Health and Sport Committee

Meeting date: Tuesday, January 22, 2013

Official Report 519KB pdf

---

Health Inequalities

Good morning and welcome to the second meeting in 2013 of the Health and Sport Committee. I remind those present to switch off mobile phones, BlackBerrys and other wireless devices as they can interfere with the sound system.

The first item on our agenda is evidence from the Scottish Government to begin our scoping exercise ahead of our inquiry into health inequalities. I give a warm welcome to Derek Feeley, director general of health and social care, and Sir Harry Burns, chief medical officer, Scottish Government, and I invite them to make opening remarks. I assume that you have agreed who will proceed first.

I will start, convener. As we go through the evidence session, you will probably find that I will defer to Harry Burns on this subject more than I would on virtually any other. When you have someone with his expertise sitting alongside you, it is often best to bow to that.

We welcome the committee’s interest in this issue, which is one of the most significant that we face. The recent Audit Scotland report on health inequalities in Scotland started by stating:

“Tackling health inequalities is challenging.”

That is an understatement. The problem is probably the most complex that we face and there is no simple solution.

When Harry Burns and I went to the Public Audit Committee to give evidence on the Audit Scotland report, we did two things. First, we welcomed the spotlight that Audit Scotland was shining on the issue. Secondly, we were keen to make the point that, although the Auditor General for Scotland’s report and its analysis of the challenge were helpful, we believed that its recommendations were too narrowly drawn and that a broader response was required.

There have been numerous reviews of the evidence on what policies and interventions should be pursued to reduce health inequalities, the best summary of which is in “Inequalities in health in Scotland: what are they and what can we do about them?”, which was written in 2007 by Sally Macintyre from the University of Glasgow to inform the Scottish Government’s task force on health inequalities. I will leave a copy of it for the clerks.

Although the paper was published in 2007, many of its recommendations remain valid. They were reinforced by a recent World Health Organization report that looked at the social determinants of health and made three broad recommendations: measure and understand the problem, improve people’s daily living conditions and tackle the inequitable distribution of money, power and resources. Scotland is well placed on the first of those recommendations. We have a range of indicators with which to monitor progress on reducing health inequalities, which we publish annually. We published the latest suite in October 2012.

There is no doubt that health services must play an important role in tackling health inequalities, which is why the work that we have done on some of the big public health challenges—such as the ban on smoking in public places and the work that we are trying to do on alcohol—is really important. Initiatives such as keep well, our targeted smoking cessation services and the new detect cancer early programme are all important contributions to tackling the problem. The conclusion that Harry Burns and I have reached—he will speak for himself in a moment—is that those measures are all necessary but unlikely to be sufficient. On its own, the national health service cannot tackle the range of daily living conditions that the WHO talks about or the broader social inequities.

To try to recognise the breadth of the challenge, we have been working with the Convention of Scottish Local Authorities to try to enhance the contribution that community planning can make. We are about to start a significant piece of collaborative work around the early years, which will go right across the public services and is aimed at reducing infant mortality and improving attachment and readiness to learn. That is an important piece of work that has the potential to make a big contribution in the health inequalities area.

As the committee will know, we recently reconstituted the ministerial task force on health inequalities. It has had one meeting and it will meet again in early February. It plans to publish a report in the summer.

I hand over to Harry Burns to add anything that he wishes to add.

It is very important not to see inequalities in health as an isolated phenomenon. If we look at the map of Scotland and shade in the areas that have the worst inequalities in health, we might be looking at the areas with the worst crime rates, the poorest educational attainment rates, the poorest environmental conditions and so on. Inequalities in health are just a manifestation of inequality across the whole of society. To target inequalities in health without trying to understand what the drivers are for adverse outcomes across all those domains is to miss the point.

The same kind of things that cause poor educational attainment in children cause an increased propensity to offend and an increased propensity to addictive behaviour in later life, and ultimately they lead to failure in the jobs market and increased poverty. In that way, the cycle of intergenerational failure begins again. Twenty-five years of interest on my part, starting as a surgeon in the east end of Glasgow, led me to the conclusion that the basic problem lies in the early years. That is not the only explanation by any means, but we will not fix the problem without changing the conditions in which very young children are nurtured and grow.

All the evidence shows that adverse and chaotic environments in childhood lead to a number of problems later in life. Children who experience adverse environments face a whole range of biological consequences that lead on to behavioural consequences. Children who experience adverse events in early life are far more likely to have mental health problems and are far less likely to succeed at school. That creates a generational cycle of failure in a number of domains of living.

There are things that we can do, not just for children but later on in life, that can ameliorate the problems of early life, but unless we break the intergenerational cycle by radically changing conditions of nurture, attachment and support for babies and their families, we will not be as effective as we can be. That is why we have started off with the major effort in the early years collaborative.

There is a range of other things that we can do. As Derek Feeley said, we have started work with COSLA and local authorities on trying to change life in ways that reduce offending and reoffending and improve educational attainment. There are active labour market programmes that are not just aimed at getting young people out of unemployment but are actively concerned with enhancing their skills for living and participating more effectively in the social environment. There are also interventions that are aimed at supporting the elderly to be independent. All those things will help to reduce both inequalities in health and other types of inequality that we see in society.

It would be a mistake for any part of society to think that inequalities in health are just an issue for the health service. They are an issue for the whole of society, just as inequalities in relation to offending, work and so on are issues for the whole of society. Unless we understand that, we will carry on experiencing problems.

The graph that shows how inequalities in health have been widening uses life expectancy as a measure. We have looked at trends in life expectancy in 16 western European countries going back 160 years. For most of that time, Scotland had pretty much the average life expectancy in western Europe. It has only fallen behind in the past 40 or 50 years. Scotland has fallen behind in that period because the gap between rich and poor has widened. Affluent people in Scotland have a life expectancy that is better than the western European average, but the gap in life expectancy between the extremes of rich and poor in our society is 14 or 15 years. If poor people’s life expectancy had improved at the same rate as it did until the 1950s or 1960s, our average life expectancy would be what it was for most of the past 150 years—the western European average or slightly better than that.

There is nothing intrinsically unhealthy about Scotland or the Scots. What has happened in the past 40 or 50 years is that a large part of our population has failed to improve its health at the same rate as the more affluent in the population have. Understanding that is the key to doing something about it.

Good morning, panel. What you describe is poverty, and most informed people accept that poverty and health inequality are bedfellows—they go hand in glove with each other. Given the prospect that the income of the working poor and the non-working poor will be cut soon, what planning is being done? What is the reaction of the Government in Scotland to that prospect?

It would be a mistake to assume that poverty is the cause. I bet that, if we went back a generation or two, we would find that the family of just about everyone in this room was very poor—that was certainly the case for my grandfather. He was a miner in west Fife and, as he had bad lung disease, he did not work much. However, from very poor communities, people emerge and succeed. What allows some people to succeed when many people fail? That question is why we are focused on the early years.

The first time that I met a well-known and very affluent Scot—I will not name him—who emerged from humble beginnings, built up a big business empire and is now actively engaged in philanthropy, I asked him what made him succeed when all his friends probably did not. He instantly said, “I had a really good family.” The notion of family support and consistent parenting that allows young people to develop a sense of being in control of their lives and allows them to make choices—not to get involved in difficult behaviour but to succeed at school and see that as a way of emerging—is the key to all this.

Poverty is a consequence of much of what we are discussing, and we must tackle it. It is not for me to come up with the economic solutions to poverty. However, if we get young people attaining at school and involved in successful activity in the jobs market, we will ultimately deal with poverty and begin to break the cycle. However, the key first and foremost is the early years.

I appreciate your point and I have experience of the issue from where I was born and raised. However, my worry relates to what we know is about to happen. We know, without doubt, that the working poor will be affected. The interventions that you wish to make for the children you talk about need to be resourced. At the same time as there will be more clientele—if I can use that word—we will see the resources that are available to the Government to tackle the issue being cut. Are we in a position to mitigate the situation or are we—to be frank—kidding ourselves on? Can we square the circle with resource? Given the cuts in income that are about to be made, the impact on ordinary people will be dramatic and I can only see things deteriorating and more families being pushed below the poverty line. Therefore, more intervention will be needed.

10:00

I think that the first thing that you are looking for is an assurance that we are building some of what you are talking about into our planning. I can give you that assurance. The task force on health inequalities will have regard to welfare reform and the broader economic situation.

Harry Burns made an important point. It is easy to get into a slough of despair as we ask ourselves how we can deal with the issue. We do not have a choice; we must tackle health inequalities. We must do the best that we can with the resources that we have.

There is a cycle that we need to break into and I agree with Harry Burns that the early years are the right place to try to do that. Much of what we are trying to do through the early years collaborative is not hugely expensive. It is about doing the evidence-based things reliably well and bringing improvement science to the will and the enthusiasm that are out there in the early years community. The environment in which we are trying to make a difference is very tough indeed, but that does not mean that we can just take a step back and not try.

We have very deprived areas and very wealthy areas, and the differential between the two is massive. If we could concentrate on one area and leave everything else alone, that would be fine, but my concern is for people who are elsewhere in the framework that I am trying to describe. If we exclusively target the neediest areas, is it likely that people in neighbouring communities who are in a slightly better position will be adversely affected, so that the tables are turned in the communities? I know well and can take you to areas where the community is in dire need but just up the road there is a slightly better area, where people are just managing. I suppose that I am asking about universality. Is there a danger that we can overtarget and create problems in areas that are performing relatively well, compared with the poorest areas?

The answer to that is yes. Statistically, there is no question but that the best way to deal with the problem is by levelling up. We classically describe five quintiles in the population, based on socioeconomic classifications and so on. The aim is not to take the best and the worst and make them look the same, because people in other areas would suffer significantly; the aim is to level up. That is what will bring the overall picture of Scotland’s health back in line with where it should be.

Families in difficulty need support, regardless of where they live. The aim of the early years collaborative, plus all the other interventions that we will bring on stream in time, is to help people in difficulty, irrespective of their postcode.

You referred in your introductory remarks to the response of Governments and the Parliament over time, and health inequalities have always been a top priority. What has gone wrong and why are we in the current position? Why have we not identified the problems? We have introduced policy and monitored it, and have had task forces. Why have we not delivered better?

It is quite difficult to make an assumption about what would have happened had successive Governments not done what they did. If they had not done that, would we be in a significantly worse position than we are in today? There are signs that some of the things that a range of Governments have done have made a difference. From the big public health measures through to the targeted things that the NHS has been doing, there have been successes along the way. However, the problem is huge.

Harry Burns might come back to this, but I think that one of the things that we must do and that we ask the committee to help us with is to make some of what has been done stick for the long term. If we could get to a position whereby the whole of Scottish civic society had a clear idea about what we will try to do about health inequalities and we committed to sticking with those things for the long term, that would make the step change that we need to make.

The fundamental problem is, as Derek Feeley said, the fact that we have not stuck at it. We have tended to introduce interventions with three years’ worth of funding and to implement them across too small an area, which means that they will not get a big enough change and enough people to be able to demonstrate a statistically significant improvement. At the end of the three years, somebody from the local university comes along and says that the intervention has not made any difference, so we stop it.

The keep well project targeted people on the basis of their postcodes and was run around general practitioner practices. It is only now, after six or seven years of the project running, that some health boards are coming to me to say, “Hey, wait a minute, we’re beginning to see some differences here.” The critical thing about areas that are beginning to report those differences is that they have gone beyond the bounds of the original project. They have said, “Well, instead of just treating people with signs of heart-disease risk, why don’t we help them with advice on their social problems? Why don’t we help change their local environment? Why don’t we do a whole range of other things to connect them more successfully with society? We’ll organise things like social events for elderly people who feel isolated.” Suddenly, by doing a whole range of things, they are beginning to see differences.

As Derek Feeley said, the problem is that we have not stuck at things for long enough and we have not done them on a big enough scale. The changes that come in from the early years task force must be done at scale and we have to stick at it until we see things happening. We should see things happening quite quickly.

This has been the Government’s top priority for the past six years and there has been monitoring. There has also been the failure of local government and health to work effectively. The need for early intervention with children has been recognised for some considerable time. What was the health department’s response to the Christie commission when it reported? What actions has the health department taken in respect of that in, say, the past couple of years?

I will come back to your point about the Christie commission, if that is okay, because I just want to go back a step. Health was already doing a lot of work around targeted and general prevention even before Christie. What we have tried to do with the Christie report through things such as the change funds is to raise our game on prevention.

As I said in response to your earlier question, this area is not completely without success. We have been making progress in some areas. Sir Harry Burns mentioned the keep well programme; according to the most recent statistics, the improvement in cardiovascular outcomes in the most deprived areas has been better than that in the richest. To my knowledge, that is the first time that that has happened. There is not a complete absence of success in this area.

However, as Harry Burns has pointed out, it has taken us 50 years to get to this position and I am not sure that it is realistic to expect 50 years of decline to be turned around rapidly in a relatively short time. It will take us a long time to recover, and getting us to that better position will require a sustained cross-government and cross-civic society response.

We have known that for some time now. Who put the light on here?

I presume that, when you make something your top priority, you discuss the possibilities and risks involved, the objectives that can be achieved and how everything will be measured. This morning, you have conceded that, on your own measurements, the approach over that time has failed. Now we have another task force coming up. What is going to radically change, how are we going to push on and how are you going to make this a genuinely top priority for the Government?

I dispute the fact that we have known this for some time. When I started looking at this issue, the answer was to get people to stop smoking. However, we then discovered that Scottish smokers actually figure quite low in the European league tables. The answer, then, was to focus on diet, which might or might not be the issue. The fall in cardiovascular death rates in Finland, where diets were radically changed, is identical to the fall in cardiovascular death rates in Scotland, where the diet has not been changed.

The issue is much more complex than you think, and the whole story has been bedevilled by people who knew the answer. It is much more complicated than anyone ever assumed. Given the number of European conferences I get invited to, someone obviously thinks that I know something about this, but I do not know whether we are at the end-point of knowing the answer. In just the past few months, a whole range of scientific publications has suggested that an even more complicated layer of causation underpins all this. We are not there yet, but we know that, if we make these early years interventions at scale and in a consistent way, we will begin to make a significant difference in the health and wellbeing of the upcoming generation.

My question, however, is whether civic society has the appetite to adopt the kind of evidence-based interventions that prevent young people from going off the rails and ending up in jail or that deal with them when they come out. I recently spoke to an MSP who, on a recent visit to Barlinnie, was told that people leaving the jail were given three nights’ accommodation in a hostel for the homeless and then were on their own. Do we seriously think that that will help those people get back into society? We are just not joined up—and that is an issue not just for the health department but for everyone. The issue is much more complicated than people think and will continue to get more complicated the more we get into it.

We on this committee and indeed other committees understand that and I hope that we will take up some of those themes. However, I do not know whether that answers my question. We spent a lot of time and put a lot of focus first on smoking and then on alcohol, but it appears that our interventions in that respect will not be the significant ones. However, the issue of health inequalities has not had the same exposure and the local government outcome agreement strategy has not moved the issue on. If you are to move on and get the committee and others behind you, there needs to be a recognition that up to now policy and delivery have failed. Why is there such a reluctance to say that?

When we published “Equally Well” in 2008, I did not hear anyone saying that that was the wrong policy.

No. That is the problem.

I did not hear anyone saying that in the Parliament, either. I heard no one saying that it was the wrong policy. “Equally Well” contains around 78 recommendations, and we are delivering reasonably well on most of them.

10:15

The message that we are getting from the figures is that we are not achieving our objective. Our top objective was to reduce health inequalities. What was the response to the Christie report when it came out? What actions did the health department take in response to that report?

The Christie report talks about prevention in the broadest terms, so we have been upping our game in relation to prevention, working in collaboration with our local authority partners. That is why we have change funds for older people and so on. We have been doing a raft of things. The stuff that you have seen most recently in the GP contract about anticipatory care is directly—

If the issue of early years is at the heart of the matter, why are we only now getting to it?

Harry Burns is desperate to say something.

I have a couple of points. First, we had an input into the Christie commission’s recommendations. The need to focus on preventative spend in part came from the recognition that a lot of health service spend has been on screening, health promotion and so on.

Secondly, I dispute the assertion that previous things failed. If you do not see a change, either a change has not occurred or you have not collected enough data to show that there is a change. I can take you around places that have participated in the equally well process and where lives have been transformed. The problem is that we do not do things at scale. We take things that have a good evidence base and do them at a small scale, then we say, “Oh, this hasn’t worked, so we’d better throw it out and start again.”

We need to build on the things that have worked and do them across the whole system. To say that the answer is to do with early years is incorrect. Taking action on the early years is the way to break the cycle, but there is a range of other things that we need to do as well. I am looking for consistency and cross-societal action.

You say that tackling health inequalities was a top priority, but did you know that screening and public health messages have not narrowed that health gap? They have widened it.

No, they have not. The gap has widened despite a number of things that have happened. It might have widened more if those things had not happened.

I was struck by your comment that, over much of the past 160 years, Scotland had pretty much the average life expectancy in western Europe and that it is only in the past 40 or 50 years, as economic inequalities have widened, that health inequality in Scotland has increased.

I want to put two points on the record before I ask about early years. First, economic inequalities are solved by using the economic levers of power, and this Parliament does not have those levers of power. Secondly, it has been widely accepted that welfare reforms have increased economic inequalities in society and, once again, this Parliament does not have the power to prevent those damaging welfare reforms.

We have heard that addressing health inequalities has been a priority for the past six years. In the hope of getting some cross-party consensus, I damn well hope that it has been a priority for more than the past six years, and that the previous Scottish Executive also had it as a priority. My concern is that, when politicians who are not in government seek to criticise other parties’ schemes, it feeds into a short-term approach, with one Government’s scheme being ditched when the next Government comes in. We have heard today that that chopping and changing is one of the significant issues in relation to what we should be doing to mainstream the pilots that work at a local level. It is important to put that on the record in order to balance the debate that we have had this morning.

I was surprised to see that, out of a total of £607 million that has been spent on health inequalities in the previous three years, the portion that was spent on early years was only £26.8 million. Is that an accurate figure?

Are those the figures from the Audit Scotland report?

Yes.

Audit Scotland derived those numbers from work that we did back in 2008 when we published “Equally Well”. To get a snapshot of where we were at the time, we asked people to make assumptions about what parts of the budget they spent on health inequalities. Therefore, the figures are illustrative, rather than definitive. Of course, there was huge expenditure on things such as education, which might not be reflected fully in the figures. The figures give a sense of where we were in 2008. In 2008, some things for 2009-10 and 2010-11 were not known about, so they are excluded from the numbers. The overall number should be treated with caution. It is intended to give a sense of the spend, rather than to be a definitive statement of it.

It is difficult to apportion time in primary care, for example, and say how much of the primary care spend is targeted at supporting children. It is almost impossible to make a judgment on that. There is a lot of activity on the early years. Derek Feeley mentioned other sectors: local authority nurseries and playgroups all contribute to the early years effort, for example. We are concerned about consistency of application and doing the things that work at scale to level up the opportunities for families and to ensure that they are supported. Families will be feeling stresses as a result of welfare changes, so we need to find ways of supporting them through that period. The children tend to suffer when the parents are stressed. It is important that we ensure that the stresses that parents feel are not visited on the children. It is hard to quantify spend in those areas.

You will appreciate that I do not want to create an audit trail just for the sake of it or to wrap up the system in bureaucracy, but Audit Scotland can audit only the figures that are collected. I must say that, as a proportion of £607 million, £26.8 million seems low, given the Parliament’s and the Government’s early intervention agenda. What is not captured in the figure that should be captured? If the figure is an underrepresentation, what figures should be added, in cash terms, so that we can see the global spend? When I look at the figures, I think that £26.8 million seems a small amount compared with the total of £607 million that is being spent on health inequalities.

The figure will be made up of particular ring-fenced allocations of money, so it will not include anything that is taken from more general allocations. A lot of the money that goes towards funding health inequalities work in, for example, the local authority sector would be difficult to split out. The Public Audit Committee has asked us to do further analysis of the work, which we will certainly have to do. I do not think that we will ever be able to say definitively exactly what we spend from every budget, because some of it is almost impossible to split out. How do we allocate the time that a health visitor spends with people in deprived communities compared with the time spent in other communities? The same applies to social workers and teachers, for example. We can do the best that we can to get the most up-to-date picture, but it will never be perfect, I am sorry to say.

In your initial comments, you moved towards saying that health work is wider than addressing the manifestation of health inequalities and is about preventing them from occurring in the first place. It is up to you what answers you give, but my reason for asking the question was that I hoped that you would make that point. You mentioned social workers. A variety of projects in our communities that address early years issues are funded by local authorities and partnerships. Are those captured in the figure of £26.8 million?

No, I would not think that they are.

Should they be?

If we sat down today and did the analysis that was done in 2008, we would try to do it differently. There is a choice for us as we think about how to respond to the committee’s request for greater clarity on the numbers and the similar requests that we have had from the Public Audit Committee. We can either try to update the numbers or try to have a more fundamental assessment of exactly where we are. My preference is to do the latter rather than the former, because I am not sure that the former would tell us the full story.

Should there be a combined health and social care integration budget to address health inequalities in the early years? Would that allow us to get towards what the overall spend is in that area?

You can expect one product of health and social care integration to be a more targeted effort around health inequalities. Bringing together the two types of organisation ought to help us to make some progress on the early years and beyond. However, that will not necessarily help us to get beneath the surface of every penny that is spent, because a lot of money will still be spent on general allocations and staff. A lot of work would have to be done to understand how staff were being deployed in order to get an accurate, to-the-pound assessment of exactly what has been spent.

I have a final question for Harry Burns. You mentioned that there have been a number of pilots and good schemes at the local level that started to show evidence, but which we have axed or changed. That has happened under successive Governments. Can you pick a current early years scheme that should be embedded for the long term—a scheme that you would not like to see wither on the vine, and which should be invested in and mainstreamed across the board?

Very early on in the introduction of the equally well programme, a project was begun in East Lothian to look at poorer areas in the local authority area. A whole series of interventions and joined-upness began to be designed. Social workers and voluntary agencies, for example, began to offer integrated support to families and young children, and the learning from that has spread to other areas.

I could also point to Fife. In Kirkcaldy, a project looking at young people’s alcohol consumption has shown amazing collaboration among the police and education, social work and health services to see that not as a criminal justice issue, but as a need for some support.

There are projects across the Lothian NHS Board area, such as the family nurse partnership intervention. I probably should not go into the details of individual cases, but there is no doubt in my mind that supporting pregnant teenage girls through their pregnancy and the first year or two of the baby’s life transforms the lives of both the baby and the mother. Mothers who would have drifted into alcohol abuse and all sorts of things in the past carry on at school, get highers, and move on into careers as a result of the support that they get from the family nurse.

There are a lot of things that are happening out there that we need to join up and learn from, and we need to share and spread the learning. That is happening, but only in pockets.

That was a really helpful answer.

I have no further questions, but I leave sitting the fact that much of what Sir Harry Burns mentioned would not be included in the £26.8 million. We must get a bit cleverer at quantifying the money that is invested across a range of public bodies to tackle health inequalities in the early years.

Thank you for your answers.

I entirely agree with the chief medical officer that we are dealing with an extremely complex problem, and it is not because of a lack of effort by successive Governments that we still have a widening gap. When Labour came in, we revisited the Black report and considered the early years. At that time, the early years were a priority for the United Kingdom Government and the Scottish Government.

We reduced absolute child poverty by a third and introduced home start, sure start, family centres and community schools. All those measures were designed to deal with the three-plus group. I think that the new thing that the chief medical officer is pointing to is the zero to three group, given the importance of the very early stages of attachment and the fact that the damage is done in the first three years. I think that that concentration, which was only reflected in home start, sure start and family centres, is perhaps the new thing.

10:30

When the chief medical officer last came in front of us, he said that, if we are successful in the early years work—if we are on the right track and are getting there—one of the things that we should see is a pretty rapid reduction in infant mortality. However, in the past couple of years, we have seen a reduction in the number of midwives and a 40 per cent reduction in recruitment of midwives. We have seen a focus on family nurse partnerships that will take 350 health visitors off to look at a very small number of families, rather than the second, slightly broader group that Gil Paterson referred to. We have seen the case load of health visitors rise and the case load of social workers become almost overwhelming.

We say that we are trying to address the problem and that we are going to make a difference to the zero to three group, but what has happened not just in the squeeze that we are now facing but in the past three to four years has actually undermined the very thing that we are talking about.

I accept that family nurse partnerships are being rolled out, and I value that. The family nurse partnership is actually a Scottish health visitor programme updated by an American who came to see it. Nevertheless, it is interesting and useful, but it is expensive. Apart from that, how are we going to tackle the problem and what outcomes will we see in a reasonably short time, as opposed to the long time that I accept is needed to see the generational change that we need?

It is actually not zero to three that we are focusing on, but minus nine months to three. We might even need to focus on what happens before conception, as we think about young girls who move on quite quickly into the potential for becoming pregnant. We need to begin to get them to understand a bit more about what pregnancy involves.

We will see some significant changes early on. Paying attention to diet, smoking and alcohol during pregnancy—actually, there should be no attention to alcohol whatsoever; I am a proponent of women not drinking at all during pregnancy—will reduce the number of stillbirths and the number of low birth-weight babies, and in turn that will have an impact on infant mortality, which is of course measured up to the first year of life.

We have already seen falling numbers of low birth-weight babies in the most deprived areas, which shows that the message is out there in the midwives and support systems for women in deprived areas, and that it is working. We cannot do this work without the support of midwives and health visitors. As we move through it, part of the exercise that is developed by the early years collaborative will be to look at the workforce implications and ensure that an appropriately trained workforce is in place to deliver that message.

A significant reduction in infant mortality is not entirely straightforward to achieve, because most deaths in the first year of life are associated with congenital malformations, which are unlikely to be significantly influenced in all of this. However, the fact is that Scotland already has the lowest infant mortality of the four UK Administrations. We think that the early years collaborative, at the end of this week, will set itself a target of a significant reduction in infant mortality, bringing us much more closely in line with Scandinavia.

We are already seeing changes. The effort that has gone into the early years work in relation to low birth-weight babies and so on has paid off a bit with the existing workforce. However, you are absolutely correct: we need to ensure that an appropriately trained workforce is in place. As we begin to see the load, I am hopeful that investment will be made from the preventative spend fund.

When it comes to social workers and so on, it will be important to change the engagement with individuals and communities. At the moment, public sector engagement is all about case load, risk management, protocols and guidelines, but the issue is actually families in trouble. I have spent a lot of time with substance misusing parents who are trying to do the right thing and move on. The best results often come from the third sector, which sits down and engages with people on a different basis from social workers. The third sector cannot take your children away. It is there to help and support you and therefore the trust that builds up is much greater.

That said, in my home town there is a very effective public sector project that is looking at substance misusing parents. The critical thing is that the health visitors and social workers who work there are friends of the families. A key part of this is a different dynamic, with public sector workers, third sector workers, individuals, parents and communities engaging differently to co-produce different outcomes. It is not us telling them what to do but working with people to change their lives. Too often, it has been top-down—“You will do X, Y and Z”. Engagement with people to help them to create positive futures for themselves requires a very different way of working. It is not just about the workforce but about how the workforce engages.

My experience matches that. When I worked in West Lothian for three years as an addiction specialist, it was the voluntary sector organisation that was able to intervene positively within families. However, the voluntary sector is subject to the short-term funding that you referred to earlier. I do not know whether you agree, but we have to find a way to ensure that the programmes that work in the third sector get long-term, core funding so that the third sector does not spend all its time repeatedly tendering. According to my third sector colleagues, the tendering process was one of the most damaging things that they had to deal with. At the time, we in the public sector—in health—had no retendering. We are beginning to have it and I am not sure that it is positive.

We had very helpful answers on the minus nine months to three group; the second group is three to 16. Are we sufficiently identifying those with conduct disorders and those who are being excluded from school, and are we picking them up in a way that provides the wraparound support that you just referred to in relation to the zero to three group? Exclusions seem to be rising again slightly. That is not a criticism of the current Government; circumstances are difficult.

On where we are, the most striking thing—I keep referring to this in the committee and in the chamber—is the finding in a paper by Professor O’Connor that in a study conducted in Stirling and Glasgow, 14 per cent of 15 and 16-year-olds self-harmed, and a further 14 per cent had seriously thought about doing so. Something fundamentally wrong is going on with the three to 16 group if we have a society in which one in three youngsters say that they are thinking about self-harming.

That is more work for the health visitors. We are introducing the 27 to 30-month health visitor assessment of developmental delay. As you rightly say, developmental delay is a sign that the previous years have not gone as well as possible. Therefore, at that stage—well before school—we hope to be able to institute evidence-based programmes to put things right, with the aim that the children will arrive at school ready to learn, socialised and able to integrate positively in school.

School exclusions are a particular irritation—I do not know whether that is the right word. If a child needs to be excluded from school because of their behaviour, that is a sign that there is a problem at home. What do we do? We take the child out of school and send them back to the environment that created the problem in the first place—daftness.

We need to rethink our systems in that regard. I have a particular interest in one way of dealing with the issue: the nurture group process, whereby children with conduct disorders are taken into a special environment in school and helped to socialise. However, the best thing to do is to stop the behaviour occurring by intervening early.

Again, across the whole education sector and indeed the whole of society we must think differently and join up. We need to see a life as a course, not just as a series of snapshots. Instead of saying, “This bit’s failing, so we need to turf the child out”, we need to stop the child failing, and if they fall through the net we need to institute appropriate measures. I expect the early years collaborative to have something to say about things such as enhancing play, enhancing parents’ reading with their children and building up attachment in the three to five age range.

When children in their teens suffer significant mental problems, the origin is very often in the first few months and years of life. I hope that as the cohort comes through from the early years interventions, we will begin to see reductions in things such as self-harm. When there are such signs of stress, lack of self-esteem and so on, we need to think more clearly about intervening at school age.

I will not tackle the third group; I will leave that to other members.

In a previous session of Parliament we heard evidence on speech and language therapy from a professor who I think was from Queen Margaret University. He said that the gap between problems starting and referrals had got longer, not shorter, because of the health visitor issue, so I welcome the introduction of the 27-month check for language delay. Early speech and language therapy prevents a child from going to school with a difficulty that will create further problems.

I have been working with the charity Place2Be, which has been working with 10 schools, including in Niddrie, to do exactly the sort of in-school nurturing that you are talking about. There is a lower rate of exclusions in those schools. The programme is being expanded to East Lothian, although the expansion is under threat because of finance—the NHS is not playing its part in funding the programme. I put that on the record, and I hope that the NHS will fund the programme in East Lothian as it does in Niddrie. A pilot in Glasgow is being looked at, too.

Place2Be’s programme is not the only such initiative, but programmes that work need to be expanded. It is not an expensive programme and it has a huge effect. Some 70 per cent of the children in the schools go to counsellors to talk. Families’ ability to talk about problems is being augmented through in-house charitable support, which is separate from the education system. I will return to the issue in the parliamentary debate on mental health later in the week.

The point was well made by Bob Doris that if we are talking about 50 years of increasing inequality, year zero goes back some way and predates the setting up of the Scottish Parliament. I appreciate that the witnesses are not in a position to talk about wider policy approaches, but the implication of what has been said is that the response is hampered by the Parliament’s lack of control in some areas.

It is clear from the discussion that politics does not do the long term very well and never has done. The electoral cycle tends to get in the way. There is a difficulty with the message that it will be years before significant improvements are manifested as a result of an intervention. Unless there is complete buy-in and an acceptance that it will take a long time for the results to show, Governments or politicians of whatever colour will be hectored for a lack of progress and we will always be in a position in which—for want of a better analogy—the baby is thrown out with the bath water.

What can we do to ensure there is an acceptance that some of the measures that you are talking about will, by their nature, take a long time to show the dramatic improvements that people want to see?

10:45

The strength of the early years collaborative approach has the potential to offer us that. We are bringing to the early years agenda the methodology that we applied to, for example, the patient safety programme, which demonstrated a clear understanding of what it takes to improve.

The early years collaborative is a much more complex agenda that, as far as we can establish, no one else in the world has tried to do at the scale that we are doing. The power of the methodology is that the data is collected as we go along.

We are getting together every community planning partnership in Scotland on Thursday and Friday this week. We will send them off to do some stuff from next week to start counting the impact of the changes that we are making. The power of the data in our approach is not that it is a big, multi-year evaluation; rather, it is the fact that data is counted every day. With that approach, at least there is the prospect of getting a sense of progress as the programme is worked on. That progress would not stand up to randomised control trials or necessarily be accepted in peer-reviewed journals, but it ought to give us a sense of whether we are heading in the right direction.

It is early days. We are just about to start the work but, we hope that, by going through the plan-do-study-act cycles that are part of the programme, the data will be collected as we go along.

On the long-term nature of the issue, I have come to this through science, not through opinion or my own political views. My background is that I was a surgeon who got interested in health inequalities. Over the years, the scientific evidence on the importance of positive and nurturing early years has become utterly compelling. I can show biochemical and neurological changes and all sorts of precise linkages between something that happens in the early years and the subsequent risk of heart disease, stroke, cancer and a range of mental health outcomes.

Politicians, on the whole, are rational people. When they are presented with scientific evidence that says that certain policies are causing neurological or biochemical abnormalities, but that certain interventions are changing the situation, they tend to accept that. Since I have been involved in policy, I have worked closely with every health minister since Sam Galbraith. They all want to do the right thing, even if they may differ slightly on how they want to achieve that. I earnestly hope that that will continue, no matter what happens.

There is very strong evidence that we will break the cycle, but there are other evidence-based actions that people can take later on in life that will change the biochemical predictors of pure outcome, the neurology and the DNA changes that we have observed taking place among affluent and deprived citizens in west central Scotland.

Clever scientists are on the case. All the evidence suggests that if we do what we are going to do on Thursday and Friday, we will see significant improvements in a new cohort of Scots, which will lead to a great reduction in the differences between affluent and deprived Scots.

Sure. There was some discussion earlier around whether the public health messages and campaigns have succeeded or failed. I guess that the only way we could have assessed that definitively would have been to establish a control group on, say, St Kilda, but that would possibly have been a little inhumane.

However, I agree that the early years are absolutely crucial. Obviously, beyond the early years, a great number of Scots have left that cohort and are part of the figures that we see on health inequalities. The worry is about how we ensure that we do not take our eye off the ball on that. We obviously do not want to write off a whole generation, or generations, of Scots by saying that they are beyond rescuing from the situation in which they find themselves. What, in a nutshell, is the answer? Where do we go from there?

It gets harder, the older you become, to make changes in your life. We think that we can do a lot on reducing offending and reoffending, and we are discussing with colleagues specific interventions on that.

One of the reasons why behaviour-change interventions are less likely to work is to do with the notion of locus of control. As a surgeon, I used to tell people to stop smoking and to eat a healthy diet. I very often got the response, “Ach, if you’re gonna die of cancer, you’re gonna die of cancer”; it was seen as being not within their control to make changes that would reduce their risk of dying of cancer, and that some kind of external focus was determining their future.

Psychologists talk about an “external locus of control”. We know from psychologists that the sense of control is built in the early years, but it can still be developed later on in life. It comes down partly to the business of engagement and it involves the notion of individuals participating in decisions about their environment, community and so on.

The classic word is “empowerment”. Have we really tried to apply that in deprived areas? I have been working in one or two deprived areas, trying to get people engaged who have become very much dislocated from society in general and who live very solitary and damaged lives. When we get them involved, they change their decisions about their health and wellbeing and about participating in society more generally.

It is invidious to talk about individuals, but I know of one individual who was housebound for seven years after the death of their spouse, but who was changed by an empowerment type of intervention. That individual is now the focus of a huge amount of community work in that area. It comes back to my point about the changing nature of how we engage with society and how we should do things with people and not to them, and how we should get them engaged, which will begin to suck in middle-aged and older people.

I cannot talk about middle-aged and older people without making a plea for them to do physical activity. If everyone did two and a half hours of physical activity a week, life expectancy in Scotland would increase by a year. It is a very significant intervention. However, why would folk who are isolated go out to take exercise? They need to feel that they are part of a group and need to become engaged.

I have a final question. I accept entirely the point about inequality being a huge factor. In that regard, we can consider the Scottish index of multiple deprivation as a guide to where intervention is most likely required. However, beyond that, Gil Paterson talked about communities to which he could take you. I could take you to what we might call middle-class suburbia and, even there, I could point to people in my school yearbook who became teenage mothers or who became addicted to drugs. Those people come from communities that would not come close to touching the “most deprived” rating in Scottish index of multiple deprivation figures, but there were people in those communities who were at risk and who could have been identified as being at risk. Do we need to get smarter even than using the index of multiple deprivation in identifying at-risk individuals, never mind at-risk communities?

We absolutely do. We should not draw circles on a map and put all our effort in those circles; we should find more sensitive ways of finding people who need help. Support and engagement should be available to people on the basis of need, not postcode.

Data from the Scottish household survey—it is a little bit out of date, but we can draw some conclusions from it—showed that about 34 per cent of low-income households lived in the 20 per cent most deprived areas. That surprised me—I do not know about the committee. I would have expected the figure to be significantly higher than 34 per cent because it means that 66 per cent of low-income households are not in the 20 per cent most deprived areas.

Are we talking about universalism-plus?

We are talking about everything. Do everything.

How does health policy reflect that in considering areas and ensuring that resources are adequate in those areas?

The family nurse partnership provides an example. In the areas where it operates—and when it is rolled out across Scotland—any teenage girl who becomes pregnant will be offered a family nurse, irrespective of where she lives. Those people are relatively easy to identify, but other things are harder to identify. We are constantly looking at ways of identifying situations and we will use community planning as a major part of that effort.

We have discussed access to GPs and time with them since I was a member of the then Health Committee. I do not know for how many years the deep-end initiative has been going. Is that another area that needs to be addressed?

We are in active discussions with the deep-end practices, and Stewart Mercer is doing a piece of work on the impact of GPs having more time with patients. The Audit Scotland report has an interesting analysis of where GP practices are. The correlation is not direct, but there are still significantly more GPs in the most deprived areas than there are in the least deprived areas.

Another part of the response to your question comes from some of what we have tried to do recently in relation to the health improvement, efficiency and governance, access and treatment—HEAT—targets. We set a universal target for smoking cessation services, but we made it particularly challenging for boards to achieve in deprived areas; we expect them to do more in deprived areas than they do in the country as a whole. We have done the same on measures such as fluoride varnishing—we have tried to emphasise boards upping their performance in deprived communities. We must do both.

We have spoken briefly about the role of the Convention of Scottish Local Authorities and of local government in wider delivery. What are we doing to improve the performance of community health partnerships and the relationships with local authorities?

The committee will be aware of the statement of ambition—the revised guidance to community planning partnerships—that was published recently. In that, reducing inequalities is a key priority and is one of six big priorities for community planning.

We have deliberately taken the community planning partnership as the collaborative home for the early years collaborative. On Thursday and Friday, people from local authorities and the health board will sit round the same table to produce a joint plan for the changes that they will make in their community planning partnerships. We have a strong signal in the community planning guidance that reducing inequalities is a priority and we will have people coming round the table to work together locally, which is where the improvement will happen.

I want to go back to the Audit Scotland report and to pick up the point about primary care. Mr Feeley said that there are more GPs in deprived areas than there are in less deprived areas, but one of the key messages in the Audit Scotland report is that

“The distribution of primary care services across Scotland does not fully reflect the higher levels of ill health and wider needs found in deprived areas”.

The report’s second key recommendation is that you should

“review the distribution of primary care services to ensure that needs associated with higher levels of deprivation are adequately resourced”.

Are you going to do that?

11:00

Harry Burns will want to say something about that, in due course.

We should keep that situation under constant review, although I have a few points to make. First, there are more GPs per head of population in Scotland than there are in any of the other countries in the UK; we have more GPs, full stop. Secondly, although Audit Scotland is right to say that there is no direct correlation between the level of ill health and the number of GPs in an area, the gap that exists in Scotland between the most deprived areas and the least deprived areas does not exist in other parts of the UK, so it is not as if there is no correlation at all. There is a significant difference between the most deprived and the least deprived areas when it comes to the number of GPs.

We have a limited number of levers that we can use to get GPs to set up in particular locations. Among the things that we can do is ensure that there are better premises in deprived communities. For example, a new state-of-the-art health centre is to be funded in Possilpark, which is one of the most deprived areas in Glasgow. It will be an outstanding primary care facility. It is possible to invest in such initiatives, but there is very little that I can do to force a general practitioner to set up in a particular location.

Another issue is what the GPs are doing in such areas. The work of the deep-end GPs is extremely interesting from the point of view of adapting the practice of GPs in those areas to better reflect the needs of their customers and clients. We have started to take some steps in the GP contract. The failure to agree a GP contract at UK level has given us an opportunity to agree a more Scottish contract, within which we have prioritised work on anticipatory care—that picks up the convener’s question about what we have been doing on prevention and anticipation—so we are trying to pick that up in the GP contract. We are also doing work on multimorbidity, which is a particular challenge in deprived communities.

We should always keep the distribution of GPs under review, but that is probably not enough. We need to think more holistically about how we use GPs, the nature of practices and how we can incentivise the right kind of care for people in deprived communities.

Harry is more eloquent than I am in making a point about where people are distributed, so I will let him do that.

Just because someone lives in an area does not mean that they are registered with a GP in that area. A few years ago, we looked at the situation in, I think, Drumchapel. We found that residents there were signed up with about 100 different practices that were spread all over Glasgow. We cannot just plonk a GP in an area and say that, suddenly, there will be more GP time available to people in that area because a lot of them will sign up with that GP. It is very difficult to estimate the amount of GP time that is available to residents of an area, because many people sign up with practices outwith the area.

Another point to make is that primary care is about a lot more than GP time. Mention has been made of health visitors, whom I consider to be an essential part of what we are trying to do. Increasingly, I see primary care expanding into a whole load of other disciplines. That has already happened in some parts of Scotland. Some of that is about supporting families in different ways; for example, there are health centres in which there are welfare rights people. We are talking about generally expanding our ability to support people who are in difficulty.

I want to see us working more closely with local authorities on such things as signposting for people who need help in specific ways that might not come from the health service. I have already spoken about physical activity; we will have to develop a way of ensuring that GPs hand on to another layer of intervention people who need help with physical fitness. The best way to do that is to get physical activity co-ordinators and so on working in primary care settings.

We will see primary care expanding into many other areas beyond general practice, which I think is absolutely right and reflects the whole-society nature of the problem that we face.

To be fair, I did ask about primary care—I did not ask specifically about GPs. I accept the point, however.

There is a challenge for us, because every question can be answered with, “It’s very complicated.” Of course it is very complicated; we all, round the table, accept that. Audit Scotland has put a report before us, so I am trying to get a sense of where you think the report is fair and where you will make changes because the report has been useful.

The chief medical officer has said that he absolutely accepts that short-term and small-scale interventions are disruptive and are not the way to do things and he went further than just accepting the point: he advocated it.

Audit Scotland also says the NHS boards are failing to allocate resources to target needs within their areas. What is the response to that? What action should we take when someone tells us that? Audit Scotland says that there is at local level a “lack of shared understanding” of what health inequalities are. You are concerned about the complex causes of health inequalities and you are concerned that we do not have a definition of those causes, but locally there is not even understanding of what the symptoms are and what the cures might be.

We have already pointed to the fact that some of the arithmetic around the expenditure has left out a lot because, of necessity, a lot of expenditure on health inequalities will come from areas other than health. Therefore, we are moving in the right direction by strengthening community planning and community planning partnerships to bring funding together.

We forget that all the funding for healthcare is skewed towards health inequalities. The reality is that people who live in deprived areas are more likely to get cancers and heart disease and have strokes, so they get treatment for those things. When I had a specific interest in cancer as a surgeon, I looked closely at the pattern of treatment, because the outcomes from some cancers—from most cancers, actually—vary by socioeconomic status; the lower down the social scale you are, the less likely you are to survive. One of the obvious reasons for that could have been that less treatment is available for people in deprived areas, but I could find no evidence of that. I did, however, find more aggressive cancers and more aggressive physiological responses to those cancers. I found a biological explanation for it, which has been shown elsewhere in other countries.

Most of the health service’s spend on healthcare actually goes on dealing with the health service’s response to socioeconomic deprivation; it is tackling it in real terms.

One of the purposes of our inquiry is to ask these questions. We will have to have other panels before us, but when we have the chief executive of the NHS in Scotland and the chief medical officer here it is not unreasonable that we concentrate on the NHS.

Does the NHS currently do anything that increases inequality?

The obvious one is anti-smoking campaigns. Historically, in campaigns on unhealthy behaviours, the people who have a stronger sense of control over their lives respond and those who do not do not respond. Traditional health improvement projects widen health inequalities, which is one of the reasons why I believe we must move beyond that approach.

I presume that that is also the case with regard to our thinking on physical activity. We need to ensure that we shape campaigns that do not make the same mistakes.

Absolutely. When I discussed that issue recently, I got the response, “Well, poor people don’t take physical activity”. If we keep telling them that they do not take physical activity, they ain’t going to start. We have to find other ways of dealing with the problem.

I live in a relatively deprived area, where the efforts of my local authority to establish running groups and so on are really very striking, and you can see the evidence on the streets of the town. We can do it, but it is a question of attitude and culture. Do we really want to make a difference? If we do, we need to find ways of delivering the intervention.

I still have to wonder whether—apart from those public health campaigns—the national health service and the Government’s health directorate are doing things that increase health inequalities. The big challenge in this is, as Mr Feeley pointed out earlier, how we redistribute power, income and resources. The chief medical officer talked about small-scale projects, but we need big budgetary changes to deal with this matter. Of course, that means having to divest something else of money. I presume that you are asking yourselves that very question; surely if you know that you need to move more money into tackling inequalities, you will have to start by looking at the things that you know do not work to reduce inequality and, indeed, might even make it worse.

There should not be a litany of such projects. For a start, we inequalities proof our policy making as we go along; in other words, as we develop policy, we ask ourselves whether we are clear about its impact not just on income or socially generated inequalities, but on all inequalities. As a result, there should not be a large number of policies that increase inequalities.

The real question that we should be asking ourselves is whether we have the balance right between the policies that improve health for all and those that—to use Harry Burns’s phrase—level up. That issue is still open, but I hope that I gave members some assurance when I listed some of our recent moves to influence behaviours through the HEAT targets. Moreover, the detect cancer early programme explicitly recognises that some of the issues with regard to cancer outcomes come down to the fact that people in deprived communities tend to present later with cancer, so we are deliberately going after that segment of the population.

Of course, we have a duty to improve everyone’s health, but one of our particular duties is to improve the health of those who are currently health-deprived, and we need to get that balance right.

In its report, Audit Scotland’s first recommendation is:

“The Scottish Government should introduce national indicators to specifically monitor progress ... and report on progress.”

As the chief medical officer has pointed out, many people have been looking at the issues for a long time now, so how can we reassure ourselves that 10 years after our report is published another chief medical officer, another head of the NHS in Scotland and another health minister—there might well have been a good few health ministers by then—will not be sitting before the health committee then, saying, “The issue’s complicated and it’s difficult to measure progress, so we don’t”?

How do you know that I will not still be here in 10 years?

I am pretty sure that I will not be. [Laughter.]

I was puzzled by that recommendation in the Audit Scotland report and, indeed, said as much to the Public Audit Committee. I point out that footnote 22 at the bottom of page 10 of the report refers to

“Long-Term Monitoring of Health Inequalities, Scottish Government, October 2012”,

which is the only reference to the fact that we are one of the few countries to report annually on progress in these areas. Every year, we report progress on healthy life expectancy at birth, premature mortality, mental wellbeing, low birth weight, hospital admissions for heart attack, heart disease, cancer incidence, cancer deaths, alcohol admissions, alcohol deaths and all-cause mortality by socioeconomic status. Such evidence means that the suggestion that there is no monitoring of such matters is not supported.

11:15

If the committee wanted to offer some advice about whether those are the right areas to monitor, that would be incredibly helpful. If we should measure other things by substituting some of, or adding to, the measures that I mentioned, I am open to hearing about that. However, there is regular monitoring of health status in those areas.

The fact that poor people get more than their fair share of treatment is a negative thing, I presume, in that they have left it too late and find themselves in hospital. Who gets the biggest share of, or the biggest benefit from, the preventative measures; is it the rich, the middle classes or the poor?

Preventative measures include things like cervical screening and breast screening. Everyone is invited for screening, but uptake is lower in poorer areas.

Is there evidence for that?

There is evidence for it, but there is also evidence that primary care staff, for example, make an extra effort to encourage folk. However, it comes back to my point about whether people feel in control of their lives.

I was just trying to get some clarity about treatment and preventative measures. Such measures are important; they are where we want to get to.

Increasingly, they are absolutely where we want to get to.

The other point that has come out is about what is important for politicians—we all plead guilty to this—in the outcomes. Outcomes are at the heart of what needs to change to implement the preventative agenda and deal with health inequalities. We measure success by whether hospitals are kept open, or by the impact of the smoking ban. Indeed, the Cabinet Secretary for Health and Wellbeing was measuring success in such a way in an article on Sunday.

Do we need to make a journey? Why are we not listening? Why have your interventions on the policy makers over time not been more successful in encouraging us to measure health outcomes differently, rather than by free prescriptions, hospitals or access?

The committee has spent a lot of time on end-of-life care and on regulation and delivery of care for older people. However, the key is clearly—as you said today and have said for a number of years—that we need a different direction and different priorities that can unlock the health inequalities; that is, early years intervention. We are just not getting there, are we?

The challenge for policy makers and parliamentarians alike is that all those things matter to people. We all spend some of our time doing what is urgent and some of it doing what is really important.

I take you back to the first words that I said: I very much welcome the inquiry. It has the potential to put us on a course that carries a sense of consensus and shared purpose. It is recognised that Administrations over a number of years have done their best to resolve some of the big complex issues, but agreement about the core issues that we will prioritise over the next 10 to 15 years would be a significant step forward. Then, there would be a legitimate challenge to us to get on and deliver improvements.

Is it the case, as I think Sir Harry Burns alluded to earlier, that the poor are less likely to vote and that the worried well vote in large numbers? Do we as politicians need to overcome that to deal with some of these issues?

Thankfully, voting habits are not my area of expertise.

You suggested earlier that, given the effects on the courts, we need early interventions for young people who are in trouble, so we need to overcome society’s feelings about the issue. Does that not come down to politics and voting? Does that not affect whether a hospital stays open?

We need a real cultural change. Instead of blaming people, we need to see people as being in need of help and support, no matter what position they are in.

When I took on this job, one of the first things that I did was to go down to Carstairs. Over the years, I have met probably a dozen mentally disordered murderers, every one of whom has a history going back before the age of three. Their lives have been blighted very early on. They have been excluded from school, they have taken refuge in drink and drugs in their teens and later they have wandered about town with a knife in their pocket with the result that somebody got stabbed. The mental ill health that comes from abuse and neglect in the early years is hugely dominant in the lives of those individuals. We need to get away from the attitude that the answer is to lock them up for ever. Thankfully, we have places such as Carstairs that try to work with those people on their mental disorders.

To a greater or lesser extent, you can see that with folk in Barlinnie and other prisons. Failure in life has its origins at that early stage. People who are neglected in early life have not learned to attach, so they do not nurture their own children in turn and therefore the cycle is perpetuated. To a large extent, that perhaps accounts for the gradual widening and the accumulation of that adversity in our society.

I am really looking forward to the results of the 27 to 30-month health visitor assessments on developmental delay. When we see those results change, we will see real evidence of a shift in the way that pregnancy and the first couple of years of life are nurtured. The fewer developmental-delay kids that we see, and the fewer children that are put on the risk register, the more we will see real change in our society. We can then look forward to closing a few prisons in future.

Should health inequality be measured differently from how we measure it now, or does that not matter?

The measurements that we have more or less come from routine statistics. As Derek Feeley said, the early years collaborative will identify, almost on a day-to-day basis, the number of women attending antenatal clinics who smoke, the number who have been given smoking cessation advice, the number who have taken that advice and the number who continue to drink alcohol during pregnancy. That will be on a chart on the wall, and we will see the figures coming down or remaining flat or whatever. If they flatline, we will need to redouble our efforts. We will move into an era when we measure a lot more about the growth and development of children. From that, we will determine the most sensitive measures.

I come back to the point that it is human nature to look for a magic bullet to solve complex problems. The magic bullet does not exist here. We need to pull together a lot of hard work across the whole of the life course. If we get that realisation out there so that people have the sense that the whole system needs to work together on the problem, that will be a mighty leap forward.

I have a quick question on the issue of people presenting, which I think Sir Harry Burns spoke about. An associated issue is that, in our most deprived areas, when people have made an appointment with the doctor, the prospect that they will turn up is not great. Are any schemes in place to help people with presenting and keeping appointments, which might have the effect of changing the situation for them?

There are successful interventions. Most folk have a mobile phone, and there are systems by which people get text reminders of when their appointment is and so on. That kind of thing has a significant effect. Again, it is about doing at scale interventions that work and ensuring that everyone participates in them. Things are happening that are having an impact.

Good. Thank you for that.

I apologise for being so late getting here, which was thanks to a broken-down ScotRail train. I therefore missed a lot of what was said at the beginning of the meeting.

I have been around long enough to have seen a lot of changes in the health service come and go, then come again. I have never been in general practice myself, but my husband was a GP for most of his working life in a practice that covered most of Aberdeen. This is perhaps going back to the future, but the way things went there was that they had a practice nurse, a health visitor and a social worker who were all pretty well attached to the practice and who met several times a week. It strikes me that that approach got to the root of the problems for families in practice areas. For example, a situation could be dealt with before a baby was born if it was anticipated that there might be an issue with a particular family.

I think that that kind of local collaboration was what Sir Harry Burns was getting at. As I said, we are perhaps talking about going back to the future, but it strikes me that that might be the way ahead. That is a comment rather than a question. However, do you think that we should go back to having practice-based health visitors where possible?

We need to go a lot further than that, and not just with practices. We mentioned the fact that people sign up with practices all over the place and not just in their own area. From what I can see, we need a much more widely co-ordinated effort that brings social care, educational interventions and pre-school interventions together in a co-ordinated way across the life course. Obviously, we are focusing a bit on the early years, but the intervention must continue even as children move into secondary school. The transition from primary to secondary can be stressful and can knock kids off track. Organisations such as Place2Be, which Richard Simpson mentioned, provide an important way of supporting children through such transitions.

I therefore think that we need to do far more than we ever did. I accept that, in the old days, because lots of people saw a situation, it was possible to synthesise ways of dealing with it. However, we need to get even smarter in that regard, because the problems in some areas are severe.

To follow on from Gil Paterson’s point about access to primary care, I recently had an interesting meeting with somebody from Optometry Scotland who has a practice in a deprived area. He feels that his practice is a good point of entry to the system because people are happy to go and get their eyes tested, which allows the practice to signpost them to wider health services. I presume that the same would apply to community pharmacies. I can see the possibility for quite a lot of collaboration at local level in that regard, which would be beneficial.

That is absolutely right. Dental practices are another example of how people can be signposted on to other services. We are working hard to ensure that, whether or not we are talking about independent contractors, the contractual arrangements in deprived areas reflect and incentivise such signposting so that any engagement with primary care becomes one that is not just about treatment, but about information, guidance and signposting to other services.

That can be done for all ages.

Absolutely.

Sir Harry, you said that health inequality is an issue for the whole of society and not just for the health service, and that we are dealing with an intergenerational failure. In your annual report, you talked about the implications of people’s genetic make-up and how that can be affected by their socioeconomic environment and then passed from one generation to the next. It then becomes embedded to the point where it becomes the norm and is part and parcel of people’s culture. Obviously, as you said, that perpetuates the cycle and so, as well as the inequalities in income, welfare and power, a variety of health inequalities accumulate. How do we deal with that challenge of genetic make-up?

11:30

I mentioned epigenetics because it is emerging as a real issue in some studies. We do not yet have a specific epigenetic study. We have identified and measured, in affluent and deprived Glaswegians, chemical changes to DNA that are often associated with epigenetic change. However, I mention that just to underline how complicated the problem is. Whenever you think that you have reached a reasonable approximation of the answer, some new aspect of science comes along and you think, “Wow, how does this affect what we are doing?”

In the course of the next year or two, we plan to conduct studies in Scotland to see to what extent epigenetics might be contributing to the problem. That particular issue arose from a study that was carried out in Sweden. Using data on nutrition and health going back to 1900, over several generations of people, in a fairly isolated part of Sweden, the study found that the risk that was accrued to young men and women in the early 1900s was expressed in at least two subsequent generations, irrespective of the experience of the people in those generations. The geneticists say that there is now good evidence that you can modify the activity of your genes in ways that can be passed on to subsequent generations.

It is leading-edge research, but we know too that some epigenetic changes can be reversed easily. That is work in progress, but it underlines the fact that there is no magic bullet; there is a complex biological consequence of adversity that gets handed on in a cycle from one generation to the next. However, the jury is still out on that as far as Scotland is concerned.

As I have heard more information about the early years collaborative, I have been thinking that, going beyond that, the issue is a societal one that is about people investing in and being in control of their futures. Using wider role funding, a local housing association, the North Glasgow Housing Association, has appointed a full-time sports and activities co-ordinator who is starting to make a significant local impact. The association sees itself as a core investor in its community. Will such organisations be part of the early years collaborative approach? I am keen to get a sense of whether the usual suspects will be involved or whether the approach will be widened out to every stakeholder in communities.

You are absolutely right. I have seen Glasgow Housing Association and other local housing associations in Glasgow beginning to get significantly involved in the agenda. The critical thing is that it is not about a top-down approach; it is about working with people to develop new sets of opportunities or insights and to give them some control over their environments. We very much want housing associations and anyone else who feels that they have a role to play to be involved in the agenda, and we would actively encourage it.

Are such organisations being actively encouraged as part of the early years collaborative? How is that work being taken forward?

One way in which the collaborative works is that it gives control over the changes to the people in the localities. We do not tell them what to do; we give them a range of options that they can follow, and that menu certainly has options around physical activity.

The other bit of comfort that I can give you—Harry Burns alluded to this—is that we are considering how best to bring some of that approach to physical activity. A bit of that work will be explicitly connected to the early years collaborative. Another bit, we will probably want to do separately, because everybody benefits from physical activity, not just children. However, we would want to do that work in a connected way, so even if organisations are not formally part of the early years collaborative, there is no reason why they should not be part of a broader physical activity collaborative in due course.

On behalf of the committee, I thank both our witnesses for their evidence. We look forward to examining it and to working with you again in future.

11:35 Meeting suspended.

11:41 On resuming—