Item 4 is a return to our early years inquiry, which is a piece of work that the committee is doing under the health inequalities theme.
Today we have a round table of health professionals. As usual, to help promote discussion, we will begin by introducing ourselves. To lay out the rules of engagement, we are interested in hearing from our invited panellists, and on all occasions I will give precedence to the panel over the politicians. Members of the committee will of course have an opportunity to come in and keep the discussion going, but I will look to the panel first.
I am the member of the Scottish Parliament for Greenock and Inverclyde and the convener of the Health and Sport Committee.
I am a GP from Govan in Glasgow and I represent GPs at the deep end.
I am an MSP for Glasgow and deputy convener of the committee.
I am a nurse team leader in Glasgow, working with homeless families and newly arrived asylum seekers. I am a health visitor by profession.
Good morning. I am the MSP for Aberdeenshire West.
I am a public health doctor in Glasgow and associate professor at the University of Oxford.
I am an MSP for Central Scotland.
In real life, I am a consultant in public health medicine in Fife and I am also the chairman of the British Medical Association Scotland’s public health committee.
Good morning. I am the MSP for Edinburgh Western.
I am an MSP for North East Scotland.
I am also from Glasgow. I am a paediatrician and I work in Possilpark in north Glasgow, but I cover a wide area, including East Dunbartonshire, which is more affluent. I see kids with disability and developmental problems. I worked for 10 years as part of the maternal and child public health team in NHS Greater Glasgow and Clyde. I am here representing the Royal College of Paediatrics and Child Health.
I am an MSP for the Highlands and Islands.
I am an MSP for the Highlands and Islands.
I am the director of the Royal College of Nursing Scotland.
I am an MSP for Mid Scotland and Fife.
Thank you, all. To set us all off, the deputy convener, Bob Doris, is going to pose a question and we will see where that takes us.
The convener informed me about four minutes ago that I was asking the first question, but I am delighted to do so. I have a general question. When I listened to the First Minister’s statement last week on the new programme of legislation and policies, one of the things that jumped out at me in relation to health inequalities was the fact that the Government seeks to appoint a new independent adviser on poverty and inequality. That is of great interest.
I am keen to know what progress you think has to be made in promoting policies that tackle health inequalities. We have heard that a lot of the rooted aspects of health inequalities come from income inequality, so there is a variety of policies that are not directly at the coalface of healthcare but have a wider impact on the health and wellbeing of the people we seek to represent.
I am looking for initial comments on how you think the role of the new adviser could fit in with the public policy development that we are all involved in. Do you believe that the poverty impact assessment, which will be on-going under a new Scottish Government initiative, should have a specific reference to health inequalities as well?
Anything that sets the agenda around poverty and sets out health inequality is a good message. Much of the work that people are trying to do is invisible, so it is not easy to document or assess the impact.
I was very pleased to see the research that came from “Growing Up in Scotland”, which talks about a couple of things that have come up in our nursing at the edge campaign. The most important thing is to get as close as possible to the marginalised groups and to be very aware of the impact that we can have on individuals. Too often we look at services as a whole. One of the things that come out of considering inequalities in groups is understanding how individuals react to services and how the focus can be on them.
When we are tackling inequalities for children, it is important to remember that the parents and the family are a big part of that. For example, work that is done with women who are offenders in prison who have children is a crucial part of looking at strategies for the child.
It is hard to look at the impact of other policies, so I would be interested to see what measures the adviser will set out to say whether something has made an impact. It is not easy to do that.
From the BMA’s point of view, the vast majority of inequalities in health, whether they be in the early years or later on, do not arise from health. Health picks up the consequences of inequalities, which arise from the effects of Government policies, both here and in the south, and also from other Government actions and actions within society. The social determinants of health have far more effect on people’s health than the NHS ever will. We are just trying to minimise the adverse consequences on people’s health that those inequalities cause.
Yes. Given the evidence that we have heard, the committee would accept that point in general, although we would not accept that there is not significant mitigation that can have a positive impact.
I suppose that I was being deliberately general. It is not for me to predict what witnesses might say in reply to our questions, but there is a cluster of policies on the early years that we could talk about. We could ask Dr Mullin how she thinks the deep-end project and the link worker system help those living in poverty and in deprived communities, or we could talk about family nurse partnerships; the proposals on childcare and the balance between childcare for children’s development and childcare as an economic necessity to allow mothers and fathers to go into employment; and the living wage policy of the Scottish Government.
I was trying to give a wrap-around test by which the committee can judge where a policy sits when we are looking at how we tackle health inequalities. I suppose that there is an opportunity for our witnesses to say, “Here’s something that we think is working well and we would like to be extended,” “Here’s something that we would like to be changed,” or, “Here’s an income maximisation policy that has to be pursued.” It is fair to say that the committee thinks that there are lots of good spends out there, but we are trying to work out whether we are getting the best value for money in tackling health inequalities for the spends that we are putting forward.
11:30
I absolutely agree that most of what we are picking up is the consequences of inequalities that then impact on health, rather than health being the cause of the inequalities. However, as health services, the last thing that we want to do is to then exacerbate those inequalities through the way in which we structure our services. The proposed adviser on poverty and inequality should look deeply into resource allocation models for how we fund the services that then pick up the difficulties.
Working as a paediatrician, I am well aware of the barriers that we put up. They often arise from trying to be more efficient. For instance, Anne Mullin will refer patients to specialist services. A lot of them, instead of just sending out an appointment, will send a letter saying, “Please respond to this letter in order to make an appointment.” It is as if they are saying, “It’s only people who are really motivated and will turn up who will make appointments, and we will not waste all these other appointments.” It is the most vulnerable people who are under stress, be it financial stress, lack of sleep, mental health problems or whatever, who will not get round to phoning and making the appointment. It would help if we just sent out the appointment in the first place.
I am sorry to go into a lot of detail on that one example, but it is the kind of thing that we meet again and again, and it involves putting up barriers. We are trying to be more efficient, but we need to consider the truth of how much extra time and effort it takes to engage with people who are more vulnerable, whether that is due to socioeconomic inequalities, disability, ethnic group or whatever. I do not think that our current formulae for calculating resource allocation hit the mark.
I agree. Working at the deep end, we have to think about progressive universalism in services, but we cannot really have that unless we have realistic universalism. We all work in areas of high deprivation, and we are aware of the social determinants of ill health. We still need the resource to address the inverse care law, which is prominent where we work. We need the resource to match the needs.
Part of that is to do with making the policies right. Some of the policies are very good, but it comes down to the resource. For example, in our south community health partnership, we are having to lose £500,000 in the next financial year from our children and families budget. We cannot realistically run universalism with that scale of cut. That is one of the very real issues that we face.
I return to my point about access, which was about exactly that. My colleague who works on homelessness might want to comment as well. The work that we have done on nursing at the edge is about people with chaotic lives, who are unable to fit in with what we put in place as a service, and how they can access services. One thing that we are asking for is that, where services are provided, there is greater authority to reduce some of the bureaucracy and paperwork that means that we may lose the person who has made the contact and made the effort to get there, but who then needs access to services and has to go through a convoluted process. Such people often do not return. One-stop places where people can get those services have worked very well for that reason.
Access is a big word. That is what I meant when I mentioned marginalised groups. It is a question of knowing where they are and who they are and understanding how we can go towards them. The work on women offenders that has been done in Perth has focused on those women and their children in a way that has made them feel that, even though they are not in the community, they are receiving services as part of the community, and similar work has been done in Grampian. It is important to look for such examples.
However, the issue often is—as we will show at our reception tomorrow night—that those projects are funded for the short term and dependent on funding coming from a number of pots and that there is no wish to fund them long enough for them to be able to show the impact of what they do.
Many people we meet talk about waiting for a year to know whether they will be funded for the next year. How do they stay with that? It is risky for health professionals to step out of what is considered to be a good and safe job to go into such a role, but most of them do it because they are really keen to make a difference. However, they more often do it at the end of their careers because they are more confident and feel more able to work within that world.
Those are some of the things that could be measured. If we do not change how we deliver the service, people will always fall between the footstools of what is there for those who know how to access it.
Bob Doris’s original question was about what we should ask the poverty and inequality adviser to do. That is a great question. In my career, I have seen advisers and tsars come and go, but I was never really sure to what effect, particularly if they operated at a national level because, if we want to make change, we have to make it at a local level.
If I were going to employ such an adviser, I would look at the evidence about what makes an effective leader in those circumstances. Al Aynsley-Green is a good example of someone who achieved something in the past, so I would look at what he did to achieve that. I do not know what makes a good commissioner, adviser or tsar, but there must be an evidence base on that. We need to think about the kind of person we want, what they might do and what they would require from us because, unless we listen to them and act on what they do, they will be ineffective and could be sitting in an office achieving nothing. Before employing such an adviser, I would think carefully about what I wanted them to do and how to make them most effective.
My point relates to Theresa Fyffe’s. It has probably been said again and again, but it is important that we invest in generic measures such as universal services. There are fabulous things to be learned from projects but, again and again, I see good people from local health visiting services being seconded into projects. The most vulnerable families really benefit from continuity of care—having the same general practitioner and health visitor for years—and, if they are all being broken up into projects, we do not get that continuity.
Under the Public Bodies (Joint Working) (Scotland) Act 2014 and the Children and Young People (Scotland) Act 2014, there is great potential for the work that we are talking about to be developed. GPs at the deep end think that the integration agenda is important for this area of work because health and social care really need to work together much more closely. We need to understand each other’s language and how we work together. That relationship has been fragmented for a number of years.
We have developed a project that we hope will be funded, because it addresses many of the issues that, as practitioners, we feel are barriers to better access for families, shared understanding, sharing information, addressing the issues and addressing inequalities. That project is unique because it has been built from the ground up; it does not come from a top-down approach. However, it needs research support and we do not have that in general practice. We do not have a lot of well-supported research through the chief scientist’s office or core funding that we can keep rolling on.
Short-term funding for projects has been mentioned. That is a real anxiety about all pilots. Where do we get the good evidence and evaluation that has international implications as well as local and national ones? That is something that we would advocate for at the deep end as well.
I will change the subject slightly but will pick up on that last point.
I have just come back to Glasgow after 12 years away. There have been massive changes in policy and things are an awful lot better in general throughout Scotland than they were 12 years ago, but a culture of evaluation is still lacking. There are so many different pilots on child obesity, parenting and so on. Sometimes, they get started and people ask which ones are effective and how effective they are but, frankly, we do not know, because not enough resource is put into evaluation at the same time as they are commissioned. They need to be longer term in scale and they need to have evaluation built in.
That needs to be part of the set-up as we move into integration. Health and social services could do lots of stuff together on, for example, looked-after children, who are marginalised and go on to form a lot of the prison population and so on. Will they do that? It depends on whether they are prepared to share information so that we can see the outcomes across the piece. That should include education if that is possible. If we do not bring all that together, we can set up all these projects but we will never have any idea whether we are making any difference.
I want to test some of that. We are here under the banner of looking at child poverty and every day of the week we see that it has almost become meaningless to people.
Professor Marmot said that being in poverty is defined as having an income of less than 60 per cent of the median income and it is unlikely that a country would have a distribution of zero, which would mean no child poverty. The country with the lowest levels is Norway, which has 10 per cent child poverty because we use the median income measurement.
We have heard evidence that because of that, we are almost hiding very vulnerable groups such as those that are defined by ethnic background or children coming out of care. We are almost blurring the edges and losing the focus because we are dealing with a generality. Governments do it as well. We are all very hot on this point. One question is how we measure child poverty. Should we have a greater focus on what we are tackling? Would that mean a greater chance of dealing with the very vulnerable groups?
The other question is about what the Government is to do. We are all very hot on the idea that the living wage will solve poverty. We are all rushing to support the living wage, but it does not measure household income at all. In some cases, it might not reduce poverty; it might increase the gap between the less well-off and the better-off. There is a lack of clear objectives in Government policies. The well-understood inverse care law can be applied to education, the economy and everything else.
There is a question in there. Do politicians need to understand what they are talking about? Do we need to evaluate it? Do we need to do better in ensuring that the measures that we take do the job that we say they are going to do? At the moment, I do not think that we are achieving our ends when the gap between rich and poor has been growing despite all the well-intentioned policies from all shades of Government right across the board. I throw that in there to see whether we can warm this discussion up. Any takers?
Last year, Dr Atkinson, the Children’s Commissioner for England, wrote an interesting report—you can all read it; it is online—about the effect of welfare reform on children. She wrote from a children’s rights perspective, which is an interesting way of looking at the welfare cuts and how they affect families and cause poor child outcomes. Anything that a Government does that undermines the rights of the child, as set out in what it has signed up to, opens it up to criticism. It is in danger of breaching its own children’s rights policies under the international agreement that it signed up to because of the retrogressive nature of its policies, which discriminate against and affect the poorest children.
That is the sort of thing that a Government has to decide how to address. A number of policies are creating inequalities by making the gap wider, and poor children are being disproportionately affected rather than other children.
11:45
You are right about poverty, but you also have to think about the other side of the equation—wealth. What is really perpetuating the inequalities is not just people staying in poverty but other people getting tremendously wealthy. There has been a lot of literature on the subject—I am sure that you have read the book that Thomas Piketty has written about it—and various other people are talking about the huge increase in wealth among a certain group in society, which is fuelling the inequalities as much as problems at the other end of the scale.
It seems that one of the ways in which the problem is mediated is through a lack of opportunities for education. Although we are talking about health inequalities, education is one of the most important things. We know from figures from Glasgow and elsewhere that poor children are beginning to fall behind by the age of two or three in terms of their early literacy, vocabulary and so on. Even the most well-intentioned early childhood programmes, which are effective and cost effective, do not completely make up for poverty. I read recently that the effect of two years in pre-school might reduce the effects of poverty on various outcomes by about a quarter, but that is all.
To some extent, you need to tackle poverty at its root, but you also need to tackle increasing wealth.
After the publication in 2007 of the UNICEF report on the wellbeing of children in 21 countries in the Organisation for Economic Co-operation and Development, in which the United Kingdom came last, UNICEF UK undertook some research that compared in more detail child wellbeing in the UK with child wellbeing in Spain and Sweden, looking particularly at the impact of inequality and materialism. As Ron Gray says, the fact that there is so much perceived wealth contributes to the inequality, and one of the recommendations of that report was to ban advertising that is directed at children—not just advertising of unhealthy foods, but all advertising that is directed at children.
If I could recommend one change to improve the health and wellbeing of children, it would be to reduce the stresses on parents. There are already stresses of poverty, poor housing, the need to maintain a job, childcare and so on, but materialistic advertising puts additional stresses on parents. The research in the UK found that the more affluent parents who are time poor because they work hard feel guilty that they are not spending enough time with their kids and buy them expensive things to compensate, whereas the poorer parents feel stressed because they think that their children will be bullied if they do not have Nike trainers. I have had patients fail to turn up for their appointments because of that. One mum did not bring her child for an appointment, and when I phoned her on her mobile she was Christmas shopping. She thought that the child getting some flashy piece of plastic was more important than their seeing the paediatrician. We have a culture in which people queue overnight to get the latest electronic gadget, and a factor in the inequality is the perceived wealth. It sounds terribly patronising, but the people who are not wealthy feel pressure to get those things for their children instead of spending their money on things that would be more appropriate.
I do not know whether advertising that is directed at children could be banned. Our borders are so porous that, even if we did that in Scotland, it would be accessed in other ways, although it would send a good message that we are a child-centred nation and we care about our children. It is important that we build resilience so that people do not feel so impacted on by the inequality and the materialism.
Some of that touches on what we heard from Harry Burns.
I am glad that he and I agree.
He talked about the difference between the situations in Glasgow and down south, and he highlighted the lack of compassion in our society now. For instance, people in Glasgow are less likely to trust their neighbour.
Going back to my original question, if we are generalising the problem, how we measure and communicate the problem in order to have some effect is important. Health is the only portfolio area where we measure inequalities—for example, in terms of smoking, birth weight and mortality rates. I am not saying that that is the only way to measure inequalities, but no other portfolio area has a measure.
I suppose the question is whether using health statistics is the right way to measure inequalities. Are there other measurements that could be applied in other portfolios that would communicate the nature of the problem more effectively?
To me, it is much easier to pull down data to illustrate inequalities in, for example, what we deliver or outcomes for children—we can use the Scottish index of multiple deprivation to show areas of deprivation by postcode—than it is to demonstrate that by any other method. There could be other ways of measuring inequalities, but at least we have a measure and we can report.
There is clustering of risk for so many families. For example, childhood disability is more common in the more deprived populations and if there is childhood disability in the family there is more likely to be adult disability as well; ethnic minorities and asylum seekers are more likely to be poor; and there are issues around looked-after and accommodated children, which we have touched on.
However, we cannot pull down any data on our routine delivery of services according to a child’s disability status and we do not even know how to record that status—we have not even decided on a definition of disability. We are not recording ethnicity well, either. At least I can use gender, age and the Scottish index of multiple deprivation to measure poverty. However, we are not measuring other risks that cluster in certain families.
We have known for decades that a number of generalisable areas need to be measured, but we have not addressed that. As we said earlier, factors include parental employment and parental income; nutrition for a woman before she becomes pregnant, while she is pregnant and after pregnancy; and nutrition for the family. We know exactly what food we would like people to eat but, by and large, many of the most deprived people do not get to eat that food because it is too expensive or not available, or because people know that if they bought such food to feed their family but they did not eat it, they would not have the money to replace it. Another factor is the socialisation of children, which we significantly fail to achieve. Particularly in very deprived areas, it is not even feasible for children to play outside safely.
Large parts of Scotland are very rural, but the deprivation data does not show rural deprivation terribly well. It is quite easy for pockets of rural deprivation to be hidden among relatively less deprived areas and to not appear in the statistics. One of my colleagues at work has a particular interest in that issue and has spent a large amount of time showing to his own and others’ satisfaction that the data that we collect misses a lot of people in rural areas who are deprived. There is no simple way to get round that and dig out such data.
We need action across Government portfolios to try to bring everybody up out of deprivation while also focusing on those who are the most deprived. Some of the initiatives that have been set up in that regard are working very well. For example, there is the childsmile initiative on dental health, which I am sure the committee is aware of, through which the numbers of decayed, missing and filled teeth in children in all categories, but particularly the most deprived, are being addressed and dealt with, and the children’s dental health has improved immeasurably.
Other programmes that are working particularly well include the family nurse partnership, but that service is restricted to women under 20—women over 20 who need it do not get it. There are other programmes that have time-limited funding. Some of them are due to finish next year because of that and we have no idea yet whether their funding will be continued.
A lot of joined-up thinking is needed for the more generalisable things that will help all children whatever their degree of relative deprivation. The specific programmes concerning the most deprived need long-term funding in order to work well. Childsmile has long-term funding and I would say that its future is pretty well established, but there are a lot of other programmes that need that sort of certainty in order to achieve the same things.
The common theme that has been coming through in what people have said is that we are not very good at knowing what data we have and how to use it. Furthermore, there is a gap in the research evidence, which is why I mentioned that the growing up in Scotland research was good to see. There is no body of research, however, that would enable people to know what the best impact would be. That is why I made the point earlier about how we measure impact. We need an evidence base that helps us to understand what the efficacy is and what we can do.
I support what Charles Saunders said about the childsmile programme, which really has demonstrated a significant drop. What has gone right with that programme? Why did it get long-term funding? What did it do to succeed while other projects got short-term funding and were not secure? I do not believe that enough is done at the very beginning about evaluation.
The family nurse partnership has been shown to work through the evidence base. Right now, however, in my position at the Royal College of Nursing, I want to see the impact of that very focused and expensive work on a targeted group, leaving others out. Does supporting the partnership really achieve things and make the difference?
We have been looking into instances where health visitors wish to provide more specialised services on top of what they do in their ordinary day. That is hard to do, and it is a hard case to make. The work that was done in Grampian on prisons came from a wish by the teams up there to do something different. It did not come from having a particular goal.
Returning to the point about what the adviser needs to do, it is to have some clear goals that cross all Government portfolios and that hold people to account. When the Children and Young People (Scotland) Bill was out for consultation, we were one of the groups that felt that there should have been more about the rights-based approach to children, and the Children and Young People (Scotland) Act 2014 does contain a duty on ministers to demonstrate how they are going to adopt such an approach. I refer here to Anne Mullin’s point about how they will be challenged. What activity are ministers undertaking to demonstrate that they have taken a more rights-based approach?
As an organisation, we believed that that approach should have been more embedded in the 2014 act, thereby requiring such activities to be taken across Government through a more constant approach. We have already highlighted the importance of continuity in who is providing the care and a constant approach to services.
We know that it will take years to make the difference. It will not take a couple of years; we know that it will take a long time. If you want an intergenerational shift, you will have to work at it for quite some time. In the end, what difference will it have made or not made? What more can you do?
I will pick up on that point—and this is a point that Dr Saunders and Dr Gray have made, too. Some of the foundations have been laid. Dr Gray mentioned education. Do you think that some of the initiatives that are in place, including getting it right for every child and curriculum for excellence, are the foundations for moving in the right direction, but do you also think—I refer to the point that Theresa Fyffe has just made—that we require a behavioural and cultural change, which will take a number of years?
There has been a tremendous change in the role of school nurses, for instance. Is it school nurses that we need, or is it perhaps health visitors within schools and initiatives like that? Are we getting the foundations right, despite taking a while to start building on them?
We know quite a lot of the things that we should do. Michael Marmot has listed a number of the interventions. They start off in the antenatal period, including those concerning alcohol, drugs, smoking during pregnancy and stress, and then go on to breastfeeding, weaning, parenting, early education and so on. We know about all those things.
12:00The issue for me is that the approach is rarely joined up. Although we have evidence on a number of those things, we often do not see local evidence of effectiveness. We need to know a number of things. We need to know not just whether the measures work but how well they work and what size of effect we get from them. We need to know whether the people who need them are really getting them—if you like, the reach of the intervention and whether it is getting to the right people. Then, we need to know whether those things are actually being implemented properly on the ground, because sometimes they are not. Sometimes, with the best will in the world, people do not implement things properly and they therefore have no effect.
For a lot of interventions, we just do not know that kind of detail, and we can get it only by having a data system so that we can look at a broad series of outcomes across health, education and social care. That would perhaps also allow us to look at positive outcomes as well as negative ones, which the convener alluded to. We might want to look at happiness, aspiration and quality of life for children. For example, we could consider aspiration among those in the most deprived quintile compared with those in the least deprived quintile. That would give us information that we could start to act on, and it would allow us to begin to see whether we are being effective.
Dr Reynolds, do you want to comment? Oh—sorry, Dr Mullin. You are too polite to nudge me in the ribs and I am always looking straight ahead, rather than to my side.
Dr Gray is right that we need to know what we are measuring, how we are going to measure it and what evidence we want. Particularly in primary care, we lack a research base that cuts across all the disciplines and allows us to see what we are doing.
Despite the strategies and so on, the work goes on at the front line and we deal with the consequences of the pressures on budgets and a lack of resource—we somehow have to muddle our way through all that. General practitioners are universally accessible and we provide an unconditionally accessible service, so we are useful contributors to the debate, yet only 3 per cent of our contract is to do with child health. In some respects, it is given very little attention, yet we do a lot of general paediatrics in general practice. Our relationship with health visiting is extremely important in the early years.
There are some very good things in education, such as the nurturing corners in nurseries, but the two programmes that have an unassailable evidence base are the family nurse partnership and the Incredible Years. The other programmes have some promise, although the positive parenting programme, or triple P, has been slightly controversial. We do not have much to go on.
At the front line, we are asking for realistic universalism so that we can have progressive universalism. There is no point in having specialist services for vulnerable children and families if we cannot get the rest of it right. That is the problem that we have.
We have heard before about universalism plus or realistic universalism. What is your definition of realistic universalism?
From the point of view of a GP working at the deep end, we need more time to provide the service. Stewart Mercer’s work in the care plus study involved estimating how much more time GPs need. Obviously, I am not here to talk only about general practice, and other services are under the same pressures. However, we need realistic times in which to see people and deal with their problems, which is what the Govan project is trying to address. The links project is another aspect of that work. That is a good project and it will be properly evaluated, but we need that time. There is room for flexibility, but unless we have that time we will not do the work that is needed. There is unmet need all the time.
Is there not a point of debate with Dr Saunders, who says that everybody needs to move up? In my humble opinion, one of the problems that we have is that, if everybody moves up, we do not address the gap—the gap is frozen. Despite everything that we add on, none of it reduces the gap.
Danny Dorling talks about the top 1 per cent and the inequalities gap there, which is massive. That needs to be sorted out, but that is an international agenda and we would have to do something with capitalism to deal with it. Meanwhile, we can work with other inequalities and do positive things about them.
I will let Jayne Sellers comment and will then give Dr Saunders a chance to come back on that.
From a practical point of view, to a health visitor on the ground universalism means that every single child has a health visitor who is accessible to them and who uses their professional judgment about how much time a family needs. Some families will need less time at some points and others will need considerably more time. Health visitors need to be able to facilitate access to specialist services that might be necessary. We must accept that every child in an area, no matter who they are or where they sit in the socioeconomic spectrum, should have a health visitor—that is what I mean by universalism. It is about allowing health visitors to make a professional judgment about who they see and how they do that.
Mr Robertson raised a point about school nursing. We have very few school nurses, particularly in Glasgow, and we need to look at the broader aspects of health and wellbeing for school-age children aside from the education and pastoral care that children get in school. The capacity for school nurses to do that work is absolutely minimal. Once they have delivered the immunisation programmes and other such things, they have absolutely no capacity to do any other work.
We need health visitors to specialise in that aspect of health and development in the pre-school years, and we need school nurses to be able to do not only the immunisation but the wider support work for families during the school-age years.
Do you see a role for health visitors in schools as well as in communities?
Not necessarily, because school nurses as a profession are well able to deliver what health visitors deliver in the pre-school years.
That aspiration prevents us from dealing with the issue of transfer of resources. The better off, the better educated and the more articulate get a disproportionate amount of the health budget. Maybe it is a fair amount but, in comparison to poorer people, they get a bigger share of the health budget and the education budget, and they get a better share of the jobs and better pensions. Is it time to tackle some of those issues? Dr Saunders talked about everybody moving up, but the challenge is that that means that the gap does not get any narrower.
Everybody needs to move up; it is just that some people need to move up slightly more than others. Everybody in Scottish society, including children, needs to improve their health. Some people have a more desperate need to improve their health than others, but everybody needs to move up.
I take on board what my colleague Jayne Sellers said about school nursing. In recent years, the school nursing service has been largely subsumed into delivering immunisation in schools and there is very little time left over for anything else.
The directors of public health at the health board level have the responsibility to take a population perspective. A large part of their job is to raise with the health boards the issues of population health, inequalities in health and deprivation. However, in the future, those who are appointed directors of public health will not be executive directors of NHS boards and will lose a great deal of authority in the boards. Directors of public health will have no formal role in the health and social care partnerships. Although, intuitively, it seems a good idea to put together health and social care, it does not seem sensible to take out the directors of public health—I am not one—who historically have had responsibility for population health, when we are aware that health inequalities in Scotland are increasing, particularly in the early years.
I return to my point about a universal service and the need to understand how to respond to deprivation. Health visitors are trying out a new tool that might at least assess the workload and take into account social deprivation. Before that tool came along, there was no means of doing that, so, in some parts, a case load could be high and extremely demanding because of increased deprivation. Health visitors in some parts of Scotland had different case loads from other health visitors just down the road from them because of deprivation, so we are trying to find a measure that at least tells us what we need in response to that deprivation. Without that, there is no doubt that, whatever an individual practitioner may do, the demand will come from those who make the most demands, who require more and who are most articulate, which means that a practitioner might miss the very people they are trying to get near.
The situation with school nursing is unfortunate, because the service has been hijacked by a need for immunisation. Do not get me wrong—there is a need for immunisation, and when that need arose everyone agreed that it was something that school nurses could do, but they forgot that they were meant to have other functions, which have been reduced in some areas. Even though there has been an emphasis on that in schools, school nurses have not increased in number—in fact, in some areas of Scotland they have decreased in number. That is another measure to consider.
I return to a point that others have mentioned. If we do not find a way of joining up all the policies and being clear about them, we risk having lots of policies but not knowing what impact they are meant to have for children or truly understanding whether those policies connect.
I have a further point to make about the integration of health and social care. As you know, we have been here to give evidence on the move to integrate those services. We support that move, but we are going to have to keep a close eye on how the partnerships work. As they look at what they believe the services to be, we need to ensure that they provide continuity. In some areas, there will be several partnerships. Glasgow, for example, will have a number of partnerships, so you will need to consider how you can ensure a cross-Glasgow approach to issues. It is not impossible to do that, but it will be challenging. In the next couple of years, you will need to keep an eye on the very things that we have been talking about, because they are more expensive and they demand a different type of resource. My concern is that we could be short changed during that period.
On universalism, I agree with what has been said about how crucial health visitors are in being proactive and going out to seek patients. GPs are also highly important, but they are not going into people’s homes to find families. In identifying the increased level of need, health visitors are absolutely crucial to those people who do not necessarily present themselves. I therefore welcome the increased investment in health visiting and the ability of health visitors to be the named person.
I work with school nurses a lot and wish that there were more of them. We must remember that, under GIRFEC, once a child is in school it is the education service that provides the named person role, so we need to think about how we support the people who perform that role. It is not a question of recreating health visitors for schools because, once children are in school every day, the people who provide their education will have a much better idea about them and will, we hope, form relationships with their families as well.
The SHANARRI indicators—safe, healthy, achieving, nurtured, active, respected, responsible and included—are pretty much from the United Nations Convention on the Rights of the Child, and people in all other parts of the UK will be working towards similar outcomes. We should ask what we are doing to make our children safe, healthy, achieving and so on, not just on an individual basis but at a population level, and health visitors and professionals in the local area should be able to build that up using initiatives such as the bottom-up initiative in Govan to which Anne Mullin referred. There are also initiatives such as the responsive, intersectoral-interdisciplinary, child-community, health, education and research initiative—the RICHER project—in Vancouver, where additional resource is put in to areas that, at a population scale, are more needy according to early development index scores, to make services more accessible.
12:15As I said at the beginning, the more complex the circumstances are, the more time the professionals will require to undertake assessments of need and support families. Overall, building up the population view is all about raising the status of children and supporting GPs and health visitors on the front line while providing easily accessible services. Specialist services—those that are provided by paediatricians, for example—must be more accessible for consultation and advocacy at the population level in addition to working with individual children.
Sorry—I have so many things to say that I get them all rather jumbled up together.
Absolutely—good for you.
I am better on paper.
That is okay; your passion came through.
If no other panel members wish to respond, I invite Nanette Milne to ask another question.
I want to follow up on a comment from Jayne Sellers, who mentioned health visitors specialising. I had some experience in my husband’s former practice, which was a mixed practice: there was some deprivation, but that was not the entire picture.
I remember from years back the real efficacy of practice-based health visitors. When they took on more of a community role, they were not so effective. What are your comments on that? Is it better to have health visitors based in practices or groups of practices? What do you see as the best way forward?
Prior to my current role in dealing with homelessness, I always worked as a health visitor attached to a practice, and I think that it is a very reasonable way for health visitors to work. It promotes a really good relationship with GPs, and it is a good way to identify people in the local area.
When there was an attempt a number of years ago to introduce more of a public health agenda for health visiting, we lost some of the ability to make direct contact with families. Nothing can come close to home visits with families on a regular basis. That system allows health visitors to build a relationship with a family and see how they live their lives, and to support them in the best way so that they—particularly the children—can live the lives that they want to live. It also allows us to facilitate access to the GPs and the other services that are located in a GP practice hub. It is an ideal way for health visitors to work.
Would many more health visitors be required in order to carry out that system?
I am not sure whether it would require many more health visitors. Perhaps it would, because in order to make it work the health visitors, particularly those working in cities and areas of high deprivation, need to have smaller case loads.
I have never worked in a rural area but presumably in rural areas the issue is less about numbers and more about spread and time.
Travel time.
Yes—travel time and things like that. I have never had that experience; I worked in Liverpool, as you might be able to tell, and now I work in Glasgow.
In order for health visitors to manage their case loads, to offer home visits—not only to the articulate people who demand them but to the more vulnerable people, as they all have needs—and to be able to get involved with some of the community work with very localised groups so that we can offer services to people on the ground, we need smaller case loads.
I understand the desire to look back at the attached model and say that it might work, but our world has changed and so has the way in which services are provided. We would use the word “aligned”: we have to have the team model working, but I have never agreed with the idea that everyone has to be in the same place with the same filing cabinets and processes.
Given the way in which services are run now and will be run in the future, one could never fit them into a GP practice, but they should absolutely be aligned and should work together to share good practice. E-health and improved technology can enable people to do that.
Some places have done something very different in their community by using a building or hospital that they have turned into something bigger. They have been able to have everybody together because they have had the premises to do that. However, I spoke to the providers in my local area, and they said that they could not fit in anyone else. We need to be careful in talking about how well the previous model worked.
We need to be absolutely clear that teams are working together—obviously, this is not just about health visitors—and we need to share the working and intelligence. That can be achieved without everybody believing that they have to be in the same place. I used to think that that model was right, but I have seen lots of places—not just involving health visitors—where people are good at team working, and that is what we should be promoting.
I agree. In years gone by, we had health visitors working in cupboards in GP services and so on, but we have moved on considerably from that. What I meant is what Theresa Fyffe alluded to—it is a matter of having relationships and hubs, and wherever the hub is, that is where the health visitor should be.
I probably meant that, too. I agree with you about team working.
Health visitors form relationships with many people, and not just GPs. Jayne Sellers or one of her team might phone me about a child from a homeless family who has developed mental problems or a disability. I am based in Possilpark, where there are also a load of GPs and various health visitors, and they will email me about cases that we share.
I was at a child protection case discussion on Friday with a health visitor who is not based in the same building as me but who had been emailing me in preparation for the discussion and for me seeing the child. Thank goodness for that health visitor, who has stuck at her job for years, because the family had about five different social workers attached to it in a period of two or three years. The health visitor was the person who really held the discussion together because she is the one person who has seen the family through a variety of different changes. There was a 35-page chronology that nobody was able to read through in five minutes, but the health visitor had it all in her head.
I agree. Alignment is not a toxic word. We do work as teams, but our practice still has the relationship with our health visitor. She works in the team within the health centre, and that is working absolutely fine. We just need more of her.
The question was whether we need more health visitors, and that is the issue. We are thrilled with the investment in health visiting, but we now have to train those people. It took a long time to get round to it, so they will not appear on the stocks straight away, and we have to get the case loads right.
I return to the point that I made about freeing up people. We have too many bureaucratic processes. Sometimes, people can see that they could do something for vulnerable families but they have to go back through the routes, which loses the moment when they might have worked with the family and been near the point of getting agreement that something would be a good step. By the time they go back, knowing that they can access it, they have lost the moment. People who are working in that kind of world know that. Anything that we can do to reduce bureaucracy and make measures more accessible to them at the time would be a good thing.
We hear about best practice when we are sitting here as a committee, but there will not always be good practice. Recently we visited a project in Edinburgh—I cannot remember its name—and we asked about family nurse partnerships. The project deals with older and younger women and children, and on the scant evidence we had it seemed that there was no integration. There are projects such as family nurse partnerships and there is a lot of resource, but do you agree that the system is sometimes not working to the best effect?
That relates to a point that my colleague Lucy Reynolds made. We end up with too many projects. I have been part of pilots for years and they are important, but we can get too many pilots and not enough clarity about what is working. We need to give things time to work and to produce the efficacy. If we do that, we can make a difference, but we tend to move on to the next thing that people think it is important to do.
I agree with your point, convener. Recently, I went out to visit a team that was not connecting across the area. It was almost like its pilot was more important. That was because it had short-term funding and the people who were involved thought, “If we focus on this, we might get the funding,” rather than looking at providing the whole service in a different way.
I wish that we could get a better way of setting up projects and getting them on to more sustainable funding.
Sometimes, as we have heard in the committee, it is not the new projects that are the problem; the problem is letting go of the old ones. People want to keep the old project, which is not as effective as the new project. There is an inability to discuss funding issues and agree on priorities and on what works.
The two things that have happened in the past five or six years that have most helped me to co-ordinate the care of vulnerable children and families were not things that were introduced for that purpose.
The first thing is secure email. I can email colleagues, health visitors, GPs and consultants in the hospital, and there is now even secure email between us and the council, so I can email social workers and teachers and so on. The other thing is the clinical portal, which is an information technology system. Now, rather than having to write to people at Yorkhill hospital to find out what they are doing, I can look at their information on the portal.
We are always thinking of a project that is going to do this or a project that is going to do that. I am not saying that we should not do projects, as they can be great; I am saying that we should do projects, evaluate them and then try to mainstream the stuff that works well. However, sometimes generic things are happening that we have never thought about evaluating, yet they are the most valuable things that we are doing.
If we were better at looking at our routine data, perhaps we would be able to build up more of an evidence base on some of the things that we have been doing for ages or that we have started doing for another reason—not because they have been mandated through a project that is going on.
That is an important point.
I agree with Dr Reynolds. We are a centralised, citywide service, so we used to have constantly to make phone calls to everybody; secure email has made things considerably easier for us.
You could be playing telephone tennis for weeks, could you not?
Absolutely. You would keep missing people.
Are those things available to—or necessary for—GP practices? Do GP practices need the portal and so on to get information?
It is available but it does not help with everything.
The Govan project is trying to recreate a relationship that existed when I first started in general practice, which was the relationship with the attached social worker in the health centre. That made a massive difference to how we worked. Part of that approach was about building up professional relationships but it was also about someone being available to discuss cases.
The Govan project is trying to recreate that. We have no evidence to say that it works but all the GPs who remember working like that think that it was a much better way of working. It was easier to sort out patients’ issues if that social work attachment was in place.
Richard Simpson and Dennis Robertson want to ask questions, but I am not letting in members before panellists, so Dr Reynolds is first.
We used to have a social work resource worker in our child development centre—we did in each of the centres in Glasgow. The service that those workers provided was never evaluated in any way and eventually, in 2008, the money went from social work. Social work thresholds have just gone up and up, and that service was pulled.
Then the healthier, wealthier children project came into Glasgow. The project is fantastic and I refer to income maximisers all the time. However, when I was sitting listening to the project presentation and the people said, “Look, we have increased the income of these families—particularly when someone has a disability, as we have used the disability living allowance. We have brought in all this money,” part of me was thinking, “That is what the resource worker used to do.”
We lost our resource worker, who used to do what that project does and a lot more. However, healthier, wealthier children was a project, so it was evaluated. I listen to the project people saying, “Oh, isn’t it fantastic?” and it is—I do not want to take anything away from that project—but the resource workers were fantastic too. They used to do all that work, but nobody ever noticed.
As no other panellists want to comment at this stage, Dr Simpson has a question.
I have been sitting here feeling that it is groundhog day. In 1975, Sir John Brotherston did his report on widening health inequalities; in 1980, there was the Black report; in 1998, there was the Acheson report. We have been through this so often. The point about recreating things is important. It keeps happening.
What I find astonishing is the fact that, when we had a situation in which health visitors and social workers were attached, they were the key people managing the children; as a GP, my input was all about the background to the family and the historical situation, because we had experience of that within the practice.
12:30It seems to me that, whatever system we have, we need continuity. Theresa Fyffe mentioned the move to a geographical organisation. When social work moved to a geographical basis, the relationship collapsed because we did not have a named person. Whatever system we have, surely—although the panellists might not agree with this—we need two things. First, we need continuity so that we do not have a different person dealing with the family and cases being opened and closed. That is something that never happens in general practice—a family is often registered with a practice for life, sometimes for generations. In contrast, social workers open and close cases. If health visitors opened and closed cases, that would be really problematic. How do we get the continuity?
Secondly, everyone on the panel is medical, or in a related profession, but the fundamental issue that we are talking about in terms of the integration of health and social care goes beyond just the family and the family’s downstream problems; rather, it is about the upstream problems. What do we do about traffic calming measures, separation of pedestrians and vehicles, child-resistant containers, the installation of smoke alarms, affordable heat and damp houses? I have taken those examples from just one section of the Macintyre report of 2007.
As medically oriented and trained individuals, what input do you have to the upstream aspect of health inequalities? Do you want some input and what are the barriers to that? Do we need it? Are we going to solve those problems without public health being based in local authorities, as it used to be, where it can influence all those things? Are we really aligning health visitors and social workers adequately within the new geographic teams?
I am sorry for rambling on, but I have been round this issue so often in the past 35 or 40 years.
I do not think that health visitors ever close cases in the same way as social workers do. We do a different kind of work. Once a health visitor is allocated, as Lucy Reynolds said, the ideal situation would be for a family to have the same health visitor from before a baby is born. I am thinking of how the family nurse partnership works and how we worked when I started health visiting, when the GP would give us a list of the women who were pregnant and we would make sure that we went out and touched base with them.
Does that still happen?
Not routinely.
So we have to create the family nurse partnership because we have lost that.
I know that the family nurse partnership has had 30 years of evaluation in the United States and is apparently very successful, but there is a little bit of me that has reservations. I applied for a post within the family nurse partnership and I have read quite a lot about the issue because I was very interested in it, but to my mind it mimics what health visiting should be, and to some extent what we used to do.
I agree with Richard Simpson. It is slightly outside my brief, but many decades ago I was a GP in a deprived rural area. We had attached health visitors and social workers, and they were invaluable in helping us to help the most deprived members of the practice population. They were very good.
Putting public health into local authorities has been done in England and it has been an abject failure, with local authorities trousering the budget—or, to use a different term, using the budget for different things—which has led to the public health workforce disappearing at a rate of knots. It has not worked well.
I was working as part of the public health team when we had community health and care partnerships in Glasgow city. That was when the health visiting review was held and our health visitors were being managed by social work managers.
I occasionally prescribe the odd melatonin, laxative or whatever, but I am mostly a very social—not just sociable—paediatrician. I am forever writing letters in support of rehousing and asylum claims and for people who want social work-type support that is not really there.
When social work managers managed health visitors, I felt that such an approach was not successful because the social work managers did not have a background in universalism. Their concept of isolated episodes is partly the reason why our health visiting review was pretty unsuccessful; it went the wrong way, and the direction that it sought to take us in has been reversed.
According to the sure start evaluations, some of the most successful projects have been led by health. I love social workers and I love working with them—and I heard what has been said about Al Aynsley-Green, who is a paediatrician, as a leader—but the fact is that people in general practice or health visiting, for example, understand universalism. Although I welcome certain aspects of integration, I simply point out that getting non-health people to manage universal stuff when they have no experience of it has been unsuccessful in the past.
To return to my earlier point about the difference between attachment and alignment, I note that RONIC—the review of nursing in the community—led to an inordinate break-up of the way in which health visitors worked in some areas. For a start, some areas proceeded with it faster than others. Since the review stopped we have without question come back to the idea that health visitors should work as part of a team, aligned with general practices and others, given the multi-agency world that we are now in. That approach would bring about what has been suggested, because it would allow health visitors to understand better what they see so they could make a difference. When the social worker resource was taken away, the relationship was not seen as being aligned any more; instead, their work became something that existed elsewhere.
That brings me back to my point about integration. If the intention is to bring things together, we need to bring those relationships and ways of working back into alignment. The principal difference, however, is that health is about need, but as far as local authority funding is concerned the issue is sometimes more about the resources that are available. That is a very different view, and we talked about that a lot when we discussed the changeover. At the moment, the health service would say, “We must respond to need, and universal services are core to that.” For other services, that would not necessarily be the case. That is what I mean when I talk about how things should come together. To tell people, “You have to close your cases,” “That person no longer needs you,” or “We don’t have enough resources,” was not a success, so we must find a way to measure the workload, understand need and demand, and find the best approach to take.
Evidence has shown that when health visitors were attached, the resource was found to be elsewhere when it was needed in areas of greater deprivation. It was really hard to say to an area, “Please give us back that resource, because we need it here.” I would never want to go back to that system, because it should be all about having aligned relationships, and about knowing, understanding and being able to measure need and allocate teams accordingly. However, we need a multi-agency approach, because that is the best way of getting a broad understanding of families in certain situations.
I support Theresa Fyffe’s remarks. The inverse care law is absolutely critical, but the fact is that we need to apply the resources. We are very lucky in Scotland in that every patient has access to a GP; that has not been the case in England, and they have faced real problems. However, the problem here is that distribution is equal and is not based on need, so we need to develop a system in which need and resource are aligned. Anne Mullin might want to comment on that, but I think that, with the resources that are given to general practices in deprived areas, even the link workers are just at the edges.
I am obviously speaking as a GP. The deep-end general practices are becoming stretched, partly because of the demographic of the population that we are serving now. Members know about the complexity of the care that is required. The assumption that those complex patients can somehow always be managed in the community with limited resources is not realistic any more. General practice needs more resources—more GPs and more GP time. I do not believe that we can get away from that.
Stewart Mercer’s work has shown the benefits of extra resources. People do not get better because they are given more GP time, but it delays their getting worse and a lot of what we are trying to do is to delay people having to go to hospital constantly and becoming sicker earlier. If we are to do the job that we are supposed to be doing, we need more GPs and more GP time. The job is becoming impossible; I have worked in general practice for 20-odd years, and recently for the first time a district nurse told me that they could not see a patient because they did not have time. That is what is happening at the front line. All that happens when services do not meet service users’ needs is that the problem comes back to the general practice to be sorted out—we are the fallback for just about every other service. The deep-end practices have made it very clear what we need.
Child health inequalities are part of the issue; the GP contract could be more robust around child health. It is great that there is more investment in health visitors—that is very welcome—but it will take a bit of time for them to bed in. The Govan project is trying to rationalise, under severe budget cuts, how we can work better with social work services. We realise that that relationship has been missing for quite a long time and that we could do more around that. For the day job, however, we need more GP time and more GPs. Those things are expensive, but that is the reality.
I agree with everything that has been said about targeting resources at deprived areas and the need to improve universal services. You asked whether, although we might be moving everything up, we are making a difference. I read the evidence from the centre for excellence for looked-after children in Scotland, which points out that there are 16,000 looked-after children in Scotland, and 4,000 in Glasgow alone. For years, I worked in prisons, and most of the people I saw there had been looked after at some stage in their childhood. Their suicide rate was something like 100 times the suicide rate in the general population. People say that we should mind the gradient as well as the gap, but I think that we can identify that group fairly easily, although getting routine data on it is another matter.
There is now a shared agenda around integration, whereby social work and health are meant to work together. Maybe it would be possible to target some resources at that group to try to make a real difference, such as has been achieved in Scandinavian countries, where there is now little difference between the outcomes of looked-after children and the outcomes of children who are not looked after. We need to aim for something like that.
To go back to the initial question about what the new adviser could do, I stick by what I said: you should go by the evidence. However, if you were to ask me what one thing I would do, I would say that we should concentrate on looked-after children and try to improve things for them. That is especially important because we are corporate parents to them, so there is expectation. We should do a lot better by that group than we do.
We are going into the last five or 10 minutes of this evidence session. Given that social work services have been bashed about a wee bit—
No—we love them.
Dennis Robertson is bracing himself. He is a former social worker and has been sitting patiently for about 15 minutes, waiting to ask a question. After he has done so, we will come back to the panellists to tell us one thing each—Dr Gray has given us a useful steer—that they would like to place on the record today. That will be useful in rounding up our discussion. What one thing—or two, three, four or five things—do the witnesses want to put on record today? First, let me bring in Dennis Robertson, former Inverclyde social worker.
12:45
I am glad that it is on the public record that someone loves social workers. I was a social worker for more than 30 years. As the convener said, I started out in Glasgow and Inverclyde, which was a wonderful experience.
I endorse the multi-agency approach, in which an appropriate key worker is identified, and I have a great deal of sympathy with Richard Simpson, who said that we have been round the issue several times. We have indeed—in many ways and forms.
Dr Gray talked about localisation. Do we need to focus more on local solutions for local problems, without pointing the finger and talking about a postcode lottery, which is a dreadful term? Sometimes a local solution is important. We need a framework, but have we moved away from localisation?
That is a good question, but it takes me back to my point about short-term funding. A lot of local projects stem from local activity and people saying, “That’s a good idea, let’s do it,” but many projects do not get funded and mainstreamed in a way that would help people. Localisation is a big part of the integration agenda. It is intended to get us close to communities and to support activity.
The committee heard earlier this year from Professor Marmot, who told us that in Birmingham and, I think, Tower Hamlets—one of those inner city areas—people had adopted his principles. He had initially been sceptical, but he was impressed by how people had delivered and made a difference. Does anyone know about that, in the context of Dennis Robertson’s point about local initiatives?
I would not like to speak about those particular areas, but I will say that although local action will help a number of people, it also lets Governments off the hook. Many of the problems that people face arise from Government policy. Local action helps to mitigate the effects of Government policy.
As I said, we need to improve the lot of all children in Scotland, and that of some children more than others. In lifting everyone up, we lift up the people at the bottom who most desperately need help. They need additional help, but if the approach is universal, as a number of benefits in the benefits system have been, it is much easier for people on the margins to access support, it is much less socially stigmatising for people to receive support and it makes life easier in general.
As we have said, the people who are most deprived need additional help, but we will reach most of those people if we give stuff to all the people. If we focus just on the tiny number of people whom we might call the deserving poor, a number of people whom we might call the undeserving poor will miss out. We should go for a “let’s improve everybody” approach, with a bit extra for some.
An issue with things being local is that when we start talking about localities we start talking about boundaries. I am a specialist, so I have to cover a lot of localities; we cannot have one community paediatrician for Possilpark, another for Springburn and another for Ruchill. I have to cover a large area because I am a specialist. A superspecialist at a children’s hospital will cover an even wider area. If policies are implemented only within a specific locality, what about the people who are just over the border? How do we co-ordinate the local thing here with the local thing there? It makes sense for different things to be done at different levels. It makes sense to do some things locally, but some things must be done at national level so that universalism can be achieved.
Is the multi-agency approach the solution to the problems, regardless of the wider community?
I am going to talk about the Govan project again, although it has not even been funded yet. Our idea is that, if you work in a locality with a cluster of GPs and a reasonably sized population of about 30,000, you can start to determine the needs of that population. You have to do the super-epidemiology stuff, but you also have to do the localised epidemiology. We look at our population needs, what third-sector agencies are in that locality and what specific issues we have in Govan. With a large asylum-seeking population, people’s needs are various, but we need to respond where there are no services attached. That local level links into national policy, and we need to understand where the links are.
In embedding all of that, long-term professional relationships are important if interagency working is to succeed.
If that does not happen, I could find myself asking whether a patient lives in East Dunbartonshire or in Glasgow, and if they are in Glasgow whether they in north-west Glasgow or north-east Glasgow, before I decide who I need to liaise with or what my patient might be entitled to.
As Richard Simpson has said, we have been dealing with the issue since he was a boy.
Surely not that long.
Maybe not quite as long as that.
The committee struggles with many of the issues that have been raised. We would all argue that we should defend health spending and protect it from cuts, but we recognise that delivering on that agenda is not just about funding hospitals. The health service is protected and local government is not, so that is a problem right away when it comes to our ambition to deliver more services in the community. Nevertheless, it has been an interesting discussion.
Do not feel under any particular pressure to respond, but if anyone wants to leave us with one single thought about their top priority—I am looking at Theresa Fyffe and her colleagues—now is your chance. Do not wait until you are on the bus going home thinking, “I wish I’d said that.”
I come back to what I have said a couple of times. It is about evidence, data and evaluation. If we can grapple with that, we might know better what we are trying to achieve and what is working; a point was made about understanding the work that has been done. I saw a television programme that described what people were doing and it sounded great, but do we know whether it was sustained?
I was here for part of the committee’s evidence session on communities working together and what community empowerment looks like. We sometimes forget that power. Lots of things happen in healthcare that happen because of community support by individuals or by groups. If we can harness that, we have a better chance of tackling the problems together, without there being divisions based on who has which bit of the resource.
For me, the overriding thing that would improve the wellbeing of children and tackle inequalities in child wellbeing is a reduction in the stresses on parents, and a reduction in the unequal spread of stresses on parents, because the stresses cluster. Some of that happens at societal level, so a society that is more financially equitable would help, and some of it happens at individual level, so health visitors, GPs and other professionals are key in finding out what those stresses are and in advocating for them to be dealt with. For all the programmes that we bring in, if the parents are under too much stress to actually do them, they will not work.
At the risk of repeating myself more than once, there is a great need for a healthy public policy, and that will have to come from the Government. People who can be helped—through equality in education and in opportunity—need public policy that creates an environment in which choices that will help parents’ health and their children’s health are made easier rather than more difficult, so that the healthy option is not the more difficult one, as it currently is for too many things.
Dr Gray, you have had your say, but would you like to add anything?
I would just combine points that have been made by saying that I also like the emphasis on evidence, data and evaluation, which should be used to improve outcomes.
From a professional point of view, I know that health visitors are well placed to deliver the best outcomes for children. Dr Gray talked about looked-after children. I know anecdotally and from experience of working at the base 75 project for women who are involved in street prostitution that a huge number of women in prostitution have come through the care system. I have also worked with homeless families, and many homeless individuals are ex-prisoners who have been through the care system. That is an area of deprivation that needs to be taken into account.
I would like to say two things. First, GPs need more time. Secondly, we need to imagine things from a child rights perspective, because that is an interesting approach that focuses people’s minds on the impact of policies.
Thank you all for your valuable time and your evidence.
12:56 Meeting continued in private until 13:45.