Health Committee, 18 Apr 2006

Meeting date: Tuesday, April 18, 2006

Official Report 216KB pdf

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Health Inequalities

I welcome everyone to the Health Committee's first meeting after the Easter recess, in particular Harry Burns, the chief medical officer for Scotland, who will discuss with us the report of the Kerr sub-group on health inequalities. The matter has been of some interest to members.

Dr Burns, do you want to make an opening statement or go straight to questions?

It might be helpful if I put the Kerr report into context.

Well, we have had quite a few dealings with the Kerr report; indeed, the man himself has been before the committee. We are particularly interested in the question of health inequalities.

An important issue is how all of this has been constructed. Those who know me know that I can talk about health inequalities till the cows come home. I have been involved with the matter since I worked as a consultant surgeon at Glasgow royal infirmary and found that, because of their socioeconomic position, people from the east end of the city did not make such a good recovery.

In the 20 years since then, we have gone up many blind alleys as far as strategies to correct the problems of health inequalities are concerned. The Kerr report represents the conclusion of a lot of thinking that acknowledges that although we have been doing what we can to change the social and economic situation in deprived communities and have been trying to persuade people to lead healthier lifestyles, an element has been missing, which is the targeting of national health service resources at deprived populations.

The evidence in the Kerr report from south Wales, which was submitted by Dr Julian Tudor Hart, showed clearly that targeting additional resources and using them in specific ways can lead to considerable improvements in life expectancy. The theme of the chapter of the Kerr report that contained that evidence was what the NHS can do to improve health inequalities to complement social and economic improvements. I am happy to take questions on the reasoning behind that.

The paper that has been circulated to the committee refers to people living in the most deprived communities. It says that, of the various studies that have been undertaken,

"Several have shown that for conditions such as hernia, gall bladder disease and joint replacement, members of the most deprived sectors of the population may be more likely to consult with a GP but are less likely to receive surgery."

Will you comment on that, please?

There are often clinical reasons for that. People from the most deprived sectors of the community will often have a wide range of illnesses. They will not just present one condition. They might have chronic bronchitis, angina and so on. Those factors might make people less suitable for surgery. There can be sound clinical reasons.

Let us take angina as an example. A patient from a deprived area might have less expectation of treatment when they go to their GP. They might ask their doctor whether they can have some pills to remedy the condition, whereas someone from a more affluent area will have done much more research and will argue for surgical intervention or whatever. There is evidence to suggest that although angina is more prevalent in deprived areas, patients from those areas will be less likely to be investigated and to have surgical treatment. That is often related to the extent to which patients expect treatment from the health service. That needs to change.

It is possibly also to do with the reduced availability of resources in primary care. There is evidence that consultation times at practices in deprived parts of the west of Scotland are shorter than consultation times in practices in affluent areas. We know that patients from deprived areas will tend to consult their GP with more problems, which means that there will be less time to spend on each one. Patients from deprived areas do not get as much primary care resource as they should. The paper argues that the health service should be pushing for equality of outcome, not equality of access. It suggests that we should increase the availability of health care in deprived areas to create a better outcome for people with greater needs.

On people having less time with their GP, have studies been carried out into why that is the case for some patients?

Professor Graham Watt, professor of general practice in Glasgow, has shown that practices in deprived areas are less likely to have the resources to achieve high-quality measures of general practice. They are less likely to be training practices or to have quality practice awards, because the GPs are running faster to stay still. It comes down to the fact that although we spread resources equally across the population, the need in some areas is greater, so the people who work in those areas are fantastically dedicated but simply have to run faster. That is the single biggest explanation.

I will probe a bit more on the point that Helen Eadie raised. From the report, it seems that the problem with people going on to receive elective surgery arises not in the local practices but after the GP consultation. The report says that although more people in deprived areas are likely to consult a GP for conditions such as hernia, gall bladder disease and joint replacement, they are less likely to receive surgery. Where is that surgery being stopped? It is not being stopped at the GP stage if people are willing to consult the GP. Are they not attending hospital out-patient appointments? Are they attending out-patient appointments but, when they get appointments for surgery, opting not to go and have it? If a condition such as a hernia or gall bladder disease turns into an emergency, a minor, inexpensive procedure can become an expensive process.

The reasons for that are complex and not easily pinned down. Having been a consultant surgeon in the east end of Glasgow and having had a large practice of patients from the most deprived constituencies in Scotland, I can say that it is not a question of clinicians deciding that patients should not get the surgery.

I know that.

Either the patients themselves decide that it is not in their interest or they have other ill health that makes it difficult or unsafe for them to be anaesthetised.

I am aware that such inequality would not be a clinical decision; I was trying to find out at what stage patients decide that they will not go any further. They go to the GP, but are they then not attending out-patient appointments or surgery?

For some conditions, patients are less likely to consult their GP. If they do so, in some instances the GP will tell them that they are unlikely to be accepted for surgery because they are too obese, their angina is really bad or their blood pressure is difficult to control, or they will go to a hospital and have the discussion with the consultant and then decide. It is difficult to unravel all of that.

Is there too much focus on prevention and screening and not enough on ensuring that people complete the medical journeys that they begin?

We must do it all. We must try to prevent ill health to begin with but, once ill health has developed, we must treat it effectively. The literature suggests that the most effective way of preventing such ill health is to have a much more proactive form of primary care in which conditions such as angina and high blood pressure are detected and treated early, and are not allowed to progress to heart failure for example. It becomes difficult to treat some of the other things that happen later on. It is risky to take out the gall bladder of someone who has chronic heart failure, so we should stop it getting to that level.

The Kerr sub-group on health equalities specifically said:

"NHS Scotland should embark on a programme of enhancing primary care capacity".

We all accept that that means that a patient should see not necessarily a GP but the qualified health professional who is most suited to their needs. We all know that early intervention can produce better outcomes and we have recently seen the advent of community health partnerships. How will they be able to provide the service on the ground? I am thinking specifically about reaching out to people in deprived areas who may not choose even to take the first step of visiting their general practitioner, which would lead to some of the other things.

The outreach element is exactly what Dr Tudor Hart provided. He knocked on doors; in a village of 2,000 people, he was able to do that and his wife was his practice assistant. We need to enhance the primary care team. You are right: that does not necessarily mean more GPs, although I suspect that in some of the most deprived areas it will. It might mean more GPs with special interests, for example in alcohol problems. Equally, it could mean more community psychiatric nurses, nurse specialists, physician assistants or counsellors. The critical element is to involve the primary care team in designing the intervention. The last thing that is likely to work is if a health board designs the intervention. I want the practice staff, who know the local population and the local needs, to say which areas are under pressure. Therefore, the resources need to be devolved at least to CHP level and, I would argue, to practice level. That is an issue for remote and rural inequalities.

Recently I visited a practice in an affluent area of Glasgow, where the staff were at pains to point out that the area had two streets of quite deprived people. It is important to recognise that there will be small pockets of deprivation, particularly in remote and rural areas, and that it is the GP who knows where those people are. We have got to involve the GPs. I would not try to tell them how to run their business but I would say—and this is what the new GP contract helps us with—that we want them to know what everyone's blood pressure is, who has high cholesterol and what is being done about it. We want to know the level of untreated ill health that is out there. We want to offer people treatment. That is the kind of proactive approach that we need. If that means knocking on doors, many GPs and other practice staff will be up for that.

Do you foresee CHPs working with local community groups, for example, to highlight the services that they can provide and to give people the opportunity to have better health care?

I am sure that many services, such as those that deal with behavioural change, smoking cessation, alcohol counselling and so on, will be provided in that way. Voluntary organisations will be the appropriate providers of many of those services. It would be great if the CHPs involved them in service delivery.

You used phrases such as "someone from a more affluent area" and "someone from a deprived area". It occurred to me that in many allegedly affluent areas there are pockets of deprivation. There is a danger in taking too broad brush an approach. Obviously, if you are dying you are dying, regardless of which bit of an area you live in. I assume that when you say "someone from a deprived area" what you really mean is people who are suffering from social and health deprivation. When you say "someone from a more affluent area", you really mean that someone who is more affluent has the wherewithal to access services. You talked about remote and rural areas. My concern is that what you are doing will be seen as a massive resource transfer, or at least as intending to carry out such a resource transfer, and that the pockets of deprivation throughout Scotland that are within allegedly affluent areas will continue to miss out. No one would want that to happen.

Towards the end of the paper is a paragraph headed "How does this approach apply in rural areas?" In it, we make the specific point that individuals should be identified by general practices. The Kerr report makes the same point. GPs will know which people are in most need, so we want GPs to design the interventions, regardless of where the people are.

Since the 1990s, much intervention work has been done. As you might agree, a lot of information should be coming from deprived areas, such as the ones I worked in when I was in general practice. We had diabetes clinics, well-woman clinics, well-man clinics and clinics for chronic obstructive airway diseases—which are mentioned in the paper.

A very important point has been raised on the subject of deprivation. Back in the 1990s, deprivation payments to GPs were halved overnight. Do you remember that?

Well—

Perhaps not. As Roseanna Cunningham says, we cannot take a broad-brush approach. Even within a deprived area, practices will work very differently. Do you agree?

Absolutely.

As you say in the paper, the time that a GP spends with each patient is most important. In deprived areas, people will go to their GP with many issues; in more affluent areas, people might know that only one issue can be dealt with at a time. It is very unpleasant for a GP to have to say to somebody, "I am sorry, but I can deal only with the most important problem today. You'll have to make other appointments for the other five problems." GP time with patients is the most important issue, but funds and deprivation are also important issues.

Health visitors and nurses have been working in communities—and I agree that we need more of them—but how will standards in hospitals be maintained when there are fewer hospital beds? You must notice the differences between your time as a surgeon and now. People are now in and out of hospital very quickly, which leads to an added burden on general practices. Patient needs are going unmet because some GPs are being worked to a standstill. In future, how will we cope with the lack of beds and the lack of capacity in the system? How can we ensure that deprivation payments are directed to the people who need them—in deprived areas and in affluent areas?

I will answer the point about deprivation payments first. We are talking not about funding general practice but about funding the broad set of interventions within primary care. The new general medical services contract has done much to change the notion that GPs are paid a global sum plus add-ons, and much to focus attention on what can be improved in practice populations—whether the improvements are made by nurses, physician assistants or GPs. We have to establish a level playing field for health outcomes rather than for inputs to general practice. That will evolve and, in a minute, I will come on to discuss how we have started.

On secondary care, the "Delivering for Health" report, which was the Executive's response to the Kerr report, makes a specific commitment on the management of chronic diseases—that is, on dealing better with long-term conditions.

When I started off my career, the fifth floor of the Glasgow royal infirmary was the vascular floor and it was full of diabetics and of people with end-stage vascular disease. Since then, the situation has changed dramatically, because better care early in their conditions means that people do not now have to come in to have legs amputated. Similarly, there has been a fall of about 40 per cent in acute myocardial infarction mortality in Scotland since the 1990s. There have been huge changes in the prevalence of certain illnesses in communities. We are gradually moving away from having to deal with acute conditions to having to deal with chronic conditions, which need to be managed in primary care. I agree absolutely that poor social conditions lead to an increased demand for hospital beds, but we do not quite understand the scale of that.

If I am allowed to, I will share an anecdote. In the early 1990s, I went over to visit Kaiser Permanente in California to see how it operated. At the time, Glasgow had 4,000 acute beds. I took Kaiser Permanente's bed occupancy rates and calculated, on an age-specific basis, how many beds Glasgow would need if it had the same rates. With those occupancy rates, Glasgow would have needed only 1,400 beds. The difference was that when people have heart surgery in California, they go back to a $2 million house in Palo Alto, rather than to a fourth-floor tenement flat in Dennistoun or Shettleston.

There is an increased demand for health care; the challenge is to reorient care. We will get a level playing field in life expectancy only if we get in early and change the health experience of the most deprived elements of our community. That must be about preventive medicine, as applied in primary care. That is where we must focus our energies, which will lead to a reduction in the demand for acute beds. We have talked about that often.

There has been screening for osteoporosis in Glasgow for some considerable time, with a high rate of success. Nevertheless, orthopaedic waiting lists have been extended time and again, despite extra capacity being put in at the Golden Jubilee hospital and other places. We are trying to prevent hip fractures, which perhaps takes a long time. Do we need to hang in there for a long time to see the benefits of early screening?

Orthopaedic waiting lists have been reduced throughout Scotland. For patients to get into the osteoporosis screening programme, they have to have had a fracture or have shown evidence of osteoporosis. We could bring forward the point at which we screen. As Dr Turner knows, there are issues about the ethics of screening too early and screening with a low expectation of finding a result, in case we find false positives. Screening is a difficult area, but I think that we will see the benefits of screening for osteoporosis. As science and technology improve, it might be possible—and safe—to bring forward the point at which we screen to considerable benefit. We know how to avoid osteoporosis by undertaking impact-type exercise and increasing calcium intake. Perhaps we need to do more on that side.

A crucial statement in the paper is that there is a need to strengthen individuals' capacity to take responsibility for their own health. Until we do that, it will be difficult to solve or prevent problems.

A couple of things concern me. In much of the work that is needed, we are talking about primary care teams rather than about general practitioners. I know that we lack nurses and allied health professionals. What is the timescale for addressing current needs?

My second question follows Roseanna Cunningham's question about pockets of deprivation. I am from the Aberdeen area. As you know, Grampian has been top-sliced—we get 9 per cent of the funding for 10 per cent of the population, under the Arbuthnott formula. There is a concern that Grampian NHS Board is running to stand still. There are pockets of serious deprivation in Aberdeen and the rural parts of Aberdeenshire, but if resources are to be refocused on deprived areas, will that affect those of us in the north-east even more?

The matter of increasing individuals' capacity to take responsibility for their own health is in the report for a reason. There is evidence to suggest that psychological resilience and an internal sense of control over one's health—being able to say, "I'm responsible for my health, not them out there"—have physical consequences that lead to better health. That is being investigated by the Glasgow Centre for Population Health. Aspiration, control, confidence and so on appear to bring beneficial physical consequences.

On rurality, I return to the point that individual general practices will eventually be funded to deal with pockets of deprivation—clusters of houses, or whatever—that they encounter. I do not envisage a removal of resource from one area to be given to another area, but I would argue for differential investment. We need what is, in health service terms, defined as capacity to benefit from an intervention. There is no doubt that need is greater in deprived areas; therefore, we should aim to fund services in those areas to ensure that identified need is met. That means that, over the years, more investment should go to the deprived areas. That should have been happening since 1948.

I asked a second question, about the capacity of the workforce.

I am sorry. As we speak, the nursing schools are beginning to develop extended roles: nurse endoscopists are being trained; radiographers are being trained to take over from radiologists in X-ray departments; and physician assistants are being developed who will do many of the diagnostic tasks and so on that doctors do. The workforce is being diversified in imaginative ways. I agree absolutely that we need to be more imaginative, but that is not going to happen until the health service is challenged to provide a different set of skills. We will keep on doing what we have always done until we can say, "Look, we need different outcomes from the health service, so we need to develop a different kind of workforce." That is happening, however, and the pace will increase as different challenges are posed.

You may have addressed some of the issues that I wanted to ask about.

We have a problem with the level playing field, although the level playing field may be an issue for us, as politicians, rather than for someone in the CMO's position. The level playing field results in people having less time with their doctors, being less likely to see consultants, being more likely to die younger, being more likely to be seen in a single practice that is already over-burdened, and being more likely to be seen by a younger doctor who has never been in a deprived community in his life until he is parachuted in there. According to the report, the level playing field also results in the gap between the rich and the poor growing rather than shrinking. What are we doing about those fundamental problems? How will we challenge the view that providing equal access to a GP actually kills people and that the Arbuthnott formula is a complete disgrace in terms of tackling the problems at that level? Those questions are fundamental to delivery.

Those are the principles that we have adopted in the report. If we are to tackle the increased prevalence of disease in deprived communities, we must match that increased prevalence with an increased number of GPs. From my experience of GPs in north and east Glasgow and south-west Glasgow, I know that some of the finest, most committed and hard-working GPs that you could ever meet are there; they are just running fast to try to cope with the amount of ill health that they have to deal with.

The aim this year is to fund enhanced services in five community health partnerships throughout Scotland—two in Glasgow and one each in Edinburgh, Lanarkshire and Dundee—to the tune of an extra £1 million each, to ensure that they provide increased time to see patients and to let them develop services that they think are appropriate. That may not be enough funding, so we will need to keep an eye on the situation. As far as I know, we are the only country in the world that has attempted to tackle the issue in that way. We have learned from a small practice in south Wales and we think that our proposals are the way to go. We will try to learn as we build up the system. Next year and the year after that, more funding will be available, which will be targeted at developing general practice and primary care up to the level that is required to deal with the issues that Duncan McNeil raises.

Evidence suggests that even if we ensure that the time that is available per condition to patients in deprived areas is the same as the time that is available to patients in affluent areas, the gap in life expectancy will still not be completely closed. The evidence is that about 30 to 50 per cent of the gap in life expectancy probably results from reduced access to care and that the rest probably results from social, economic and behavioural problems. We need to tackle both aspects. For the past 20 to 30 years, we have concentrated on changes to housing and so on, but those changes have not brought about the expected benefits. Therefore, we must ensure that the NHS tackles the issue.

An analogy that I use is that, in the 1950s, we knew that there were two ways to deal with tuberculosis: one was to reduce overcrowding in housing and the other was to treat tuberculosis with streptomycin. No one would have suggested doing only one or the other—we had to do both. We need to continue to tackle the social and economic dimensions while expanding primary care and establishing better management of chronic conditions and better preventive care. That is what the report says.

How can we ensure that we get a better Arbuthnott settlement that addresses the problems? Working back from evidence that the committee has taken about the financing of the health service, it is difficult for us to see where the money actually goes.

You are not the only ones.

Not only was there a small amount of money involved, but it was not getting to the people who are not in doctors surgeries. How are we going to increase the number of GPs and shift them from affluent areas to poorer areas? What is the timeframe for that?

As you know, the Arbuthnott formula is being reviewed. In evidence to the review committee, I explained the notion of anticipatory care and my belief that the evidence points overwhelmingly to a need for an expansion in primary care. We will have to wait to see what shift of moneys will result. We need to add money until we reach the point at which there is a level playing field for primary care in deprived areas. I do not know when that point will be reached, but we need to be committed to reaching it.

When can we expect the results of the review?

I do not know. My sense is that my arguments gave the group cause to think, which has perhaps delayed the results of the review, although that might be no bad thing.

On attracting staff, there can surely be few things more inspiring to committed health care staff than helping the people who are most in need. If we give folk the opportunity to exercise their skills in deprived areas without running them ragged, they will take it. After all, as I have said, some of the most committed and able GPs whom I know work in Glasgow's east end. They want to work there because doing so gives them the best opportunity to exercise their skills. I do not think that we will find it difficult to establish primary care services because people find the work very exciting. I am aware of no other country in the world that has deliberately narrowed health inequalities through systematic investment in health care.

No one is questioning your commitment, but you have asked us to trust you and the review group that more money will be made available, and you have suggested that we will get more GPs into deprived areas by appealing to their better nature. However, the GPs are not in those places; in fact, they have not been there for the past 20 years. They are simply not venturing outside the local practices in the comfortable areas where they were born and brought up.

I know that more money will be made available this year. Five CHPs will receive £5 million to get the approach going and to see how it works.

We can attract GPs in many ways; for example, salaried GPs are now quite common and are being used by quite a few health boards. Indeed, I know of a homeless persons practice in Glasgow that is run by salaried GPs. Instead of wanting to run small businesses—which is what most general practices are—those people just want to work for a salary.

CHPs have many tools at their disposal to establish such an approach. If it does not work, we will review the plans; however, at this stage, I have no reason to doubt that it will work.

Just to reiterate that the matter is not confined to certain areas, I point out that a homeless persons practice in Perth is run by salaried GPs.

For clarification, did Dr Burns say that £5 million would be available for all CHPs in Scotland?

I think that he said that £5 million would be given to each CHP.

In the first wave, £5 million will be available to five CHPs. We do not know whether that will be enough; indeed, it might be too much. We shall see. It is simply a ranging shot.

You have made it clear that you are talking about new investment rather than the transfer of existing resources—although I am sure that that debate has already taken place.

You are absolutely right to say that 70 per cent of health inequalities problems are socioeconomic in nature. However, that highlights the fact that investment in the NHS is only part of the solution. One question that the committee has discussed is how local authorities that represent deprived areas are funded. After all, if we are talking about joined-up government, one supposes that there have been discussions about how we can ensure that the local authorities that represent deprived areas are not discriminated against. For example, services in very deprived communities in Glasgow and Dundee are under real pressure. Are ministers with different portfolios discussing how local government financing can join up with plans to ensure that resources get to the most deprived communities? If those discussions are not taking place, we can complete only part of the jigsaw.

At the coalface, Glasgow, Dundee and the Lothians have developed combined community health and social care partnership models. The leaders of some of those CHPs have come from local government, and attempts are being made to run local government social work, care and health budgets not as a single pool—which would raise governance issues—but in parallel, and under the control of the community health and social care partnerships.

Interesting models are emerging that will seek to harmonise these important services and to remove the boundaries between them. As I said, we are moving into new territory, where we will have to develop new ways of handling budgets. It would not be appropriate for me to talk about local government funding, but as far as I can see, there is tremendous good will on the part of a number of local authorities that are dealing with highly deprived areas and are trying to harmonise and pull together services.

I suppose that the point that I am making is that the same arguments that you, as chief medical officer, are making about how funding should be distributed in the health service could equally be applied to local government. Funding needs to be allocated in areas that are currently discriminated against because of the funding formula and the council-tax base.

I am not sure that the chief medical officer can answer questions about local government funding.

As chief medical officer, his role is, I presume, to tackle public health problems.

With the five leading CHPs—the first wave of CHPs—we are trying to make more explicit what services are available through broad primary and social care services. We shall learn from that, and that learning will be communicated widely. I hope that that will influence many decisions in many quarters. There are crucial things that we can learn from that experience.

I have a question that arises from the phrase that you used in connection with prevention and early intervention. You said that we need to get in early on—I think most members of the committee would agree—but I would like to explore further the question of how to target services. I have had a discussion with representatives of the Royal College of Paediatrics and Child Health, who pointed out forcefully that the biggest single indicator of future health problems is birth weight. They feel that birth weight is simply not included in the equation as a red flag. If you do not agree with that, will you comment? If you do agree, are we doing anything to begin the monitoring that might be needed at the earliest stage? One might argue that monitoring should go back to a few months earlier than birth, but birth weight as an absolute factual indicator cannot be contradicted.

I am not sure that I agree with the Royal College of Paediatrics and Child Health that birth weight is the biggest single indicator, although it is the biggest single indicator that a paediatrician has to deal with. I argue—as would others, such as respiratory physicians—that the biggest single indicator of future health is whether or not a person smokes, but both points of view are equally valid. There is no question but that birth weight has an influence on the risk of problems such as hypertension and diabetes 40 or 50 years down the track, so rather than just monitoring birth weight, we should be trying to deal with the problems. We know, for example, that maternal smoking is powerful in reducing a child's birth weight through its causing problems with placental nutrition, so we should be doing something to reduce the number of low-weight births in Scotland.

We have started work on identifying risk. If we are going to tell primary care teams that there is a swathe of people out there who never come near them because they are negative about their health or their lives, or because they ignore their symptoms—

Because they are Scottish.

Exactly. How can we advise primary care teams to deal with that? We have started work with our statistics colleagues on developing risk scoring systems that will allow GPs to go first to the groups of patients who are most at risk.

I am asking whether we should start the process as early as birth. It is one thing to intervene at the point at which an adult has already begun to smoke and drink too much, in which case they will already be exhibiting a lot of the problems, but it is another matter to enter the equation at a much earlier stage to try to head off some of those problems.

There is an interesting choice. If we really want to influence the lung-cancer figures, adult smokers rather than teenage smokers must be targeted because adult smokers will get lung cancer in the next three to five years. That risk might be reduced if they were to stop smoking immediately. Teenage smokers are tomorrow's problem—they will get lung cancer 40 years down the line—so both must be targeted. We must worry about babies with low birth weights and we must intervene, but we must also deal with adults who are in danger of dying in the next year or two.

Scotland's infant mortality statistics are among the lowest in Europe. The mortality rate of boys and girls up to the age of 15 and the mortality rate of adults over the age of 75 are lower than the European averages, but the mortality rates of working-age men and women are the highest in western Europe. We must deal with that age group if we want to change the figures within the next generation, but we must not ignore people at the age extremes. Improvement of the health of babies before and shortly after birth will pay off in future generations, but we must change the attitudes of working men and women to their health if we want results soon.

A resource issue enters the equation. How should resources be allocated to different age groups as well as to geographical areas? The equation becomes very complex.

It does, but it is possible to do a calculation because we can calculate the improvement in life expectancy from a range of interventions per thousand pounds that are spent.

Are we doing such calculations?

In some respects we are. Two elements are involved. First, I encourage health boards and CHPs to take on board the evidence and to have a public debate on it. That would mean disinvestment in some areas of low health gain. Secondly, we need more information—we need the information that the pilot studies will offer us.

Will you clarify what you mean by the phrase,

"disinvestment in some areas of low health gain"?

To which areas are you referring?

The National Institute for Health and Clinical Excellence has said that the cost effectiveness of some drugs is extremely high, while the benefits of some drugs are not great. There must be a public debate on resources in the future—I hope that there will be. As more and more effective work can be done, there will need to be a debate on how much of the national cake goes into health.

Are you talking about rationing?

I am talking about prioritisation.

That sounds like rationing.

There is rationing now—indeed, it has just been described. Having a level playing field militates against unhealthy people, and large numbers of unhealthy people consequently die. Perhaps you could give an estimate of the numbers that are involved so that we can put things in perspective.

Identification of who is who is crucial to all of us. Information technology can help. Perhaps we can be told when we can look forward to an update on what is being done and whether IT and the gathering of records can be rolled out in deprived areas rather than in other areas.

On risk assessment, you will be more aware than I am that the midspan project underestimated by 48 per cent the incidence of heart disease among manual employees. There are other figures. General practitioners' surgeries are effectively managing people, but hospitals deal with a large number of people who are missed—I am talking about five times as many people. How can we use IT to focus on the problem? That is a challenge for politicians, who need to recognise that money must go where needs are greatest.

Our information systems in Scotland are extremely good for that purpose. We have linked data—each patient's record is linked electronically going back to the early 1980s. We can use those data to target individuals who have been in hospital with heart disease and whose GPs are sitting with information on them. GPs can look at their practice population and say, "These are the individuals with whom I need to deal first."

As for risk, the midspan study did not show that we underestimate the prevalence of heart disease; rather, it showed that using conventional risk-assessment exercises—which are based on an American population in Massachusetts and are used all over the world—comes back to what we said about Kaiser Permanente, which is that the social mix is completely different. The study showed that, for a given level of cholesterol or blood pressure, the more socially and economically deprived people have a higher risk of having a heart attack than do people on whom the risk-scoring system is based, so we must develop our own Scotland-based risk-scoring system to take account of that. That is being done now. We have the evidence and we are well on the way to developing a system that will target the people in Duncan McNeil's constituency who are most at risk.

I return to the point that we need patients to be on side. We want primary care to be proactive, but we will not force people to do something that they do not want to do because that would be unethical. However, we want to make it explicit to people that we can make a dramatic difference.

People always talk about Finland, which gets on my wick. They say that Finland has made dramatic changes to its heart-disease mortality since the 1970s, but the fall in heart disease mortality there since the 1970s is identical to that in Scotland, although we do not get credit for that. The two curves are identical. I argue that some of that fall is a result of reducing the prevalence of smoking here. We take more exercise and many of our health behaviours are improving and we do not give ourselves enough credit for that. Much of the reduction in the heart-disease mortality rate has been because the health service has started—albeit that it has been in an ill co-ordinated fashion—to deal effectively with the risk.

The health inequalities paper says that we should co-ordinate activity and systematically offer people the opportunity to change their life expectancy so that we can see how far we can go in reducing health inequalities, and that we should ensure that the health service, local authorities and central Government are doing what they can. They are all trying to do things but—for goodness' sake—we must ensure that the health service is up there acting in a co-ordinated fashion.

That is probably a useful note on which to end. I suspect that we will continue to have a conversation with you.

I will be happy to do that.

We will consider public health for our work programme, so we may return to you on several issues. Thank you for coming along.

Meeting suspended.

On resuming—