AND OTHER HEALTH PROMOTION SERVICES

239. More generally, ASH presented some shocking evidence to us concerning a failure on the part of secondary care services to refer their patients to smoking cessation services, even when suffering from smoking related illnesses. Part of the problem may be with availability of smoking cessation services to secondary care:

Only half of UK chest specialists have direct access to a Stop Smoking counsellor (despite the fact that smoking cessation is the only intervention that changes the natural history of chronic obstructive pulmonary disease (COPD) or reduces the risk of lung cancer).[173]

240. However ASH also argued that even where smoking cessation services are readily available, health professionals in secondary care are not making the best use of them. A survey carried out by ASH in one hospital found that while 20% of inpatients smoked, fewer than a third of these were given smoking cessation advice, despite the hospital having a smoking cessation service. Furthermore while there were high levels of awareness amongst health professionals of the local Stop Smoking Service in a District General hospital, only one in five had referred smokers to the service.

241. According to ASH, much of the problem is that public health interventions are not prioritised in secondary care, because the Payment by Results system does not incentivise them:

We have got in this country some of the best smoking cessation services in the world, probably the best in the world, but when they were set up they very much focused in primary care, and the problem is that we know that what is happening in primary care is not replicated in what is happening in secondary care. Hospitals do what they are paid to do and what they are measured on, and currently they are not measured on smoking cessation.

It may seem strange but this is not happening, even in respiratory wards, where 80% of serious respiratory disease and death from respiratory disease is down to smoking, because doctors focus on the immediate rather than the long-term impact of what they are doing. I think there is also a danger that people think it is so difficult to give up smoking, let us not worry about that; we will put that to one side. …The problem is that public health work tends not to get a priority in the hospital setting.[174]

242. ASH argue that smoking cessation should be included in the Standards for Better Health assessed by the Healthcare Commission, and in particular hospitals should be required to monitor smoking rates of patients coming into hospital, and to give all smokers brief advice to quit, access to stop smoking medicines and referral to stop smoking services, and smoking rates should be monitored leaving hospital as well. ASH also mentioned anecdotal reports that PCTs were reluctant to fund smoking cessation initiatives because PCTs are concerned that smokers quitting in hospitals won't count towards their quit targets.[175]

243. Alwen Williams, Chief Executive of Tower Hamlets PCT, told us that in her PCT efforts were already being made to ensure secondary care services played their part in tackling health inequalities through providing public health interventions:

There are some interesting examples where patients with lung cancer have said, "Actually we went through the NHS system and nobody did talk to us about Stop Smoking". Really getting this high on everyone's agenda strategically at board level, but also critically in terms of the frontline delivery of services we think is very important … the contractor requirements with acute trusts, we are now requiring what we would call brief interventions, so that we are training and putting some resource into the acute trust to train frontline staff to be able to talk to patients about maybe Stop Smoking or Lose Weight. There is the Stop Before the Op initiative, where we are encouraging people through their interface with acute clinicians.[176]

244. In addition to smoking cessation, there are many other ways in which secondary care could potentially make a valuable contribution to tackling health inequalities through health promotion. Obvious examples include brief interventions and referrals to specialist services for those risk factors mentioned at the beginning of this report, including nutrition, activity and weight, alcohol and drug use, sexual health, and blood pressure. In addition to the evidence that brief health promotion interventions are effective, there is also evidence that illness and admission to hospital sensitises people to health issues and makes them more receptive to health promotion messages. If patients with risk factors go through the secondary care system without those being identified and addressed, this may give patients the impression that the NHS is tacitly colluding with their unhealthy lifestyle factors.

CONCLUSION

245. Primary care is the chief target of most efforts to tackle health inequalities through improving NHS services; however, in solely focusing on this, there is a very real risk that inequalities in other NHS services will persist, and that the great opportunities that exist throughout the rest of the NHS to tackle inequalities will be missed. We heard evidence that the physical health needs of mental health patients are almost entirely ignored by specialist mental health services, leading to shocking health differences between mental health patients and the rest of the population. We find it scandalous that hospital patients—even those hospitalised for smoking-related illness—are not being referred to smoking cessation services—this was offered to only one third of smokers in one trust surveyed by ASH. In our view these examples are likely to represent only the tip of the iceberg in terms of missed opportunities to tackle health inequalities away from primary care. We recommend that the role of secondary care in tackling health inequalities should be specifically considered by Professor Sir Michael Marmot's forthcoming review, and this should include consideration of including tackling health inequalities as part of the Payment by Results framework and/ or the Standards for Better Health.

Early years NHS services—maternity and health visiting

246. As discussed in Chapter 5, witnesses to this inquiry have described the 'early years'—and services provided to children and their families within this period—as potentially very important in tackling health inequalities.[177]

247. Crucial factors include maternal smoking during and after pregnancy as well as alcohol and drug use; maternal diet during pregnancy; maternal obesity during pregnancy; infant and child nutrition; smoking in the family home; postnatal depression; and parenting skills. Breastfeeding was repeatedly emphasised by our witnesses—including the Secretary of State—as a top priority for reducing health inequalities, yet breastfeeding, in common with other lifestyle factors, follows a social gradient: only 67% of women in routine and manual occupations initiate breastfeeding compared with 89% of women in managerial and professional occupations. The differences are even more pronounced in terms of the duration of breastfeeding—only 32 per cent of women in the routine and manual socio-economic group breastfeeding beyond six weeks, compared with 65 per cent in managerial and professional groups. Data from the 2005 quinquennial infant feeding survey suggests that there has been a slight increase in women initiating breastfeeding across the board, and this increase has actually been slightly bigger in routine and manual occupations. However Professor Mary Renfrew, Director of the Mother and Infant Research Unit at the University of York, ascribes this to the increased age of women in the sample, and comments that duration rates (how long women manage to breastfeed for) remain 'abysmally low' across all social groupings, and describes exclusive breastfeeding as 'vanishingly rare' amongst all social groups (The Department of Health recommendation is for all women to breastfeed exclusively for the first 6 months of their child's life).[178]

248. Currently NHS early years services—spanning from conception to 5 years—are provided by a number of different organisations, in both primary and secondary care:

a) Maternity services, during pregnancy, childbirth and the postnatal period, are predominantly provided by midwives either in community or secondary care services; obstetric (medical) services are also provided where necessary in secondary care, and some GPs also provide maternity care; for ten days after a new birth (check) midwives continue to provide care for mothers and infants at home, before discharging them to community GP and health visiting services.

b) On discharge to the community, mothers and babies can access GP services in the usual way; to supplement this, additional services are provided by health visiting teams.

c) Health visitors are specially trained health professionals drawn from a nursing background. They offer a programme of screening and developmental checks over the first years of life, as well as health promotion and parenting support services. Immunisations are provided by health visitors, GPs or community nurses.

249. Professor Edward Melhuish, who led the national evaluation of the Sure Start programme, emphasised the importance of maternity and health visiting services in supporting early years interventions such as Sure Start:

The health services give you immediate access to parents in pregnancy and children at birth, and, therefore, the Sure Start programmes can get into contact with those families very early on … Any ideal services would involve very close integration of the health services with Sure Start type programmes … I would expand the midwife and health visitor services so that those services could integrate more thoroughly with Sure Start programmes; and I would also improve the training of midwives and health visitors so that they have a better understanding of the factors affecting early child development and parenting. Currently, they are not as good at that as they could be. I would have cross-agency training for people who work in Sure Start programmes and health visitors and midwives, and maybe even some doctors as well.[179]

MATERNITY SERVICES

250. Maternity services are well placed to offer opportunistic health promotion advice to women, and changes made at this point have the double benefit of improving the health of both mother and baby. Maternity services are used by women when most are still at a relatively young age so lifestyle changes made at this time can have a longer effect. They also serve a large number of women (approximately 660,000 per year) spanning all sectors of society, again increasing their potential impact. Finally, unlike a single GP appointment, those using maternity services are likely to be in contact with services over a number of months, providing opportunity to both identify those mothers with particular health promotion needs, and to reinforce health promotion messages and support compliance with them.[180] Key health promotion interventions delivered by maternity services include nutrition, activity and weight, smoking cessation, alcohol and drug use, and breastfeeding.

251. However, according to the RCM, maternity services are severely below the capacity they need to be, largely because of funding and staffing shortages.

Staffing increases in the NHS overall have largely passed midwifery by. Both the full-time-equivalent number of midwives in England's NHS fell in the last annual staffing snapshot (down 87 between 2005 and 2006) and the headcount number fell at both of the last two counts (down 375 between 2004 and 2006).

In 1997/98, for instance, maternity services absorbed 3.1% of the NHS budget in England, but by 2006/07 this had fallen to 2.0%. Total spending on NHS maternity services in England actually fell by £55m in the last financial year for which figures are available (2006/07).

These cuts come despite England witnessing a rapidly rising birth rate (in the five years between 2001 and 2006 the total number of births increased by 13%).[181]

252. Declining numbers of midwives coupled with increasing numbers of births means that midwives' workloads are increasing (the number of births in England per full-time-equivalent midwife rose at the last count (September 2006) from 32 to 33. The result of this is that midwives are increasingly having to focus their limited time on labour and birth, the most 'high risk' part of maternity care, and may be devoting less time to antenatal and postnatal care, which offer the best opportunities for health promotion. The RCM also argues that Payment by Results (PbR) is having an additional, unintended effect on maternity services, drawing funding away from community services.

HEALTH VISITING

253. Sarah Cowley, Professor of Community Practice at King's College London, and Christine Bidmead, a practising health visitor at South London and the Maudesley, argued that health visitors are uniquely well placed to contribute to tacking health inequalities, as they offer health promotion support to families in the first few weeks of a new baby's life:

Universal health visiting services are a primary line of defence against social exclusion, since they reach out to all families with new born babies, providing support for parents and for parenting at the most vulnerable and significant period of an infant's life.

Early child development is a vital time for influencing life patterns that lead to health inequalities. However, health inequalities are addressed only if concerns are identified sufficiently early to prevent the infant from entering an adverse life trajectory, with established physiological and behavioural patterns, which might have been changed in the first months and years of life.[182]

254. The national Sure Start evaluation found that Sure Start programmes that were led by health visiting teams rather than by any other professional group were those most likely to succeed. However, in recent years numbers of health visitors have fallen dramatically, and there is also an ageing workforce.

255. Christine Bidmead, a health visitor at South London and the Maudesley NHS Trust, ascribed this to health visiting being an 'easy target' during PCTs' recent financial difficulties:

Because the budgets of PCTs were overspent the health visiting service was an easy target to be cut and so what we have seen is a huge decline in the numbers of health visitors being employed and in the number of training places being commissioned by PCTs for health visitors.[183]

256. According to health visitors, the strength of health visiting is that, over a course of visits both antenatally and postnatally, a health visitor is able to develop a relationship with a family that firstly makes it possible to offer and help implement health promotion advice on a sustained basis; and secondly enables health visitors to form a deeper understanding of families that will help them identify hidden needs, for example, around postnatal depression. However, perhaps unsurprisingly given the decline in health visiting capacity, this type of service is becoming increasingly rare, with recent research showing that 60% of areas now deliver only a restricted service of one visit shortly after the birth of a baby, followed by drop-in baby clinics and child protection services. In the same survey, 69% of health visitors reported that they no longer had the resources to respond to the needs of the most vulnerable children, with more than half (58%) believing there was a chance that a horrific child death, such as that of Victoria Climbie, could happen where they work, a telling indictment in the wake of the case of Baby P.[184]

257. Just before we agreed this report, the Government published a strategy for children and young people's health, which stated that its policies would include "further development of the health visitor workforce to deliver the Healthy Child Programme".[185]

CONCLUSION

258. We have been told repeatedly that the early years offer a crucial opportunity to 'nip in the bud' health inequalities that will otherwise become entrenched and last a lifetime. While there is little evidence about the cost-effectiveness of current early years services, it seems odd that numbers of health visitors and midwives, currently the main providers of early years' services, are falling, and members of both those professions report finding themselves increasingly unable to provide the health promotion services needed by the poorest families at the same time as the Government reiterates its commitments to early years services. The Department of Health must undertake research to find out the consequences of the decline in numbers of health visitors and midwives and to consider whether some aspects of the health promotion role played by midwives and health visitors could be effectively done by other types of staff to bolster early years health services.

132 Q 403 Back

133 Q 403 Back

134 Q 404 Back

135 http://www.lho.org.uk/HEALTH_INEQUALITIES/Health_Inequalities_Tool.aspx Back

136 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083822 Back

137 Putting Prevention First - a presentation, DH, 2008; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083822 Back

138 HI 37 Back

139 HI 37 Back

140 Guidance for Commissioners on the Cost Effectiveness of Smoking Cessation Interventions, C Godfrey et al, Thorax 1998; 53; http://thorax.bmj.com/cgi/content/full/53/suppl_5/S2 Back

141 HI 96 Back