Meeting date: Tuesday, May 9, 2017
Health and Sport Committee 09 May 2017
Agenda: Preventative Agenda, NHS National Waiting Times Centre, Subordinate Legislation
Good morning and welcome to the 12th meeting in 2017 of the Health and Sport Committee. I ask everyone to ensure that their mobile phones have been switched to silent. You can, of course, use them for social media but not for taking photographs or filming proceedings.
Agenda item 1 is an evidence-taking session on the preventative agenda. I welcome to the meeting Dr Una MacFadyen, a consultant paediatrician at Forth Valley Royal hospital and a fellow and member of the college council of the Royal College of Physicians of Edinburgh; Dr Margaret McCartney, a general practitioner; and Dr Helene Irvine, a consultant in public health. We are due to be joined by Emilia Crighton, the head of health services in the public health directorate at NHS Greater Glasgow and Clyde.
We move directly to questions, the first of which is from Alison Johnstone.
Good morning, and thank you for joining us. I see common themes emerging from all our witnesses’ written submissions. For example, in Dr Irvine’s submission, she says that, as a result of the demand that we are facing, we need to prioritise and that
“no area should be exempt from scrutiny or regarded as sacred”.
Indeed, the breast screening programme is discussed in those terms in the submissions from Dr Irvine and Dr McCartney. How is evidence that counters current practice discussed in Scotland, and how are decisions either to continue or to discontinue programmes that might not be cost effective made?
That is a very good question. With regard to the breast screening programme and, indeed, most of the other major screening programmes, the decisions are really made by a United Kingdom-wide screening committee and are then implemented by Scotland. In a bigger piece of work that I carried out on data that is routinely collected in Scotland, in which I voiced my concerns about how we were adopting policies from England, I highlighted the same issue and expressed my fear of our sometimes implementing policies that are decided south of the border. I suspect that, when it comes to the breast screening programme, we do not review all the evidence in Scotland and then decide what we are going to do; instead, we follow the UK National Screening Committee.
Is that your view, too, Dr McCartney?
Yes, I think so. The UK National Screening Committee is a very good organisation, but one might almost say that it franchises out parts of its remit to look at evidence. There is, for example, an advisory committee on breast cancer screening. However, what I am concerned about is that, for some time, there has been no good cost-effectiveness analysis, particularly with regard to opportunity costs—in other words, the amount of time that we spend doing one thing when we could be doing something else of more value.
The other big question is how good we are at sharing decision making with regard to not only breast cancer screening but all forms of screening in Scotland. After all, the matter is devolved. I do not think that we do this work well or thoroughly enough, and I do not think that we do it with the attitude that, if we find that something is not working, we should interrogate the evidence and ask whether we should simply stop doing it. For example, there is quite a lot of evidence that says that the keep well health check programme does not work, does not improve quality of life and does not extend life. I would therefore ask why we are spending so much money on that when we could be spending the money on other things that we know really do work. Opportunity costs are a huge issue, because if there is a limited amount of GPs and GP time and you ask them to spend money on stuff that does not work, that means that we are not doing the things that work and which really make a difference to people’s lives. As I have said, that is a huge issue, and it has been sailing under the current without being interrogated properly for decades now.
Obviously stopping such a programme would be a politically difficult decision. I see that it has been questioned in other countries—I note, in particular, your evidence about Switzerland—and I know that there is a view that it just got past the last UK review, which was carried out by Sir Michael Marmot. If we were to look at the matter more discretely and with a Scottish focus, might we come to a different decision?
I do not see how a Scottish perspective on the matter would be any different from an English perspective. It should be looked at, and anyone who looks at it objectively will conclude that it is not a good idea to do it at a universal level.
Targeted screening should be considered for high-risk women, because the return for the effort is higher and the risks incurred are lower, and therefore the cost benefit ratio is better. I do not think that a Scottish analysis would be any different, other than that, in terms of the statistics, it would be about 11 per cent of the UK figure. The beauty of the UK-wide approach is that we are looking at a bigger sample size. If we did it at the Scottish level, we would be looking at a much smaller number of women screened and lives saved and so on. I think that it should be looked at UK-wide. It would be odd if Scotland went ahead unilaterally and tried to scrap the programme, leaving England carrying on with it. It is one of those very sensitive issues where it would be awkward to try to go it alone.
There is some evidence in the submission about how the programme originated in the first place, under Margaret Thatcher’s Government.
Can I add something about that? In 1989, I did the master of public health course at 1 Lilybank Gardens in Glasgow with Professor Jim McEwen. We studied all the reports in detail and, even then, many of us on the MPH programme had major concerns about the screening programme. In fact, that same year, Maureen Roberts, a breast physician from Edinburgh who had spent 10 years looking at the subject and had advocated going ahead with the screening programme, wrote in The BMJ that she suspected that it had been an error of judgment. That was published posthumously. I have those papers with me and the material from Maureen Roberts makes compelling reading from the dead—the fact that a woman who had devoted her career to breast screening and breast pathology died from the disease and then wrote in the last months before she died that it had been a mistake to advocate a national screening programme. She cited all the criticisms of the programme. That was 1989—just one year after the decision was made by the Tory Government of the day to go ahead, possibly because it would be a vote winner among women. It worries me that there was a political dimension to the programme, and then one of the Scottish experts expressed concern about it in the months before she died from the disease.
You spoke about having a more targeted approach and making sure that we are seeing high-risk women. Concerns are raised about the worried well and the amount of resources that are used inequitably. I would like to understand how we make sure that we reach the high-risk women. You say in your submission that any new model is doomed to fail if it does not have GPs at its heart. I suppose that GPs are essential. We have heard concerns from GPs at the deep end about the inequity in funding. Will you expand on that, please?
Let me answer your second question first. I have done a major piece of work on the funding of the various components of the national health service, and the amount of money that we are spending on hospital consultants, GPs, district nurses, social care, the elderly and so on, and I have major concerns about the disinvestment in general practice. I believe that, at the moment, the entire NHS is at risk because of progressive and on-going disinvestment since 2006. I do not see how we can expect GPs to pick up early signs of cancer in patients who already have the disease. I do not see how GPs can promote health and discourage patients from smoking and drinking too much and so on—all the things that we know would have a high return on investment. We know that people are more likely to listen to such messages from their GP than they are from anyone else. It is bizarre that we spend vast sums of money on something like breast screening, which exposes all women aged 50 to 70 to radiation every three years, generates a huge false positive rate and has a very high screening-to-life-saved ratio, yet we disinvest progressively in GPs. The breast screening programme is one of many public health programmes. You may think it odd that a public health doctor would question some of those initiatives, but we need to review all of them and see what we are getting for the money, what potential harm we are causing and whether we are contributing to health inequality, which I believe we are.
On the first part of your question, I am not an expert on breast screening and how you would go about targeting, but it would probably involve genetic markers. You would identify the women who have family history and are positive for breast cancer markers. If you focused on those women, you would get a better return on any kind of routine screening.
I thank the panellists for coming.
Taking a wider perspective, I am a wee bit concerned that we talk about prevention but we jump straight in and start talking about screening as if screening equals prevention and vice versa. To my mind, prevention goes much wider than that. Dr Irvine makes that point in her submission, but she also says that
“preventative medicine as we think of it in public health terms”
does not include what I would consider to be the main part of prevention, which is what GPs do—in other words, the upstream stuff. Therefore, I am bit concerned about the terminology. I think that we need to refocus on the wider concept of prevention, which is about doing stuff earlier to stop other things happening later.
I want to focus on the cost side and to find out what data and mechanisms we have for judging the effectiveness of interventions. You use words such as “huge”, “substantial” and “considerable” to describe the costs. You have included some data—from a quick look at that, we are talking about a spend of £250 million. That sounds like a big number, but it is less than 2 per cent of the total health service spend in Scotland, so it is not a big number in the overall scheme of things.
I also want to explore Christie’s idea that 40 per cent of public sector spend is potentially preventable if we take action upstream. I want to find out what mechanisms are there that allow us to do data crunching that enables us to say, from a financial point of view, “Doing this works,” whether we are talking about screening, investment in GPs, investment in primary rather than secondary care or whatever. That is the nub of the issue. What tools and mechanisms are there to allow us to make proper, quantified, evidence and data-driven decisions on preventative spend in the wider sense?
Are you asking me?
I am asking anyone who wants to answer.
Does anyone else want to have a go at that?
The committee asked which areas of preventative spending it would be most useful for it to investigate, and I addressed that in my submission. I am interested in putting resources where they work. If we do not have evidence-based policy making in the NHS, we are sunk. I am worried that we are throwing good money after bad again and again. You might say that it is only 2 or 3 per cent of the health service spend, but those small numbers add up and make a big difference.
For example, when it comes to the general practice service, how can we do more work in the community when we simply do not have enough hands-on staff to do that? If we do not have the number of district nurses that we need, we cannot allow people to have a good death at home. The existing district nurses cannot simply multiply their number. Our health visitors are now working horizontally across practices. We are putting at risk the primary care team, which we know has had huge benefits with regard to vaccinations and so forth as a result of women and families having long-term relationships with the staff in that team, whom they know and trust.
You asked where the data is. There is a lot of data, but there is a lot of data to tell us that we are doing stuff that does not work and which wastes money and causes harm. With breast cancer screening, for example, the big issue is overdiagnosis. Early diagnosis sounds so attractive. The idea of having a health check and picking up on something early so that we can make a difference is incredibly attractive. It is a political vote winner—over many generations, politicians from many parties in many areas of the world have used it, but the problem is that it is not possible to get full information about the process from a soundbite.
I understand that. You say that we need to be data driven in our decisions, but you say that we are not. I want to get at the data on where you would spend the money. If you say that we should spend it on nursing or whatever, what data do you have to show that that works from a preventative spend point of view? What analytical mechanisms are in place to understand where we should spend the money?
Are you asking about randomised control trials or systematic reviews?
I am asking about evidence on spend.
There are good Cochrane reviews that show that people who live in high-quality housing that is not damp and cold have fewer asthma exacerbations.
Can you point to the financial evidence for that?
I would need to go back and look at the Cochrane review. You can google it; I think that it involved studies that were done primarily in New Zealand, but some were also done in England.
A lot of people say that we should do this rather than that, but I am trying to find out what data-driven analysis is available that says, “If we spend X hundred million pounds on nurses, we will save X billion pounds in that area.” Where can we find those numbers?
You need a health economist to answer those questions. If you wanted that kind of answer it would have been useful to have the questions framed like that. Then I would have spent more time doing what you wanted and giving you the data that you were looking for—it is completely possible to do that.
Okay. That is fine.10:15
Can I try to answer now?
You did not think that the sums of money that we are currently spending are very big, because they are not a large percentage. I think that what we are spending is a lot of money if it is not giving us a sufficient return on the investment. The evidence for that is the rising index of inequality—the fact that the gap between rich and poor in terms of life expectancy is increasing every year. Mortality rates are falling for both rich and poor, but the gap is getting wider every year.
One obvious failing of our current strategy is that we are spending that £250 million but we are leaving the poor behind. The most cost-effective way to improve public health is to reduce the gap in income, wealth and opportunity between the rich and the poor. I am sure that most of you will have read “The Spirit Level” and the subsequent book by Richard Wilkinson and Kate Pickett. I do not want to seem simplistic, but that really is the essence of public health.
If we reduced that gap deliberately, we would improve on hundreds of parameters. We have to focus on that. Once we remove the focus from that gap and start introducing a myriad of other approaches, we get distracted and we create a lot of false positives. The hospital is focused on dealing with all the breast lumps that have been identified and all the false positives in that cohort, and we lose sight of what needs to be done, which is ensuring that the gap is minimised.
Suppose that we had nothing that was on that list—pandemic flu, health screening, tobacco control, alcohol misuse, health protection and the whole lot—what would you spend the £250 million on and what difference would that make?
I would not just cancel a lot of those things. I would also look at the huge wastage in what is spent on responding to unnecessary admission to hospital. Because we have starved general practice, district nursing and social care of the elderly, we have a much higher emergency admission rate than we should have, we are having to pour money into more accident and emergency physicians, acute physicians and staff for the hospital, and we do not see that. It is obvious; all we have to do is plot the data—the emergency admissions and the compliance failures in A and E—and we will see that those coincide with clusters of very old patients. The reason why the old patients are pouring into A and E is not demographics—it is because we have cut back on GPs, district nurses and the social care of the elderly. That is data driven, and I can absolutely demonstrate it.
Are you able to quantify that? If we spent another £100 million—
I did not show you that data because you were asking me about preventative spend. I chose the breast screening programme as one example among others that we need to review to see whether we can liberate some funds. The big money is being spent in the hospitals, and we could shed a lot of that if we reduced the demand for it by providing a strong community-based service, which we do not have.
There are two parts to that. One is about screening; if we stopped screening, how much money would that save?
Whatever is spent on the screening, which depends on which programme it is. However, I am not suggesting that we cancel all the screening programmes.
So you do not have a number for that.
I am suggesting that we review every one of the screening programmes to see what we are getting for the money—its cost effectiveness—and, if that does not stack up, we should consider toning the programme down.
But you do not have any numbers on how much that would save.
No. If you look at my submission, I said that we need to review the programmes.
Right—so you are taking a view on that without the data.
I am looking at the data. I looked at the Marmot inquiry, which reported that it is estimated that, in the whole of the UK, screening would save 1,300 lives from breast cancer. At least 200, but up to 1,000, women would need to be screened to save each life, but three—or, according to other studies, up to 13—of those women would have an unnecessary mastectomy or lumpectomy, with or without other treatment. It depends on the studies that are looked at. I think that those numbers need to be examined; they are not good enough and I do not think that that is a public health approach—it is an interventionist approach.
Coming back to preventative spend, you do not have any data on how much we would save if we did not run the screening programme.
Part of the problem is finding out what things cost. I have published material recently on health screening, and we found wildly different answers from different health boards giving different figures. Part of the problem is that the data is so fragmented—the costs are not fully inclusive. For example, opportunity cost is hardly ever examined—pharmacy time, patient time and, in particular, patient burden. Gathering data on this would be a PhD thesis in itself. The data is almost impossible to find—that is one of the problems. I emphasise again that opportunity cost is almost never examined. You can state the cost of the drugs and the cost of supplying a certain number of staff for a certain time, but the distraction that is caused is a fundamental problem, and that is not examined.
Some 160,000 people are employed in the health service, and we spend £13 billion on it. It is concerning that we cannot find someone to do the number crunching that would enable us to understand where the money is being spent. That looks like a problem to me.
It is difficult to get the data. You will find that academics, probably working in their own time, have published writings about small areas. However, it is remarkably difficult to get coherent numbers across the whole of Scotland. The other problem concerns cost-effectiveness analyses, which are rarely done independent of the organisation that is funding the work.
In terms of assessing the cost of programmes, they have been designed to be embedded into delivery of the NHS, which means that it would not be difficult to find out how much we spend. As a screening co-ordinator, I know exactly what staff we employ to deliver what we do, so finding the data is not impossible.
The UK National Screening Committee is tasked with reviewing evidence—it commissioned the Marmot review. If there are any issues, it is up to the National Screening Committee to go back to the evidence and look at cost effectiveness.
Helene Irvine identified the value of the lives that are saved through screening and, through the National Institute for Health and Care Excellence, we have information about value for money in terms of how much it costs to get any outcome, whether it is a life saved or an improvement in the quality of life.
We have seen, particularly through screening programmes, that the way in which humans are designed means that if we save a person from one disease they will simply get another one. For example, California has saved coronary care beds through preventative measures on coronary heart disease, but now people there are finding that they have to do more joint replacements because degenerative conditions kick in as people age. It is up to us to decide what is worth doing. Certainly, it is worth our while to extend life by preventing people from dying young from diseases that are highly preventable. However, having grown up in communist Romania, I can say that the fact that we were all equal has not stopped us from smoking and drinking excessively and from dying young as a result of preventable diseases. We have to strike a fine balance.
Could you provide the committee with the data that you have on costs?
We can send that to you.
I would like to add a small point to pick up on Ivan McKee’s question about prevention versus screening, and to mention some positives that have been shown in respect of prevention. In relation to breast cancer, there is a positive in terms of breastfeeding. You will see from the Royal College of Physicians’s submission about early intervention that there is good evidence to show that breastfeeding reduces the risk of breast cancer. That evidence includes data from the Unicef “baby friendly” initiative. Breastfeeding could be viewed as a preventative measure against breast cancer that costs nothing but the mum providing milk for the baby.
We could reduce the risk of people developing a disease by pushing positive messages rather than the potentially negative message that says that we will catch people when they show early signs of a disease. A number of initiatives that are not specifically related to screening programmes could be positive preventative measures.
Another point to make about data collection is that there is little uniformity among health boards in terms of how data is collected. If you are going to ask a question that covers the country, it is important to ask the right question so that you not trying to draw data from answers that were provided for different reasons. It is also important to make collection of data easy and part of what is done routinely so that we do not employ people just for data collection, and that the information technology facilities that ensure that that happens are provided. Differences between health boards’ IT systems interfere with the reliability of data.
Breastfeeding is much more likely among the privileged classes, which is another reason to try to improve the economic welfare of the people at the bottom end. In my view, it is a bit cheeky to expect people who are really struggling, who are not well educated and who are not employed or do not have meaningful employment to adopt healthy lifestyles and to breastfeed. Anyone who has done it knows that breastfeeding is not easy. It is inconvenient at times, and if someone is trying to breastfeed fully their husband cannot just give a bottle. Having breastfed two children myself and having witnessed my daughter doing it recently, I know that it is something to which one has to be really committed. It is also very difficult to combine it with having a job. The idea that we can just get everyone to breastfeed when people are struggling and have major financial worries and housing problems is, I think, cheeky and unrealistic.
Good morning, panel. I am glad that Dr MacFadyen made that observation, because it feels slightly incongruous to me that we are looking at screening as part of our preventative agenda. For me, screening means catching things after they have happened, although it is early intervention. In political circles, we often conflate early intervention and prevention and think that they are the same thing; actually, we need to get to the issues before they get out of the traps. I guess that some screening could pick up DNA profiles that might show that people are more susceptible to certain conditions, which could be preventative.
My question relates to health inequalities. Dr Irvine articulated the issues well when she talked about communities in which breastfeeding is less likely because of social deprivation and various factors around that. I would like to explore the uptake of screening opportunities. We do not screen everybody: it is voluntary and nobody is mandated to be screened. As a result, the demographics will include a heavier weight of the worried well than of people from populations that are perhaps more at risk of some conditions, given their lifestyle factors. How do we fix that? A lot of time, energy and resource are spent on checking people who keep themselves pretty well anyway, who probably know how to check themselves for lumps and who are fine, whereas a nucleus of people in deprived communities, who do not necessarily open their mail and who do not see that there is an opportunity to be screened, do not take up the opportunity.
Are you basically asking me to advise how we could increase uptake of screening programmes among those who are at highest risk?
I suppose that I would backtrack and say that I do not want to promote screening generally unless there is a very sensitive and specific test. That brings us to the breast screening programme. In my opinion, it is not good enough. It creates some false negatives and a lot of false positives, so spending even more money, time and effort on trying to target the quarter of the population in which there would be a better return is not the way that I would go. I would emphasise primary prevention. Alex Cole-Hamilton hit the nail on the head when he said that screening is picking up disease that is already there, so it is what we call secondary prevention. That was outlined in the submission by my health board, NHS Greater Glasgow and Clyde. By the way, I need to remind everyone that I am not representing the views of my health board today, but am here as a consultant in my own right.
I would not want to go down the route of promoting screening; I would want to promote a healthy diet. I would not do that by telling people repeatedly what to eat and what not to eat, which is not working; I would do it by having a public health protective policy on, for example, trans fatty acids in chip fat. I would even regulate the amount of salt that is allowed to come out of the salt shaker in your chippy and I would regulate the amount of salt, sugar and fat in junk foods. We have far too many types of junk food to choose from and far too many types of alcohol that are available too close to us physically—we can buy it anywhere. People spend too many long hours in the pub. When the licensing laws were changed to make it easier to drink at all hours, I thought that that was one of the most bizarre things that the Scots could do. Given the existing problematic relationship that the Scots have with alcohol, why would we make it even easier to drink?
I believe in primary prevention, but I do not believe in relying on health education, which we know is not working because we can see the inequality gap getting wider. I believe in reducing the gap proactively using taxation and a range of other fiscal policies. There is a report by Chik Collins—“Working-class discourses of politics, policy and health: ‘I don’t smoke; I don’t drink. The only thing wrong with me is my health’”—which is about people who are unhealthy because they are poor and stressed. That approach is the way to go; I absolutely fervently believe that, and I am not going to change my mind.10:30
I have been in public health for 26 years. In 1989, I was doing my master of public health degree, and I had been in the UK for five years, having left Canada. I despaired when I heard the plan for Scotland in 1989—to hire an army of health improvement officers who would have no contact with patients and who would produce boxes of leaflets to be distributed to people who would not read them. The leaflets sit in general practice surgeries and often do not even get used. I despaired because I knew that the solution was meaningful employment, not complex benefit systems—meaningful employment through which people could live on the wage that they were paid. It is as simple as that.
You do not need to hire consultants like me; you just need to reduce the gap and everything will improve, including mental health and physical health. If you read “The Spirit Level”, you should be persuaded. If you have not read that book, you need to do so.
Wow! Thank you for that. That was very compelling. It is very much grist to the mill of members around the table who would like the committee to produce an obesity bill to tackle some of the practical issues that you describe.
As I said, your evidence is very compelling and I find that I have been educated by what you said about how, in some cases, screening may be a false flag. It may be a comfort blanket for politicians and the wider public to be able to say that decision makers are doing something about breast cancer when, actually, we are not. We are just spotting cancer in a few people; we are not preventing it in anybody. That was really helpful. Thank you.
I will just say one more thing about something that has bothered me slightly. When I looked at the routinely collected data for my health board, the most common medical elective diagnosis—that is, reason for admission—in all the medical elective work was breast cancer. It may only be 2 per cent of all the medical elective admissions, but we are talking about tens of thousands of admissions, of which the commonest was the medical elective for breast cancer. To me, that is a symptom of our focus on the breast screening programme and the general obsession with lumps. Unfortunately, breasts are lumpy, so if you become obsessed with trying to prevent every death from breast cancer, you end up treating a lot of lumps that do not need to be treated. You then get what I have just pointed out—breast cancer ends up being the commonest medical elective admission.
I submit that it will be difficult to measure the actual cost of the breast screening programme because you have to measure the cost of the lady coming in and being worried about it, having a lumpectomy that she does not need, taking time off work and so on. There is also the fact that it is difficult to feel the breast thereafter because there is a big scar on the breast where the lump has been taken out. All those costs are impossible to measure. That is why, overall, I concur with Margaret McCartney: apart from the financial costs of the screening programme, you have to measure all the other unforeseen costs, and there are impossible-to-measure costs.
I worry—in respect of breast screening and the health checks programme—about exactly the point that Alex Cole-Hamilton made. People who are at low risk present themselves—the healthy-attender effect—so we automatically think that we are doing some good, because we pick up stuff early. However, that would have happened anyway; people would have had good treatment. The problem with breast cancer screening and, to a certain extent, health checks, is overdiagnosis. Bona fide cancers that would never have progressed to being invasive cancers that would have done harm are diagnosed through the breast cancer screening programme. The problem is that if that effort is focused on women who are well-off and already have long life expectancy, you are putting into that group more resources that can then never reach other groups in society.
What was said earlier about true preventative healthcare is exactly right—it is outside healthcare. It is about social justice, fair food laws, tobacco laws, active commuting, being able to play outside with your kids knowing that you will not be run over by a car, safe places to work, fair laws and fair employment laws. It is about fair play from Atos Healthcare and the Department for Work and Pensions: the absolute carnage in the benefits system has created so much stress and hassle for my patients that I am daily heartbroken by its effect on people.
All those things have a profound effect on health, but I am unable to influence them as a GP. I am happy to come to the committee and tell you about them, but I would love to see the committee take flight and start to say that to get real preventative healthcare, we need far more than the NHS.
On discrepancies in uptake in screening and picking up on Helene Irvine’s point about education, I say that affluent people understand the health messages that we put out. In Glasgow, we developed campaigns to promote screening programmes, including the cervical cancer screening programme, which we tested on the least affluent people. What happens time and again is that there is lower uptake among the people who most need the programmes. There are wider influences at play that prevent the least affluent people from engaging with the programmes that we promote.
The only way to be effective is to have policies that make the right choices easy choices. With regard to breast screening, for example, we know that obesity is a factor that drives breast cancers, that breastfeeding is protective against them and that a number of cancers appear because of the amount of alcohol that women drink. There are, therefore, primary preventions or interventions that can be made. However, even if we have effective obesity policies that involve people having the right foods with reduced calorie density and the right nutrients, we will still in 20 years be arguing about whether it has made a difference, or about how much money we have spent, because if something does not appear, we cannot count it and we do not know what made a difference.
The reality is complex because it is hard to attribute causality to a lot of interventions. Aside from in the breast screening programme, we have seen that in screening programmes including triple A—abdominal aortic aneurysm—screening, for which we had randomised controlled trial evidence on its effectiveness. We put that programme in place in Scotland, but because of the changes in how we dealt with cardiovascular disease and the preventative agenda, we did not find the number of cases that we expected, luckily: the world had simply moved on.
The issue is how we get smart and understand that the world is constantly moving on, and that what we believe will deliver might not deliver in a new context, or might give us something very different to what we expect. We need a constant process of reassessing what we do and adjusting our efforts.
Can I add a point?
Ivan McKee focused on data-driven evidence. Although I spend most days analysing data—more so than most consultant colleagues, because I am particularly focused on data analysis and routinely collected data—I would accuse him of being excessively impressed by a data-driven approach. Some of this is just plain common sense. If we made it harder for people to eat rubbish and drink alcohol, a whole range of things would improve; for example, there would be less ischaemic heart disease and there would be lower incidence of about 15—maybe even 25—types of cancer. We also know that tobacco use causes about 25 to 30 different types of cancer and that obesity is a major risk factor for breast cancer, as Emilia Crighton has just said. If we reduce the ability of the public to eat rubbish and high-fat foods, we will improve health and reduce the incidence of a range of diseases. There would be no chance in heaven of measuring perfectly, or even remotely closely, what the impact would be, but if we were to improve the obesity situation, we would improve the situation in a range of diseases, including diabetes. I do not need a data-driven approach.
But we know that stuff only because the data tells us it.
I sense that you have seen the committee before, Dr Irvine.
Good morning. I have a supplementary question on a specific matter. I very much appreciate the points that you are making, Dr Irvine, but do you not agree that unhealthy lifestyles that involve a propensity to drink excessively and to eat poor food are in themselves symptoms of economic inequality, low pay, alienation—to use an old-fashioned word—and the dehumanising effect of precarious work? Simply removing access to cheap alcohol and food would not take away what motivates people to pursue those things. Can you comment on that problem and tension?
First, I point out to you that middle-class people also pig out and drink too much alcohol—and are doing so increasingly. It is therefore not just a problem of the poor and the unemployed. However, I agree generally, because I have always focused on the poverty issue first because it is about social injustice. That is why I keep banging on about “The Spirit Level”. We have to examine why living in this world is stressful and why a substantial minority are being left behind. That is how we should really tackle public health.
On top of reducing the gap between the rich and the poor as regards income, wealth, opportunity, education and so on, we also have to introduce a protective public health policy, which is why I am very proud of the Scots for beating the English in banning smoking in public places. That was a fantastic piece of legislation, and we did it first in Scotland.
We have to use a number of approaches, including good-quality health education that is available nationally, and GPs promoting healthy lifestyles and identifying high-risk patients. However, our priority has to be reduction of the gap in income and wealth, and we must never forget that. If we do, we will end up going off at a bunch of tangents—which is what we are doing at the moment in having lots of different initiatives that give us a low return on our investment.
I am interested in the bias towards screening programmes and interventions. As a paediatrician, I am a glass-half-full person and have a lot of faith in children. We have seen preventive health initiatives that have worked because children and young people have adopted them. Taking the approach that, as well as the state helping and supporting them, everyone can help themselves, has a lot of potential.
The so-called “worried well” often miss the risks and benefits of the decisions that they make. Margaret McCartney commented earlier on giving people facts about the risks of interventions and screening programmes as well as about the potential benefits. From my perspective as a paediatrician, I see worried parents of children who are in various states from wellness to illness. Very often, giving facts on the benefits and risks of an intervention is important—and not just going for the programme that offers an intervention itself.
The Scottish initiative of the daily mile in schools has been an enormous success and has applied to all children in all social groups. I see children and young people for whom giving them the respect to make the right decision for their own needs has had a hugely positive impact on their self-esteem and self-confidence and, in turn, their potential to be peer supporters of other young people to make change happen from the inside out. An example from some years ago is what Bathgate academy’s pupils did in changing the attitude of their entire school to keeping themselves fit, because they owned the programme and took it forward for themselves. There are a lot of areas in which a different attitude towards preventive health could reap benefits for possibly a lot less cost than some of the major programmes that are in place at present.
I want to pick up on the argument about environment and poverty driving people to drink excessively. As regards alcohol consumption, the most affluent people drink just as much as the least affluent people, yet we know that a male in the least affluent decile is 16 times more likely to die from that than is a person in the most affluent category. Unhealthy behaviours are pervasive in society.
It would be remiss of me not to mention the problem that we have in Glasgow with drugs including heroin and the new psychotropes. People who are fairly close to me have experienced the deaths of very young people in their families. From looking at the evidence, I say that what works is offering young people alternatives. Una MacFadyen mentioned giving people the choice to do something different. If we look at the example of Iceland, we can see that the authorities simply engage families and children in alternatives that they are interested in—for some that might be sport and for others it might be cultural activities. We need to create an environment that engages people in something that they care about and in which they really want to participate. Food needs to be the right food and not the junk that people get at counters, and alcohol has to be more expensive. Through the school survey in Glasgow, we have seen that the least affluent children now buy less alcohol, because they do not have enough pocket money. Therefore the approach is about having the right policies as well.
We are extremely tight for time this morning, so I ask for short and sharp questions and answers.10:45
I am interested in the tension between data-driven, evidence-based medicine and the “intuitively sensible” approach, which I think is an issue throughout medicine but particularly in public health. A number of people have questioned the flu vaccine, and a Cochrane review a few years ago asked how much difference it had made to our health, but Helene Irvine said that the programme is “intuitively sensible”.
Why would we take an approach to a vaccine that is different from our approach to a screening programme, about which lots of questions have been raised? Is it because the costs of vaccination are less? There is the cost of the drug, but little clinical harm is done to people who get a flu vaccine unnecessarily. There is also an opportunity cost to giving the vaccine. Does Dr Irvine or Dr McCartney have any thoughts on that?
The flu vaccine is different from a vaccine such as the measles, mumps and rubella vaccine, because flu changes every year and we have to predict what the flu outbreak will be like—
And sometimes the vaccine is not at all effective.
That is right, and that is the problem. Vaccines such as MMR are highly effective, but there are legitimate questions to be asked about flu vaccination. There is high-quality evidence that people with significant underlying lung disease are far more likely to benefit from vaccination—a person who has really bad chronic bronchitis is very likely to benefit. However, the group that I worry about is healthy adults who just happen to be older. I worry that GPs get payments for hitting vaccination targets, as opposed to offering an informed choice about vaccination. It should be the GP’s job to say, “Here’s an intervention, and these are the pros and cons; what would you like to do?” We should not be paid to do more, when some people do not want the vaccination, for all sorts of reasons.
The decision that has to be made outwith the general practitioner’s person-to-person discussion is about what the Scottish Government is willing to fund and whether the best use of resources is an intervention for everyone, or our doctors and nurses doing something better with their time.
Like many GPs, I start early and finish late, to give a little more time to every patient, and I want to use that time to talk to the patient about what is important to them. I want a dialogue, as opposed to a directed approach, where I have to say, “It’s time for your vaccination now.” A person might say, “I just want to talk about the death of my father”, “I am worried about this symptom” or “I am concerned that my depression is coming back”.
It is hard to capture that kind of nuance when we are talking about opportunity cost, but I am worried that we are almost turning general practice into a factory setting where everyone automatically gets the same thing, rather than a high-quality choice.
A couple of people said in their submissions that the accident and emergency four-hour target had directed attention at A and E. When Harry Burns came to talk to the committee about targets, we all agreed that there are problems with some of the targets. However, that particular target seemed to be quite useful. It is a kind of canary in the mine: it tells us something about what is happening in the A and E, which also tells us about the health of the whole system. For example, it tells us who is coming in for unscheduled care, how many such cases appear and where in the hospital people are moved on to. The four-hour target seems to me to be reasonably useful, compared with some of the other targets. What are the witnesses’ thoughts on that?
The four-hour target seems rather illogical on its own. That takes me back to the issue of knowing what question one wants to answer, which is important. If we do not set the questions beforehand, the data from the four-hour target simply tell us how many people are seen within four hours. If the people who are seen did not need to be at A and E in the first place, having a four-hour target is meaningless. If we work back from there, we can ask, “Is the target all that we need or is there something more to that?”
I work as a hospital doctor, and I see many people who could have been seen in another way, which has led me to ask how people are advised to find help with their health. We have been hearing a lot about GPs; there are other people who can answer some of the questions that end up with someone coming to an emergency department. Someone might say, “I have a headache but no paracetamol” and then go to the hospital for their paracetamol, which seems completely illogical until we realise that that is the only place where the person knows that they can get help when they do not feel well.
We must ensure that young people—I am talking about young people again—are aware of how to look after their health and deal with their symptoms. That might be an important aspect of looking at the ED four-hour target. I do not know why four hours is seen as the magic number. As a doctor, I think that clinical priority is much more important than the number of minutes or hours for which somebody waits to be seen.
We know that when emergency departments are busy, the mortality rate among people who attend hospital increases. We need to find a balance by providing the right venues for people to attend when they need care.
Targets are set arbitrarily. If we have targets, we tend to find ways to manage the target rather than the patient. We need to take a whole-system approach, as Una MacFadyen said, to ensure that we see the right people in the right place rather than just being mindful of our target.
The four-hour target was introduced in 2007. It was useful at that time because it attracted attention to unscheduled care and to A and E in particular. It encouraged hospitals to invest in their A and E service, to hire more staff and so on. The quality of the service improved and the waiting time experience improved dramatically.
Between 2007 and 2010, compliance performance in Scotland, including in our health board, was excellent, but thereafter it deteriorated. In our health board, it deteriorated markedly, with extremely low troughs—going down to 70 per cent, for instance. Now we are starting to go back to those really appalling statistics.
The collapse of the four-hour A and E target reflects the inadequacy of community-based services. If you ignore the alarm bells when they keep going off intermittently, and every winter in particular, and you do not address the inadequacy of social care for the elderly, district nursing, GPs and other community-based services, what is the point of continuing to measure progress against the four-hour target? You are not addressing the root cause of the problem; you simply hire more A and E consultants, as we have been doing for many years. I am not a fan of the target any more—it has outlived its usefulness.
My final question is on breastfeeding, so I am delighted that Una MacFadyen raised the subject. Breastfeeding has been implicated in preventing many of the illnesses and conditions that we have discussed today, including breast cancer and obesity.
When the topic of breastfeeding was raised, I immediately thought of the graph in the NHS Greater Glasgow and Clyde submission that highlights lifestyle drift. Interventions tend to focus on education and on telling people that they should breastfeed, rather than on addressing the issues that may prevent us from creating a culture in which breastfeeding is easier, as it is in some of the Scandinavian countries where the regulation of marketing is tighter and economic inequality is less acute. I would be interested to hear your thoughts on whether we could take action other than in the field of education to improve breastfeeding rates.
There are a lot of things that we could do. I work in neonatal care, so I see a lot of babies and their mums, and I believe that it is imperative that one-to-one support is provided for a mum who is trying to breastfeed. That is the intervention that makes the biggest difference. That leads us on to think about health economics and the need to have people who can support mothers in the community: not only professional health visitors but peer supporters.
In Scotland, it has been quite a challenge to change the culture. In wartime, women were encouraged to go out to work and to bottle feed with national dried milk. That culture is now two generations old, and it takes a long time to change. At that time, the media—which are now involved even more actively in the debate—promoted formula feeding because women were needed at work. To move away from that, and to see that formula is not the best way to feed a baby, means a whole culture changing its beliefs. There is a great need for that.
We should not accept social discrimination between different income groups as a given. A lot of women in lower socioeconomic groups would love to breastfeed if they were given the support to do so, and we should be targeting those groups. It is like the daily mile initiative: if we assume that one group of people will not breastfeed, they will not do so. We may need to look at targeting through extra input to encourage the positive benefits and to let people enjoy breastfeeding their babies, which is what it is all about. Those babies will be the next generation, who we hope will be healthier and less obese, which will improve the Scottish economy.
We have to move on. We have five people waiting to ask questions and five minutes left.
Given the prominence of false positives in screening, in the discussions that occur between screening and intervention, to what extent is realistic medicine being practised? Could you comment on the cultural drivers of demand within healthcare and the preventative agenda? What role in altering those cultural demands do health boards and the Government have?
Is that question for me?
It is for anyone.
I am concerned that the invitations and adverts for screening always emphasise the importance of attending screening. They do not encourage shared decision-making. They do not encourage people to make a decision that is based on their values and what they would prefer to do. That is the biggest cultural problem. GPs are trained to believe in patient autonomy and in giving people good information on which they can base their decisions, but the invitations are sent from a central agency with my name on them. Invitations essentially say, “Dr McCartney says that it is time for your cervical screening and you have to come along for it now” without giving people information about the potential for false positives and overtreatment.
Women who want to have cervical screening should absolutely be supported to do so, but we have to be respectful of people who, for whatever reason, have decided that they do not want to have it. I do not think that that is embedded in the current system.
I have a comment on the “Realising Realistic Medicine” report, which is a positive document that has been positively received, in relation to antibiotic treatment. You asked about the pros and cons about how information is presented. There is huge potential to change people’s demands on the health service by allowing them to truly understand the benefits and the risks of the treatment that they might think would be right for them. People can change their attitudes, but it takes time and it takes person-to-person interaction. One-to-one contact, with media back-up, is an effective way to go. Media alone will not be enough. If someone asks for an antibiotic and they are told that it might give them a tummy upset and cause resistant organisms, and that they probably have a viral illness that will not respond anyway, most of them go for not having an antibiotic. However, it does take that brief discussion to make sense of it. How would anyone understand if we did not give them that explanation?
There is good evidence that someone who has a continuous relationship with their healthcare professional is more likely to be satisfied with their care and less likely to increase costs. Their care is cheaper because they have fewer interventions and, overall, people prefer it.
There is some wonderful material in the “Realising Realistic Medicine” reports, but I am concerned that there is a bit of a conflicting message, in that the Government has encouraged the concept of screening generally and encouraged people to go and see their GP at the drop of a hat, including if they have a cough for more than three weeks. I have had a cough for something like eight weeks. I get it every winter, I have had it for many years now and I certainly do not go the GP about it.
I worry that, with one voice, we encourage people to become a little bit health neurotic and look for disease and worry that every time they have a lump or a bump or a sniffle, there is something seriously wrong with them, and then we issue a document that says that we need to start practising realistic medicine. It is a bit late now. We have a huge cultural demand that will be hard to put back in the bottle. Governments have to take some responsibility for that, particularly south of the border, where they encouraged people to screen for depression and we saw an increase in the prescribing of antidepressants. We encouraged people to screen for prostate cancer and get prostate-specific antigen tests done when we know it is not a good idea to screen the general male population for PSA. The Government has to be consistent now and in the future, otherwise we will not get away from the problems that we are experiencing.
One of the things that has come out of everyone’s submissions this morning is the need for behaviour change around preventative medicine and the agenda of preventative healthcare. Dr Irvine highlighted meaningful employment and how that could help to solve the problems that we are facing. Obviously, the education system has a key role to play in giving kids the currency to trade in the marketplace through their qualifications. Do we need to reconfigure our understanding of health education, and do we need to look at behaviour change in the education system to help close the attainment gap between the poorest and the richest kids?11:00
The daily mile, which Dr MacFadyen highlighted, is all well and good, but we need to join up physical activity in schools, whether that is physical education or whatever, with the theory behind it. We might, for example, use modern studies to look at social inequality and link behaviour change with that, and we could also look at food education. Does the panel have any views on whether the education system can play a role in the preventative agenda?
I was looking at curriculum for excellence just before I came to this meeting, and I think that there is huge potential to incorporate in the curriculum more about keeping your own health as it should be. Certain big topics, such as sexual health, will be presented in a number of ways, but the one-to-one approach—I guess that it would be called respect for the individual—is very important in relation to health.
Indeed, in a recent survey that they carried out with the Scottish Government, young people themselves identified their mental health as a concern. That population is saying, “I want help”, and we should be ready to address that and go with what people feel they want. After all, behaviour change happens when you want to be helped, and that brings us back to listening to users as much as seeking to impose a service on people from the outside. I think that Emilia Crighton, too, talked about addressing the issues that people want to know about.
With regard to the role that education can play, we must have the right environments, and they must be in place very early on. We carry out vision screening in children’s pre-school year and the orthoptics people came back from the east end of Glasgow and said, “You know, there are children who can’t name common objects.” How do we ensure that children who reach school age have the cognitive ability to engage with the education system? The answer is to have a pre-school system that is available to all children, particularly those from the least affluent backgrounds; we need them to get bedtime stories, for example. We need to engage and give support to families very early on, because by the time the children are 10 or 11, it is a bit too late.
I suppose that my question is whether there is a role for the health service, GPs or someone from the healthcare industry to come into schools and speak more readily to children about accessing the appropriate healthcare professionals. After all, one of the key points that has been highlighted this morning is folk going to A and E when they do not need to. If we want to change behaviour, is the answer not to get to the next generation and to teach those behaviours accordingly? If so, do you think that there is a role for the healthcare industry to have more of an input? For example, Medics Against Violence goes into secondary schools in Glasgow and across the country to speak to pupils about its work, and that helps to develop understanding. Is there a case for having a better link between health and education in that respect?
In theory, yes. You can teach children to do anything you want. However, you have to remember that the curriculum is already very tight. As you will have read in today’s Herald, there are difficulties in teaching, what with the pressures with regard to budgets, achievement and so on, and I think that it is a bit utopian to think that we can teach the general public at a very early age how to use the NHS.
As for the abuse of A and E, Tayside has cracked that issue with its redirection policy. People who go in get triaged by a nurse, who might say, “You are not really supposed to use the A and E for this. Go and use the pharmacy instead—this is where it’s located at this hour.” They might be told to go and see their GP the next morning, and the GP will be geared up to take them. As a result, the A and E attendance rates in Tayside are a fraction of those in our health board.
You therefore do not need to teach all children at school not to abuse A and E; with a redirection policy, you can teach the patient themselves the very first time that they do so. In fact, I believe that that is the direction in which Scottish A and E departments will increasingly be moving—out of necessity, it has to be said, because we simply cannot cope with unnecessary attendances.
Just to add—
Please be very brief, because we have to move on.
Instead of young people waiting to go to A and E, school nurses are a force that could be utilised to help young people feel confident about using health services. I think that it is unfair on young people to expect them to know how to use the NHS in what we would see as an appropriate way either by instinct or through following what their parents have always done.
Following on from Jenny Gilruth’s questions about education, I wonder whether we can look at methods of communicating preventative health messages to the public. A range of things have been done; we all remember the striking and powerful national advertising campaigns and we all know about the posters in GP surgeries and the use of social media. In a sentence, can you tell us what we are doing right and what we are doing wrong, particularly in reaching the unworried unwell in perhaps highly deprived communities who might not have access to the internet or ready access to broadcast media?
I would always say, “Use the children.” For example, our smoke busters programme in Stirling was the most effective force in stopping smoking in public places before the legislation that banned it came in. If children know and believe a message, they will get it to their parents, so perhaps one way of doing this is to start young.
What we do right in Scotland is have the right policies. We have been brave enough to ban smoking in public places and to support minimum alcohol pricing, so we have to be brave enough to say, “These are the right foods that you need to eat”. The industry will follow. We have already seen the readjustment of the sugar content in soft drinks on the back of the sugar tax. What we need is policy that affects everyone instead of having to rely on the intelligent processing of information that has to be available and then enabling these things through behaviours.
I actually think that most people know that they should be eating, say, more fruit and vegetables, but they do not like them or they are not used to eating them; their parents never gave them any, so they do not have the palate for them. We encourage people to consume more healthy food by making it cheaper and making not so healthy food more expensive. We should be taxing junk food and subsidising fruit, vegetables and, indeed, wholemeal bread. Imagine how many people would eat wholemeal bread if it cost 15p and white bread cost £1.20.
We need evidence-based policy making, which means doing some things right and some things wrong. Everything should be driven by evidence, and we should get rid of stuff that does not work. The staff in the NHS love working there and are driven by their vocation, but that keeps getting subverted by our being asked to do stuff that is wrong and ineffective.
In response to our question about the preventative agenda, Dr Irvine says in her submission:
“The implication in the question is that there are wonderful initiatives out there that prevent ill health and premature death but we simply can’t measure their cost-effectiveness and we need to try harder to demonstrate their existence and their value for money. The truth is that the wonderful initiative is staring us in the face: equalise opportunity and reduce the income/wealth gap. Use existing powers to do so.”
I could not agree with that more. All the issues that lie outside health—structural change in the economy, fair work, fair pay and all of that stuff—are the very ones that we have to tackle. Have you seen any evidence of that happening?
No, and I am distressed by how little people talk about it. I feel ostracised and a bit of an oddball for raising the issue, but I feel that it is my job to do so and I am not going to stop doing it for the rest of my career. This is an absolutely essential point, and my fervent belief comes from being brought up in Canada under Pierre Elliott Trudeau in the 1960s and 1970s—I was born in 1957—when the gap between rich and poor was very narrow. I will never forget Canada in those days and how it changed as we went into the 1980s, which is when I decided to leave and come to the UK. We have to reduce that gap and show commitment to young people.
I am a product of that attitude. I do not think that I would be what I am now if I was born in Canada today, because it is now much more like America, with a bigger gap between rich and poor. Reducing that gap is the way to go, and if we continue to tolerate huge accumulations of wealth by a tiny minority, we are just going to have more and more problems. We do not have enough millions of pounds available in the public sector to rectify that situation, and you cannot solve it through health promotion or health screening. None of that will work, but reducing that gap has to be the priority.
It is a very difficult question. Despite our best efforts, we are not closing that gap. However, what we in an equal society can do to narrow it is to provide education very early on, and there is good evidence that neighbourhood-based education in the first years of life promotes social mobility. That is the one thing that we can do.
Is that you abandoning any willingness to have redistribution?
I sincerely hope that that will come. Some measures have been put in place, but we need to be bolder. It is not the final solution, because we will require vaccination programmes and many other things in addition.
Finally, would you still get rid of screening even if money was no object?
Yes, but we should keep targeted screening for higher-risk women.
The problem, though, is that you would still be creating avoidable harm, which is something that we want to get rid of. We can always spend the money on something better.
Screening for babies is a different issue. Please do not take all screening away.
Many screening programmes are worth while, and I would continue with them even if there were not a lot of money.
Let us say that we allowed individuals to do whatever they pleased. In the States, there are huge disparities because the wealthy think that, on balance, they can afford to have their mammograph every year as opposed to the three-yearly programme that the UK offers; actually, most countries offer mammography every two years. We need to be critical of what we offer and to whom we offer it, but allowing a free-for-all would widen the inequality gap even more.
Thank you very much for your attendance. I really welcome this session, because having these kinds of challenging submissions and discussions is healthy.
I suspend the meeting briefly to change the panel.11:10 Meeting suspended.
11:13 On resuming—