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Margaret Hodge (Barking) (Lab)
I welcome the opportunity, despite the sparsity of Members in the Chamber today, to debate one of the many reports that we have published since July, when we were established as the new Public Accounts Committee for this Parliament. I take the opportunity to thank the members of my Committee who, although many have not stayed for the debate this Thursday afternoon, do a fantastic job in coming to grips with all the issues on our hugely busy and diverse agenda and in holding the Executive to account over a vast range of areas. I thank the staff of the House, particularly our Committee Clerk and his staff, for working incredibly hard to keep up with the volume of work, and the National Audit Office, which always provides us with excellent material as a basis for our investigations into this vast range of Government business.
Health inequality is the most awful and terrible thing. People who live in poorer wards can expect to die seven years earlier than people who live in the most affluent wards in this country. Furthermore, they spend, on average, 17 years of their lives with a disability. That is unacceptable in a free, democratic, fair and compassionate society. Let me give some reality to those statistics. Some 3,000 more individuals die than otherwise might have done as a result of the dreadful inequalities between the richest and poorest areas. My own personal passion for tackling inequality comes, in part, from the knowledge that I have of how it impacts on my own constituency. The estimates say that, if someone lived most of their life in Barking and Dagenham, they are likely to die eight years earlier than a person who lived most of their life in Kensington and Chelsea.
Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)
Is my right hon. Friend aware that there are twice as many doctors in Wandsworth as there are in Barking and Dagenham, and that for every stop further that a person lives on the Jubilee line between Westminster and Canning Town, their life expectancy goes down by at least a year?
Margaret Hodge
My hon. Friend makes a hugely important point, and I want to spend quite a lot of my contribution talking about the distribution of general practitioners, and the relationship between that and health inequalities.
As a Committee, we believe that addressing health inequality should be at the heart of every Government. All MPs from all political parties share the desire and commitment to work towards eradicating those inequalities. It is because it is a shared ambition that our report makes particularly depressing reading. The previous Government came into power publicly committed to reducing health inequalities, so there was a strong political commitment to achieve progress in the area. During the 13 years of that Government, there was a huge injection of money into the health service, which resulted in welcome improvements for everybody, including increases in life expectancy among the whole population. We now have life expectancy for men of 78 years and for women of 82 years. In our session on pensions yesterday, we received evidence from the King’s Fund that showed a massive improvement in life expectancy over the past decade or so, whereas in the last century there was hardly any improvement.
Given the general positive trend, it is horribly depressing to see that, while the health of the nation as a whole has improved, the gap between the richest and poorest, as measured by life expectancy, has widened. If we compare the life expectancy of men in the spearhead authorities—the most deprived authorities, in which a quarter of the population live, that were selected by the previous Government—the absolute gap and the relative gap increased between 1998 and 2007-09. In absolute terms, the increase was 8.6% and in relative terms it was 4.6%. If we look at the same statistics for women, the absolute gap increased by 9.3% for women and the relative gap by 6.5%.
What is so worrying about those statistics is that the gap between the richest and poorest women is growing at a faster rate than the same gap between the richest and poorest men. As yet, we do not have any good answers for why that is—unless the Minister can help us—except that women are smoking more today than they were a generation ago and are, therefore, more prone to diseases such as lung cancer that then kill them. I urge the Government to do some better evidence collecting so that we can understand what is happening and see whether we can take appropriate action to improve the figures.
Given our real determination to tackle health inequalities, why have we failed so far, and what should this Government do to improve performance and therefore close those unacceptable inequalities? We all understand that this is a hugely difficult area, and it is not just an issue for the health service; inequalities arise from socio-economic factors. If we consider the evidence, most of the inequalities—between 80% and 85%—come from socio-economic factors, such as income, education and housing, and probably between 15% and 20% arise from poor access to good-quality health services. It is important, therefore, that the health service does what it can. If it performed better, we would reduce that gap, but on its own it cannot tackle the problems of life expectancy that arise from whether someone is rich or poor or where they tend to live.
If we accept the importance of those wide socio-economic factors, it is vital that we have a comprehensive and coherent approach across Government. Integrating health inequalities into the wider agenda of tackling poverty inequality becomes hugely important. Without wanting to be politically partisan, I have to strike a warning note about the proposed cuts in public expenditure, which look as though they will hit the poorest hardest. If that is the case, I have not yet seen anything that provides me with the comfort that the direction of travel will reduce inequalities. In fact, quite the contrary, inequalities could be intensified. Will the Minister address that issue in her response to the debate?
I urge the Government to keep a focus on health inequalities as part of their agenda of tackling poverty and general inequality, and to judge all the actions that they take by how they will impact on health inequalities. That focus is hugely important.
Mr Richard Bacon (South Norfolk) (Con)
I agree with the right hon. Lady that the Government need to maintain focus. I noted that our Committee’s report says that the Department of Health itself acknowledged that it was slow to put in place key mechanisms to deliver its target and that it had used such mechanisms in other areas such as treatment of cancer, diabetes and stroke, where national clinical directors have proved quite successful. Does she think that there is scope for doing more in that regard in relation to health inequalities?
Margaret Hodge
Absolutely. I am grateful to the hon. Gentleman, who took through our recent inquiry into cancer. That inquiry demonstrated that, if there is that focus, outcomes will improve, although we can always do better. Having set the context in my opening remarks, I was going to make that point: access to and the responsiveness of the health service are hugely important. We need to do a lot of work to improve those things.
Tackling health inequality must be a real priority for everybody involved, which is the first lesson that we learned from our inquiry. It is not just about the politicians, for whom it has always been a priority. It must be a priority for the Department of Health, the new NHS commissioning board, GPs and all health service providers, local authorities, pharmacists and all others who have an interest in ensuring that we are healthy and live longer.
There is a criticism to be made of the previous Government. They were good at writing policy papers, but less good at following through those policies with specific actions. There were plenty of papers. We had the commitment in 1997, when the Government came in. We had the Acheson report in 1998. We had a target in the comprehensive spending review in 2000, which was pretty general but was about reducing inequalities. We had a refined target in 2002, which was more specific but perhaps a little less ambitious, and was aimed at reducing inequalities by 10% in the 20% of health authorities where there was the lowest life expectancy. We had a plan of action in 2003. That is an interesting point to pause at, because that plan of action had 82 so- called commitments. I do not think that our Committee looked at the plan in detail. I certainly have not done so. By December 2006, the then Government claimed to have met 75 of those 82 commitments, but we know from the statistics that the outcomes grew worse in terms of inequality. So there is something to be learned from the focus of that plan of action.
In the 2004 comprehensive spending review, the then Government revised and revisited the target. Again, we focused on it. We made it slightly less ambitious but more specific by focusing on 70 spearhead areas of the country. However, there is a danger with that approach, because more than half of the people who have an unequal life expectancy outcome at present do not live in those 70 spearhead areas. Inevitably, therefore, by concentrating action on those areas, we were leaving out far too many people.
Finally, in 2006—nine years after the previous Government came into office—reducing inequalities became one of the top NHS priorities. I think that it was at that point that we started to get things right. One of the lessons to learn from that is that, if we are not specific and focused, and tackling health inequality is not a high priority, we will not deliver, despite having the best intentions. In 2007, we got the primary care trusts to report on the progress that they had made on health inequalities.
Therefore, the view of the Committee is that reducing health inequality must be an explicit priority throughout the system and that it must be measured. I hope that the Minister will agree with that comment and I look forward to hearing her response to learn how she will ensure that the agenda on reducing health inequality is taken forward by this Government.
Ms Abbott
I have listened with great care to my right hon. Friend, who has had the opportunity to study these matters in detail. Does she agree that one of the problems in tackling health inequalities is that it does turn on good public health, which has never had the glamour or the immediacy of acute care in hospitals?
Margaret Hodge
I agree and I will develop that point a little later. However, the previous Government almost doubled the expenditure on public health, from an incredibly low base: it was 1.9% and it increased to 3.6% of NHS spending. I hope that the present Government will do even better in that regard. However, spending on public health is still a minute part of NHS resources, especially when it is an area that would prevent a lot of the health inequalities from emerging. Having conducted a study on cancer, both my hon. Friend the Member for Blaenau Gwent (Nick Smith) and the hon. Member for South Norfolk (Mr Bacon) would agree that the earlier that one can diagnose a condition the better the outcome. That was a key finding of the report that our Committee published this week on cancer.
I move to the issue of resources and I will talk about it in three contexts. First, I will talk about the resources—the actual money—that are distributed between geographical areas. Secondly, I will talk about the distribution of general practitioners. Thirdly, I will talk about the expenditure on prevention.
On resources, our study made it clear that at present there is an inequitable distribution of resources. The report showed that, in 2010-11, 68%—more than two out of three—of the spearhead PCTs were still not receiving the money that they should have been receiving on a needs-based allocation formula. That meant that more than £400 million of NHS money was diverted from those neediest areas to other parts of the country.
From the response of the Government in the Treasury minute, I know that they will continue to try to redistribute resources, but I would be grateful if the Minister gave us some indication of a time frame within which she would hope that there would be a much fairer distribution of resources to reflect need and therefore at least to give our neediest areas the capability and capacity to tackle health inequality.
I also note from the response of the Government in the Treasury minute that responsibility for the distribution of resources will go to the NHS commissioning board. What comfort can the Minister give my Committee about the instructions that the Department will give to the commissioning board regarding the action that it needs to take to ensure that there is genuine equity in the distribution of funding? Again, I know from my own borough that there is a real need for political commitment and drive to achieve that redistribution of resources. Obviously, there is a limited cake, we are in difficult financial circumstances and we are trying to see how we can cut that cake differently.
I and some of my colleagues in our local PCT area had to work extremely hard with Ministers in the previous Government to achieve a fair distribution of resources for Barking and Dagenham. That was the one area where we did okay. Obviously, that work was very local and it is not a pattern that we observed when we carried out the study across Government. So that is the first issue—a proper distribution of resources to poorer areas.
On the issue raised by my hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott), we must spend money on prevention. The issue of public health investment is crucial, because we know that other key causes of health inequality are what are known as “the risk factors”: obesity, smoking, drinking, diet and lack of exercise.
In that regard, the previous Government did well. They increased the spending on public health, doubling it from an extremely low base to a pretty low level of 3.6% of NHS spending in 2006-07. I think that the members of my Committee would say that we need further progress in that sector to ensure that we prevent people from developing the illnesses that limit their life expectancy.
Under the present Government’s reforms, we will have the new health and well-being boards, and they will receive resources. However, there are huge pressures on local authority budgets. Local authorities are probably having to absorb more cuts than any other part of the public sector. I have particular concerns about what mechanisms will be in place to ensure that local authorities spend the money they have, and prioritise expenditure on public health facilities and policies.
The commissioning board will have the responsibility to ensure proper expenditure on prevention, but the evidence given to the Committee showed that the problem with expenditure being devolved to GPs, who one would think were best placed in the health economy to think about investing in prevention rather than cure, is that their record in pursuing such investment is poor. GPs who have already been commissioning, and who control their budgets, do not have a good record of ensuring that they properly spend on prevention.
Finally on this point, the national health service has to find between £15 billion and £20 billion of expenditure savings, and while I accept that that money will be redirected within health, it is easiest to cut that which is most difficult to measure, which is investment in the prevention of poor health outcomes. In a climate in which the health service is trying to identify the very challenging savings that the Government have asked it to find—I accept that the savings were initiated by the previous Government—I fear that investment in preventive health measures will fall to the bottom of the agenda. How will the Minister and the Government ensure that money is properly spent on prevention?
Ms Abbott
Is my right hon. Friend aware that even now local authorities and primary care trusts are cutting public health expenditure, for example on community midwives and smoking cessation? Such expenditure is non-statutory, and it is going. Although one appreciates the intentions of Ministers in giving local authorities ring-fenced moneys, the danger is that those authorities will, under force majeure, use the money to backfill expenditure on environmental health and social care, and I have even heard of authorities believing they can spend their public health money on leisure services.
Margaret Hodge
I have a rather depressing example from my own area. We have had an effective smoking cessation service, but the regional health body looked at the expenditure both there and in Waltham Forest, which is spending far less, and instead of considering the impact and effectiveness of that expenditure, asked, “If Waltham Forest can do it for less, why can’t Barking and Dagenham?” That very effective intervention is now being cut because the comparison made by the regional health body was on the basis of inputs rather than outcomes, and that is a depressing trend that we will see mirrored elsewhere in the country.
Thirdly on resources, we need to ensure that there are the right GPs in the right areas. All the statistics that were provided to the Committee on that make for extremely depressing reading. The least deprived areas of the country have on average 64 GPs per 100,000 people, and the most deprived have 57. In Barking and Dagenham we have only 40 GPs per 100,000 people. I hope those statistics are right—I got them only the other day—because it is shocking if they are. The previous Government tried to tackle that issue locally, and the Committee was given evidence about what they did nationally. For example, in 2007 we had the £250 million programme to establish 112 new practices and 150 GP-led health centres in areas with the fewest primary care clinicians. I assume that that programme is coming to an end and that most of those facilities have now opened, but perhaps the Minister can confirm that.
In my borough, we have had a paucity of GPs, and a concentration of single-person practices and very poor environments and, try as we might, we still have this very challenging problem. Over the past 10 to 12 years I have been engaged in encouraging innovation, including having salaried GPs, and linking our GPs to universities as an incentive, and we were the first borough to try to encourage private providers to come in. One of them was successful, but the health authority has, I think, closed the other one’s contract. We have new health centres and practices, but the problem is that GPs are essentially independent providers and can choose to work wherever they wish. That is a hugely important point, and not just in tackling health inequalities, because if the Government cannot make the situation better, there will be much greater pressure on accident and emergency units and hospitals, and resources will be driven into the acute sector at the expense of community services.
Nick Smith (Blaenau Gwent) (Lab)
When we discussed the role of GPs in public health, I was disappointed to discover that they were not incentivised by GP contracts to treat public health issues seriously and put resources into them. If they had been, that would have made a difference.
Margaret Hodge
I agree entirely with my hon. Friend. I understand that the Government have said in their Treasury minute that they intend to try to renegotiate the GP contract, and to increase the focus of the quality and outcomes framework on prevention, with 15% of the outcomes centred on it. I am really interested in hearing what the Minister has to say about that. We have to provide incentives in the system, but we also need to ensure that GPs do not cherry-pick. There must be incentives to ensure that GPs focus on the hardest-to-reach groups—on those people who do not automatically go to their doctor when they feel ill.
Finally, what will the Government do to support the health service to do what works? One of the most depressing findings in our report was in this area. We know that most health inequalities arise because of issues that are outside the control of the NHS, but 15% to 20% of them come about because of the quality of the health service that people experience, and their access to it. We also know that two thirds of the difference in life expectancy is due to people dying from respiratory and circulatory illnesses, and from cancer. I have no doubt that the hon. Member for South Norfolk will want to draw attention to the report on cancer that we published this week, which talks a lot about the fact that if we got better at early identification of cancer, particularly in poorer areas, we would be more successful in reducing health inequalities. We also know, from the Marmot review, that if we do not get better at reducing people’s propensity to develop such illnesses, the additional associated treatment cost to the NHS, and therefore the cost of dealing with health inequalities, will be £5.5 billion. There is a fantastic financial incentive as well as an ethical incentive to spread practice that we know works in a much better, more structured and more defined way.
Our inquiry found three cost-effective interventions. They are so simple that we were all slightly gobsmacked that they are not more widely used. The first is giving anti-hypertensive drugs to lower blood pressure, the second is giving statins to lower cholesterol levels and the third is dealing properly with smoking cessation. There is probably a class bias involved. I cannot think of middle-class people who are not aware of those preventive interventions for respiratory and circulatory illnesses and who do not take them almost before they need them. However, poorer communities lack the same understanding and self-advocacy, which would support a reduction in health inequalities. Our inquiry also found that it would cost a mere £24 million—I say “mere,” but it is relatively small in NHS expenditure terms—to ensure that those three interventions were properly implemented in the spearhead areas. At present, those spearhead authorities spend £3.9 billion each year on treating people who develop the illnesses that arise through lack of preventive action.
We also found that our record on reducing health inequalities varied across the country. London, for a change, did relatively well, whereas Yorkshire and Humberside did particularly badly. However, the Department of Health had not developed any proper understanding of why such differences existed, and therefore had not decided how to use the data to lever action.
Probably the most shocking graph in our report involved smoking cessation. There is a lot of evidence that one-to-one sessions do not particularly help people to stop smoking, whereas putting them into groups where they are influenced and encouraged by their peers tends to have a better impact, yet PCTs were putting nearly all their money into one-to-one sessions and very little into group sessions. That seemed an absurd waste of investment and a failure of those empowered to take decisions to do the right thing with their money, which could have had much more impact.
What are the good and bad things that we know so far about how the country will perform on health inequality under the reforms? The Government have said that reducing health inequality remains a key priority, and I welcome that, as we all should. I welcome the fact that the NHS commissioning board will have a duty to reduce inequality, but that in itself is not enough; we must understand how the board will focus on it. I welcome the fact that central Government will make information about good practice available, but I worry that the implementation of that good practice will not be directed more from the centre, if not mandatory. What does the Minister have to say about that?
I worry that there will be no central benchmarking of cost-effectiveness in reducing health inequalities. I welcome the commitment to move towards fairer funding between areas, but I worry about the rate of change. Will the Minister comment on that? I welcome the fact that the Government are seeking to renegotiate the GP contract and are minded to give greater weight to local health needs in that regard. I welcome the fact that they wish to change the quality and outcomes framework, and that health premiums will be available to local authorities that reduce inequalities.
However, there are risks, to which my hon. Friends have alluded, in relation to the public health proposals and local authorities’ capacity properly to meet their requirements for reducing inequalities. I worry that the health premium will reward disadvantaged areas only if they make progress, and will disadvantage such areas further in the distribution of resources if they fail to do so. That would mean that people living in poor areas, who are likely not to live as long as people elsewhere, will be disadvantaged by a failure of the institutions that we have established.
How do the Government intend to ensure that local bodies work cost-effectively to reduce inequalities and provide value for money in their work? What powers, if any, will the Department, the NHS commissioning board or local health and well-being boards have to direct local GPs and providers who are not reducing health inequalities or are doing so in a way that gives bad value for money? What measures, if any, will be taken to ensure that the £20 billion in savings will not lead to short-sighted cuts to prevention budgets?
If the Minister can answer some of those questions, hopefully the good report that we as a Committee have put together can support the shared national endeavour to tackle this hugely difficult problem, which is so important in the life of our society.
Mr Richard Bacon (South Norfolk) (Con)
It is a pleasure, Miss Clark, to join under your chairmanship this debate on my favourite subject, the Select Committee on Public Accounts, along with the right hon. Member for Barking (Margaret Hodge) and other Committee members, as well as one of my favourite Ministers, the Under-Secretary of State for Health, my hon. Friend the Member for Guildford (Anne Milton). This three-hour debate is sparsely attended. I was a little worried that we might not fill the time, but then I reflected on the old maxim by Fidel Castro that a speech less than three hours long cannot possibly do anyone any good. Although I will not take off my jacket, I am prepared to be expansive should the need arise.
To be serious, although I do not plan to take up too much time, I think that the report is valuable. It points to something much broader than the single issue of health inequality, although that is an interesting and important issue. We begin our report by pointing out that in 1997, the new Labour Government announced that they would put reducing health inequalities at the heart of tackling the root causes of ill health. That was stated as a clear policy—it is not particularly politically controversial; most people would support it—yet many years later, here we are.
When my right hon. Friend the Work and Pensions Secretary was in opposition and doing a lot of work with his think tank, the Centre for Social Justice, he drew attention to health inequalities in Scotland. They are, strictly speaking, outside the terms of our report, but many people were shocked to learn—Scottish MPs probably knew this, but I did not—that the life expectancy in parts of Glasgow is lower than in the Gaza strip. My right hon. Friend did a lot of work on that issue in opposition, and he is now in a position in the Department for Work and Pensions to help others, including my hon. Friend the Minister, do something about it.
The issues are difficult and vexing, but they are not massively politically controversial, although the report shows that the gap between asserting the intention to do something and actually delivering it is often huge. That is the experience I have had many times in many different areas during the 10 years I have served on the Committee. Often, when Ministers are expanding on any number of subjects, my hon. Friends talk as if everything will be okay, just because it is our political party that is now discussing these things. When the Government make announcements of any kind, I think that, in a few years, we will be getting a National Audit Office report about all the things they forgot to do, all the things that went wrong and the eight common causes of project failure that they failed to observe.
My attention was drawn to a comment by the new hon. Member for Walthamstow (Stella Creasy), who is a new member of the Committee. She brings a lot of extra intellectual firepower to the Committee; indeed, she has a PhD from the London School of Economics. My right hon. Friend the Member for Barking—I will call her my right hon. Friend in this case—and I are also alumni of that fine institution. I believe, however, that the hon. Lady did not pay a large management consultancy to do her fieldwork for her, in the way that this morning’s newspapers say Saif al-Islam did. That aside, she said in a recent debate:
“Governments should not just start projects or policies—the public expect them to be able to finish them too. Essentially, implementation is as important as ideology in politics.”—[Official Report, 16 December 2010; Vol. 520, c. 1134.]
The interesting thing is that we are not even talking about an area where ideology is that important. There is general agreement that changes would be a good thing, but it has still proved extraordinarily difficult to make the progress that we would all like.
The report is divided into three sections. We started by looking at the weaknesses in the approach taken by the previous Government. One of the most shocking things for me was that, in a period when life expectancy overall has improved, the gap between the national average and what we term the spearhead areas has actually widened, as the right hon. Lady said. Under the previous Government’s approach, more than half the local authority wards in the bottom fifth for life expectancy were outside the spearheads, so there was not the slightest chance they would be covered, even though they had some of the worst figures. In fairness, the Department has recognised that its targeting and leadership were not adequate and that it was slow to put in place the right priorities.
There is considerable scope for the Department to take further the model of a national clinical director, which has been applied with considerable—I will not say unqualified—success to areas such as the cancer reform strategy. As the right hon. Lady said, we took evidence on that strategy and published a report on it this week, and it showed, in addition to some success and improvements, that there were still quite shocking variations. For example, there was an eightfold variation in the preparedness of GPs—I nearly said MPs, as well—to refer patients to cancer specialists, and that variation cannot be explained by socio-economic factors. In that respect, we had a fascinating hearing earlier this week with, among others, the King’s Fund, the chair of the Royal College of General Practitioners and a general practitioner running a consortium covering 180,000 patients in Essex. The fact that they took quite different views of the Government’s proposed reforms and GP consortia led to a fruitful dialogue, and the process of creative tension and debate meant that we got quite a lot of extra information that we might not have got if all the witnesses had believed and said the same thing.
It is clear that there were weaknesses in the approach that was taken, and I would like to hear more from the Minister about what proposals the Government have to make specific improvements and whether the idea of a clinical director should be taken further. I say that especially in the context of pushing public health budgets out to local authorities, because there will potentially be more stools for things to fall between. The Department of Health will presumably drive any national clinical director programme, but the influencing will be done with people in local authorities.
The second issue that the report looked at was the role of general practitioners. The hon. Member for Blaenau Gwent (Nick Smith) is right that, according to the Department, the GP contract does not give GPs enough of an incentive to focus on the neediest groups, although part of me wonders why there should need to be an incentive. I know from my experience of talking to GPs that people who go into medicine and general practice take a very holistic approach to their patient group. They will ask some patients to come in once every three or four weeks for no other reason than to keep an eye on them. They are fearful for such patients because they come from certain socio-economic groups and probably need an extra eye kept on them. However, let us take it at face value that the Department believes that the GP contract in its present form is not adequate.
Nick Smith
I am struck by the hon. Gentleman’s point about GPs. Every GP I have met absolutely throws themselves into their job, and, with very few exceptions, usually does a fantastic job. However, after the evidence session, I could not help thinking that people will do what we pay them to do. If we get the incentives right and we are clear about the targets and the benefits of the activity that the Department, health board or primary care trust has emphasised, we will get better results. We need GPs absolutely to focus on the important topic before us.
Mr Bacon
That is right: people will do what they are paid to do. One criticism I have also heard is that the more we treat people like employees, the more they will behave like employees. In recent years, a lot of GPs have felt more bossed around, so they act like employees, rather than people who are running their own organisations.
Ms Abbott
Is it not also the case that in inner-city areas, such as the east end of London, large numbers of people who are reservoirs of disease are simply not on GPs’ lists? As we move to GP commissioning, it will be important that GPs commission for the population, not just for the people who happen to be on their lists.
Mr Bacon
The hon. Lady makes an important point. One issue is the number of GPs in deprived areas, and a chart in the report shows the variation in those numbers. At one extreme, we have about 110 or 115 GPs per 100,000 of population, although that figure is an outlier, and the rest of the figures start at about 80 GPs and go down to an average of about 59 or 60. At the other extreme, in Redcar and Cleveland, the number of GPs per 100,000 of population is only 25. In other words, there is a fivefold differential between the best and the worst. Even if we cut out the extreme outliers, the figures still go from just over 40 to about 80, which is double. If there are not enough GPs in a given area, it will be that much more difficult to identify and get on to the GP list all the people we should—those whom the hon. Lady calls reservoirs of disease. That is an important public health problem, as well as a policy problem in terms of where GPs sit.
If the Minister does not mind, I would like her to comment on single-practice GPs. Although the proportion of such GPs has dropped from 34% to 22% in the most deprived areas, there are still 371 single-handed practices. All other things being equal, a single-handed practice is almost certainly not a good idea. There may be good reasons why one exists in a particular locality, and it is certainly likely to be better to have a single-handed practice than no practice, although Dr Harold Shipman comes to mind. There is also the fact that a GP is much more likely to work well if they are with a group of people than if they are by themselves; most of us work better in groups than we do wholly by ourselves. I would be interested to hear the Minister’s comments on policy on single-handed practices and where the Government think we are heading on that. As I mentioned, I should also like to hear her comments on the proposed outcomes framework, and how she thinks the changes in the GP contract will make the kind of difference that is needed, both in getting GPs into the right areas, and in making sure that they focus enough on health inequalities.
The third part of our report applied the lessons to the wider NHS. There is of course considerable discussion and controversy about the Government’s health reforms. We are not a policy Committee, so our report does not address whether the GP consortia reforms are a good idea. People have different views on that. I have my own, and instinctively I have always been in favour of giving more authority and power to GPs, for one simple reason, which is to do with what happens whenever, in the 10 years in which I have been a Member of Parliament, I have sat down with a group of GPs. I accept that what happens may be because, although South Norfolk is not economically very prosperous, it is not massively deprived either, and it is a pleasant place to live. Some might even call it leafy, but we have plenty of socio-economic problems, and employment problems. I do not want to gild the lily, but it is not in most respects a deprived area compared with many others, so perhaps the GPs I meet are a biased sample. None the less, every time I sit down with general practitioners, from whichever practice in my constituency they come, I always walk away thinking, “My, what a sensible bunch of people. If only they were given more control and power in the running of the health service. Things would almost certainly work better.” Of course, the Government’s proposals are in that direction, so my instincts are to support what they are doing.
My experience of 10 years on the Committee, however, is that whenever the Government try to change anything of any kind, anywhere, they always underestimate the risk and over-egg the benefits. There are considerable risks to the change, including the fact that it is a change. All change, particularly when it involves big management change, raises risks. It is likely, I think, that the best of the people working in the primary care trusts, if they are good at managing health consortia, will be hired to do the job. If things works out as well as we all hope, we shall probably end up with better management, and fewer and better-paid people doing a sharper, leaner job than has happened with primary care trusts. In addition to lots of meetings with GPs over 10 years, I have had plenty of meetings with the primary care trusts in my constituency. When I was first elected, there were six PCTs just for my constituency, which was then one of eight in Norfolk, with a total population of 800,000. Each had its own finance director on a six-figure salary, and not all were particularly well qualified, which may be one reason why the PCTs began to get into serious financial trouble a few years ago, despite the fact that the NHS was receiving record funding increases.
I have probably dwelt on the issue a bit too long, and I am not trying to make a political point. I merely say that I instinctively have a degree of support for what the Government are trying to do in the context, but it still gives rise to a series of questions. I was quite surprised when I heard that public health would be moving away from the health service towards local authorities, because, on the basis of my experience of my local hospital, which is a good and fairly new acute hospital built in the past 10 years, and based on my experience of general practitioners, I would sooner that those responsibilities were left with clinicians than that they were given to the council.
When I see the proposal for health and well-being boards, I think “What if?” Let us think back to 1997, as the sun came up over the Thames and the then new Prime Minister Tony Blair said, among other things, that the Government were going to put reducing health inequalities at the heart of tackling the root causes of ill health. What if he had said after a couple of years, “I know; here’s another thing we’re going to do. We’re going to have something we will call health and well-being boards, and because we are in favour of democracy we’re going to give them to local councils”? What if we had then watched as not a lot happened for the next 10 years? I am just making this up, because it never happened, but say those bodies had been established, and had not achieved quite as much as we hoped: I can see that we might have gone into the general election saying, “As for those health and well-being boards run by the council, well you’ve all read about them in the Daily Mail and we’ll be getting rid of them on day one.” I am sure it will not work out in that way, and that my hon. Friend the Minister is well aware of the risks and has them under control.
I was interested that the Department told us that the money for the public health budgets would be ring-fenced. Paragraph 22—the final paragraph of our report—said:
“The Department told us that action for improving population-wide health and reducing health inequalities would be funded from a ring-fenced public health budget.”
One of the questions I have for my hon. Friend is, “When is a ring fence not a ring fence?” I have had meetings with my local council, which is rather eager to get hold of the £11.7 million coming its way for its public health budget. It is not its impression that it will be spending it all on public health. Some of us think that it may have other priorities in different areas, which have nothing to do with public health, but which it seems to believe have merit, and for which it can make a strong case—and, indeed, many of my constituents would make a similarly strong case. I want to understand exactly what the health and well-being boards will do, and what leverage they will have over the GP consortia, to ensure that they deliver the priorities they are supposed to—or what other methods there will be to make sure that the consortia deliver those priorities.
That all comes back to what I was saying earlier to my hon. Friend about the need for greater clarity about ensuring that the outcomes framework and the new GP contract deliver what they are supposed to. I do not care whether it is health and well-being boards who do it, or whether they exist. I care that it should happen, and it is not abundantly clear to me that there is yet a picture with all the dots joined up, so that we can be sure that if health and well-being boards are carrying out that task either they will have the correct leverage over GP consortia or there will be other mechanisms in place, through the outcomes framework or the new contract, to achieve what the Government, like the previous Government, say they want to do about health inequalities.
Ms Abbott
It has been my experience in my present Front-Bench role that local authorities throughout the country believe, broadly speaking, that what they call public health is public health, and that they can spend the money on that. As I said earlier, they can spend it on environmental health, social care or leisure services. I am concerned precisely with the point he made: when is ring-fencing ring-fencing? Because I do not believe that the money can be effectively ring-fenced for what we would recognise as public health expense.
Mr Bacon
I am interested in the hon. Lady’s comments. Of course, if we made sure that every schoolchild got a tangerine every day as part of their five a day, it would not be difficult to make a strong case for that being in the interests of public health. It would not be necessary to be a member of the tangerine growers association to make that argument.
The Parliamentary Under-Secretary of State for Health (Anne Milton)
I hesitate to intervene at this stage, because I will have an opportunity to speak later, but I must say, as it is such an important point, that the fact that the child gets the tangerine is not the point. The point is, does the child eat it?
Mr Bacon
I am pleased to say that my son would eat it, if given a chance, but he has been indoctrinated by my wife to think that fruit is the best thing going. However, to go back to what the right hon. Member for Barking said earlier, that is what happens in middle-class households, where children have lots of fruit and vegetables. My son is three and one of the things he loves the most is cucumber; he adores it. I am sure it is full of the right nutrients, although I think it is 99% water. The point is that we must make sure that those messages are getting across.
When I think about a cross-section of the population of my constituency, and ask whom I would most trust to persuade a little boy to eat tangerines—the local councillors or the general practitioners—I am not sure that I would immediately plump for the councillors, particularly given the fact, as the hon. Member for Hackney North and Stoke Newington (Ms Abbott) has said, that councillors have a lot of other pressures on them and have other priorities. I asked when a ring fence is not a ring fence, but of course there is another question about whether there should be one. One thing that we apparently feel unable to admit is that if we take off the ring fences and tell people, “We mean it when we say that you at the local authority will decide what happens,” the natural concomitant will be variation between different parts of the country. The rhetoric and the argument is that it is down to local people and if they do not like it, they can choose a different councillor.
I attended a meeting with a senior Minister in the Cabinet Office. It was just after the general election and he had been to a meeting with local councillors from across the country. He relayed a story about how a group of Conservative councillors had asked him, “Right, Francis”—that gives away who I am talking about—“we have won the election, or partially won it, at least. What do you want us to do?” He replied, “I want you to stop asking that question.” In other words, the Government seriously want to give local authorities the power to make these decisions. The obvious concomitant, however, is that there will be differences in different parts of the country. If that is the case—and in the light of the fact that, even when we have tried to have a co-ordinated strategy to get the same outcomes and reduce health inequalities, we have managed simultaneously to improve life expectancy and to widen the gap between the best and the worst—how much more likely is it to go wrong when we have this degree of local autonomy?
These things always come in waves—localism and centralisation have gone backwards and forwards. Some may remember Tony Crosland saying in 1974, “The party’s over,” and I am sure that we will come to a “party’s over” moment, although it is probably a few years away yet. I am interested in what happens on the ground to achieve change, and it sounds like my hon. Friend the Minister is as well. I shall not speak for much longer, because I am keen to hear her response.
I shall conclude with one further point to make my hon. Friend’s job a little easier, although no one pretends that this is easy. Indeed, we say in conclusion 7 of our report:
“Addressing health inequalities is a complex challenge requiring sustained and targeted action. The Department’s experience to date shows that greater focus and persistence will be needed to drive the right interventions.”
That is about strong leadership, as we go on to say in that paragraph. That is why the examples from other areas, such as Professor Sir Mike Richards’s cancer strategy, may have something to tell us about what we ought to do about reducing health inequalities. We all agree on the ends, but there still seems to be a lot of confusion about which means will work best. It is important for the whole country that we sort out that confusion and start seeing improved results.
Nick Smith (Blaenau Gwent) (Lab)
I am pleased that you have called me to speak in this debate, Miss Clark, following the terrific contributions of the Chair of the Public Accounts Committee, my right hon. Friend the Member for Barking (Margaret Hodge), and my fellow PAC member, the hon. Member for South Norfolk (Mr Bacon). As a new Member, I feel privileged to serve on the PAC, given its powers to review all areas of Government spending and to assess whether individual programmes are good value for money.
In the report, we looked at how the Department of Health delivers action to reduce the inequalities in life expectancy that we find in each of the nations of the UK, not just England, although the report looked at England specifically. On the day that we took evidence for the report, I went away with a very heavy heart. I was hugely disappointed that the Government and public policy had failed to make a real dent in this crucial area. I am sorry to say that I was convinced of the failure of senior politicians to drive the issue harder over 10 years, and of senior national health service managers to implement good practice and policies. That is just not good enough.
It is with a mixture of sadness and anger that I must report that adults in my constituency of Blaenau Gwent have life expectancy rates of just 75.6 years for males and 79.1 years for women. Blaenau Gwent has the 10th lowest life expectancy at age 65 in the whole of the United Kingdom. Worryingly, figures released recently by Save the Children revealed that 20% of the children in my constituency—2,000 youngsters—could be living without basic necessities. It is the highest rate in Wales. We are talking about children whose parents skimp on food so that their home can be heated and the youngsters can be fed, and children who are more prone to infections, colds and accidents. That deprivation is likely to have an impact on their health and their life expectancy. These young children are our responsibility and we must do better.
It is because I see the consequences of deprivation in my own constituency that I was absolutely incensed to learn how the Department of Health has been failing families living with poor health in similar constituencies in England. After all, it is more than 30 years since the Black report set out the scale of health inequality in the UK. I do not want to be partisan—this has been a good debate—but that report was buried by Margaret Thatcher, so in 1997 the new Labour Secretary of State for Health, my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), asked Sir Donald Acheson to update it. Subsequently, the Labour Government set a target of narrowing the health inequality gap by 10%.
Colleagues have already said that tackling health inequality is complex. Acheson flagged up a number of initiatives, such as better housing, higher child benefit, and pre-school investment, which he urged the Government to adopt. A number of those things have been done and have made a difference. The 2008 World Health Organisation inquiry by Professor Marmot was equally radical. It identified low incomes, bad housing and a failure to curb junk food as some of the factors that contributed to poorer life expectancy. He also advocated a higher minimum wage, which we will be pushing for in the future, difficult though it may be.
It is important to set the context of the PAC inquiry, because action by the Department of Health is by no means the only action needed to tackle health inequalities. I am sympathetic to a degree with the idea of involving local authorities in the task. We all remember gas and water socialism, whereby local authorities played a big part in ensuring that we had a cleaner environment and gas to heat our homes. Having said that, I am keen for health authorities and GP practices to keep an eye on the issues that make a big difference in public health.
The wealth of reports, information and good practice on public health that were already in the public domain should have galvanised the Department into early action on matters upon which it could deliver. Tackling health inequalities was, after all, one of its key objectives in 1997. As my right hon. Friend the Member for Barking has said, in 2004 the Department set the task of reducing the gap in life expectancy between 70 spearhead areas and the population as a whole. However, although national life expectancy has improved, the gap between the spearhead authorities and the national average has widened. What a depressing fact that is. By looking at why the Department of Health failed in its objective, the PAC was keen to identify pointers, and they will, I hope, enable us to make progress on reducing life expectancy differentials, particularly because no target has been set at present.
The PAC is keen to promote best value, which is very important at all times, but particularly so in the straitened economic circumstances in which we now find ourselves. As NICE has said:
“Public Health interventions are extremely good value when compared with the costs of clinical interventions.”
In our investigation, the PAC found that the Department was slow to get off the starting block and to utilise NHS resources effectively. I stress that this was a priority for the Labour Government in 1997, but it took nearly 10 years for it to be implemented on the ground by PCTs. It should have been a fantastic opportunity to make a difference in a key area for Labour that is representative of our core values. Targets were adopted in 2004, but reducing health inequalities did not make the Department’s top six until 2006, and it took another year for PCTs to be fully involved, which is way too long.
As early as 2002, three key cost-effective policies were identified to help to meet the objectives. My right hon. Friend has pointed them out, but I think they are worth repeating. They should be part of national initiatives, despite the Government’s localism agenda, and should be given emphasis in the future. The first was medication to control high blood pressure, the second was medication to reduce cholesterol, and the third was help for people to stop smoking. Those three things alone would have a marked effect on the agenda.
However, it still took five years for the Department to advise on the best way to implement those policies and to monitor what PCTs were going to do in their patch. Some extra funds were transferred to the spearhead areas on the basis of higher need, but they only trickled through. The spearhead authorities did not reach their target funding levels. If we set public health objectives, we have to deliver the funding. Hon. Members’ comments this afternoon on the need to be clear about what money will go forward and precisely how it will be spent are really important for this agenda.
Like other hon. Members, I shall turn to the role of GPs in tackling health inequalities. We all know that GPs are a fantastic and unique asset but, unsurprisingly, the spearhead areas did not have enough of them. It is as blunt as that. There just were not enough GPs. The reality is that the Department has failed to secure sufficient GPs for poorer areas, despite some good initiatives, which my right hon. Friend has mentioned. The Department has failed to make a difference and to negotiate a GP contract that gives an adequate incentive to focus on patients with the greatest need. I am absolutely clear that people will do that if they are paid to do it. That needs to be promoted and pushed as simply and as hard as possible.
The record also shows that few preventive services have been commissioned by GPs under the practice-based commissioning system introduced in England in 2004. That is a fact. Unfortunately, that does not inspire confidence in the Government’s plans to move to an NHS in England where services are predominantly GP commissioned. If there are not enough GPs in the first place, it is just not going to happen in a lot of areas. The new health and well-being boards, which will be set up by local authorities in 2013, will scrutinise how local commissioners are reducing health inequalities. However, what teeth—or sanctions—will they have? What budget will there be for public health and what exactly will that include? We must get to the bottom of that, otherwise more wasted years lie ahead of us. I hope that the Minister will address those points this afternoon.
A recent review and study of the impact of the economic downturn on health in Wales considered my constituency and concluded:
“In Blaenau Gwent, the recession has hit hard and was felt to have exacerbated the existing long term problems of the area.”
Things were bad already and, with unemployment, they will get worse. The study found that young people are the age group most likely to suffer in the long run
“as the transition from education to employment, further education or training is pivotal for long term secure employment and health”.
Given the current high levels of youth unemployment—we read about that in this week’s papers—I am afraid that the Government are storing up a large health inequalities problem for the future. The study recommends the development of leisure services to help those distressed by job loss, extra resources for debt counselling and access to affordable loans to help to reduce the anxieties associated with loss of income and low incomes. We need to look at the wider agenda and be mindful of that, as public health discussions go forward. In a nutshell, public health outcomes have to be addressed by all levels of government.
Finally, as the Minister responsible for public health is here, I cannot pass up the opportunity to comment on the Department’s plans to help people to stop smoking. Certainly, the NHS must assist individuals to give up smoking using local resources such as nurses, pharmacists and GPs. All of that is terrific. However, the Government must also implement the ban on tobacco displays in newsagents. Such actions may deter young people from smoking in the first place. I commend the Welsh Assembly’s tobacco control action plan, which continues to deliver smoking prevention programmes in our schools in Wales. In terms of the economic picture, that should be rolled out across the UK—certainly in areas such as mine.
Another of my public health priorities is alcohol pricing. Some commentators have predicted that the continued squeeze on family incomes will lead to a reduction in alcohol consumption. However, the Government could be much bolder on minimum pricing. VAT plus duty is not enough and if the NHS spent less on treating the consequences of alcohol misuse, we would have more money to invest in public health and improving life expectancy for the poorest in our society.
Thank you, Miss Clark, for calling me to speak. I am grateful to the National Audit Office for producing a fantastic report and to my fellow PAC members for adding value to it. I hope that the Department of Health and others will act on it soon.
Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)
I congratulate the Public Accounts Committee and the NAO on an important report that sheds light on a lot of health policy issues. I read with care the Government’s response to the report and it seemed that although it was well-meaning, it was sketchy. I hope that we will get some more detail on the points of concern to everyone who has spoken in the debate.
I cannot address the issue without repeating what the PAC has said: under my Government, inequality widened. I would not want to resile from that. I hope that the new Government can build on our achievements in fighting health inequality—there were substantial achievements—and learn from our mistakes. That is what the PAC is trying to point towards in its report. In its report summary, the PAC states:
“It is important that tackling health inequalities does not slip down the Department’s agenda.”
I will try to refrain from commenting on the drama and excitement surrounding the Government’s health reforms. However, in that drama, excitement and Sturm and Drang—as the Germans say—it would be very sad indeed if the progress made was lost sight of and the need to deal with health inequalities in practice and in a targeted fashion slipped down the agenda. One of the most important points made by my right hon. Friend the Member for Barking (Margaret Hodge), the Chair of the PAC, was that we can have all the good will in the world but unless we are focused on the issue and there is a targeted policy approach, the outcomes that we all want to see will slip away.
Health inequalities are an international issue. In the United States, research shows that if black Americans had the same mortality rates as white Americans, there would be 800,000 fewer deaths over a decade. Even in one of the richest countries in the world, they have not been able to tackle the blight of health inequality. If we consider other countries, we will see that life expectancy for women in Zimbabwe is 42 and in Afghanistan it is 44. In contrast, that figure is 86 in Japan.
Probably the greatest single contribution to tackling health inequalities was made by Clem Attlee’s Government under the leadership of Aneurin Bevan in establishing a national health service. We were given a health service that is comprehensive, universal and free at the point of access. There is no question but that the nation’s health has improved massively since the introduction of the NHS. Yet since the 1930s, despite the creation of the NHS, vast social reforms and colossal scientific advances, the gap in mortality between professional and unskilled men has more than doubled. We need to pause and reflect on that because it shows the difficulty of engaging with inequalities.
I think it was more than 30 years ago that Julian Tudor Hart wrote about the inverse care law and pointed out that the availability of good medical care tends to vary inversely with the needs of the population that is being served. That accounts for the very low numbers of doctors in some parts of the east end of London and so on. As we touched on earlier, people in the poorest areas of London, Manchester or Glasgow will die seven, 11 and, in Glasgow, 28 years earlier than people living in the same urban conurbation.
We have heard in the debate about what a Labour Government tried to do on health inequality. From the glittering eminence of my right hon. Friend’s position as Chair of the PAC, she said on the issue that the previous Labour Government were good at policy papers but not so good at implementation. As a humble Opposition Front Bencher, I would not dream of saying that, but I repeat what she said because it might be of interest to people who are following the debate. Of course, there is a lesson there for the Government and all of us concerned with public health. I would like to make this point about Labour’s time in government. The decline in public health outcomes did not begin with a Labour Government—or certainly not the last Labour Government. In the early 1970s, the mortality rate among men from the lower socio-economic groups was twice as high as those in the top professional groups. By the early 1990s, that was three times higher.
The then Health Secretary, my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), commissioned the Black report and we instituted a programme for action, which, as we heard, in some ways fell short. Let us not forget the advances that were made, however: shorter waiting times, many more operations, greatly improved infection control, and better survival rates for cancer and heart disease. Those advances were not just about figures. The most recent Ipsos MORI poll on voter satisfaction with the NHS showed that it had risen from when the Labour Government came in from 55% to 71%—the highest ever reported.
We did make some advances, and some of them specifically related to health inequalities: on cardiovascular disease, the gap closed by almost a third; on cancer, it closed by an eighth, and the trend should be for it to close even faster; life expectancy and infant mortality rates have improved; and last year, statistics showed that the rate of teenage pregnancies was at its lowest for a decade. We put £21 billion into early years education and child care and we have gone from having no Sure Start children’s centres in 1997 to more than 3,000. Overall, we raised total health expenditure on public health, as hon. Members said earlier. By the time we left office, we were spending 4% on public health. None the less, the gap remains.
On this side of the House, we accept the PAC report, but there are specifics in the Government’s response on which I would like to hear more information. The Government partially agree with the report’s first conclusion, which is that the gap in life expectancy is continuing to widen. However, it is not clear what the Government will do to narrow the gap more quickly than the previous Government. The second conclusion relates to cost-effective recommendations. As has been said, there are three specific recommendations: medicine for blood pressure, medicine for cholesterol, and smoking cessation. It is not clear from the Government’s response how they will embed those specific targets and strategies into the system that they are building. They talk about the Department embedding health inequalities in the emerging system, but they do not say how. The Government’s response states:
“Duties will be placed on the NHS Commissioning Board to reduce inequalities in access to outcomes from healthcare.”
That does not state how. That does not say what the targets will be. That does not say what the penalties will be if those duties are not met.
One of the most important points, which my right hon. Friend the Member for Barking spoke about, relates to GP shortages and the existence, still, of some single-handed GP practices, which are not the best. All the Government have to say on that is:
“The Government is committed to addressing these issues…following discussions with the BMA General Practitioners Committee.”
For anyone who knows Government and who knows the BMA General Practitioners Committee, that does not say very much at all. Again, I would like a little bit more detail on how the Government are going to battle with the BMA on that one.
No. 4 in the conclusions and recommendations section of the report states that
“GPs fail to focus their attention sufficiently on the more deprived people registered with their practices”—
and I would add, as an east end MP, those people who are not registered at all. Tuberculosis and malaria are big issues in the east end for populations who are largely not registered. I am not against more GP involvement in commissioning in principle, but one of my fears is that it would be all too easy for GPs to commission for the list. It would be disastrous for public health and health inequality to do that in the east end of London. For all sorts of reasons, we have large populations of people who are not on the list, not least because historically people in the east end would just rock up at Guy’s, Tommy’s or Bart’s and get treated—they did not bother to register. We therefore have to understand how, under the new system, the GP commissioners will be able—will be forced, actually—to commission for the population, and not the list.
I read what the Government have to say about making GPs focus more attention on deprived people. I have read it several times and I still do not understand, because if the GPs can make a decent living while not focusing on the most deprived people on their lists, which is what they have done hitherto, what is to make them change their habits?
Another concern is the numbers of PCTs. That will change with the reorganisation, but the fact is that areas with the highest deprivation still do not get the money due to them under the Department’s funding formula. We hear about the health premium, which sounds reassuring, but I know, from examining how the education premium will work in Hackney, that it will not leave us a penny better off. I would like to know how a health premium will help to get extra money to areas of high deprivation.
One issue of most concern is that when the PAC report states:
“The NHS spends 4% of its funding on prevention, although individual commissioners’ spending on prevention is not readily identifiable”,
the Government respond by stating:
“The Department does not believe it is for central Government to require Directors of Public Health to benchmark the costs and effectiveness of their public health activity—this will be a local responsibility.”
All that is well and good—in Hackney there some activist and committed GPs who came to Hackney because they are committed to fighting health inequality. I worry, however, that it will leave some of the most vulnerable members of our society entirely at the mercy of what their local authority thinks it is able to deliver in public health. I am very concerned about the unwillingness of the Government to benchmark costs and effectiveness and to find a way to promote the simple activities on blood pressure medication, cholesterol medication and smoking cessation.
In conclusion, the Government have said some encouraging things about public health in a general sense, but if there is one lesson to learn from the PAC report it is that having good intentions in a general sense, and even having wonderful policies in a general sense, is not the same as having targeted mechanisms to deliver improved public health outcomes for the very poorest. The Government set a lot of store by a more informed population going online, comparing statistics and choosing—the market, really. In the part of London that I come from, it is not reasonable to expect the poor, the elderly and the very young to universally have access to computers and, at a time of crisis and illness, to be comparing figures and doing sums on their laptop computers.
If the Government are serious about public health, they must first learn from the mistakes of the previous Government. Secondly, they simply cannot leave it to the vagaries of local authorities and the interests of local GP consortia to deliver the overall consistency in public health that will give us the narrowing of health inequalities that we want to see. I can stand on the top floor of my house in Hackney and see the towers of the City of London, but I might as well be in another country. It would be a tragedy if, despite the challenges that the Minister will no doubt tell us about, in one of the wealthiest countries in the world we cannot deliver the mechanisms to narrow that gap. That would be very sad indeed and I await with interest the Minister’s response to the debate.
The Parliamentary Under-Secretary of State for Health (Anne Milton)
It is a pleasure to be here this afternoon serving under your chairmanship, Miss Clark, for what I think is the second time.
I will endeavour to answer all the issues that have been raised in the debate. I welcome the report from the Public Accounts Committee. There is no doubt that health inequalities belong to another age and certainly have no place in modern society. Anything that brings this issue to the fore is entirely welcome. As the right hon. Member for Barking (Margaret Hodge) said, health inequalities are terrible, and it is shocking that they exist to such a great extent. I shall deal later in my remarks with the questions that have been raised. If Members wish to intervene, I will be happy to take interventions, but if they hang on, I will get to all their questions in time.
The hon. Member for Hackney North and Stoke Newington (Ms Abbott) was absolutely right to say that lessons should be learned. The problem with government generally, at every level and irrespective of political party, is that people tend to turn up bright-eyed and bushy-tailed but do not take any notice of what has gone before. In fact, the Government and politicians should have the humility to recognise that if things were not achieved earlier, it was not necessarily because of the incompetence of the previous incumbents but because sometimes it is difficult to do something, and this is one area where that applies. As was said earlier, this is not a partisan issue. It is something that we need to act on across the board. The important thing is truly to understand what we are talking about when we talk about public health.
I do not think that, strictly speaking, I have to register an interest, but I should mention that my husband is a public health physician, although not working as a director of public health. It is extraordinary that we have had this discussion this afternoon without yet mentioning the public health profession or directors of public health—members of the public health profession will be somewhat disappointed, because they are pivotal to many of the changes that we want to introduce.
My Government want to improve the health of the poorest most quickly. If we are to achieve better health outcomes, particularly compared with other countries, that must be more than a pipe-dream. My hon. Friend the Member for South Norfolk (Mr Bacon), who is, indeed, my favourite member of the Public Accounts Committee— [Interruption.] This is a love-in. He mentioned that it is extremely easy to assert things, but we do not want assertions but real action. That must be a fundamental part of our strategy in health care and in other areas such as housing, education and social care. We believe that the more devolved health system that we are developing will enable a sharper focus on disadvantaged areas across the country.
The Government want to provide far more opportunities for local people and organisations, including statutory organisations, to plan and run health initiatives specifically tailored to their communities. We have set out proposals to reform the delivery of health services in England. They are contained in two White Papers, which I am sure Members are familiar with: one is for NHS services, and the other is for public health. Reducing health inequalities must, and will, be embedded in the reformed architecture that we propose.
Margaret Hodge
I believe that, in principle, all of us would support devolution of power, but I draw to the Minister’s attention constituencies such as mine—this is more a constituency point than a general point. My constituency, which is a working-class area, is quite uniform in class structure. The whole public service infrastructure is weak, whether one looks at education, health, public health, GPs or the voluntary sector. If there is devolution to the poorest areas with poor infrastructure, it will be extremely difficult for them to grow from within themselves the necessary capabilities to tackle some of these deeply entrenched problems. There is a role for the centre, through Government, to intervene and try to build capability so that we can achieve an impact. I am concerned that if the whole mantra is about devolution, we will leave large areas of the country with concentrations of poverty and need struggling to achieve the kind of outcomes that she and we would want.
Anne Milton
I thank the right hon. Lady for that intervention. She is absolutely right to mention capacity building. There are areas where there is weakness across the board, and that is certainly something that we need to address. However, it is quite interesting what local areas can do with good leadership and the right levers and safeguards in place. I believe that it was out her way that I visited a scheme in an area with a high incidence of domestic violence. The local authority connected the council’s noise nuisance helpline and the domestic violence team, on the basis that where there is noise from neighbours there will probably be violence in the home. After a certain number of calls about a certain address, the domestic violence team is alerted and then goes in—a simple intervention, and a kind of capacity. Some of that is down to the confidence of the people working in the area, some of it is to do with expertise, and some of it—general practice has been mentioned quite a lot—involves putting in incentives to ensure that we get people with the skills that are needed to build that capacity.
I was not going to mention this, but we have made, for instance, a commitment to increasing radically the health visitor work force. One of the modules in health visitor training that we are looking at is about teaching new health visitors how to build capacity in communities. It is a nebulous thing, but it is important that we understand it. There is no doubt that communities, Governments and even empires have struggled for donkeys’ years with the question of how to improve public health. The hon. Member for Hackney North and Stoke Newington mentioned that in 1948, the NHS itself was a major public health advance. It secured health services for all, regardless of ability to pay. I make no apology for giving a history lesson. I am not a history scholar, but it is important to take on board the history of public health. At the same time, local authorities were given responsibilities for the health of children and mothers, and for the control of infections. At the same time, they retained their role in planning, sanitation and overseeing the health of their local population through medical officers of health.
In the NHS reforms of 1974, further unification of health services resulted in the transfer of some of those health functions from local government to the NHS, including many that we would recognise as public health functions. I draw Members back to the comments of the hon. Member for Hackney North and Stoke Newington about the status of public health. One of the reasons why the medical profession at that time pulled public health out of local authorities was to do with status, and the clout that they felt they had. Clearly, if one looks at what we are doing now, that was probably a mistake, but there were issues to deal with. The Government have to be clear about how we want the public health profession to look.
That period coincided with advancing knowledge that allowed us to identify the causes of chronic disease and health inequalities. All of those things needed to be tackled as they became apparent. The hon. Member for Blaenau Gwent (Nick Smith) mentioned the Black report, which was published in 1980. It showed that although there had been a significant improvement in health across society, there was still a relationship between class and infant mortality, life expectancy and access to medical services. It is shocking that one could write the same thing today, 31 years on.
That report was followed by the first public health White Paper, “The Health of the Nation”, which recognised that there were considerable variations in health by area, ethnic group and occupation. A new public health agenda was set, and it provided a foundation for action over the past 30 years. There has been a great deal of work, with the best of intentions. I do not doubt the previous Government’s intentions. As I said in my opening remarks, it is important to have some humility and understand that the intent was there. However, we did not get the results that everyone wanted.
We need a new approach, and that is backed up by recent data from the London Health Observatory and from the Marmot review team, which show that although life expectancy is increasing in all socio-economic groups, it also reinforces inequalities. The data also show the variation in life expectancy at birth between men and women and between local authorities, and the pronounced inequalities even within local authority areas including, for example, Westminster, which has the widest within-area inequality gap, at just under 17 years for men: a man born in one part of the borough can conceivably expect to live almost two decades longer than his friend born a short distance away.
I do not apologise for using figures, because when we talk about health inequalities, people glaze over and are not terribly sure what it is about. They think it is something to do with obesity, smoking or something like that, but the figures tell the real story. The smallest inequality gap for men is in Wokingham in Berkshire, at less than three years, and for women the smallest gap is in Telford and Wrekin, at slightly less than two years—so we all know where to move. It is worth repeating that those are the smallest differences in the entire country, so even in the areas with the best outcomes, we are still talking about differences in years.
It stands to reason that a community in Lancashire, for example, might face different health problems from one in Hackney, where I used to work. The public health White Paper therefore sets out a new way of working. It gives a different flavour to how we view public health, looking at our lifecycles and highlighting the points where we can intervene to make a difference. It is a way of working that shifts power away from central Government and into the hands of communities.
We had a short discussion about devolving power, and it is a brave Government who devolve authority for something for which they will be held responsible in the end. That is why I disagree with my hon. Friend the Member for South Norfolk, who said there has been a yo-yo between local devolution and centralised power; there has not. All Governments like to centralise things and keep control, because at the end of the day at a general election they will be blamed or otherwise for what has happened. It is quite brave to devolve power, but sometimes it is the right thing to do.
The new way of working will enable local areas to improve health throughout people’s lives, reduce inequalities and focus on the needs of the local population. The White Paper also underlines the priority we have given to tackling inequalities in supporting the principles of the Marmot review, which is important. The White Paper recognises the value of an approach that sees the importance of starting well, even before a child is born. Life chances are set well before someone pokes their head out into the world.
The new body, Public Health England, will have an important role. It will bring together what I suggest is a rather fragmented system and will span public health; it will improve the well-being of the population, targeting the poor in particular; and it will protect the public from health threats, which have not been mentioned, but they are an issue. There are inequalities in public health threats and, without a doubt, there are inequalities worldwide. Public Health England will need to work closely with the NHS, to ensure that health services continue to play a strong role and that NHS services play an increasingly large part in that mission. There has been a tendency for NHS services to see themselves simply as services to cure an immediate problem, rather than as part of a wider, more holistic approach to improving individuals’ health.
Ms Abbott
The Minister spoke about enabling communities, which is one of those things that sound very nice. How could one disagree with it? My right hon. Friend the Member for Barking made a point about how social infrastructure in some communities has never been robust, but there is also a point about the social capital of some of those communities. Many of them are simply not socially homogenous. Representing Hackney, my fear is that enabling communities is all well and good, but it will enable the parts of the community with more social capital and confidence, who are generally noisier, at the expense of socially excluded groups.
Anne Milton
The hon. Lady is right to raise the issue. That is what has happened. On a more general point, cherry-picking is a problem. It is very easy to get certain people to lose a couple of stone—[Interruption.] Actually, sometimes it is quite hard to get them to lose a couple of stone and go down the gym. To be rather crass and non-specific, it is easier to get the middle classes to go to the gym and to eat a better diet.
The hon. Lady is absolutely right to highlight the fact that some areas are very disparate and disconnected. I am an optimist, and I believe that there is social capital. Central Government are very poor at delivering in local areas. I have worked in the most deprived part of the country and lived in the most affluent, and there is a world of difference. It is extraordinary to see—they could be different planets. Central Government is a clumsy tool to deliver something that is very difficult to bring about on the ground, so we must ensure that we have levers and build social capital.
I mentioned health visitors as an example, and a universal health visiting service is extremely important. When we think about hard-to-reach communities, we forget just how hard to reach they are. For some people, the only interaction they have with any health or social service is when they have their baby. Their kids might not go to nursery school or might frequently play truant from school, and they are extremely difficult to get hold of. To be honest, a universal health visiting service is probably the single most important measure we have announced, because it will get hold of those families who are so difficult to reach.
There has been talk of increased health funding. I will not deny that the previous Government put a significant amount of money into health, and I welcome the rather cross-party approach in this debate to acknowledging that that did not always produce returns, certainly not in public health. One problem was that the budget was not ring-fenced, but it will be ring-fenced now. I will return to some points made on ring-fencing and localism and the tension between them. It is important that local government be given the responsibility and freedoms to make a major impact on improving health, backed by ring-fenced budgets.
The right hon. Member for Barking gave an interesting example about the ineffectiveness of one-to-one smoking cessation programmes. More generally, she said that it is extraordinary that we do not drive or back up with evidence what we do in health, which to most people is a science-based discipline with science-based professions. I may have a higher opinion of local government than my hon. Friend the Member for South Norfolk. I think that local government knows a lot about its local area and is often better at dealing with evidence than health services are.
The size of the ring-fenced grant will be important, because when the money was not ring-fenced it was an easy pot from which to pinch. The trouble is that the tabloid newspapers—I hesitate to mention one in particular—do not come out screaming about the poverty of the public’s health, although they come out screaming when services go. It was too easy to pinch the money, which is why it needs to be ring-fenced. It must also be based on relative population health need and weighted for inequalities, so that the areas with the greatest need will get the most.
Directors of public health will lead on action to address health inequalities. Public health physicians have done tremendous work. The public health observatories have done fantastic work, but they have tended to work in a cupboard and do not feel that they are getting their message across. Locating them in local authorities will bring together the threads that influence health, not only health care itself, but other determinants such as housing, transport, employment—the causes of the causes of poor public health, if you like.
There will be financial rewards for progress, and greater transparency so that people can see the results achieved. The new health premium will provide an incentive to reduce health inequalities and reward progress. That does not necessarily mean cherry-picking the easy cases. The programme will be designed to reward instances where progress has been made, and those places that have seen the greatest impact in areas with a poverty of outcomes in reducing inequalities. Almost by definition, those will be the areas where health inequalities are greatest.
Margaret Hodge
I understand the thinking behind the incentives and rewards, but my point was about the other side of that coin. Will there be penalties for those high-need areas with huge health inequalities that fail to perform? Although it is good to reward the good performers, that does not help people living in communities where there are bad performers. What are the Government’s intentions on that point?
Anne Milton
The right hon. Lady is right to raise that point. I was trying to stress that the healthiest areas will not necessarily be those that receive the most money. In theory, those areas that start from the lowest base should have the greatest opportunity to get those rewards.
Perhaps I can connect the right hon. Lady’s point with that made by the hon. Member for Hackney North and Stoke Newington. This debate is slightly premature because a consultation on the outcomes is currently under way, and we are also looking at the finances, at how much each local authority will have and at the size of the health premium. We are acutely aware—as I am sure are all Opposition Members—of the problem of unintended consequences.
Let us take an obvious example of A and E waiting times. It is right to want people not to wait in A and E for very long, and indeed they did not. If that is given as a target, the health service is good—as are most professionals—and it will fulfil that target. It will get people out of A and E. However, what was never measured was whether people got the care they needed. Did they get better or were they just transferred up to a ward sooner than they should have been? It is important to look at that. To some extent, this matter is a work in progress and we are keen to learn and listen to what people have to say. It is important not to have perverse incentives but to put in place the levers that we need to produce the right results in areas where there is possibly poor capacity, or areas that need building up or contain inequalities.
In some areas there are difficult cultural issues. To return to the issue of domestic violence, sometimes those working in the health service will collude with some of the men who perpetrate that violence. It gets very complicated and we need a system that takes account of all those issues.
Nick Smith
I commend the Minister’s emphasis on the directors of public health. The director of the Aneurin Bevan health board in south Wales is terrific and I will meet with her in a few weeks’ time. She has a good action plan together with her comparable officer in the local authority, and I hope that they will build a good partnership working together on public health. Will the Minister let us know how negotiations are going with the British Medical Association, and whether as part of the contract with GPs, public health will be given enough attention and emphasis?
Anne Milton
I will give a politician’s answer and say that we are currently having a constructive dialogue with the BMA. I cannot give the details of that and I am not personally involved. However, it is important to get that matter right, and I am sure that details will emerge. The Health and Social Care Bill is currently in Committee, and some of the details about how the mechanisms will work have been considered during that process. The negotiations are ongoing, and we will let hon. Members know.
Ms Abbott
Neither am I. My point is that some parts of the GP profession may be resistant to hearing anything from a local authority director of public health because they might see that as local authority bureaucrats telling them what to do. There may be some parts of the GP profession that think they know what public health is. They think that it is about injecting people and about cash money per hundred. It must be clear in the contract negotiation that GPs are signed up to public health in the sense that we in this debate understand it, rather than in the way that some of them have historically understood it.
Anne Milton
I am sure that those GPs are few and far between, but it is important to acknowledge that point. I say to the hon. Lady that the world just changed. The NHS has a key role to play in helping to reduce inequalities that affect disadvantaged people, and GPs are part of that. I know that there has been a lot of debate and discussion about the issue, and bringing decision making closer to home for GPs will be an extremely important part of levering-in better commissioning and focus on public health. Services are often commissioned because people’s health is poor. GPs will be faced with the consequences of poor public health every day, and they will commission services to deal with those consequences.
The White Paper set the proposals for the establishment of the independent national health service commissioning board and the new NHS outcomes. The proposed outcome frameworks for the NHS and public health will have the promotion and protection of equality at their heart. That aim underpinned everything when the frameworks were developed and it is no less relevant now.
As the hon. Lady said, the Health and Social Care Bill introduces specific duties on health inequalities that are enshrined in law for the first time. I share her cynicism a little. Governments often enshrine duties in law, but what matters is who holds them to account. The Secretary of State will be held to account, but Parliament has a role. Although this debate is not attended by many people, it is part of that process of holding the Government to account.
Mr Bacon
I was interested in that exchange and the intervention by the hon. Member for Hackney North and Stoke Newington (Ms Abbott). I draw her attention to the evidence taken by the Committee on Tuesday morning from the GP running the consortium in Essex. Together with the chair of the Royal College of General Practitioners, we were exploring the fact that there is great variation among GPs that cannot all be explained by the health variations and socio-economic conditions one would expect.
It was acknowledged that there are serious and challenging questions that need to be put to GPs. The GP from Essex is involved with teaching and improving the capacities of the consortia, and he has conversations with other GPs as he goes around his patch to look at the variations. I asked him how important it is during those conversations that he is also a GP and a clinician. He said, “It is essential. I would not be able to have the conversation otherwise.” I listened to the intervention by hon. Member for Hackney North and Stoke Newington with some interest. When that conversation between the director of public health and the GP takes place, the question will be whether the GP is listening.
Anne Milton
There is a question of whether the GP is listening and of whether the levers exist to make the GP listen.
This is a nebulous point to make, but I have to make it. Improving public health is about changing a mindset. We always underplay the importance of not only ministerial but parliamentary leadership on issues such as this. I am talking about a shift of focus on to public health, ensuring that the professions involved in health service delivery and the professions involved in the delivery of other services that affect people’s health receive a clear message that that is now a priority for the Government. When we talk to people who work on the ground, particularly at senior management levels, we see that that message is heard very clearly by them; it does filter down. Ministerial leadership is required, as is leadership from all of us on our individual patches.
Nick Smith
Does the Minister anticipate growth in the number of GPs in areas of multiple deprivation, which therefore have high levels of health inequalities? That has emerged from this afternoon’s debate as one of the big issues that need to be addressed. How easy will it be for practice-based commissioning to allow for growth in GP numbers in those areas, which are suffering the greatest health inequalities?
Anne Milton
As many people have pointed out—the Public Accounts Committee report focused on this—access to GPs is a major issue, and not just in urban areas such as Redcar but in rural and isolated communities. I will come on to that.
Subject to parliamentary approval, because the Health and Social Care Bill is in Committee at the moment, the NHS commissioning board and GP commissioning consortia will be duty bound to have regard to the need to reduce inequalities in access to and the outcomes from health care. That does not make it happen, but the duty is in the Bill and will be important. GP commissioning consortia will have to keep on improving the quality of their services, reducing geographical variations in standards. To increase the democratic legitimacy of health services, health and well-being boards will have elected councillors to represent the views of local communities.
To be truly successful, we need to be sure that the most vulnerable groups experience the most pronounced benefits. That is an obvious thing to say, but it is important. We are therefore driving ahead with the “Inclusion Health” programme, to focus on improving access and outcomes for the most vulnerable groups. Those are often the groups of people who are not registered with GPs or who are homeless. It is important that the really hard-to-reach groups get that additional focus, because they are not necessarily swept up by the other things that we are doing. We need to keep an eye on that.
I apologise if I am incorrect, but I believe that the life expectancy of the average Traveller is 59 years. The figures for the most excluded groups are truly shocking. Therefore, I fully welcome the Public Accounts Committee report and its recommendations. They were formally responded to in the “Treasury Minutes” dated 16 February. I know that many questions remain, but those minutes give a flavour of how we propose to embed the recommendations in the reformed health care system.
We need to ensure that the GP-patient relationship is as effective as possible. If we are not talking about a family who perhaps have contact with health care services only when they have a baby, the GP is the most important point of contact. On average, families with children under the age of two will visit their GP eight times a year. That is a massive opportunity to put additional emphasis on information and action to improve the health of families. We want to renegotiate the GP contract. The idea is to ensure that disadvantaged areas get the right level of access to GPs. The way to do that, as has always been the case, is to provide incentives to make it happen.
GPs need to improve the health of vulnerable people, not cherry-pick the easiest ones at the top of the pile. They need to encourage the uptake of good-practice preventive treatments. Changes to the quality and outcomes framework prevalence adjustment reward practices in a fairer way, particularly because deprived communities often have a higher prevalence of many of the QOF conditions.
I urge my hon. Friend the Member for South Norfolk to exercise some caution when talking about single-handed GP practices. His point was well made, in that practitioners who practise independently—single-handed—do not necessarily have the best outcomes, but in saying that, we should not exclude the very good single-handed practices. I saw one such practice recently. The GP there has recently been accredited for training and was serving his community absolutely brilliantly.
We have also proposed that at least 15% of the current value of the QOF should be devoted to evidence-based public health and primary prevention indicators from 2013. That answers a point raised by the right hon. Member for Barking. The funding for that element of the QOF will be within the public health England budget.
As the Public Accounts Committee report says, the most cost-effective interventions to improve life expectancy have been developed. Now we need to ensure that they are rolled out as far and as effectively as possible. The report of the review by Professor Marmot has helped us to understand the steps that we need to take, and we shall take them. The public health White Paper adopts the review’s framework of lifelong attention, which will mean a truly cradle-to-grave approach.
In thinking about public health, we must not forget that that is not just about physical health. It is also about people’s mental health and well-being. We need only consider some of the difficult issues that surround young people when they are growing up. We can consider the incidence of sexually transmitted diseases. In the last year for which there were figures, there was a rise of 3%. There has been good progress on unwanted pregnancies and abortions. There has been some progress on unintended conceptions among under-18s, but there are still 36,000. There are still 189,000 abortions every year, of which one third are repeat abortions. We can consider the figures for drinking and young people and the fact that 320,000 young people take up smoking every year. We have a lot to do with regard to young people’s health.
We can split health services into NHS services and public health. We can split public health further, into preventive work and curative work. What do we do when people have started to smoke or drink or have had sex when they should not have done? Then we can consider how to prevent that. There is no doubt that we need to do a great deal to ensure that young people have the skills, the self-confidence and the self-esteem that mean that they are equipped to make decisions about the difficult issues that they face.
Anne Milton
I have not quite finished yet, but I will happily give way. I will not keep my hon. Friend long!
Mr Bacon
I mistook what the Minister was saying for her peroration; it was the dulcet way in which she was speaking. On single-handed practices and particularly because she mentioned mental health, I want to say for the record that I do not doubt for one minute that there are some superb single-handed practices. The point that we made in our report, at paragraph 13, was this:
“A contributory factor to low levels of GP coverage has been the presence of single-handed GP practices.”
I was also making the point that people generally work better together, and it is better for someone’s mental health as a worker if they are working with people rather than alone. I speak from experience, having worked in a large agency in London with 200 employees and then having set up my own business and worked solus. What surprised me most—apart from my clients, of course—was the amount of contact that I had in the workplace, which was much lower. That was quite an unexpected aspect of it. All other things being equal, surely it must be better for GPs to work in groups than to work alone. That is in addition to the effect that it would have on overall levels of coverage.
Anne Milton
My hon. Friend is right to say that it is better to work together. Peer support is important, as is peer review. The identification of children at risk in A and E is important, but it is often junior paediatricians who see such children when what is actually needed is access—it can be by phone—to someone who has been doing the job a lot longer so that they can run through with them the signs and symptoms that they have seen at A and E. That sort of support is invaluable. A single- handed GP might well miss out on that. Where there are good single-handed GPs, we should encourage them to work together—not necessarily in the same practice, but perhaps in the same building. What matters to me, and my hon. Friend mentioned it earlier, is not how things happen, but doing what works.
The right hon. Member for Barking spoke about evidence, which is crucial. She rightly highlighted the issue of cancer, which was the subject of a recent Committee report, and the need for early diagnosis and early intervention. I accept what the hon. Member for Hackney North and Stoke Newington said about not everyone having access to computers or other fancy communications equipment, although most people can text these days, so there other ways of communicating. However much the Government do and whatever is done locally by GPs on early diagnosis, at the end of the day, we rely on people going to the doctor with their symptoms.
For instance, when it comes to bowel cancer, we are not very good at talking about what is in our knickers or underpants, and men are particularly bad at it. The problem with bowel cancer is that men do not go to their doctor when they have symptoms. We need to get the information out there, but improving the public’s health is largely about giving people the information, levering them into settings and giving them lots of opportunities to do so.
The right hon. Lady said that some things are much easier to do than others. For instance, it is easier to do things on which figures can be collected. However, smoking is still difficult to deal with. We and, I think, Canada perform better than almost any other country. We have made huge progress on that front, but there is a great deal more to do.
I have probably touched on most of the matters raised during our debate, but I wish to say a final word about public health. Public health goes back a lot further than people might think. The first report into the health of the working man was the Chadwick report of the 1840s. Many remember John Snow and the Broad street pump in 1854, and the outbreak of cholera that killed 500 in the first 10 days. Then we had the London sewers in 1858 and the Royal Sanitary Commission of 1871. Interventions in public health go back a long way, but it is important to remember that most of them derived from local authority action. Public health is not just about the health service.
I sit on many committees, including two Cabinet sub-committees—one on social justice and one on public health. The one on public health is particularly successful. It brings all Departments together because it recognises that public health is everybody’s business. It is a transport issue, an environment issue, a local government issue, and an education issue. It spans all the Whitehall Departments. It therefore has to span all the ministries. One of the challenges for the Department of Health is to ensure that every Department is taking whatever action it can to improve people’s health.
I know that the matter is well suited to local government. Everyone loves to hate the local council, particularly at this time of year, but they are complex organisations, dealing with a multitude of things and they know the local community well. I want to get to the day when, instead of seeing local councillors in the council chamber arguing about whether Mrs Smith at 17 Acacia avenue puts an extension on the back of her kitchen, they are saying things such as, “It’s a disgrace that the people who live in your ward live 17 years longer than those in my ward.” That would be a real success. I look to local councillors to take up the baton and to fight for public health in their areas.
We know what we need to do in the short and long terms, and we know that it can be done. Indeed, some disadvantaged areas are already narrowing some of the gaps in health outcomes. I know that our proposed reforms will put incentives in place to drive delivery at a local level, allowing local authorities and the NHS to work together.
There are health imperatives and there are financial imperatives, but there is also a moral imperative. We in Government can spend a lot of time legislating and making regulations. A lot of things are going on at the moment; we have a very difficult economic climate, and foreign affairs are now exercising us. We have to remember sometimes that there are strong and ever-present moral imperatives to take action and to improve public health.
Margaret Hodge
I thank both Front Benchers—the Minister and my hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott)—for their contributions, and I thank you Miss Clark for chairing our debate so well. It is the first time that I have heard the hon. Member for Guildford (Anne Milton) speak as Minister. I am sorry that it is always so difficult to keep other Members in this place on Thursday afternoons. None the less, it has been a quality debate, and I am grateful for the remarks made by hon. Members on both sides of the Chamber. We will return to the subject because, as the Minister said, it unites parties and is of huge importance to the people. I look forward to being able to say, “And we are making progress.”
Question put and agreed to.