Examination of witnesses (Questions 560
THURSDAY 11 JANUARY 2001
and DR FADUMA
560. Why are we not? Given that it is 30 per
cent of the population of London and given that 90 per cent of
the beds are occupied by people from ethnic communities, why are
we not doing better and what can we do to make it better?
(Mr Blake) I have to say from my own view it is an
issue in terms of our institutions taking on that importance.
The executive office of the NHS in London actually produced a
Mental Health Strategy last year, a 28 page document with lots
of outputs and targets and things related to the National Service
Framework etc, and they had one page on race equality.
561. But why, that is again the question? You
are giving me reasons why it is not working, which I understand,
but what can we do to make it work?
(Mr Blake) One of the key things has got to be around
making the issue a priority. If people do not see it as a service
priority, if they see it merely as an equal opportunity issue,
which unfortunately relegates it to being a side agenda issue,
if our institutions do not see it as a core service issue, that
in terms of targeting these particular needs we could actually
do a lot more in terms of enabling people not to get to that acute
stage and all the benefits to the health service that would gain,
then how do you get there? I think we are starting to wake up
to the issue. Within London we had an excellent Health Strategy
for London which was produced by the NHS Executive in London last
year and the Mayor's office is also bringing a new impetus on
a London level to all of this. Quite crucially, our institutions
have to change. I walked into the NHS Executive in London's offices
in Paddington and the people there do not reflect London.
562. Do you think that the communities themselves
ought to be more proactive in that case? If the institutions that
run the system do not seem to recognise these problems then why
is it that the communities themselves are not coming forward and
actually organising themselves better and being more proactive
in bringing these issues to their attention?
(Mr Blake) I think we saw some of that coming through
in the consultations for the London Health Strategy because, quite
frankly, the regional office were not prepared, I think, for the
onslaught that they got, not just from people like me but from
people working within the NHS at the ground level who said "folks,
these are big issues and we have not done well enough". That
started to happen through the consultation for that particular
strategy. I think that people at Eastbourne House started to wake
up and to take these issues a wee bit more seriously.
563. Do you think that things will get better?
(Mr Blake) I think things will get better but it is
(1) around having a long-term view and (2) viewing the issues
as core service issues, not as a peripheral equality issue that
we have to pay some lip service to.
564. Can I ask you if you attribute any of your
successes to national initiatives or have you succeeded despite
(Ms Edmans) The project that I worked in started during
the Conservative Government, so many of the initiatives that are
talked about now did not exist. It was mainly funded through the
Health Action Trust thinking about what were the links between
health and regeneration, but also at that particular time there
were the London Implementation Zone monies around to look at pump
priming primary care. It was a very difficult time when we could
not talk about health inequalities. We could talk about the health
divide but not health inequalities, so it was a bit of a struggle.
The change in policies and thinking has helped tremendously. There
was a point when the LIZ money was running out and projects like
ours were going to be stopped. The new policy changes and thinking
helped people to realise that these were the kinds of things we
should be thinking about doing because they were starting to provide
some of the answers for the new agenda. It has helped me tremendously
to come from what was a very tight struggle to something where
you sit around the table and start talking about health and regeneration,
the wider determinants of health, public health, partnership working,
etc., etc., which was very difficult before. In addition to that
is the additional money that comes along with it that has helped
to lubricate and provide opportunities that were not there before
or were very difficult before.
565. You were within the health authority itself
but for someone from the voluntary sector have those sorts of
initiatives made your relationship with local health and social
services easier or does it still depend on local personalities?
(Mr Blake) I think to an extent it still depends on
local relationships. The framework that some of the policy initiatives
have created, picking up some of the points Teresa has made, has
been positive. Specifically for my organisation, around HIV and
Aids it is incredibly difficult because we are advocating for
communities that are seeing the greatest increases in terms of
people presenting with HIV. Unfortunately it is within a context
where more of the resources, if you like the HIV pot, are being
spent on drugs. That is an issue for organisations like us who
are very much focused on community responses and initiatives.
I do welcome the Government's move around the Integrated Sexual
Health Strategy because I think one of the pitfalls in the past
was that the whole focus specifically in terms of sexual health
in the last decade and into the late 1980s basically meant HIV
prevention and we did not have a holistic view. Some of the chickens
are now coming home to roost around that and particularly around
the rise of other sexually transmitted infections, which is incredibly
dangerous. I also have to commend the Government around the Teenage
Pregnancy Strategy for acknowledging that particular issue and
trying to make a response in terms of tackling that.
566. All of you are working with some of the
most disadvantaged and deprived communities, often in small projects.
Is there a danger that there are lots of groups all trying to
reinvent the wheel? If you have successes how do you think they
can be exported elsewhere or how can you learn from good practice
and successes elsewhere?
(Ms Edmans) Certainly from the point of view of the
Community Health Project, yes, it did start as a very small project,
one person on two housing estates, that then developed and took
a larger community. Looking at the benefits and the integration
of the things we were doing in terms of trying to tackle unemployment,
the wider determinants of health, etc., etc., we wrote an SRB
bidSingle Regeneration bidlooking at single regeneration
and inequalities in health and we were successful with that, as
well as some other things. Here is a small model, it has worked,
how can we build on it, how can we extend it? We have been successful.
We then tried to look at how we could transfer that to another
borough and that was where we came into some slight difficulties
because part of the thing that made the project successful was
engaging the community and community ownership and it was much
harder to start transferring those things without having to do
that ground work, engaging the communities and helping the ownership,
because there was a lot of distrust and some feelings of "that
worked there, that is that borough, we want to do it our way".
Although you can use models of good practice to help inform and
show people how it can be done I still think you have to do some
of the community involvement if you are going to do community
projects. It is very important to have local ownership, whether
that is in the statutory services as well, because people can
be a little bit suspicious.
567. We were talking earlier about the need
to recognise issues and Dr Hussein was talking about female genital
mutilation, and we would all agree that the authorities have been
somewhat slow to recognise the extent of the problem. You were
talking in terms of the long-term effects for those people who
have suffered under this but, as far as the community that is
here now in terms of public health, is there an issue for young
girls who are here and is that being successfully addressed and
(Dr Hussein) What I believe is that people do not
have access to have that operation done in this country because
it is really difficult. I am looking forward to a new generation
that will be out of this problem. On the other hand, we know that
some people do come with their young children already circumcised
from Somalia or somewhere else. These young people do have the
same problems as the older women. This is what we are working
on, to talk to the young people about the health problems of female
genital mutilation. Women do come to me with their problems and
with their daughters' problems and I refer them to the service
appropriate for them and talk to them and give them more information
about their problems and how they can help themselves.
568. You are aware of the issues?
(Dr Hussein) Yes.
569. Do you think that your local health authority
and service providers are aware that this is an issue that needs
to be addressed?
(Dr Hussein) Here is the problem really because women
do not like to talk about it to anybody, even to their GPs. They
like to talk to somebody who understands the problem and for that
reason they are coming to me. On the other hand, maybe their GP
is not aware of which communities practise this type of circumcision.
It is something really sensitive and women do not talk about it
openly to anybody. If they have a problem they do not go to their
GP and talk about it. I have some women who have been married
for one or two years who still have not had any reversal operation
done to them because they are afraid to go and ask their GP or
talk to their GP about it. If she gets pregnant maybe that will
be found out on the delivery table, that is a real problem. This
is why we are giving health promotion, talking to them about the
services available to them which they can use.
570. Can I just ask how you actually reach out
to every woman in that community and how they get access to you,
how do they know about you?
(Dr Hussein) Knowing about me is word of mouth mostly.
That project is based in East London and it is for the community
located in that borough but I have clients from Liverpool, from
Manchester, from everywhere in London. They know me as a gynaecologist
from Somalia who worked there for 20 years, so by word of mouth
they come and look for me
571. Ms Edmans, how easy have you found it to
get money for your projects? Is funding a constant problem? You
have mentioned already the change of attitude and more openness
and awareness about these issues and it does seem that things
are getting better, in your own words, but is money still a problem?
(Ms Edmans) There are some difficulties. For example,
Faduma has just spoken about how people come from all around the
area and officially our money is meant to be for a specific catchment
area but we try to flex that a little bit because of the needs.
There are difficulties in the way in which money is given to you,
whether on a community basis or a bigger basis. I think a lot
of the problems around the additional money coming on stream are
to do with the administration, particularly among community groups
and voluntary sectors, the administration that you need to do
it and the amount of time you need to make the bids and do the
bids, that is quite difficult. Also hearing about what money becomes
available. The people this morning talked very much about the
fact that it feels a bit like a patchwork quilt or bits of a jigsaw
puzzle and sometimes those jigsaw puzzles meet together. For example,
you might have SureStart here, New Deal for Communities here,
sometimes those things meet together and sometimes they do not
and there are all sorts of complications around trying to get
all of those bits to fit and meet all the criteria outputs and
monitoring, etc., that are required for those things and a lot
of resources go into doing it.
572. You have been quite successful by all accounts.
Why have you succeeded in getting money when other people constantly
complain that they have not been successful? What is the difference?
(Ms Edmans) I think you get good at it after a little
while, after you have done a few. I think it is also about the
fact that we can show how we have involved the community and involved
partnerships, we can demonstrate that. Sometimes it is a bit difficult
when things that have been successful get more money and things
that have not been successful do not and that keeps happening.
Sometimes I feel a bit bad when we are successful and getting
things when I think that some other groups should be beneficiaries
of things like that. Although there is scope in saying you should
build on what is good and what is working, it is about how do
you support and develop those who are struggling, who may not
be successful, who may have systems that do not always work for
573. That is a fair point. How easy is it to
secure long-term funding to keep those successes going rather
than letting them fizzle out after one or two years when the money
runs out? How do you continue to ensure that you can look to the
future on successful projects?
(Ms Edmans) I think you expect that some of them will
fizzle out because some of it is about pump priming, making changes,
and using that experience to test out things, to try to get people
to take a bit of risk, to use money that is not already tied up
because there is not the money, to do that by showing and demonstrating
how you can change mainstream services, bring partnerships together
or get better value for money. You hope that it will become mainstream
because that is what you try to do, but also that it will strengthen
people like the voluntary sector and the communities to start
being successful in their own right.
574. My next point was going to be is there
not a risk if something becomes mainstream that it loses its immediacy
and ownership for ordinary people if it becomes part of the institutionalised
(Ms Edmans) There are two factors. One is that mainstreaming
helps keep it on the agenda but it also makes it quite vulnerable
because it is often at the fringes. I do not think it is one answer
or another answer, it is a combination. There should be some money
that is not mainstream that is specifically for pump priming,
testing out, etc. It is very difficult year on year to keep justifying
your work, to keep doing the things to ensure you get the funding.
It is about the disappointments that are created in the communities
and the distrust when things do not get funded. What you are trying
to do is to build that trust after a long history of distrust.
If you are continually coming up with "this might be cut",
it does not do that, it undermines some of that joint working
and the community trust.
Dr Stoate: Sure. Thank you.
575. Is there another way rather than the bidding
process to actually get access to funds? Can you see a better
way of doing it?
(Mr Blake) Speaking for my organisation, you have
got to try to have access to different types of resources and
certainly not being reliant on one particular source of funding
is absolutely key. In terms of is there another way, certainly
we could improve a lot of the bidding processes. In our Health
Action Zone in South London there have been lots of discussions
around the bidding process and one of the suggestions we have
made is rather than sending out these massive forms which are
20/30 pages asking for information going back ten years, why not
have a two stage system where you ask for short expressions of
interest maybe around particular projects, assess those and you
might have two or three different bids that you might invite to
become a consortium and to bid together? There are ways around
improving the bidding processes and one of those is encouraging
consortia and organisations to bring different skills to joint
(Ms Edmans) I do not think there is an easy answer.
Ring-fencing pockets of money has advantages and disadvantages,
as does the bidding system have advantages and disadvantages.
It is thinking about how you can streamline those and make them
more user friendly, less administrative, looking at the way in
which outputs are set, things like that that are much more user
friendly so you can get on with the job really. I do not think
there is an easy answer because both of those have pros and cons
to them. When we had ring-fenced money there was internal resentment
because you had got this money and it was easy and you were very
vulnerable when that ring-fencing then went away. I do not think
there is an easy answer.
576. Are there ways of coping with the disappointment
that you mentioned when people do not have a successful bid? Is
there enough feedback or support? How can that disappointment
(Mr Blake) I think certainly within the voluntary
sector there is a lot of use of this term "capacity building".
Maybe an organisation just does not have the capacity to manage
a large project. We have had lots of examples where money as a
quick fix has been thrown at voluntary organisations and they
have not delivered and we need to be aware of that. I think supporting
organisations in terms of building up their capacity, building
up their skills and their expertise, is crucial. I think also
the other side of that, which we have seen at a local level, is
sometimes with these bidding processes you could have identified
the successful bidders before the processes started and that is
something we have been aware of and have tried to avoid as well.
(Ms Edmans) I think the reality is that there is a
lot of need out there, lots of people wanting resources, whether
they be financial or other. It is also about acknowledging that
and, therefore, being more realistic about what bids are going
to be able to do and what they are not going to be able to do.
I think also something around giving feedback earlier, what Mark
was saying, not expecting people to put a lot of work into bids
that are not successful, having some kind of first stage thing
and then people have less disappointment than when they have put
lots of staff time, energy, commitment and work into doing a bid.
I think it is about streamlining some of that that will reduce
some of the disappointment.
577. The buzz word now is partnership, and quite
rightly so, it is obviously better to work with others and you
can achieve much more. There are all these different partnerships
appearing all the time. Is there a danger that the actual process
of getting these partnerships is a substitute for action? As you
said these are fairly new initiatives and there are cultural changes
to make about attitudes between different agencies and professional
pride and all this sort of thing. Is the actual process of creating
partnerships stopping you from achieving anything?
(Ms Edmans) I think it is the number of partnerships.
I do not think partnerships themselves are stopping anything,
partnerships are useful, they have certainly been useful for me.
Partnerships with communities, partnerships with the voluntary
sector, have enabled us to do the things we have done. It is the
number of partnerships and the complexity in having to be in all
sorts of places all at once that prevents you doing what you need
to be doing, providing the services at the ground level, supporting
the communities. I think there should be a streamlining or rationalising
of some of the way in which partnerships are done across agencies.
Often you see the same people, you have ten meetings and the core
of them are the same people. It does make you wonder how is that
the best use of people's time.
(Mr Blake) There is an issue around the whole bureaucracy
that can be generated, and duplication in terms of different Government
programmes. You can have Regeneration Programmes, Health Action
Zones, Education Action Zones, all these different things going
on in a particular locality, and there is certainly a good deal
of duplication going on there. I think, also, in terms of how
many different bureaucratic structures have to be created, in
relation to the Health Action Zones, with most of those we saw
whole new bureaucratic structures being created. I think there
is an argument that really a lot of things that should have been
coming out of the Health Action Zones should have been mainstreamed
anyway, why could they not have been managed within existing structures?
There are issues around bureaucracy.
(Ms Edmans) If I can add just one more thing. The
links between the partnerships tend to be quite weak. There is
not enough linkage and rationalisation between what these different
partnerships are doing and often they are actually overlapping.
578. Is there a solution to that and, also,
this thing you mentioned about seeing the same people at the meetings
all the time?
(Ms Edmans) I think the people this morning started
to touch on that and it was about having one overarching partnership
to which you may have certain subsets that tackle certain agendas.
That would be one of the ways. Also, looking at how the organisations
might encompass much stronger participation from the community
rather than being very top heavy and professionally heavy.
579. It has been acknowledged that there are
often positive health outcomes from successful regeneration projects
and health is usually the beneficiary, whereas in some areas health
has been the engine and the driver for some regeneration projects.
We have seen some examples of where there are opportunities for
the creation of employment, particularly with Community Health
Programmes and we have just been talking about the Sandwell area.
The NHS itself in any event in most of our areas is one of the
largest, if not the largest, employer. Very often some of the
most disadvantaged people in our communities, particularly from
ethnic minority groups, may not have the necessary skills to access
jobs there. Do you think that the NHS could be doing much moreand
if so, whatto open up access to employment both in creating
posts and mainstreaming employment practice?
(Mr Blake) I think the NHS could be
doing a great deal more. It is starting to do that but it could
possibly learn from some of the initiatives from other public
services, such as the police and the army. I certainly feel that
Mr Austin: I have not heard the police held
up as an example of good practice.
580. Or the army.
(Mr Blake) Both of those have spent a great deal on
targeting ethnic communities and there are certainly lessons that
can be learned there post the Stephen Lawrence Inquiry report.
Just coming back to my organisation's own specific area with regard
to sexual health, just a local example within South London. There
is a major shortage of health advisers within sexual health clinics
from the ethnic minority communities and, unfortunately, as I
alluded to earlier, these communities are over-represented amongst
the user group and there is a lot that could be done there locally,
specifically talking about within South London, to promote this
as a career with young people. There is a lot of work that could
be done there.
(Ms Edmans) I think there is a lot of work that could
be done within the NHS. It is often one of the largest employers.
The Single Regeneration bid that we wrote was about how you could
create stepping stones for local communities and the benefits
of local people becoming employed. It is one of the organisations
that has such a diversity of skills within it from unskilled to
the most skilled people and different kinds of employment opportunities.
I think people are beginning to grasp that because that has been
partly forced by the shortages in the NHS. For example, I was
working in an area that had the fifteenth highest unemployment
rate, yet in our trusts alone we had 500 job vacancies. There
is a huge mismatch, why is this happening? We are beginning to
get our heads around that but there is a long way to go. In addition
to that, the health service is concentrating much more on the
modernisation agenda and they see this as another thing rather
than something that is integrated and can show the benefits to
their organisation. It is somehow about saying how can we say
this is not an additional thing but it is integral to what our
business should be? It is not just about employment, it is also
about the NHS being big spenders in terms of what they purchase
because the way in which they could support local businesses,
even in a small proportion, would substantially help the local
economy and health in the local population. It is those two things
where the health sector does not traditionally think about what
its role is, it thinks more about health improvement, health services,
and I think we need to start shifting and getting the thinking
and discussions around what else could the NHS be doing around
being employers and also about purchasing strategies.
Mr Austin: Do any of my colleagues have any
further questions? Can I thank you very much for coming and for
the written evidence you have provided as well. Thank you very
1 We also produce leaflets in English and Somali. We
also contact the local Community Group. Back