Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 440 - 459)



  440. Can I explore your views on the location of the public health function? I am sure you are aware that there has been much discussion within the inquiry so far in the formal sessions we have had about whether the current location of public health within health authorities is the most appropriate location. Some of us recall the local government involvement with public health some years ago and the worry I have had is the way in which, to some extent, the function has been sidelined and become a science rather than a concern with the practical driving forward. What generally are your views on the current location? Perhaps at some point, Dr Crowley, we can explore with you the Newcastle situation but in general terms what are your views about the current location and future possible options in relation to the public health function as such?
  (Dr Archard) The view of the College is that the current positioning of public health services in health authorities does tend to be distanced from primary care and distanced from those people at the coal face who are trying to facilitate the agenda. There is no doubt that if this came closer to the primary care organisations, primary care groups and care trusts, this would be seen as a much more main line practice for primary care. One of the problems of that of course is that some of the sizes of primary care groups in particular are that small that they could be seen to be perhaps not being able to represent a global view or support a global view of public health. Having said that, I am in a very small PCG, one of the smallest in the country; yet, we have an area of social deprivation which has a lot of public health input with great success. It almost needs to be on two levels: firstly, there needs to be a more global level which is very much more associated with health improvement plans and then you have a more local level of public health which will be more associated with primary care organisations.
  (Professor Drinkwater) My view and the Alliance view on this would be yes, with qualifications. There are some issues in terms of the location of the function is less important than how it actually operates. The Alliance view would be that good public health is very much dependent on the involvement of both the public and front line health professionals. Health authorities have not always been as good as they might have been in terms of engaging with the public and with front line professionals. There are some issues about that that you very rightly raise. I think it then comes back to there are different functions at different levels. Clearly, there is a public health function at the national level, if you like, which is about regulation and safety including food safety. That would have to take place at the national level around regulation. There is a bit below that which is regional and that might be public health observatories, epidemiology, comparative data and somebody who is collecting all of that data and handling all of that data. There is a subregional bit and I have not called it health authority because I think it is subregional rather than health authority; infectious disease control, commissioning, evidence and information. The crucial bit and the bit that I personally am most interested in is the bit at the local level, at the PCG/PCT. There are some real opportunities around the current restructuring, around PCTs and local authorities and community plans that, if we can get that right, then there are some opportunities around a real inter-agency way forward, around delivering locally responsive services that meet the needs of local communities and really engage at that level with front line professionals and with the public. That is the critical bit. There are some concerns that, as the system changes and as we move to PCTs, if PCTs get caught up in becoming mini-health authorities, they will still operate a very medical model rather than a social model and just a concern that we need to invest in that social model of health at the locality level.
  (Ms Jackson) The CPHVA would see public health departments being too far removed given the situation with health authorities. We would like to see them coming much closer together with PCGs and PCTs, essentially to effect communication. Communication should be two way. We want to move away from science model to a more social model. The two way communication would facilitate that. It is using nursing information as health intelligence to inform those assessment processes because at the moment we feel they tend to be top down from public health departments.
  (Ms Amadi) I would agree.

  441. Ms Amadi, I was about to ask your organisation. I would imagine you have had the experience of working within a local authority structure, but I have talked to health visitors who worked pre-1974 in the local authority structure, who felt far more able to influence the wider public health factors affecting the lives of the people they were dealing with than they have been subsequently because of that separation from local government. Is that an issue that you have given any thought to, on issues like housing, for example? Within the same organisation that is responsible for housing provision, some people I have spoken to felt that the older arrangement made more sense from their point of view.
  (Ms Amadi) Yes, a more similar arrangement where there are less boundaries and less bureaucratic processes involved would help the work of community practitioners in terms of fulfilling public health functions and working with the community, communicating with the community. It is going to be a much more straightforward process of effecting change if there are those links.

  442. The issue of the future role of DHAs is an interesting question with PCTs. How do you see the future role of the DHA, particularly as it relates to public health, if there are no fundamental changes brought in by the government and we are not in a position to say what this Committee will be recommending at this stage obviously, but how do you see the future role of the DHA operating within the new climate where the PCTs are emerging and with the concept of care trusts? Any thoughts?
  (Dr Heath) From my perspective, they would appear to be pretty largely doomed.

  443. If they are, which is certainly the picture that I get, does that not open up opportunities to look quite radically at the future placement of future public health functions?
  (Dr Heath) Absolutely.

  444. Therefore, what should we do about it?
  (Dr Heath) We would concur that the very placement of public health within health of any nature, directly within health, perpetuates the notion that public health is a health care related topic, which I think we would all agree it is not. Therefore, I share your nostalgia and fond memories of the situation prior to 1974. I wanted to make a point about the two different dimensions of public health, one of which is health protection which can be delivered at all the levels that Chris talked about, which is to do with the care of populations, which is very largely outside the health care service; and then there is the issue of health promotion, much of which has to be delivered to individuals on the basis of trust and therefore grows naturally out of the delivery of personal medical services. It is at that point that public health and primary care services come very close together, but there is a whole other arena. Now we are in a situation where, for example, housing managers are delivering a substantial proportion of the daily care to the chronically mentally ill at a complete distance from the health care services. If public health were placed closer to those sort of factors that have such a strong influence on the health of the most vulnerable, that would be a very positive move.

  445. Dr Crowley, you have a particular example in Newcastle of what you have tried to achieve. How does that relate to the future structures, as far as you see them? Having read in some detail the evidence you have given us, which was of great interest, would it be fair to say that you have had to create structures because the current formal arrangements did not work, or is that an unfair criticism of the background to what you have done?
  (Dr Crowley) We are talking about a very different context six years ago when we started down the route of creating links between primary care and the communities that they serve in an organised fashion. At that time, the structures were only emerging whereby primary care began to look at things a bit more collectively. We had a locality commissioning model in Newcastle alongside fund holding and that created an opportunity for dialogue across that interface that we were able to develop and nurture. For me, the new structures of primary care groups and primary care trusts strengthen the opportunities for alliances between local communities and front line staff and organised primary care in that way. My worry however is that the move from primary care groups to trusts could debilitate the kind of partnership working that certainly we have developed in Newcastle at PCG level which is more local clearly than a primary care trust city wide level. We have been working a lot with the primary care organisations to ensure that that is addressed in the design of the primary care trusts with strong locality focuses.

  446. Could you be specific about why you see that change possibly damaging what you have done?
  (Dr Crowley) The danger is that the primary care trust could become a distant bureaucracy at city wide level. While some communities of interest and identity that we work with are organised on a city wide basis, many communities have a sense of community very much more local than that. With the new responsibilities the primary care trusts will have and the new statutory requirements about how decisions will be made, the ability to penetrate that decision making could be weakened in comparison to the kind of local arrangements we have developed in Newcastle, where primary care groups have had accountable representation from local communities on their primary care boards, where we have had annual conferences with broad ranges of communities and front line staff and primary care managers and practitioners coming together to prioritise the public health agenda for their locality. We are keen that that locality focus is retained and I think the trust proposal from Newcastle demonstrates the equipment to maintain that.

  447. Speculating about the future models and the possible demise of health authorities, the role of local government, do you see from your experience any potential for change that would enhance the work you have been able to do within the structure that you have created?
  (Dr Crowley) I would hope so. The commitment in the NHS plan and in local government, the Local Government Act, for local government to take more responsibility for the wellbeing and health and then scrutiny of health hopefully will bring health back on the local authority agenda, which in our experience it has drifted off in those intervening years. Clearly, from a community perspective, we would be very keen for that to happen because a lot of the issues that communities will seek to address, public health issues, will not be addressed without strong partnership with local government.

Mrs Roe

  448. Dr Heath, would you not agree that GPs and other primary carers already carry out a great deal of the day to day public health work? Would you tell us whether you think that the current incentive systems actually discourage them from doing more?
  (Dr Heath) I always have a bit of a semantic problem in that I cannot conceive of public health being anything more than the health of all the individuals that make up the population. Somehow, that sometimes seems to be lost and it takes on an autonomous existence of its own as public health separated from the individuals. I think we do an enormous amount. There are problems in that we are now being set extraordinarily high standards for responsiveness around personal medical services in terms of access to people who believe themselves to be sick. Unless we respond properly and effectively to those, which will always be as working general practitioners our number one commitment, we will lose the trust of the patients which enables us to engage them in health promotion initiatives around taking medication to prevent future disease, around accepting immunisations, around altering their lifestyles. Those sorts of things you cannot do if you are not actually providing a decent service for their self-expressed needs. There will always be a balance and a tension between those two things. I think we could do enormously much more if we had closer links with other agencies in the community and if we had more ready access to public health expertise. At the moment, we have no way. We now understand how powerful the socio-economic determents of health are and yet we continue to practise where we take a history that ignores them. We ask about smoking but we do not ask routinely about housing stress. We may ask; we hold a lot of knowledge but we have no way of recording these things. We have no way using the huge knowledge base within general practice to inform the delivery of public health more widely. We know who the most vulnerable people are from our day to day knowledge because we have more contact than any other professional group, but it is making that transition, sharing that information and that knowledge that does not yet happen.

  449. Would you say that primary care trusts would be better suited to trying to drive up the actual quality of primary medical care, rather than trying to deliver the public health agenda too? Do you think primary care is equipped to take on public health responsibilities?
  (Dr Heath) I very much do. What I am trying to argue is you cannot have one without the other. The two go hand in hand. They are deeply enmeshed. The structures need to recognise that more clearly.
  (Professor Drinkwater) I wanted to focus a little on the issue of incentives but also around inequalities in health. The incentives issue historically, if we go back to the 1990 general practice contract with health promotion clinics, the Alliance view on that would be that that was a total disaster in that it reinforced the inverse care law in the GPs were funded to run health promotion clinics. It was very easy for GPs in the leafy suburbs to do that because everyone wanted to come along for a health check but in the inner cities nobody turned up, so in effect more money ended up going to the better off practices rather than the practices that were really struggling in areas of social disadvantage. There is a major issue in terms of you have to be very thoughtful about how you put incentives into place, or you may find out that they are perverse incentives and do not do what you want them to do. That is one key point. The other point goes back to this issue of inequalities in health and incentives and what is the public health function within primary care. If you look at areas where there are high levels of social disadvantage, inequalities in health, those are precisely the areas where practices are struggling because of the demands that are made on them. They have a much heavier workload and we still have not addressed the issues in terms of ensuring that resources are equally distributed and that those practices in areas of inequality get sufficient resources to meet needs within that area. There are some issues in terms of you need an enhanced public health function within those areas, which is about people on the ground, working with local communities, because I think that is where you have the greatest opportunity to make a difference and to produce real health gain. It is very, very important that we do actually address that issue.

Siobhain McDonagh

  450. I am new to this Committee and this is a bit of a bee in my bonnet about GPs. It strikes me that GPs are removing themselves from the community rather than becoming more involved in it. Clearly there are notable exceptions and they really stand out. They tend to be perversely single handed GPs who become involved in that whole issue of their locality, the greater needs of their patients, and I looked at your submission and the three examples you gave of GPs in practices being involved in public health care. Examples two and three were just brilliant, except in my constituency I do not ever see any of those examples. I get to the stage where I beg GP practices to use some of the information and knowledge they have to encourage the council or any other public body to do things in a particular way, but I find it very difficult to do that.
  (Dr Archard) There is inevitably going to be a spectrum of commitment and a spectrum of quality within general practice, as in any profession. I would probably take issue with your submission that general practitioners are removing themselves from the community. I think exactly the contrary is happening, particularly with the advent of primary care organisations. This has given general practitioner as well as practices an enormous opportunity, which in my own primary care group has been grasped by almost every practitioner within the PCG, to move towards a community focus rather than an individual practice focus. It has been quite remarkable, the change around in attitude from a competitive attitude to a cooperative attitude with the introduction of PCGs. In particularly, although I do practise in a leafy suburb, there is one area of quite marked social deprivation in which practitioners have got together with other agencies and have made an enormous difference to public health in that area. For example, last week in the schools there was a fruit week and each child was given five pieces of fruit a day which had been begged from the local fruit stalls. It was a remarkable success. Children were eating fruits they had never seen before. That is the sort of aspect of public health which has been promoted by primary care groups and trusts no doubt, but as trusts become larger it is very difficult to keep that focus with a very small group. This is one school. I would disagree with you. I do not think that general practitioners are becoming more removed and I think primary care organisations have done an awful lot to make them more generous than they were before. The additional pressures, workload and consultancy rate and so on within general practice sometimes demands that practitioners have not been able to give as much time outside practice as they had previously been able to do.

John Austin

  451. Dr Archard and Dr Heath, in the written evidence the Alliance are saying that because the PCTs will be heavily involved in developing robust and effective commissioning in government structures that in itself will mean they will not put weight on public health capacity and will not have time to devote to inter-agency working etc., and that the public health agenda will be lost. Do you share the Alliance's view on that?
  (Dr Heath) I think we do share the Alliance's anxieties that these will be bigger structures; they will be more bureaucratised; there will be less direct input from people working in the front line of health or social care directly into this decision making. There is also a shame in areas like mine. PCGs have been slow to become established for reasons of demoralisation and work pressure and people feeling ground down by the circumstances that prevail now in some deprived inner city areas. It has taken a lot of time to get the involvement of people in the PCG and it has not had a chance to run and we have to become a PCT. That feels like a lost opportunity for development, learning and change that is very locally based, and that we will be subsumed into a PCT and back to having a health authority.


  452. Going back to the Royal College evidence, I was interested that you stated, "As primary care trusts are created there is a risk that public health physicians will become isolated in health authorities." I put a note when I read it saying, "In my view, they already are." Taking up Siobhan's point, I had an example a couple of years ago, when my constituency was reorganised with the kindness of the Boundary Commission, which put me within two different local authority and health authority areas. I met some GPs in one part and said I had been very impressed with the public health people working in the health authority. They did not even know their names. I found that astonishing. There was no connection whatsoever between primary care and public health. I am a bit surprised to see that you feel they would become isolated, because—
  (Dr Heath) Because they have been involved in PCGs, they have become a little less isolated in the interim. There is a fear of a return but the whole corporatisation of public health within health authorities with completely different agendas from their traditional ones has been very concerning for people working directly with patients.
  (Dr Crowley) You can see the involvement of primary care and GPs and the local issues at different levels. I would agree that there is no other service in the list of public services with the amount of contact with local people that primary care has. The potential for that contact to be built on is largely unrealised because of the time issue of delivering what primary care has to deliver. The possibilities around linking into benefits maximisation, which we have done a bit of in Newcastle, and many other services which could link in and create access to are currently poorly accessed by certain excluded communities is unrealised. Primary care organisations have allowed some of the time that is lacking in primary care because of the resources that have come in to fund people to fulfil roles to then come out of their practices for a while and create some of these partnerships. Certainly we have noticed a significant difference.
  (Ms Jackson) Coming back to the point of public health knowledge within general practice, what we would like to see is integration of information systems within primary care because there are other workers within primary care setting. Health visitors, school nurses and other community nurses are out there with the community, working with them and for them everyday. Currently, their information is separate from general practice information. General practice information tends to be fairly quantitative and can identify an issue; whereas it is the nursing information, the qualitative information, that can identify why a particular issue is arising. It is about painting the whole picture within primary care.

Mr Burns

  453. Professor Drinkwater, do you think that the development of PCTs realistically can be expected to make a difference to the contribution made by primary care to public health?
  (Professor Drinkwater) It is an enormous opportunity and if we miss this opportunity we will have failed. The opportunity is essentially, if we can get it right, around the inter-agency mix and a more partnership, corporate approach between practices which will cover a whole range of things. One of the issues in terms of our own particular patch, Newcastle West PCG, is we run an out of hours service in that patch. That was a very good way of getting the GPs together and the GPs beginning to look at what they collectively were doing and to work much more corporately. There are lots of opportunities for practices to work more corporately rather than work in competition with one another. That is an important thing to hang onto. There are also some key opportunities that we need to take advantage of around the information systems at locality level and I would share the CPHVA's concern about records being dispersed in all sorts of bits of the system. In our patch, we have a specialist nurse, child and adolescent mental health service. One of the issues about that is a number of children are being seen by different agencies without any of the agencies being aware that they are each seeing them. It is a very wasteful system. The patients who are subject to that system do not know who they are seeing, why they are seeing them and so there is a major opportunity in terms of getting it right at locality level. I would still argue that locality level probably has to be around the 100,000, because there are some issues about the size of a patch that can deliver services where the professionals can work together and support one another and where you get continuity within the professionals. There are some issues about where general practice is at the moment. There are some dangers and threats to continuity. If you talk to the public and patients, what they very much want is continuity of care from an individual and there are some dangers that that bit goes out of the window. There are some challenges. I would hope it is achievable but it does need to be resourced at that local level.

  454. You said you expect them to work more corporately together, which is presumably a wish and a hope. Is there not a potential problem? If it is not worked more corporately together, there is going to be a danger that PCTs are dealing with such relatively small numbers of people that you will not get a general overview of public health trends throughout the country because of the independence of them all, working in isolation?
  (Professor Drinkwater) I do not think that is necessarily the function of the locality structures. I think the locality structures are around engaging with the front line professionals and local people, looking at the national framework and what the national framework is supporting, but then delivering what needs to be delivered within that national framework at local level. All the evidence is that dictats from on high do not work. It is only when you engage at local level and work within the framework constructively with the professionals in the community that you do deliver services that make a difference.
  (Dr Heath) I would agree with that. It is a bit about my health protection and health promotion thing. Your surveillance is at a different level from where you are trying to achieve change. One has to have a flexibility at local level to incorporate things that local people view as priorities, which are not necessarily going to be national priorities. Then you might be able to deliver national priorities as well, but you cannot do the one unless you do the other first.
  (Professor Drinkwater) Our best example from Newcastle West would be about coronary rehabilitation, rehabilitation of people after heart attacks. When we looked at our patch, we had a standardised mortality rate which was 235, more than twice the national average for men under 65. Only 15 per cent of people after a heart attack were accessing rehabilitation which was based in the hospital and that was all sorts of issues about access, perception and fear of hospitals, a whole bundle of issues there, so we went to the health authority and said, "It ain't working" and managed to persuade them to fund a community based programme. Over three years, that has the uptake up to above 80 per cent. That is because it is locally based and patch based and because it is engaged with the local community.

  455. Is there potentially a conflict between health authorities and PCTs where they will fall between two stools and no one will actually take primary responsibility for delivery?
  (Professor Drinkwater) Yes. There is a potential conflict and there are some dangers there. It is a separation out of the science bit of public health from the public health practice bit. The science bit is the performance management end, the commissioning end, where evidence, data, information, having comparative data from different areas, are going to be very important. That then needs to be separated out. That is perhaps the subregional or whatever health authorities become level that that needs to operate at. At the locality level, it has to be about delivering real change and real public health practice. Again, I think there are some examples around personal medical services pilots. In our own patch, we have just agreed to go ahead with a personal medical service pilot for refugees and asylum seekers, a very important group with clear health problems that need to be addressed. There are some flexibilities within the system where you can begin to do that at local level, taking advantage of some of the rules and regulations that already exist.

Mrs Gordon

  456. During the course of the inquiry, we have looked at various community schemes. It was a particular problem that they could not get GPs involved, however much they tried. Usually, the reasons given were the workload, too many initiatives, too many committee meetings for GPs to be involved in. I wondered if you could give us an idea of what practical measures you think could be taken to help this perceived problem of being overwhelmed by the work. Do you think that personal medical services contracts are part of the answer to this, especially in deprived areas? Can they make a difference to the public health role of GPs?
  (Dr Heath) The great strength and the great problem for general practice is the broadness of the base of general practice means that almost every organisation wishes to engage with GPs, every organisation that is dealing with a particular problem. To cite some local examples, domestic violence, means of child protection, local traffic schemes. Everybody would value input from a GP. I could spend my entire week twice over just attending very valuable and very important meetings and yet I have 24 hour responsibility for over 1,500 patients. There is just a point where these two things are incompatible. I am not sure that any amount of bureaucratic change is going to change that basic problem. Every single hospital specialist feels that there is something they need to tell GPs about their particular things, so that the range of educational events that one gets invited to—again, we could attend educational events the entire time, because the catch phrase is general practice is ideally placed to deliver my agenda, not necessarily our agenda or our patients' agenda, but there are a lot of agendas for which general practice is ideally placed. It is a very difficult balance between the service commitment, which is essential to get the trust of ordinarily people on which you can build everything else, and get proper engagement, which is why PCG's were actually good. That was bringing together GPs in a small group with other health and social care professionals, to look at things in a different way and come up with different approaches. I come back to the fact that that has been cut short by the development of PCTs.
  (Dr Crowley) The experience in the west end of Newcastle was at a time when clearly general practice was under strain. Part of the reason it was under strain was it was constantly dealing with issues to which it did not have the solutions. That became a key driver for a partnership both with the community and with other providers of services, in the west end of Newcastle anyway, where if you like the pay off was to take some of the pressure off by providing appropriate services for the needs that were either the hidden agenda in the consultation or in fact expressed in the consultation but just beyond the capability of primary care to resolve. One of the initiatives that arose out of that way of thinking was Families First, which is an initiative where local people have been trained to provide basic support and signposting to families who have been identified by primary care as being under considerable and particular stress at any given time, either because they have recently moved into the area and are particularly isolated or under stress for racial harassment or other reasons. They have been able to go in and provide support to families. It is an appropriate service for the need. Primary care did not have the time or maybe the ability to engage with the kind of social issues that were being raised by families at that time. That was why primary care became involved before PCGs in the west end of Newcastle.
  (Dr Archard) If I might come back to your point again about involvement of general practitioners, there is a breed of general practitioners and indeed others within primary care who are very keen to take the challenges forward, to try to improve quality and so on. It comes back again to available time. The situation arose in my own situation personally in that the only way I could address the sorts of issues which I felt were important for general practice was to go part time, which is what I did five years ago. In so doing, I cut my salary in half with no protection. I stopped my superannuation by 50 per cent and so on. I am not remunerated at all for the time I take out, and yet, if I am to take more time out, my partners become all the more aggrieved because the amount of work which is left for them to do mounts and mounts. Therefore, the practitioners who are trying to address these problems are becoming the bete noires of primary care. I and a number of my colleagues, quite senior general practitioner colleagues, have enormous pressures from their partnerships to get back and do some proper work, rather than get out there and address the sorts of issues on which we are all very concerned. I do have a lot of sympathy with that as well, because they are left with an enormous additional workload, which locums are usually unable to address, not because of their inability, but because patients like to see their own doctor or a proper doctor, which very often they feel a locum is not. Of course they are misplaced in their thoughts on that but nevertheless that is the way the public often see them. Consequently, there is enormous pressure. You either go part time, which is what I have done, in which case you limit your financial security; you lose your superannuation and a lot of income; or alternatively you stay where you are or go back into general practice, feeling quite disillusioned and burned out as a consequence. You ask what is the way forward. My feeling is that the way forward is to recognise that there is a very real career structure which should address the sorts of problems which you are quoting, so that specific resource can be put into time so that people can actually address the sorts of concerns which everybody in this room is worried about.

  457. We have heard that in the Newcastle example, which has made a difference to the way that you work there. What would make a difference?
  (Dr Archard) I think the difference would be a career structure such that people would have time and recognised positions to address themselves to these areas. Some people are particularly good at clinical medicine and some people are—

  458. Would having more time mean more bodies?
  (Dr Heath) The west end of Newcastle is a fantastic example of what can be done by extremely committed and energetic individuals who have achieved an enormous amount, but there are things about the system that do not make that sort of thing easy. The achievement is magnificent. It is not going to happen across the country unless the whole system is incentivised in a different way. Phillip is absolutely right. If you stand back enough, you can put in services that will make your life easier, but if you are just seeing patients at ten minute intervals and wondering whether you are even going to have time for lunch, to step back, to make that sort of change, is very difficult for people.
  (Professor Drinkwater) I think some of that goes back to the whole career structure of general practices. One of the bits that has begun to happen around Newcastle west PCG is a recognition that you almost need to buy people out of their practices, give them time out. There are opportunities to do that around the PCT structure. Equally, I would agree that personal medical services pilots are another way in which general practice is experimenting with a different approach.

  459. What do you think of them and whether they can make a difference in public health?
  (Dr Heath) That evokes my worries about the universal provision as opposed to the experimental provision; the whole fragmentary nature of personal medical services pilots and how they can be properly evaluated and what system we can have for taking what is good and universalising it, because the worry is constant. To come back to health visitors, I cannot waste this opportunity to say that the whole thing about Sure Start and the fact that this is in lumps—people get Sure Start in patches, while the universal service around that is eroded, so people who are not in Sure Start are getting an ever worse service as case loads go up and up. I really have a problem about patchy initiatives that, okay, may do great things for services in a particular area but do nothing for the population as a whole and leave some of the most vulnerable people out in the cold. There is a tension around personal medical services and, if they are genuinely treated as pilots and one learns from them and takes the best from them and there is time and resources to evaluate them properly and disseminate what you find, then yes, but history does not teach me to be optimistic that we will learn properly from these initiatives.

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