(8 years, 5 months ago)
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Lord Crisp
To move that this House takes note of the case for building a health-creating society in the United Kingdom where all sectors contribute to creating a healthy and resilient population.
Lord Crisp (CB)
My Lords, first, I thank my noble friends on the Cross Benches for choosing this debate today, but I also thank all noble Lords who are taking part in it. I am very much looking forward to hearing everybody’s contributions. I recognise that this is last business on a Thursday, so I am particularly grateful to noble Lords taking part. I also welcome the three noble Lords making their maiden speeches. I know that we are very much looking forward to what they have to say now and in many future contributions in your Lordships House.
The health and care system is under great strain as needs grow, particularly from older people with long-term conditions, and as costs rise. This mirrors the position elsewhere, not only in Europe and America but in many fast-developing countries. Not surprisingly, and not just in the UK, there is widespread concern and considerable confusion about the future for health. This uncertainty and insecurity means that it is more important than ever to understand the complex nature of health problems and what can be done about them, and to set out a long-term vision and strategy for the future.
Health and well-being are affected by three big things: the availability and quality of health and care services; individual lifestyles and behaviours—individual responsibility for our own health is absolutely vital; and all the physical, economic and social factors such as education, employment, wealth, social structures and the physical environment. Those are the many determinants of health, and co-ordinated action is need across all three areas. However, my focus today is on the third of these—the wider determinants of health, which go way beyond the reach of the NHS and individuals.
There is a great World Health Organization quotation:
“Modern societies actively market unhealthy life styles”.
I want to talk about how we can set that on its head. What would it be like, instead, to build a health-creating society where everyone—citizens, families, communities and businesses alike—had a role to play? None of what I have said, however, should detract from the importance of the first two—the health and care system, and the choices and actions of individuals—and I am sure other noble Lords will address those.
Let me just give a few examples of what I am talking about. Barely half of our children achieve a good level of development by the time they start school, which affects their future physical and mental health and, of course, their ability to learn. Going to the other end of the age range, social isolation and loneliness in old age have the equivalent health impact of smoking 15 cigarettes a day and a slow recovery from illness. There is recent evidence that they also lead to earlier death. Having a social network and some meaning in life is hugely beneficial. Some groups in the population are affected more than others, including people with mental health problems. Men with severe mental health problems die up to 20 years earlier, and women 15 years earlier, than people without such problems. Importantly, there are also lower levels of subjective well-being and a higher burden of ill health in people from black and minority ethnic communities. Moreover, as Sir Michael Marmot has demonstrated, inequality damages health, with the most disadvantaged being most prone to ill health and living shorter lives.
Perhaps the most alarming statistic of all is that, on average, UK citizens have about seven years of ill health before we die; at the top of the scale, the Norwegians have only two years. What if we could reduce the UK figure by even one year? What a difference that would make for individuals and, at the same time, for the health and care system and therefore the economy. What is so different about Norway? This surely gives us a target to aim at.
These are complex problems, and they illustrate clearly that health cannot simply be left to individuals, the NHS, professionals or government. Everyone in every sector has a role to play. Moreover, improvements in health go hand in hand with improvements elsewhere. Education, the environment and the economy: all will benefit from a health-creating society. Better health and greater prosperity go together.
This is also very relevant to the future sustainability of the NHS, which is often discussed, like so much in health, in largely economic terms, as if it were really an economic problem and there could be purely economic solutions concerned with financing and/or restricting services and treatments. However, experience from the Netherlands to the USA shows that those solutions produce at best limited gains and may increase the economic cost to society as well as individuals. The long-term sustainability of the health and care system will come from changes in practice, finding health solutions to health problems and moving upstream into prevention, health promotion and, as I suggest here, building a health-creating society. Arguably, the NHS will not be sustainable without this.
Those are the problems, but an enormous amount is already being done. We can look at what is going on in the community and voluntary sector, and I am sure we will hear a great deal about that from other noble Lords. We know, for example, that informal carers contribute services worth an estimated £119 billion a year at least. If the informal care sector fails, the burden falls on the formal sector. People do not want to be dependent and are keen to live independent lives.
Connecting Communities brings together many of the organisations that work on small, local health projects. There is a wonderful African saying: health is made at home, hospitals are for repairs. It matches the scientific evidence about creating the right environment in every sense. It is also for us a reminder of the work in the UK of the Early Intervention Foundation.
Let me turn to other sectors: to designers, architects and planners, who can design buildings which encourage walking and the use of stairs, communities where people meet each other and public buildings which bring together different services. I declare an interest as a member of the council of Reading University, and note as an example the work going on there on the built environment. Researchers are looking at topics as diverse as indoor air quality in schools and workplaces and its effect on health and the well-being and educational performance of children and workers, and the relationship between the design of homes and health and well-being.
Moving on to businesses, as well as developing healthy products, they can create healthy environments for their workforce, recognising how much time and productivity is lost every year through ill health. They can both promote health and tackle specific problems, as the firms working together in the City Mental Health Alliance are doing. It is good to see the work of Dame Carol Black as a government adviser raising standards in this area. Schools, colleges and universities can promote health literacy and competencies, integrate healthy activities into daily life and share facilities with health and other services.
I very much hope that my noble friend Lord Mawson will talk about the St Paul’s Way Transformation Project in the East End of London. It is perhaps the most complete example of all these things that I have ever come across. It is about the community coming together with the private sector, education, health and care services: joining up the dots, as I suspect he may say, and informed by an entrepreneurial spirit. It is very much a model for the future.
Of course, government has many roles here. I recognise the importance of the economy and that the aspiration for a higher skilled and higher paid workforce is fundamental to health and well-being. Government is also able to address regulation and legislation, be it on salt, sugar, alcohol or elsewhere. Government can run great public education campaigns, but it also needs to do more to support civil society. I question whether it is doing enough now to build the sort of enabling environment we want, with all the social and community activities I mentioned earlier. It can also support disabled people to live independent lives. I am sure that my noble friend Lady Campbell will have something to say on this, both in this debate and elsewhere.
So there is already an enormous amount going on. Let me note the work of NHS England, Public Health England and other such bodies, local government—I welcome the devolution of responsibilities in Manchester and elsewhere—voluntary bodies, professional associations, researchers and many more than I have listed here. My purpose in this debate is to point to all this and ask how much more we could achieve if we did it in an even more co-ordinated way. I am sure the Minister has a briefing folder bulging with excellent examples of policies, initiatives and activities, and I look forward to hearing about them. There are many out there. However, the Government could do much more in a joined-up way across government, bringing in all those bodies and sectors of society that shape the health of the population. In truth, only Government can really mobilise everyone who needs to be involved.
As the Minister knows, I wrote to the Prime Minister immediately after the election to propose that he and the Government take a big, bold initiative to mobilise all sectors around building a health-creating society. I received a broadly warm reply and understand that the time needs to be right for such an initiative. Now, with winter coming and industrial action planned, is certainly not it, but the time will come for a bold and imaginative commitment to engage all sectors in building a health-creating society. Does the Minister accept this analysis? Will the Government, at the right time, reach out and mobilise all those other sectors to help build a health-creating society—and not, as it so often appears in the newspapers, leave it all to the NHS, government and individuals?
There is also a challenge here for all political parties. I meet a lot of people working in the health and care system and I observe two things. One is frustration, depression and sometimes even despair about the future. However, when I listen to them I also hear a common vision of what that future might be like. In summary, and in very simplified form, this vision is of a transition from the current hospital-led, professional-dominated and fragmented system where things are done to and for patients, to a much more seamless people and community-based one where patients and communities play their roles alongside professionals. This is a vision of high-quality services, delivered in homes as well as local facilities, with a different infrastructure and far greater use of technology. My noble friend Lady Lane-Fox has talked about that, and I suspect she will do so again. With these changes comes the potential for both higher quality and lower costs.
This vision will require major change. I have no doubt that it will require the closure of some hospitals and changing roles for staff. This will be difficult, both practically and politically, and will need political support. The challenge to the political parties seems to be that we need a shared vision for the future and some cross-party political will to make this happen. There will be plenty of political differences about the means of getting there but it seems that this end, this sort of vision, is common ground.
We already have some elements of such a vision in current policy: the Five Year Forward View is very good and has a lot of support, but is ultimately a technocratic and managerial document—I know because I have written such documents in the past. There is a need for a broad-based, cross-party coalition of agreement about what the future looks like. I do not know how that should be achieved, whether through some appointed commission or otherwise. What I do know is that people in the NHS and the country more widely would benefit from clarity of vision and strategy.
Your Lordships’ House also has a role here. It has very often led the way in discussing new and coming ideas and influencing the future. I think of debates I have heard here, for example, on genetics and, most recently, on securing parity between mental and physical health. Noble Lords from all sides of this House argued that case cogently and ultimately very successfully. I hope we might be able to do the same sort of thing here. I note that we are presently asked if we want to put forward proposals for ad hoc committees. I wonder if we should put forward one on building a health-creating society, so that these important ideas can be deliberated on in much more detail than the five minutes noble Lords have today allows. I would be interested to know if noble Lords thought that a good idea and would like to join me in making such a proposal.
Let me finish in optimistic and mildly jingoistic style. The UK is a great world leader in health. We have astonishing strengths in academia, the NHS, the role of DfID globally, the voluntary sector and our commercial organisations. The UK was a pioneer in providing a National Health Service that covered everyone in the population. It would be wonderful if we could lead the way again in moving beyond the professionally dominated and rather industrialised system of service to build a health-creating society served by a modern, fit for purpose health and care system. That would benefit us all as individuals, and bring with it wide-ranging benefits to the country in both prosperity and health. I beg to move.
Baroness Jay of Paddington (Lab)
My Lords, I thank the noble Lord, Lord Crisp, for introducing this debate in such an informative and authoritative way. It is obviously a very important issue. I wholeheartedly agree with the terms of the noble Lord’s Motion and support his points about the way in which the determinants of health in today’s society are often driven by matters such as alcoholism, obesity and other concerns, which are obviously not the sole responsibility of the NHS, however much we support it.
I think that the way that the noble Lord has proposed is the only way to improve the stark health inequalities in this country. As he reminded us, we are all familiar with the really disgraceful record of discrepancies in morbidity and mortality between different social and economic groups in this country. It has become almost a truism of health economics that low income and low social status are major contributors to ill health, and probably the determining factor in more rapid ageing.
The proposal of the noble Lord, Lord Crisp, for working towards a “health-creating society”—I am still finding it a little difficult to put those three words together—must be the right approach, but my concern this afternoon is: if the ideas and the vision he describes gain general support, how are they to be delivered? How will we make it happen? As noble Lords are aware, there is enormous emphasis nowadays on localism and finding solutions and organising action as near as possible to the communities involved. I worry that there are difficulties in relying primarily on the local approach to tackle some of the somewhat intractable problems of public health.
Of course, community-based alliances of public service, private enterprise and the voluntary sector can often unleash especially effective energy, and there have been some interesting and radical ideas put forward recently on this ground. I was intrigued, for example, by an article by the chief executive of the Royal Society for Public Health, who wrote about the local high street as “an untapped resource” for promoting health. She picked up on the WHO statement that modern society is actively marketing very unhealthy lifestyles, which the noble Lord, Lord Crisp, has already referred to, and argued that stricter local planning laws and differential business rates could drive businesses such as fast-food outlets, betting shops and payday loan shops out of the high street and reduce the tempting opportunities for unhealthy lifestyle choices. I can see the attraction of this proposal, but in the broader picture I fear that the huge reductions in the budgets of local authorities, combined with a lack of local expertise in specialist problems such as sexual health, may make local projects inadequate and sometimes even increase inequalities.
I hope I will not be labelled a centralist dinosaur for saying that national government and a senior Minister must take the lead responsibility for promoting change in this area and achieving the necessary collaboration to build a health-creating society. I was proud to be a Health Minister when the very first Minister for Public Health, my noble friend Lady Jowell, was appointed to that post. She was a senior Minister of State with a wide remit and, although the post has continued in successive Governments, it has not always had the authority of the original appointment and, very importantly from my point of view, it has always been based in the Department of Health. In my view, a Cabinet post should be created—we will have to think of a good title—to take forward the cross-cutting policies we are discussing. This Minister should be based in the Cabinet Office, with co-ordinating powers across government.
My enthusiasm for this approach is partly based on my experience as Minister for Women, when I was based in the Cabinet Office and worked with several departments across Whitehall and with outside agencies. It was a largely successful arrangement. My Cabinet Office team acted as a kind of internal pressure group within the Government; we legitimately raised issues of women’s employment, education, health and pensions across Whitehall and had the authority to do so. I think that the interesting and imaginative proposals for a health-creating society can only be delivered by an imaginative approach from the machinery of government, and I would like to see a Cabinet Minister leading the initiative towards this vision.
Baroness Williams of Crosby (LD)
My Lords, I, too, congratulate the noble Lord, Lord Crisp. He has the holistic and internationalist approach that health worldwide requires. We know that he has drawn the attention of the whole world to the impact of influential and dangerous diseases, such as Ebola and other national and international illnesses, crossing borders. I wholly agree with him that what this country needs most is an all-party approach to our National Health Service that recognises the remarkable things it has achieved and that, instead of quarrelling among ourselves, we should take strength from it and extend its influence and understanding more widely than at present.
In my four minutes, I shall whizz through a number of things that we ought to be able to do. One thing they show up is that many departments, not simply the Department of Health, have a responsibility. It is very important to notice that, in the last spending review, we sadly saw serious cuts to local government—for example, 6.2% of public health expenditure by local government, which amounts to a loss of £200 million—so what the noble Baroness, Lady Jay, said is very relevant. That will be saved, thank God, by central government giving additional resources to the National Health Service: the £8 billion or so that was announced only yesterday, to my great pleasure. It still means that the local connection and local responsibility have been fundamentally weakened, and that is not in the long-term interest of this country’s prospective health-creating society.
I shall stop for a moment on the position of central government, to which the noble Baroness, Lady Jay, referred. We could save between £10 billion and £12 billion a year by effectively addressing the illnesses that are very closely related to excessive sugar in our diet. I shall not make a direct connection to type 2 diabetes, but there is enough medical evidence to show that there is a very close relationship. Bearing out what the noble Baroness, Lady Jay, said, the House will know that in the poorest parts of the country and among the poorest people in those parts of the country, consumption of sugar, fizzy drinks and other sugar-related foods is very much higher than in Kensington and Chelsea. That means we are pushing some of the poorest members of our society into eating cheap unhealthy foods, which lands the National Health Service with the responsibility for dealing with the consequences. Last year, those consequences were estimated to be of the order of £14 billion. It is interesting that the amount of extra money given to the health service is £8 billion, which shows very forcefully the case made by the noble Lord, Lord Crisp, about what happens if you do not address prevention soon enough and land the whole price on cure, which is exactly the wrong way to go.
My second point relates to the Department for Education, which we have not discussed very much. There has been a considerable fall in the amount of time given in state-maintained schools to PE and games. The figure has dropped from around 127 hours a month to fewer than 100 hours. There has been a sharp decline in the amount of time spent on PE and, in a situation where so many children inevitably spend their time watching television, the effects of that drop are very serious.
As my time is running out, I shall conclude very quickly with one reference to mental health, to which the noble Lord, Lord Crisp, referred. There are three things about it. The first is the terrifying increase in domestic violence casualties—not of overall crime, which has fallen—both women and men, but primarily women.
The second is the impact of social networks, particularly in legalising, as it were, serious bullying in education and of young people and adults alike, which we have to address. I suggest to the House—my last thought but one—that we should begin to look at the possibility of insisting that social networks hold a contact name and address of those who use them, not to censor people but just so that they know that somebody knows they are the person responsible for trolling in a way that makes the lives of many of our fellow citizens highly disagreeable, and which is sometimes cruel and brutal.
Finally on mental health, I agree completely with what the noble Lord, Lord Crisp, said about the equality of treatment working both ways, but we must also address very closely, therefore, the effects of loneliness—of families and societies that are breaking down—on mental health, particularly that of many older people.
Baroness Campbell of Surbiton (CB)
My Lords, I thank my noble friend Lord Crisp for tabling this very timely debate. Over the years, my noble friend and I have often exchanged ideas on what I like to refer to as the empowerment model of health and social care well-being. That was the model that drove my leadership of the charities the National Centre for Independent Living and, after that, the Social Care Institute for Excellence, where I was privileged to be founding chair from 2001 to 2006.
Michael Marmot, in his book The Health Gap, argues that not health services but the social determinants of health are more important in determining the health of the population. Like Marmot, I believe it is more important to change the conditions in which people live—to empower people holistically—than simply to address their medical condition or their care need, which disabled people have described to me as the medical model.
It is more important to empower people in health and social care than simply to address their immediate medical conditions. Therefore, the National Centre for Independent Living used the empowerment model to support disabled people to move from dependency-creating care provision to independent living support. Our work was born out of the Community Care (Direct Payments) Act, legislation that was conceived and largely implemented by disabled people. For the first time in our lives we had direct control over our social care budgets. I have to say that traditional care providers were very opposed at the time but, with the assistance of enlightened directors of social services, civil servants and a very enlightened politician, the tectonic plates of power shifted from “the professional knows best” to “the client knows better”.
This care revolution could not have been achieved without the national infrastructure of local centres for independent living. These local centres are largely run and controlled by disabled people, who provide advocacy, advice, buddying, volunteering and jobs. Over 15 years, I saw people society had written off come out of residential care, long-stay hospital wards or their parents’ homes and begin to live as rounded human beings. Relationships were formed, families were made and children born.
Things have rightly progressed over the years, and now people with learning disabilities also enjoy the same right to choice and control over the way their support is delivered and experienced. So, too, do people with enduring mental health challenges, who developed their own empowerment model, the recovery model, which demands greater focus on life chances rather than more psychiatrists, more treatment and more loneliness, pushing a culture shift in the provision of mental health services.
There is rich evidence that the independent living movement drove a culture shift that has led to a wider personalisation approach and now, at last, it is beginning to catch on with personal health budgets. But I remind noble Lords that this was conceived by the people who have the condition and not the experts.
It really baffles me why, when the economy shrank, local and national politicians decided to cut first the independent living infrastructure that is necessary for progressive personalisation. I remember campaigning for a national independent living scheme, which became the Independent Living Fund, over 21 years ago. It was the epitome of the independent living empowerment approach, yet again it was sadly cast aside without a government strategy to ensure its principle and outcomes were not lost when transferred to local authorities.
Independent living pays for itself again and again. It is well evidenced that people who live independently in the community with the right support lead healthier and more cost-effective lives. It is the very basis of health and well-being creation, where professionals enable, facilitate and inform, and the service user learns, takes control and lives—not just survives.
Finally, I congratulate the Government on the Chancellor’s spending review statement yesterday, allowing as it does local authorities to levy a new social care precept of up to 2% on council tax. This is good news. But a word of caution: let the £2 billion investment be directed at social care that enables the service user to become an active, empowered citizen.
Winston Churchill said of scientists that they need to be,
“on tap, not on top”.
We need their expertise, but for God’s sake, do not let them run the country. I would argue that the same applies to health and social care professionals: we need their expertise, but for God’s sake, do not let them run people’s lives. I suggest that legislators, policymakers, economists and politicians should seriously reach out to disabled people and the service users and let them be part of the solution, not a problem to be dealt with. Perhaps we could give leadership to my noble friend’s health-creating society and not simply be the users of it.
Baroness Redfern (Con) (Maiden Speech)
My Lords, it is with a great source of pride, having spent more than 28 years in continuous service to the Isle of Axholme as an elected councillor and now leader, to be able to stand among you today as a Member of your Lordships’ House.
Preparing for today—I am sure many noble Lords are acquainted with this—I realised my predicament in speaking before so many learned and talented individuals from all sides of the House. Now that I am a Member of your Lordships’ House, I should like to say what a delight it is to observe the wealth of knowledge that this House provides, and the great kindness and warmth shown to me not only by noble Lords but by all the staff who I have encountered since I took my seat here. I would also like to register my eternal thanks to my family and long-standing colleagues. I also thank my two sponsors, my noble friends Lord Taylor of Holbeach and Lady Eaton, both of whom have aided me and provided helpful guidance in my initial few weeks here.
I will, if I may, briefly take this opportunity to share with noble Lords the historic origins of the Isle of Axholme and how the isle came into being. I moved to the isle following marriage and we started our businesses here, enabling us to integrate into what continues to be a close-knit and very friendly community.
The isle is dominated by marshland and peat, with many of the original communities, including Crowle, Epworth and Haxey, all built on what was previously the only high and dry land available. Indeed, the isle is known to many by the early influences of the Dutchman, Cornelius Vermuyden, an engineer whose work at Windsor brought him to the notice of Charles I. The King subsequently commissioned him in 1626 to drain Hatfield Chase.
The isle is known as an isle as it was previously separated by four rivers—the Idle, Don, Trent and Torn—which created a unique and strong identity. A number of notable individuals hail from the isle, and Epworth is the birthplace of Wesleyan Methodism. We have a strong appreciation of agricultural activity and the beautiful watercourses that the isle has to offer, which have produced, among other things, high-quality beetroot and celery. That said, the isle and our area more widely are very susceptible to flooding, and securing funding for proper flood defences is something that I have already championed and will continue to pursue.
It might seem appropriate to speak on health, considering my heart rate in delivering this maiden speech, and I welcome the debate secured by the noble Lord, Lord Crisp, today. Across North Lincolnshire, we have worked hard to engage all of the community and provide opportunities to improve health prospects—both physically and mentally. North Lincolnshire Council has invested in a successful programme of community well-being hubs, which provide advice and support for a wide range of individuals and groups, including vulnerable adults. This is against a backdrop of declining local government budgets and I am proud that we have achieved this by making necessary savings elsewhere to secure and improve front-line services.
The hubs work with and support older people, young adults and also carers; recognising the wide mix of people involved in healthcare. They work neatly with the national health agenda by integrating services for the benefit of both patients and the broader health economy. Indeed, the regulation of health and social care professionals not only impacts on the lives of registered and aspiring professionals but affects the lives of all those who use these services. The community hubs also provide a base for well-being checks which, among other aims, address poor nutrition and raise awareness of healthy eating and choice. Poor nutrition, which manifests itself very much in older people, is estimated to cost the NHS £13 billion a year. Looking at ways of addressing this and creating health aspirations locally is something that I am passionate about.
The latest addition to our commitment to develop health opportunities in North Lincolnshire is the Sir John Mason House intermediate care facility in Winterton, the town where I was born, and this brand-new facility was launched this year. Those using this service may stay there for a period of rehabilitation and reablement, for example following a hospital stay. With an ever-increasing older population, loneliness and isolation are key challenges for all local authorities, and North Lincolnshire Council is working hard to combat this. Like many areas, memory cafes are held across North Lincolnshire and help link residents with health services. These are shining examples of co-operation between the community and different agencies. However, we must look at ways to further integrate services and at the wider health debate as social isolation is known to increase the chances of premature death by up to a third.
Finally, the Isle of Axholme is blessed with some outstanding scenery and is a very special place. I am passionate about encouraging and assisting local residents to access this shared space with opportunities such as Walking the Way to Health, which is a project to organise walking activities. While my walking days are nowhere near behind me, I look forward to spending plenty of time sitting in on the many future debates regarding health and sharing the positive achievements across North Lincolnshire, and particularly on the isle, with this House.
Lord Best (CB)
My Lords, I am delighted to follow the maiden speech of the noble Baroness, Lady Redfern. She comes to us as a distinguished council leader whose insights, not least from North Lincolnshire, will add an important localist dimension to our deliberations, as she has so impressively shown today. Greg Clark, the Secretary of State, said last year that she was,
“one of the Conservative Party’s most effective politicians”.
Wearing my hat as a past president of the Local Government Association, I am particularly pleased to see the voice of local government strengthened by her presence here. We all look forward to her future contributions in your Lordships’ House.
I, too, am grateful to the noble Lord, Lord Crisp, for initiating and organising this debate, and for his insightful and excellent opening speech. I want to fasten on to the first words in the title of our debate—“building a health-creating society”—and to make a connection between the buildings we inhabit and the health we enjoy.
Housing and health have long been intertwined. For the first half of the last century the Minister for Health doubled as the Housing Minister, so close were the two issues. In the ageing society of the 21st century that linkage needs revitalising and reinforcing. Unsuitable accommodation carries with it a series of dangers to our health and well-being. Overcrowding and poor conditions can create endless ailments and mental health problems. All families have a fundamental need for a decent home in which children have the space and security to develop.
Speaking as chair of the HAPPI group—Housing our Ageing Population: Panel for Innovation—and as co-chair of the Housing and Care for Older People APPG, I want to concentrate on the housing and health equation as it affects older people. So many older people spend virtually every hour of every day inside their home. It can be a trap, a virtual prison, if mobility problems mean that steps and stairs become an insuperable barrier, or if your spouse or your carer must carry you upstairs for a bath. If your central heating has not worked for years because you cannot afford to replace the old system and if the two steps at the front door get icy in bad weather, sooner or later your home will let you down—or indeed, may be the death of you.
As research by Professor Sir Michael Marmot has shown so clearly, cold conditions in this country’s homes lead to respiratory and circulatory diseases and premature winter deaths, contrasting with the outcomes from the far better-insulated homes in Scandinavia, where mortality rates do not vary with the seasons. Trips and falls in the home account for a high proportion of hospital admissions by older people. It is the unsuitability of the home that prevents so many older people being discharged from hospital, or causes them to be readmitted after they have left. You may want to go home, and the hospital certainly wants the bed you occupy, but if your accommodation is totally unsuitable, you must stay in hospital and the NHS is left with an escalating bill for a service you do not want.
Conversely, decent, well-designed housing enhances our enjoyment of life and our ability to live independently and well for longer. If our homes are well insulated, warm and efficient, as well as being well ventilated; if they are light and bright, with sufficient space; if they are lifetime homes—fully accessible, even when we may need a wheelchair—we are unlikely to require hugely costly residential care, and our later years can continue to be fulfilling. I welcome the spending review measures to raise funds for social care, but the biggest savings can come from preventing the need for residential and other care.
Housing designed specifically for older people can also combat that scourge of later life referred to by the noble Baroness, Lady Redfern—loneliness from isolation and a lack of social contacts. Retirement villages, age-exclusive apartments, extra care and assisted living—today’s version by housing associations of the sheltered housing of yesteryear—are all housing solutions that can provide companionable, engaging communities for people with similar ages and interests.
In my five minutes I cannot spell out the range of steps that could be taken by central government in joining up housing with health and care, supporting the creation of new accommodation and funding grants for disabled facilities and home improvement; or by local government in planning policies on integrating housing, care and health, with joint assessment and commissioning, not just in new combined authorities with devolved powers but through health and well-being boards everywhere; or even by each of us past retirement age who should not just wait for a crisis before considering downsizing to sustain our own independence, free up our family homes for the next generation and save the resources of the NHS, social care budgets and our own funds. I must satisfy myself with simply making the plea that all those interested in the health of the nation should never forget the immense significance of housing.
Baroness Masham of Ilton (CB)
My Lords, I thank my noble friend Lord Crisp for securing this debate, which comes at a time when the NHS is under serious stress. The demands on it are immense, but, as my noble friend suggests, if everybody pulled together a healthy and resilient population may be achieved.
It is of great concern that the funds for public health are being cut back, because grants to voluntary organisations can help people who need support in so many different ways. It will be at our peril if sexually transmitted diseases and their clinics are neglected. In West Yorkshire some strains of gonorrhoea have become resistant to their treatment drugs. In London there are some excellent HIV/AIDS treatment units, but HIV infection is still increasing. Drug-resistant strains of tuberculosis are also increasing. It would be very unwise to become complacent.
Public Health England should educate the public about the dangers of a wide variety of infections. Hepatitis C can now be cured, but few patients are getting the drugs they need. The problems of alcohol abuse, alcoholism and drug abuse must be addressed. Treatment centres should not be put at risk. I ask the Minister: how will cuts to public health budgets affect drug and alcohol clinics? If Public Health England cannot afford to tackle these problems with NHS England and NGOs, perhaps the drinks industry and the private sector can help. Working together must be the answer.
Simon Stevens, head of NHS England, said that hospitals should be health-promoting environments. Hospital food is integral to the health and resilience of patients, hospital visitors and NHS staff. I experienced hospital food that was tasteless and unpalatable. Much of it was wasted. It came from Wales and was reheated. People in spinal units, who have serious injuries and have to be in for long periods, sometimes being treated for pressure sores, need good diet and nutrition, which is key to building health resilience in patients. Also, hospitals are where people are at their most vulnerable. Many of them may be elderly and have eating problems. They need good nutrition to heal, gain a healthy weight and recover from their illness. Good food builds good morale. Indeed, patients getting depressed can look forward to meals and going home early.
There is currently a TV programme called “Doctor in the House” on BBC1. Last week a doctor visited a family in their home, and there was a diabetic man who was eating all the wrong food. The family was shown what a good, healthy diet and plenty of exercise could do to bring high sugar levels down. The woman was shown how to beat anxiety and the daughter how to prevent infections by washing her hands. Many people need to be helped to live healthy lives and to feel good. I am sure that these sorts of programmes will help.
The paraplegic sports movement was started by an inspired Jewish doctor at Stoke Mandeville Hospital rehabilitating wounded military personnel from the Second World War. It was found that if you could compete in sport you could compete in normal life and work, however disabled. These sports became the Paralympics. Many disabled people worldwide live healthy and resilient lives, having been stimulated through sport. I salute His Royal Highness Prince Harry for the Invictus Games, which show the amazing feats accomplished by modern injured military personnel, who achieve so much.
I congratulate the three maiden speakers, and I am pleased they have chosen health as their subject for debate.
Lord Foster of Bath (LD) (Maiden Speech)
My Lords, I, too, congratulate the noble Lord, Lord Crisp. I am grateful for this opportunity to make my maiden speech and, of course, for the privilege of joining your Lordships’ House. I hope I will be able to make a useful contribution.
I am also grateful for the generous welcome I have received from all sides of the House, and for the patient support and help from noble Lords—not least my noble friend Lady Walmsley—and from the attendants, doorkeepers, catering staff and all the excellent and courteous parliamentary staff as I struggle to find my feet and my way round this end of the building. I am especially grateful for the advice, “If lost, look for the blue carpet”.
I rise with a sense of trepidation similar to that which I felt when, 23 years ago, I rose to make my maiden speech in the other place, and, in 2010, when I seconded the Loyal Address following the formation of the coalition Government. That was a particularly difficult speech for a then 63 year-old to make, since the tradition is that that role is usually given to a “young, rising star”. I felt trepidation also when, as a junior Minister, I stood at the Dispatch Box to answer questions for the first time: a noisy and acrimonious event, full of the yah-boo which plagues the other place. They could learn a great deal from the courtesy and civility of your Lordships’ House.
Trepidation or not, it is a great honour to be here among many distinguished Peers, just as it was a great honour to serve the people of Bath as their MP for 23 years. As noble Lords will know, Bath is a beautiful World Heritage city with two universities, a Premiership Rugby club, vibrant businesses, excellent festivals and wonderful people. It is my mark of gratitude to those people, who allowed me the privilege of being their representative for so many years, that I chose Bath—or “Barrth” as they prefer to call it—for my title.
My trepidation is also enhanced by following contributions from such eloquent and expert speakers. The noble Lord, Lord Crisp, who introduced the debate, is a case in point. Few could know more about health, in this country and globally, than him. I was especially struck by his view that all sectors should contribute to creating a healthy and resilient population.
Of course, we should all take greater personal responsibility for our own health. More needs to be done to encourage people to look after themselves. To take the example of obesity and the often-accompanying type 2 diabetes, it could often be reduced by greater personal discipline, but many organisations also have a role to play. Preparations for the hugely successful 2012 Olympics and Paralympics emphasised seeking the legacy of a healthier nation. Much was done, from encouraging businesses to help employees get fit to assisting clubs in boosting grass-roots sports participation. In this latter regard, I hope we will continue to protect sports playing fields and address the lamentable state of PE in our primary schools.
Our engineers and designers can play a role. I am the president of a Bath-based charity called Designability, which brings such experts together to create devices that improve well-being. Their “Day Clock”, for example, helps people with dementia maintain their routine. The clock constantly displays the day of the week and whether it is morning, afternoon, evening or night. This can reduce anxiety, increase independence and make life easier for those suffering from dementia. Their Wizzybug—a fun-looking powered wheelchair for children under 5—addresses the needs of children with conditions such as cerebral palsy and muscular dystrophy. It gives them mobility and independence.
I echo the views of my noble friend Lady Williams. As she rightly says, many government departments have a role to play—some more obviously than others—in creating a healthy nation. Like education and the housing and planning elements of DCLG, the health department’s role is obvious. I welcome its increased emphasis on prevention and mental health.
I am delighted that important steps spearheaded by my right honourable friend Norman Lamb have been taken towards ending NHS bias in favour of physical health conditions. The introduction of NHS waiting time standards for people with common mental health conditions such as depression has started this process. I welcome the additional £600 million for mental health announced yesterday. However, the potential contribution of other departments is often less understood. Take, for example, the Department for Culture, Media and Sport, which is a much undervalued department, yet its work in the arts and sport can make an enormous contribution to the health of the nation.
Mental health campaigner Rachel Kelly says that poetry kick-started her own recovery from mental health problems. She calls for the bonds between well-being and the arts to be strengthened. I entirely agree. No wonder the Department for Work and Pensions, back in 2009, acknowledged:
“There is increasing recognition that having a sense of purpose through leisure and cultural activities contributes to older people’s well-being”.
Creating a healthy and resilient population does indeed require contributions from all sectors. If government is to maximise its contribution, we need to recognise that many government departments, not just the most obvious ones, can play a role, ideally as part of a cross-government strategy. However, none of this diminishes the need for us all to take greater responsibility for our own health.
Lord Alton of Liverpool (CB)
My Lords, it is a particular pleasure to congratulate the noble Lord, Lord Foster of Bath, on his exemplary and cogent speech, not least because, having served together in another place, we share many common interests and experiences, not least that we were part of that exclusive group of former Chief Whips.
The noble Lord was born in Lancashire, in Preston, worked as a science teacher in Kent, and was an elected member of Avon County Council, on which he became his group’s leader. Elected to the House of Commons in 1992, he was fortunate enough to represent the beautiful world heritage city of Bath until standing down earlier this year. A diligent, respected and hard-working Member of the House of Commons, at various times the noble Lord served as his party’s spokesman on education, environment, work and pensions, transport, and culture, media and sport. Like many members of the noble Lord’s party, responsibilities came thick and fast for him. As we heard, in the coalition Government he served as a Minister in the Department for Communities and Local Government. Today, the whole House will want to welcome him. Judging by the quality of his excellent maiden speech, we have a rising star in the making again. We have good reason to look forward to hearing the noble Lord on many occasions in the future.
It was a Liverpool physician, Dr Benjamin Moore, who, in 1910, in The Dawn of the Health Age, is credited as probably the first to use the words “National Health Service”. When it was founded in 1948, Aneurin Bevan declared that it would,
“last as long as there are folk left with the faith to fight for it”.
Bevan saw the NHS as a bulwark against fear. Although we all still have the faith to fight for it, the world in which it functions is fundamentally different, with dramatically changed demographics of population and disease. The backdrop against which today’s debate is being held is a sobering one, from overspending to strikes and demoralised health workers. A consultant recently told me, “Currently, more and more is being asked of us, but we are being given less and less resources to achieve it. There is increasing exhaustion as every bit of spare capacity in every respect is stretched”. That is leading to demoralisation and disaffection. A health-creating society must value its health workers.
It may be a National Health Service but there are endless disparities and inequalities within its system, and modern England is simply too diverse for a model that insists one size should fit all. This is true of our attitude to lifestyle as well as to care itself. For example, smoking rates during pregnancy range from 2% in west London to 28% in Blackpool. Malnutrition has reappeared in some places but not others, with 193 episodes of malnutrition at Salford over a 12-month period, while even the day on which you are admitted to a hospital can affect your chances of survival, with Imperial College publishing research that babies born at weekends in hospitals in England have a greater chance of dying than those born on weekdays. End-of-life care and hospice provision are brilliant in some parts of the country and patchy at best in others. The noble Baroness, Lady Williams, reminded us of our equally patchy approach to mental health, a point that was also touched on by the noble Lord, Lord Foster of Bath, in his maiden speech.
A few weeks ago the Minister gave me a Written Answer about prescriptions for antidepressants and confirmed that since 1991 more than 660 million antidepressants—at a cost of nearly £6 billion—have been prescribed by the NHS, with year-on-year figures increasing exponentially. If the overuse of antibiotics is creating cause for concern—and it is—should we not also be exercised by the overuse of antidepressants and our failure to address toxic loneliness and isolation? For instance, it is said that around 1 million elderly people do not see a friend or a neighbour during an average week. This has an inevitable detrimental effect on health. Like operations for obesity, this is another disturbing example of putting a poultice on a problem rather than attacking the root causes.
In the search for a healthy society, my bottom line would be that healthy relationships create a healthy society. It is especially important for the vulnerable to know that they are valued, as the noble Baroness, Lady Campbell, reminded us earlier. It is no good if our attitude or treatment say otherwise. With around 700,000 people in Britain with degenerative diseases such as Alzheimer’s and predictions that there will be 1 million dementia sufferers by 2026, we cannot value this by cost alone. It has to be how we see people themselves.
If we started from a different place, putting much greater emphasis on our responsibilities to society and to one another, rather than slogans about choice and autonomy, we would create a much healthier, happier and more resilient society. We can smoke, drink, neglect our health or use lethal injections to get rid of the unwanted because we assume that medicine will fix everything and take care of us. But that is simply not so, which is why my noble friend was so right to initiate today’s debate.
The Lord Bishop of Bristol
My Lords, I, too, am grateful to the noble Lord, Lord Crisp, for introducing this debate and this very big idea into the Chamber. Already we start to see that the breadth of material that needs to be thought about in relation to creating a healthy society is indeed vast. I sat here for some of the debate thinking were I the Minister—God forbid—how I might respond to such a plethora of concerns that have been articulated. I wish him well with that.
Of course, what we cannot do, as several noble Lords have noted, is expect the Government to solve this on their own, although I think there is a major challenge involved in this for government. That is what I would call the alignment of policy—how do you align policy over a very wide range of areas in life in such a way that human well-being emerges from it?
Your Lordships are very well aware that the danger of these debates is vain repetition. I have no wish to enter into that. In the few minutes available to me, I will focus on a particular aspect of our society at the moment, which causes great concern and, as we have already heard, has some rather serious health outcomes. I speak of social isolation—loneliness. On the Mind website, loneliness is defined as,
“not feeling part of the world”.
It goes on to explain that it is therefore perfectly conceivable—I sense that I might have experienced this in my own life—to be part of a crowd and yet feel extremely lonely. It goes on to talk about the impact of loneliness on an area of health that several noble Lords have mentioned—mental health.
However, as the noble Lord, Lord Crisp, reminded us with the rather horrendous statistic of the physical health outcomes of loneliness being tantamount to smoking 15 cigarettes a day, loneliness should indeed concern us. It is not just the preserve of the elderly in our society; loneliness exists among a number of groups, including housebound people, those in the dormitory suburbs we speak about, where neighbourliness seems in short supply, young mothers, bereaved people and those who feel discriminated against. Lots of people experience a sense of social isolation and loneliness. A GP in Bristol shocked me recently by saying that a good number of the people who attend her surgery come not because there is anything particularly wrong with them from a health point of view but because they simply want to be heard by somebody for a few minutes and that is their only chance. That is very disturbing, partly because I believe we are social beings. John Donne poetically wrote:
“No man is an island”.
I think we were designed to thrive in community: significant social contacts are very important for us.
It would be very easy for us to sink into a mire of depression around all this, but it is worth saying that there are many groups in society who contribute hugely to creating social networks, or at least the opportunity for social networks and for significant social contact. Here, I think of course of churches, faith groups, charities and clubs, and the many other community organisations that create an environment where people can meet each other and speak. I am also well aware—this is a point that the Government might like to think about—that increasingly some of the bureaucratic apparatus, some of it necessary, is interfering with our need to create a volunteer culture that would service these organisations and, in the end, lead to good health.
Back in 1942, the Beveridge report named the five giant evils that the welfare state was set up to tackle. They were want, disease, squalor, ignorance and idleness. I certainly would not want to describe loneliness as an evil but it is a growing fact of life in our society, and its destructive impact on human well-being needs further research and further understanding, as well as further imagination in seeking to combat it. How do we create communities of wholeness where people take responsibility? I realise that some of the questions asked this afternoon by me and others might fall into the realm of essay questions, but I look forward to hearing what my noble friend the Minister has to say.
Baroness Lane-Fox of Soho (CB)
My Lords, I, too, thank the noble Lord for securing this debate. I was reflecting on whether he is happy or sad that he no longer runs the great NHS, for it seems to me that in many ways there has been no greater time of excitement, with innovations and improvements. At the same time—my goodness me—we need them more than ever. Perhaps the greatest of those innovations and improvements is the internet. I would call it the organising principle of our age, yet there is by no means the same organisation around it in our health service.
You can perhaps keep on your phone in your pocket as much health information as your GP has about you—perhaps even more. When I describe the House of Lords to people outside it, I often put some of the longevity in this Chamber down to the fact that noble Lords walk around so much along the endless corridors. I would love to be able to give all noble Lords a Jawbone UP or other device to wear around their wrists to test my philosophy. I have—although I do not have it with me today—a bracelet that nudges me every now and then to help my nerves by moving and wriggling. There are endless devices, of which I am sure some noble Lords are aware, that help people to read practically every single vital life sign. This is an exciting time: it can only be a good thing to have more information, not less.
I have worked with two small UK companies. One, called Sleepio, is helping to address the enormous challenge of insomnia. It has an app—a device that it uses to help people talk about their health after having had a bad night’s sleep, and to give tips about how to get a better one. There has been a more than 50% improvement in people’s sleep, and a 100% improvement in respect of the number of sleep drugs people are taking. Another small company, HealthUnlocked, helps people to find patient groups with diseases like their own. One of its most important and useful groups is concerned with diabetes. The people using it say that they have experienced an improvement in quality of life with the disease of some 60%, and a 30% reduction in the number of drugs they use. These are profound and important shifts, all enabled by the internet.
However, I must wave two enormous red banners about the huge risks that I see coming over the horizon. The first is one that I mention not out of any parochialism or jingoism: we would be mistaken to think that it is not a very small area of a very small bit of the west coast of America that is likely to dominate the health creation of the future. Google, Facebook and the other big US platforms have designs on our health. Google, even in its failed attempt to build health records, took 30 million individuals’ health records in a very short space of time. This is an enormous issue that we need to debate and think about much more carefully. The force for good is hugely powerful, but the possibility that our enormously valuable NHS will lose ground to these incredibly well-invested organisations, which understand technology at their very core, is real. If we are to have a truly health-creating society, deploying all the tools in our armoury, we must think very carefully about enabling the NHS to “compete”—in the right way—with some of these giants. For me, the potential access to the data that our great NHS has, and the inclusivity and universality of those data, is one of our greatest weapons, but it would be a mistake to imagine that we are anywhere near that right now.
My second red flag concerns digital skills and inclusion. I declare an interest as chair of Go ON UK, a charity that I set up to build digital skills in the UK. There are 12 million adults in this country who cannot do basic things online, yet we know that the internet is one of the most powerful tools in combating the loneliness that I am delighted to say many people in this Chamber have already mentioned.
I end with a story from a woman I met in Birmingham, who told me that the internet has quite literally saved her life. Even I, prone to hyperbole, was sceptical, but she described how she was one of the 1.5 million people over 65 who see no one in a week. She had learnt how to use social media and had connected to family that she had not seen in many years. She told me that it had stopped her wanting to jump off the building where she lived. If that is not health creation, I do not know what is.
Lord Smith of Hindhead (Con) (Maiden speech)
My Lords, I have been advised by some noble Lords to make my maiden speech as soon as possible, and by others to wait a few months. I have been advised to wait until a subject comes up that I at least know something about, and by others not to worry about the subject and just to work my way through it. I wonder if I have become a victim of “Peer pressure”.
Since being introduced to your Lordships’ House on 12 October, the support that I have received has been overwhelming, but comes as no surprise as the reputation of this House is well known. I was more surprised at how many noble Lords congratulated me on the Hindhead tunnel, which now allows motorists to avoid a well-known former traffic bottleneck at the Hindhead crossroads. Indeed, I suspect that people who were once held up for several hours on their travels would have agreed with William Cobbett, who wrote in 1822 in his book Rural Rides that Hindhead was,
“that miserable hill, the most villainous spot that God ever made”,
which he,
“disdainfully scorned to go over”.
It seems that my entire time so far in your Lordships’ House has been one in which I am “not content”. Indeed, I am starting to wonder whether I shall ever be “content”, and a day will come when the occasion arises to divide and “go through the door by the right of the Throne”. There is no doubt, however, that all new Members of this House must be more than content with the friendly and helpful staff—from the ever-present and steadfast doorkeepers to those who work unseen in the many and far-flung corners of this House, who do all they can to assist every noble Lord, but particularly those of us who are new and who inevitably spend a little time wandering around and getting lost. As with most things in life, one needs to get lost before one can find the right way. The honour of being here is both extraordinary and humbling. I thank my supporters, my noble friends Lord Feldman of Elstree and Lord Strathclyde, for ensuring that I was not overly daunted on my introduction day.
Bearing in mind my background of working with Conservative clubs and being chairman of the Committee of Registered Clubs Association, an organisation that encompasses all 11 of the main club groups and comprises more than 4,000 clubs with an estimated 2 million members—here I must declare an interest—some may have been surprised that I chose to speak in this debate on building a health-creating society where all sectors contribute, given that I have spent so many years involved with alcohol and gambling. I am grateful to the noble Lord, Lord Crisp, for introducing the debate, since I have always believed that a society which socialises together is a stronger and healthier society. Human contact is vital and a component part of a healthy lifestyle. Those people who suffer isolation, both young and old, will suffer from health issues.
I know that some noble Lords may now be expecting me to advocate the benefits of moderate alcohol consumption and the occasional flutter. Indeed it is the case, in my entirely unqualified medical opinion, that such activities have a beneficial effect on the quality of one’s life. Virtual friends can never be the same as actual friends, watching dancing is not the same as actual dancing and participating in sport is better than watching sport. Within sport, I am happy to include snooker, darts, skittles and bowling. The stay-at-home culture is a matter which should concern us all. Lonely people have high blood pressure, are more vulnerable to infection and more likely to develop both dementia and Alzheimer’s disease.
The formation of clubs is almost unique to the United Kingdom, and they play a special and established role in the fabric of leisure and community activities. We have had a love of clubs throughout our history. Your Lordships may be interested to know that one of the earliest social clubs was the Everlasting Club, limited in membership to 100. The members divided their time so that there were always some present at the club, which was eventually burnt down in the Great Fire of London of 1666, when the only remaining member was nearly burnt to death because he refused to leave until he had emptied all the bottles on the table. During the 50 years of the club’s existence, these 100 members smoked 50 tonnes of tobacco and drank more than 30 million pints of ale and 576,000 cases of port, besides other drinks. I thought this was perhaps slightly overindulgent but I am assured by a member of the catering team in the other place that the members of the Everlasting Club were mere lightweights. However, the catering team of your Lordships’ House was not available for comment.
We should remember that the average life expectancy in 1666 was only 35. However, life expectancy has been the subject of recent news, with the average in some areas being as low as 54 and “healthy life expectancy” differing enormously within a matter of streets. We have much to do but, in so doing, let us not be too harsh on those of us who may not be regular attendees at the gym, and who may on occasion—just once in a while—have more than one round of drinks.
Samuel Johnson’s dictionary definition of a club was:
“An assembly of good fellows, meeting under certain conditions”.
This noble House is sometimes referred to as a club by commentators who perhaps know little of its function. But if it is indeed a club, there is no doubt that it is one with the sole object of dedication to public service. I hope that in the months, years and, with the help of a healthyish lifestyle, decades to come I may prove myself to be a worthy Member of it.
Baroness Neuberger (LD)
My Lords, it is a great pleasure to be able to follow the noble Lord, Lord Smith of Hindhead, and congratulate him on what he had to say. His maiden speech has given us a great deal of information about his role as chief executive of the Association of Conservative Clubs and chairman of the Committee of Registered Clubs Associations, but has also made us laugh. One of the things that we enjoy in this House among all the good fellowship that the noble Lord referred to is occasionally being allowed to laugh. What the noble Lord said to us was both moving and sensible, and he has illustrated in what he had to say the essential nature of human-to-human contact—not only virtual but in fact, in clubs and associations. I very much look forward, as I know we all do, to what he has to say in future debates. If the noble Lord is not an expert, he certainly had something of substance to say, which we all valued hugely.
I also pay tribute to the noble Lord, Lord Crisp, for introducing this debate. I will contribute a few thoughts about one of the wider issues that shapes the nature of the nation’s health and which many other noble Lords have referred to—the issue of loneliness and isolation. However, I want to start by talking about babies and young children and about the considerable body of evidence we now possess about the development of a child’s neural networks and the fact that it is absolutely essential for parents and caregivers to talk to children and hug them. This is not only about making them feel secure and loved but about allowing their brains to develop properly.
I raise this point to draw a comparison with newspaper reports a couple of days ago, which some of your Lordships may have seen, about a major piece of research conducted by scientists at the University of Chicago. The research demonstrated that people who live alone and are lonely have signs of highly strung so-called “fight or flight” responses in their nervous systems, as well as greater numbers of a type of white blood cell that boosts inflammation. People who had this in their bloodstream were also more likely to report that they felt lonely even a year after the original study was undertaken, suggesting that the emotions and the chemistry may feed off each other or be related in some way. The academics described the loneliness as chronic and suggested that the constant stress, and its biological effects, could “amplify or prolong” people’s sense of isolation, much as those who feel ill often tend, unconsciously, to avoid other people.
What can we possibly draw from this? As the right reverend Prelate said, it is that lonely people are more prone to disease; the noble Lord, Lord Crisp, said this too. It means that loneliness is dangerous, that lonely people die earlier and that there is a real physical effect—we have heard that from many speakers around the House. Just like babies, older people need human interaction and stimulus, and the lack of it may lead to physical ill health and early death. Just as babies need human interaction for their brains to develop and grow, so adults need human interaction to keep them healthy. But with older people, the science is in its infancy, even though the psychosocial observation is commonplace. We all need to be needed.
What can we do? Along with the great charities that do much to try to reduce the isolation of lonely people, such as the Silver Line, Contact the Elderly and many others, I believe that we need to encourage everyone to contribute something to society, even if they are housebound or isolated. Housebound people can be telephone volunteers: they can buddy other isolated people and can plan activities from home. But doing this is not a free good. The people concerned would need to be chivvied, encouraged, monitored, thanked and probably trained as well. The cost is in sorting out the systems and in getting sufficiently motivated volunteer organisers to keep it going. But it would undoubtedly be life-transforming and, arguably, if the statistics are right about the actual financial cost of loneliness, let alone its emotional and social costs, worth it.
If we were to invest in this kind of loneliness-avoiding work, which is largely low-tech and easy to manage, we would create a healthier society with fewer costs to the NHS. A small investment here could make a big difference and save the public purse millions, as well as alleviating distress, loneliness, ill health and isolation. It has to be worth a try in creating a healthier society. So I very much second my noble friend Lord Crisp’s call for an ad hoc committee on creating a healthy society, because I think there are practical ways in which we could do it.
Lord Rea (Lab)
My Lords, I thank the noble Lord, Lord Crisp, for introducing this important debate and his excellent speech. I declare an interest as a long-time trustee and now honorary president of the UK Health Forum, the public health think tank co-ordinating some 80 national organisations interested in upstream or primary prevention of non-communicable disease. The noble Lord has drawn attention to the wide spread of social and environmental factors behind our current burden of disease, and shown that many causes of those diseases lie outside the remit of the National Health Service. To prevent or delay their onset requires political and economic engagement rather than traditional public health solutions, important though they still are.
Historically, public health measures have been regarded as an imposition on individuals and industry, because they require changes in behaviour or the products of industry. They are regarded pejoratively by some as the “nanny state”—a term particularly favoured by some who may be financially affected by the changes needed to protect public health.
To divert from the general to the particular, the marketing of harmful food products could be curtailed and their composition improved by regulation and taxation—for example, of their sugar content. Here, I echo other noble Lords. The voluntary approach, the responsibility deal, has not worked, although it has been in place for five years. If all sections of society enjoyed the health status of the best off and best educated in the population, the health status of the whole nation would be greatly improved. To achieve the noble Lord’s health-creating society, we should logically consider the factors that favour the upper layer and bring them, as far as possible, to all sections of the population, to bring the bottom section closer to the top.
Most of us know the most common risk factors for heart disease, stroke, obesity, diabetes and some kinds of cancer. These are, of course, cigarette smoking, physical inactivity, poor diet and so on. It is true that the least well off have higher risk scores and that these show a gradation from the poorest to the most favoured groups of the population. A number of studies, particularly those by Sir Michael Marmot—who seems to be the father of this debate—and colleagues, have shown that when all the known risk factors are taken into account, the social gradient of health remains. The NHS can affect only a small part of these health inequalities, which have their roots in the social fabric and economy of the country.
From conception onwards, the odds are stacked against the less privileged in diet, housing, working conditions and social status. Low income is the dominant feature of the lives of the underprivileged. The environment in which children are brought up is particularly important, especially the early years from conception onwards, as other noble Lords have pointed out. Poor nutrition and social deprivation may lead to chronic disease in later life. To protect children from the effects of poverty and deprivation should be number one on the list of any policy to promote health.
In this connection, I ask the Minister about the present status and funding of Sure Start centres. They were beginning to have some effect, but some of them have had to close and others are struggling because of local government cuts. Has the Minister any news for us on Sure Start centres?
To build a resilient society, a wide range of improvements need to be made, and many or most of them have already been mentioned. Nearly every government policy has a health dimension. This should be assessed. I suggest that the Cabinet-level committee looking at the health impact of all government policy should be restored. Here I very much agree with the suggestion of my noble friend Lady Jay that a Cabinet-level Minister should look after public health.
Welfare benefits have been developed over the past century for good reason: to protect the vulnerable. To cut them further, as is still planned despite the Chancellor’s decision to listen to your Lordships’ House on tax credits, will diminish the health and resilience of the population.
The Earl of Listowel (CB)
My Lords, it is a privilege to follow the considered and humane words of the noble Lord. I, too, am most grateful to my noble friend for calling this debate, for opening it so helpfully and for his courtesy in preparing for it. I will make five points on loneliness.
I begin by praising the Government. Evidence is clear on the benefits of employment for mental health. The Government have done a tremendous job here. The latest employment figures—with the lowest rate of unemployment since 2008 and the highest rate of employment since records began—speak to that success. That is so important in combating isolation. At my local cash desk there is a pregnant woman due to give birth in December. She had her last week at work a fortnight ago. While she has never given birth before, she was working beside a woman who has a child, so she could speak to others who had given birth. She had customers going up to her to wish her well. She was not isolated. As the Minister knows very well from the recent report on perinatal mental health, we must be concerned about mothers during pregnancy becoming isolated and depressed, and the cost to the nation as a result of that. I strongly praise the Government for their achievements in this area.
I have a number of concerns. I am very worried about the housing insecurity that so many families in this country experience. I call on the Government to bring forward a strategy along the lines that the noble Baroness, Lady Jay, called for, with a senior Minister developing and implementing a strategy to address housing insecurity. Increasing numbers of children grow up homeless and in bed and breakfasts. I speak to mothers with young children who look forward to the prospect of being sent to some distant local authority outside London where they will know no one and where their child will lose their school. This is a growing problem. Of course, there is an increasing issue with questions about immigration there as well. I hope the Minister will speak to his colleagues about that.
So many looked-after children speak of the experience of care as a lonely one, going into adulthood isolated. Because of their early experiences, they may well not trust others and find it difficult to relate to them. It is imperative that, the moment that they enter care, mental health professionals provide them with a proper, dedicated mental health assessment—as the NSPCC called for—and that the services they need follow on from that.
Furthermore, I really stress to the Minister that the best difference that mental health professionals can make is to support the relationships between adoptive parents and children, foster carers and children, and residential childcare workers and children. Supporting those stable relationships over time and making them work is the best way to help these children recover from trauma, rather than, important as it is, working directly with the children. I am afraid that that is often not recognised by the health service, where, unless one is working directly with the child, it is not recognised as helpful—because the child is not seen as “sick”—to support the foster carer or residential childcare worker.
Moving on, adolescence is a time of upheaval. Anna Freud entitled her last writings on the subject, Adolescence as a Developmental Disturbance. There are huge challenges throughout adolescence. It is important to meet those and not allow adolescents to become isolated, as they so easily can be. I commend to the noble Lord the institution in north London, the Brent Centre for Young People, which since 1989 has provided excellent specialist service in mental health for adolescents. If he ever has the time to go up there, I am sure he will find that a most interesting experience.
Early years were mentioned by the noble Baroness, Lady Neuberger, and, I think, others. I recently had the privilege of visiting a nursery in Hayes Park School, west London, and watching a nurture group in action. The Minister may be aware of the Nurture Group Network. These were eight disadvantaged three year-old children. One young girl, blonde, went up to the board, picked up a piece of paper with the word “embarrassment” on it and said “I am embarrassed”. She was shy. She was learning to talk about her feelings, as were her neighbours, so that they could communicate their feelings to each other. They sat at a table and enjoyed toast together. They may never have sat together in their own homes around a meal—they may never have had that experience—but here they were getting a chance to sit with others, to eat toast, to say “please” and “thank you”, to learn how to relate to others, so that they could be reintegrated into the larger group, know how to relate to other children, and thereby not grow up lonely and possibly depressed because they just did not know how to manage relationships with other people.
To sum up, so many people in this country, because of early disruptions in their lives, find relating to others an uncomfortable experience. If we want to build a healthy society, we really need to enable all our citizens to feel comfortable in themselves and with each other, so that they go on to lead full and productive lives. I look forward to the Minister’s response.
Lord Mawson (CB)
My Lords, our health is too important a matter to be left simply in the hands of doctors and health professionals; it belongs to all of us. We must all own our well-being. It no longer sits in a convenient government silo marked “Health Service”—by the way, it never has—but what does a health-creating society look like in practice; how do you turn these aspirations into practical realities on the ground, up and down this country; and how does the health service move on from its outdated silo approaches to health and make these aspirations real in local communities? Three words are used again and again in the Health and Social Care Act as the key hallmarks of a modern health service: innovation, integration and enterprise. But how do we make them real and why are there so few examples in the health service?
I have spoken frequently, in this House and elsewhere, about the 30 years I have spent in east London, establishing an entrepreneurial ecosystem built around the Bromley by Bow Centre, which today offers a fully integrated health centre, including traditional health services, yes, but also offering a wide range of employment and housing services, the opportunity to set up your own business and a wide range of artistic and creative projects, all at one point of entry. The centre today operates on 25 sites across Tower Hamlets and offers services to 36,000 patients across a network of four integrated health centres. We have also taken this experience and a built a street in St Paul’s Way in Tower Hamlets, bringing together a wide range of services and organisations, the details of which can be seen on my website and read about in Hansard—there is not really time to describe in detail what this has been about. There is a helpful Radio 4 feature on the website and the Minister may be interested to listen to it.
I should like to share, in the brief time I have, some of the lessons we have learnt over 30 years. Over the years, one of the most challenging and regular questions we have to answer at the Bromley by Bow Centre is how our model can be replicated. Put simply, trying to replicate something as complex and contextualised as the Bromley by Bow Centre is not possible. The reality is that the centre is a response to a series of deep-seated and complicated social conditions and has evolved over a long period, not by following a clearly established recipe but by trial and error and a great deal of experimentation. However, that process of experimentation has not, in itself, led us to the “right answer”, which can then be pinged out across the whole system so that something magical will happen.
On the contrary, one of the reasons for our success is the very process of experimentation itself and a whole range of diverse people co-creating a new way of doing things over an extended period. So it is in the design process that we have created the unique model that is Bromley by Bow and, of course, this has now also happened in St Paul’s Way in Tower Hamlets. Our work is now beginning to infect the developments on the Olympic Park. A better way to frame the question is in terms of translation, rather than replication. This is a much better question and leads to a much richer answer, which is significantly different in substance and content, not just in tone. There is a basic principle behind the Bromley by Bow Centre’s model, which is that you start small and grow things.
It is a basic business model. Yet in public and statutory systems, often driven by politicians, the desire is to start big. Politicians like big programmes. They like building 200 city academies across the country or more than 300 healthy living centres, which have, by the way, not withstood the test of time. Our belief is that inventing something small and growing it in context might be far more effective in the long term; it might deliver much more bespoke and locally relevant services and be far more cost-effective long term. Our thinking is not to start with the totality of the Bromley by Bow operation—its structures, systems, budgets and business plans—but to start with the small, subtle stuff that sometimes lies under the surface.
When you spend time with us, you very quickly begin to see that the most powerful influencers of our model are very simple human principles. We are talking about a range of features that are often overlooked when new services are being designed or are put into a neat box to one side and treated like they are the icing on the cake, when in fact they are the cake.
What kind of things am I talking about? Here are my top 10 to start with. The first is the quality of the human relationships and how people interact with each other. The internet is a very important tool, but it will never replace human relationships. The second is compassion, an inbuilt sense of caring between people. There is a close correlation here with the sense that we are here to serve. The third is generosity, the idea that giving freely to people creates a sense of self-worth for both the giver and the receiver. The fourth is mutual need, recognising that none of us is fully well and that we can share our humanity together and not be compromised as professionals. The fifth is positive design and environments creating spaces that engage and provide a sense of welcome or safety, like being at home. The sixth is blurring the boundaries, as services work best when they are not in silos. We all live complex and sometimes chaotic lives, so neat solutions do not always work. The seventh is long journeys, as we are committed to generational change. So many health services seem to be obsessed with moving people on or getting them out of the door, but we believe in sticking with people. The eighth is building in fun, which is often seen as having nothing to do with work. That is a very big mistake as it is essential for success. The ninth is having big expectations. The model is all about raising aspirations and encouraging everyone, staff and clients alike, to assume it is possible. The final thing is to let go, encourage freedom to innovate and provide resources for people to be entrepreneurial.
These key features of the Bromley by Bow Centre model absolutely lend themselves to translation; we have translated them elsewhere. Every health service organisation could grapple with these features and find ways of translating them into practical changes in their own contexts. It would not lead to replications of the Bromley by Bow Centre model, but it would lead to services being transformed by shifts in culture and values. Of course, none of this is really about money or resourcing; most of it is about attitude and behaviour. Will the Minister tell the House what priority the Government give to the principles I have set out for a health creating society and what in practice they are doing to encourage this cultural change? The Minister might like to visit the street the noble Lord, Lord Crisp, and I have mentioned and see these human principles in action for himself.
Baroness Walmsley (LD)
My Lords, this has been an excellent debate with some fascinating speeches. I shall certainly go on the website. There were three interesting maiden speeches. I was fascinated by my noble friend Lord Foster of Bath’s examples of how business and the arts can contribute to our health. Of course, I would say that as a founder member of the Parliament choir—although I am not sure that last night’s excellent concert has particularly enhanced my health.
Last September at the Liberal Democrat party conference, I made a speech about the future of health provision in the UK. I did not spend all my time talking about the NHS because, like the noble Lord, Lord Crisp, I believe that the crisis in the health service cannot be resolved by the NHS alone. The noble Lord and I are clearly on the same wavelength, so I very much welcome this debate.
As many have said, health affects everything: how long we live and our well-being, achievements, family life, contribution to society and, of course, happiness. Yet the NHS is struggling. Some say it has become a sickness service rather than a health service, spending a huge amount of resource fire-fighting preventable diseases, dealing with the complex needs of an ageing population and providing ever more wonderful, but expensive, treatments.
The pressures on NHS staff are enormous, and it seems that no matter how hard they work, how much they care and how much the Government spend, it is never enough. However, it is incredibly cost effective. Despite spending less per capita on health than most developed nations, the NHS is top in most rankings but next to bottom on living “healthy lives”. So unless we can turn around our public health problems, the pressures on the NHS will continue.
So I agree with the noble Lord, Lord Crisp, that we must stop dealing with health policy in isolation when its implications are so broad. Health should be a “whole government” responsibility, not just the job of the Department of Health. As I said to my party conference, suggesting that health is just the responsibility of the NHS is like expecting the goalkeeper to win the match on his own without the help of the other players. It should be very obvious that the rest of the team have to play their part, too.
The keys to the sustainable future of the health and social care systems are prevention, integration, innovation and “getting it right first time”. If 40% of ill health is due to diet and lifestyle, it is therefore preventable. New ways of working are also vital, and the vanguard sites, set up in response to the NHS Five Year Forward View, demonstrate that better care can be delivered for less if people will only work together. However, we need to ensure that competition legislation does not get in the way of providers working together. They also need the £3.8 billion announced this week to achieve that transformation, yet the Treasury says that the money will be spent on more treatments. Either the money is there to cover part of the shortfall in NHS budgets or it can be used to initiate new ways of working which will bring cost benefits in the future. It cannot do both—you cannot spend money twice.
“Getting it right first time” is the mantra of a number of ground-breaking hospitals that have shown that it is cheaper in the long run to provide excellent services first time round rather than have a lot of readmissions. We also need a complete overhaul of patient discharge and transfer arrangements, which cause bottlenecks and waste money. I am delighted that former Health Minister Paul Burstow is leading a commission on behalf of NHS providers to identify and disseminate best practice on transfers of care. More efficient working will enable the NHS to fulfil its important ambition in the wider picture of sickness prevention, and it should start at the very beginning.
A good start for a baby depends on the health and well-being of its mother and her ability to bond with her child, but perinatal mental health services are patchy—yet this is health creation at its most basic. We need a new standard, delivered everywhere, to promote the future health of the baby and the well-being of the mother. Academics believe that UK children are at a higher risk of premature death than their western European counterparts because of the growing gap between rich and poor and a lack of targeted public health policies. But if a child is born into a low-income family, he is not automatically on a pathway to ill health, as several imaginative interventions have already shown. A new, holistic approach to child health would tackle health inequalities at source.
Moving beyond the NHS’s own role in the health-creating society, it is clear that poverty is a major cause of poor health. According to Sir Michael Marmot’s recent book, 200,000 people die prematurely every year in the UK simply because they are poor. Dealing with the economic divide would go a long way to improving the health of the country and address health inequalities.
Since the foundations of a healthy life are laid in childhood, the Department for Education has a role to play. Liberal Democrats support mandatory personal, social, health and economic education in all state-funded schools, but we still fall far short of that. Children need to know about a healthy diet, the importance of physical activity, how to recognise a respectful relationship as opposed to an abusive one, and about the dangers of tobacco, drugs and alcohol, and so on. Therefore they need good-quality PSHE.
A love of sport is often developed at school, and this can stand a child’s health in good stead in the future. I really commend the daily mile, run or walked by every child in St Ninians primary school in Stirling every morning. But many children drop sport as soon as they leave school. This is where the Department for Culture, Media and Sport, local sports clubs and local government come in. But the cuts of the last five years have made it very difficult for them to provide the facilities needed—we just need to look at the number of swimming pools that have closed.
Local authorities are ideally placed to deliver public health interventions that will improve community health outcomes. Yet within a month of being in power on their own, the Conservative Government announced an immediate £200 million cut in public health funding, putting further at risk the health service’s ability to make ends meet. This and yesterday’s further cuts to local authorities are appallingly short-sighted. How can the Government justify them?
Then there is housing. Cold, damp homes foster colds, bronchitis and many other problems. We need more decent affordable homes for families to rent as well as buy, and smaller, well-insulated homes for older people. I am one of those who is currently about to downsize to a highly insulated passive house—a home for life, I hope. Successive Governments have failed on this for decades and, as the cost of energy has risen, even people who have decent homes are finding it hard to heat them. We know that the most cost-effective way to reduce energy bills is good insulation, but much of our old housing stock is poorly insulated. The Green Deal home improvement fund provided funding for energy efficiency improvements to homes, making them greener, cheaper, warmer and of course healthier. But the Conservative Government decided to cut it. Where now will people get help to make their homes warmer and healthier?
The Department for Transport does not escape responsibility. Air pollution causes major problems for asthmatics such as myself and others. Transport policies therefore play a part. I have heard it rumoured that, alongside cutting the subsidy for solar and wind power, the Government are now planning to cut the £5,000 subsidy for electric cars. Can the Minister confirm or deny this?
If health is a whole-government issue, which I believe it is, it requires proper oversight. My answer is very slightly different from that of the noble Baroness, Lady Jay. I would like to see the Government beef up the Cabinet Committee on Health, headed by a senior Minister and involving all relevant departments at a senior level to ensure that all government policies can be scrutinised as to whether they contribute to the better health of the nation. There can be no better focus for a Government if they are truly concerned about the well-being of their people. I also believe that the Chancellor of the Exchequer should be answerable to Parliament for the health consequences of his policies.
The NHS is supported by the whole nation. It must be supported by all of government, national and local. Let us not leave it to the goalkeeper. Let us ensure that the whole team contributes to winning the cup.
Lord Hunt of Kings Heath (Lab)
My Lords, as we have debated public health so much, I must remind the House of my presidency of the Royal Society for Public Health.
I pay tribute to the noble Lord, Lord Crisp. He was a very distinguished chief executive in the NHS and Permanent Secretary, and more recently he has led some incredibly important work on global health issues. I thought he made a very profound speech this afternoon.
I, too, congratulate our maiden speakers, the noble Baroness, Lady Redfern, and the noble Lords, Lord Foster and Lord Smith. They were excellent maiden speeches and we very much look forward to hearing them, I hope, in the not too distant future.
We have had some amazing contributions from speakers: my noble friend Lady Jay on cross-government working; the noble Baroness, Lady Campbell, on independent living; the noble Lord, Lord Best, on housing. I find it quite remarkable that so many health and well-being boards do not have the housing sector represented, given that they are meant to be driving forward public health in their locality. We heard from the noble Baroness, Lady Masham, on the really worrying issue of sexual health programmes and policies, which risk being decimated because of the transfer of responsibility to local government.
The noble Lord, Lord Alton, spoke about the very different health and social care scene that we face now compared with 1948, yet we are still trying to work with a 1948 model. In fact, a lot of the barriers to the integration that noble Lords want to see are built into the very architecture—the targets that separate government departments set. I take the point made by the noble Baroness, Lady Walmsley, about vanguards, but until we get Whitehall to change its own architecture, it will always be driving forward the type of change that she identified with a hand behind its back.
The noble Lord, Lord Foster, talked about personal responsibilities, and the right reverend Prelate the Bishop of Bristol talked about isolation, which a number of noble Lords referred to. The noble Baroness, Lady Lane-Fox, talked about the NHS and technology. I agree with her—finally, having dabbled in this and spent a few billion pounds on the issue as well, we are on the edge of a major change in healthcare, and there are positive signs now coming through.
The noble Lord, Lord Smith, talked about human contact and the role of clubs, which I fully accept. The noble Baroness, Lady Neuberger, spoke about children and isolation, and the noble Lord, Lord Rea, spoke about the role of government in regulation and taxation, dealing with poverty in particular. The noble Earl, Lord Listowel, talked about loneliness and mentioned housing security in particular.
I thought that the noble Lord, Lord Mawson, was very interesting. He described health as an outdated silo and wondered how you translate excellence using the example of Bromley-by-Bow. I take his point. You cannot just ordain this: you have to grow it locally.
Clearly, in essence all speakers support the general point made by the noble Lord, Lord Crisp, which is that we need a paradigm shift in the way that we think about health and the role of the National Health Service. However, I am very wary of the five-year forward plan on the basis that suddenly, if we build these new models, we can actually expect to see a shift of resources from the NHS in order to fund them. I do not believe that.
If we look at the international comparisons, we spend so little on health and social care in this country. The recent OECD report showed that, of the OECD countries, we are 19th in terms of health expenditure per capita. In terms of doctors, we are 24th, nurses 19th, and hospital beds 26th, yet we know that the population will rise hugely. It has risen by 10 million in the past 10 years and it will rise hugely in the next 10 years. We have to be very careful not to think that suddenly we can turn off the tap of NHS provision by adopting this approach. All we can do is to slow down the growth.
I am very wary of people who think that the NHS can lose acute capacity. The idea that we could actually reduce the number of beds in the health service is ill-thought-out and ill-considered. It just does not accord with the reality of the pressure on the system. When I look at the five-year forward plan and the models, I can see that they are very good models, but the reason why no one believes we can reach the efficiency savings of £22 billion is that it is built on the fantasy of being able to transfer money from NHS acute care.
The other point made by the noble Lord, Lord Crisp, was about the huge range of inequalities in this country. The noble Baroness, Lady Walmsley, referred to the Commonwealth Fund, which gave us a great rating except in health outcomes. The OECD report does not give us such a good rating. Where it agrees with the Commonwealth Fund is about our appalling health status. Again, if we look at the OECD statistics for life expectancy at birth for men, we are 14th and for women we are 24th. It is the same when you look at life expectancy at 65. In terms of smoking among adults, we are 20th; we are 19th on alcohol consumption; and on obesity, where levels are appalling, we are 27th..There are 26 countries with a better record on obesity that this country.
We could also have mentioned mental health—again there is a huge worry about the scale of mental health issues. I have seen recent research suggesting that common mental disorders are twice as frequent in carers who care for more than 20 hours a week than in the general population. We know, simply from looking at population statistics, that the number of carers will have to grow hugely in the next few years.
The challenge is immense. I have to say to the noble Lord, Lord Prior, that the great thing in the five-year forward plan was the reference in a managerial document to the importance of health. That is the first time I have seen it so explicitly expressed. Yet, we see the public health budget being cut. It is so hard to fathom how a Government could do that. I hope that the noble Lord, Lord Prior, will address that in his response.
On the issue of Whitehall working, I agree with my noble friend Lady Jay. We used to have public service agreement targets which tied in different government departments into a common goal. I know that we can overdo targets, and I suspect we did, but there is no doubt that if different departments can be tied into a target that is enforced either by the Treasury, the Cabinet Office, or often by Downing Street, something does get done. This Government do not really do that.
We can see that in relation to the Department for Education. The Department for Education seems to be totally isolated from anything else in public policy in Whitehall. We debated a Bill on education recently. It is bizarre that, in respect of the Cities and Local Government Devolution Bill, which is all about the devolution of powers from Whitehall to the combined authorities, the Department for Education seems to know nothing about it and wants to have nothing to do with it. If we take the issue of obesity and the points raised by noble Lords on the lack of activity in PE, again the Department for Education is oblivious to this and its outcomes.
The DCMS is another example of a government department that does not understand Whitehall working at all. I have read its recent sports strategy. It is true that the Department of Health has a half-page in it, but why on earth is DCMS not doing, along with the Department of Health, a sports and health strategy?
In conclusion, this has been a great debate, but I would say to the noble Lord, Lord Prior, that the Government can do much; they cannot do everything. They can give leadership, and in this regard that is what this debate is asking for.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, I shall try to do this without hesitation, repetition or deviation, but I fear I shall fail on all three counts.
First, I echo what all noble Lords have said and thank the noble Lord, Lord Crisp, for introducing this debate, which has been fascinating. He brings to it a lifetime of experience in healthcare, both in the NHS in the UK and, of course, globally. He mentioned two quotes in his speech. The first was:
“Modern societies actively market unhealthy life styles”.
In a sense, that lies at the heart of much of what he said.
He also referred to the African saying: health is made at home, hospitals are for repairs. That is something we should take to heart. He has always said that we have much to learn from other countries, and perhaps we can learn a great deal from that particular saying.
I want to pick up some of the important issues raised by noble Lords in this debate. The noble Baroness, Lady Jay, talked about localism, about which she has some reservations. I suspect that that is an issue we will come to many times over the next few years. While I do not regard her as “a centralised dinosaur”, as she put it, the thrust of much of government policy over the course of this Parliament will be very much towards accountable localism.
The noble Baroness, Lady Williams, started her speech by almost praying for a whole-party approach to healthcare. It is probably unlikely, but it would be nice. She talked about prevention and education. I think that the curriculum for those aged up to 14 now has more time for nutrition and healthy eating, but she and other noble Lords mentioned the lack of time for PE. She also talked about mental health, domestic violence and equality of treatment for those suffering from mental health issues, something we all support in this House.
The noble Baroness, Lady Campbell, spoke movingly about what she called the empowerment model of putting patients—service users, or clients—much more in charge. We should not be so hamstrung by the medical model that has dominated healthcare for so long.
I congratulate my noble friend Lady Redfern on her wonderful maiden speech. She talked about nutrition—perhaps not surprisingly, as she said that she comes from a place where beetroot and celery are much talked about. She also talked about rehabilitation and reablement. Acute hospitals need to do a lot in the field of rehabilitation and reablement so that we can get much earlier discharge of care.
The noble Lord, Lord Best, reminded us that housing and health used to be part of the same department. I do not know how many years ago that was, but it is an interesting observation. He reminded us that home can become a trap, a prison—indeed, a fridge if the temperature is not right. Those were very important observations.
The noble Baroness, Lady Masham, talked very powerfully about the Paralympics and the power of sport. However, she also reminded us that there is no room for complacency about infectious disease and the treatment of people with drug and alcohol problems, and, of course, about the importance of hospital food.
I congratulate the noble Lord, Lord Foster, on his maiden speech. Like many of us, he was once a young rising star, but sadly those days are behind most of us. What he had to say about personal responsibility is very important. We can look to the state and to government institutions, but we need to take responsibility for ourselves as well, wherever possible.
The noble Lord, Lord Alton, made some very interesting comments about variation across the system. It is patchy. We talk about a National Health Service, but it is very different depending on where you live. It was interesting to hear him say that 660 million antidepressants have been prescribed where the underlying problem is loneliness, and that medicine is not a remedy for that. The right reverend Prelate the Bishop of Bristol quoted John Donne:
“No man is an island”.
We are all “part of the main”. I fear that the bell might be tolling for myself this evening, but he again made a very strong point. Social isolation and loneliness were common themes from many of your Lordships.
The noble Baroness, Lady Lane-Fox, knows a great deal about the internet. When she said that the organising principle of our age is the internet, she made a profound point. I have absolutely no doubt that the power of the mobile phone and of the various apps being developed will reshape healthcare. It will shift power away from medical professionals towards individual users. I believe that there is now an app that can monitor your life signs from a drop of blood taken once a month. That is hugely powerful. She warned us of the risk that so much of this technology is concentrated in a small number of highly successful technology firms based in California. We need to be well aware of that.
My noble friend Lord Smith talked about the importance of clubs, participation and social interaction. He reminded me of Burke’s “little platoons”, which are such an important part of society. He also reminded us that in 1666, the average life expectancy was 35, so we have come a long way since then.
The noble Baroness, Lady Neuberger, talked about loneliness and how hugging a young baby or child actually helps develop their brain. It is not just about the very young, but the old as well. Lonely people suffer both physically and mentally. We all love human interaction and know that it is not just the elderly who suffer from isolation; many parts of society suffer from loneliness. I fear that computers have not done us proud when it comes to interacting as individuals with others.
The noble Lord, Lord Rea, talked about the importance of primary prevention. He quoted from Sir Michael Marmot’s book on health inequalities, which of, course, is very powerful. I will write to him, if I may, on Sure Start centres after this debate. The noble Earl, Lord Listowel, talked before to me about loneliness and isolation, in particular the importance of relationships for looked-after children, adolescents and those in their early years. I am not familiar with the Bromley-by-Bow model raised by the noble Lord, Lord Mawson, but I would like to learn about it. I was fascinated by his strictures about replication: you cannot just pick up a model in Bromley and dump it in Birmingham, or probably in any other part of London. There are aspects, however, that can be translated. He said it is always better to start small, rather than trying to start big. In the NHS, we perhaps get ahead of ourselves sometimes.
I turn to the comments made by the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt. This has been an important debate that reaches across a wide part of government. It raises issues that are not just pertinent to this country, but global. At their base, they reflect the fact that our population is increasingly elderly and people are suffering from many chronic long-term conditions. Lifestyles are causing a growing disease burden, particularly from obesity but also from alcohol and smoking. People’s expectations are changing all the time, and, of course, the cost of new surgical and pharmaceutical developments is huge. I suspect that genomic development and genomics will only add to those costs.
At the moment, however you measure how we fund these things—whether it is 16% of national wealth in America or more like 8.5% in this country or 11% in Germany—healthcare is consuming a vast amount of our GNP. Whatever health system you are in, there is an issue of sustainability. I believe that a strong economy is fundamental to any strategy that any of our parties would wish to have. We must have a strong economy, but that is not just so that we can afford better healthcare: it is actually more profound than that. It is because we have a strong economy that we will have high levels of employment. Work is a critical part of addressing some of the concerns of my noble friend Lord Crisp. If people have decent employment, they will tend to have higher levels of physical and mental health.
Education is also fundamental. It was Sir Michael Marmot, I think—or somebody else—who said that you could pretty much predict people’s future lifestyles from the age of 11. If their educational attainment is well below average at the age of 11, the outlook for the rest of their lives is not good. We also need to consider that the transition from adolescence into adulthood is also a critically important time. So I welcome the last Government’s and this Government’s increased commitment to apprenticeships.
The life expectancy of people living in Kensington and Chelsea was referred to earlier in the debate. I think I am right in saying that the life expectancy of people living in Salford is something like 25 years less than that of people living in Kensington. That cannot be explained just by reference to healthcare. Healthcare is demonstrably a very small explanatory component of such a difference in life expectancy. The differences are much more profound than just those associated with the NHS. When we talk about the health of the nation, it is tempting to focus just on the NHS, but it is only a very small part of it.
I wish to expand on devolution a little more because the driving force for devolution, particularly in Manchester but increasingly in the Black Country and other parts of the country, is to try to get greater economic regeneration. I believe that that, together with devolving more power to local authorities, will help to build a healthier society. I do not want to make a party-political point on this at all but I congratulate the principles underlying the work that Iain Duncan Smith has done in developing the universal benefit to try to make it easier for people to move from welfare into work. It is my fundamental belief that work is a crucial part of building a healthier society.
I wish to give noble Lords two quotes. Having said that the NHS is not a big part of this, I want to dwell briefly on it. The first quote is from the NHS Plan 2000. Perhaps the noble Lord, Lord Hunt, was a member of the Government in 2000. The NHS Plan states:
“The NHS is a 1940s system operating in a 21st century world”.
I believe that that comment, made in 2000, was profound. Now here we are in 2015 and the NHS Five Year Forward View states that,
“there is broad consensus on what that future needs to be. … It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment. One that no longer sees expertise locked into often out-dated buildings, with services fragmented, patients having to visit multiple professionals for multiple appointments, endlessly repeating their details because they use separate paper records. One organised to support people with multiple health conditions, not just single diseases”.
So we all know what the issue is and yet getting change in the NHS has proved extremely difficult. I take issue with the noble Lord, Lord Hunt: I think that we have to push these new models of care and treat more people outside hospital settings, not because it is lower cost but because it is better care.
Lord Hunt of Kings Heath
I am not arguing against the models; all I am saying is that I think there is a simplistic view that, if you develop the models, you can reduce the pressure on your acute care capacity. I, and I think many commentators, are doubtful about that, given that our acute care capacity is so much less than that of most comparable countries. That is the point I was making.
Lord Prior of Brampton
I understand that fully. To be clear, at the heart of the Five Year Forward View are both the new care models—the vanguards referred to by the noble Baroness, Lady Walmsley—and a change in productivity. I wish to dwell on productivity for a minute because the NHS is a lean system. I do not argue against that at all. It is a very high-value system. I was at a meeting with people from the Mayo clinic very recently and they said that they felt the NHS was the highest value healthcare system in the world. That does not mean that it is perfect. However, although we are always highly critical of it, by world standards it is a very good system.
We are going to address productivity through using much greater transparency—using the work of the noble Lord, Lord Carter—as well as trying to get a much higher degree of clinical engagement so that we get real traction. In the past we have had a top-down approach to try to drive through productivity improvements. This time we hope to have a much more bottom-up approach, with a much higher degree of clinical engagement.
The noble Lord, Lord Crisp, divided this issue into three, and the third aspect was the most important. The message is that it can be done. For example, the number of teenage pregnancies has been reduced by half. The number of people who die in fires has been reduced by half. Smoking prevalence has come down from 40% to 18%. Health-acquired infections such as MRSA and C. diff have come down very significantly. We can do it, if people work together.
Some of your Lordships may have read the McKinsey Global Institute report into obesity. It is a very good report. Obesity is a global problem: 2.1 billion people in the world are overweight—30% of the global population. It is going to rise to 50% by 2030. It costs billions of pounds and wrecks millions of lives. The McKinsey analysis makes three good points. First, there is no single intervention—no silver bullet. It is not just passing a sugar tax or a new regulation. In its view, when it comes to tackling obesity there are 74 separate interventions that must be done: housing, education, personal responsibility—it is a combination of all these things. Secondly, no part of society can do it on its own. It cannot just be top-down from government. It cannot just be bottom-up from individuals or the community. It has to be top-down, bottom-up and in between. Thirdly, you can never have all the evidence. If we wait until we have all the evidence about every single intervention, we will end up doing nothing. That is quite a good illustration of what the noble Lord, Lord Crisp, is aiming at. If we are going to have an effective strategy for obesity, which we will be revealing early in the new year, it has to be multifaceted. There is no silver bullet.
Treating illness is the tip of the iceberg that we all focus on but the much greater part of the iceberg is below the water. Improving and reducing health inequalities will require an effort that goes way beyond the NHS. Of course, the NHS has a big part to play but there is a much bigger and wider role for society as a whole. I thank the noble Lord, Lord Crisp, for raising this issue. It has been a fascinating debate and I look forward to pursuing discussions with him and others outside the Chamber.
Lord Crisp
My Lords, as I said at the beginning of the debate, I am very conscious that this is the last business of the day, so I will not detain the House for any length of time. I just want to thank noble Lords for the outstanding contributions from all parts of the House and for the wisdom, experience, imagination, practicality and practical experience that they have brought to bear to the debate. I have learnt a lot, not least about the Isle of Axholme and Bath, and indeed I intend to visit the Hindhead Tunnel—when I say it like that, I make it sound a bit like a pub, which is perhaps appropriate.
We have heard three impressive maiden speeches covering the health and well-being hubs in north Lincolnshire, personal responsibility and the role that government should play, and the importance—this was also drawn out by other noble Lords—of sociability and social networks.
There are four big themes, which I shall set out briefly. The first is the role of the Government. At the beginning of the debate, the noble Baroness, Lady Jay, spoke about needing a Cabinet-level Minister to provide some real drive and traction. The second theme, which I was slightly surprised to hear so much about, concerns relationships, sociability and loneliness. Many noble Lords raised that issue, which is of fundamental importance. The third theme is concern about vulnerable people and inequality, with the recognition that we understand that social structures affect health. The final theme is innovation and imagination, and the fact that there are new things which we can do and which we need to deploy.
Noble Lords will not be surprised to hear that I do not want to leave this subject here. A lot is happening but, as I said at the beginning, it is not being done with enough scale and co-ordination—or perhaps “oomph”, to use a technical expression. Therefore, I will be pressing for an ad hoc committee to dive deeper into these issues and to find practical ways of moving this issue forward.