Health Inequalities: North-west London
(1 year, 6 months ago)
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Dr Rupa Huq (Ealing Central and Acton) (Lab)
As Public Health England said in 2017:
“Everyone should have the same opportunity to lead a healthy life, no matter where they live or who they are.”
In reality, someone’s socioeconomic and environmental circumstances will determine that. Health inequalities are about not just clinical disease, but wellbeing and a complex cycle of interacting factors. Income, education, housing, environment, experience of discrimination and “sharp-elbowedness” are all unevenly distributed among the population and the playing field is far from level.
The Government have been widely condemned by the British Medical Association, numerous pressure groups, royal colleges and professors for their U-turn on their 2021 commitment to publish a White Paper on health disparities. The ex-deputy director of health inequalities at the Department of Health, David Buck, is now at the King’s Fund. He called it
“the latest example of repeated political failure to tackle the widening inequalities that leave thousands of people suffering and dying earlier than they need to.”
In talking about north-west London, I am referring to the health administration definition of that area. That comprises suburban Ealing, Brent, Hillingdon, Harrow and Hounslow, and the more inner-city areas of Kensington and Chelsea, and Hammersmith and Fulham. At first sight, they look to be an affluent chunk of both the capital and the country, with a population of 2 million-plus. On closer inspection, however, the eight boroughs covered by the integrated care board contain huge discrepancies, both within and between, in life expectancy, ethnicity, income and multiple determinants behind headline health issues. Big ones locally include diabetes, cardiovascular, maternity and mental health services—all factors identified by the integrated care board’s decent “addressing inequalities” strategy last year.
So what’s class got to do with it, as Tina Turner might have said? Well, the answer is a lot. Average income in Ealing Broadway is £49,100, which is above the national average. However, if you get off Crossrail five minutes later at Southall, it drops to below £30,000. That is £20,000 down in a couple of tube stops. A man in Chiswick will, on average, live for over 82 years. That is 5.8 years longer than in neighbouring south Acton. One is in W4 and the other is in W3. And if anyone has a serious mental health condition, we have to subtract 15 to 20 years from those totals.
Demographically, north-west London has a young population. There are worryingly long waits for child and adolescent mental health services appointments. Every parent knows how children were affected by lockdowns, whether mentally, in lost learning or socialisation. The population is young, but it is ageing. In the ICB, 13.1% of people are over 65. That is forecast to climb, putting a strain on council budgets for adult social care and dementia services. My own late mother, who is looking down somewhere from above, was a dementia sufferer, so I know all too well about that condition. If we add to all those factors Brexit, the cost of living crisis, the aftershocks of long covid and the long waiting lists that have grown since, our cradle-to-grave health service locally is under pressure like never before. Medical staff at the sharp end are in danger of burnout and stress. What I want to say to the Minister is that political intervention can help to solve that and address all those problems.
North-west London is ethnically diverse and that is seen in the disproportionality. For example, 164,435 people in north-west London live with diabetes. Forty-three per cent. of those registered are Asian British, 24% are the population at large. Ditto heart disease: 30% of registered patients are Asian British, 24% are the general population. In the eight boroughs, 18,000-plus people have serious mental health problems. The black British community represent over twice the number of registered mental health patients: 17%, compared with the wider population, at 8%. On cancer, which saw off my late father, who is looking down from somewhere, the white community make up 61% of cancer patients, but 42% of the whole population and prevalence is strongly linked to age.
Poorer finances lead to stress, which, in turn, can lead to the take-up of unhealthy behaviours, such as smoking, and a drop in the take-up of healthy leisure activities. It is a vicious cycle, with happiness and loneliness also in the mix. So what can be done? I have a series of lessons for the Minister. They are things that are fixable, and would be easy wins for the Government and for the country.
First, if we pay people fairly, we will have a contented workforce. That includes those in health and social care who we somehow expect to be superhuman. We have seen junior doctors, paramedics and, for the first time ever, nurses out on strike, when, not that long ago, all of them were hailed as heroes. It was a common sight to see those rainbow drawings with, “Thank you NHS”, pasted up around our streets. We have clapped for carers, but the poorly paid adult care sector, which covers private companies through to council provision, is non-unionised and too disorganised, with too many zero-hour contracts for its workers to be able even to withdraw their labour.
I emailed the title of this debate, “Health Inequalities: North-west London”, to a few people, including a very respected retired consultant at Ealing Hospital. His answer was, “I never needed to supplement my NHS income with private work in my day, but I understand that a lot of the younger generation do”. Again, that shows how this question can be interpreted differently by different people. It should not have to be that NHS employees have to bump up their wages through other means.
Secondly, councils should be sufficiently resourced. Ealing has developed a great healthy lives strategy, and even a racial equality commission following what happened to George Floyd, thanks to Councillors Josh Blacker and Aysha Raza. However, £6 out of every £10 that the borough had in 2010 has gone in local government cuts. It is facing a rising population and is expected to do more and more with less and less, because public health has been added to its brief. That means that corners are cut. Some boroughs, for example, have stopped smoking cessation services. Although smoking in the population has declined, it is still the biggest avoidable risky lifestyle factor everywhere.
The third lesson is to stop reaching for facile “solutionism” and the target culture, which can have perverse outcomes: for example, if one vows to reduce waiting lists and then there is no treatment available at the other end. There is the unintended consequence of patient choice at the eye department at Central Middlesex Hospital. I visited there and was told that private providers cream off some of the easy cataract work—the typical patients are majority-white elderly patients. They are opting to do so because they can, leaving the NHS with unaffordably big bills, plus all the complex procedures—the patients are commonly BAME people—for things such as glaucoma and diabetic eye disease. So the NHS is left with all the difficult stuff. It also means that junior doctors training in hospital are not able to start on the easy stuff. The profile of their training is getting skewed, which needs to be addressed. It is an unintended consequence. We should be under no illusions that backlogs were present before covid.
The fourth lesson is to go out to communities and housing estates. Both Ealing and Camden have an HIV bus and a diabetes bus that go into the estates. That is better than expecting those hard-to-reach populations to come to the hospitals.
The fifth lesson is to listen to the person at the frontline, not just the man from the Ministry. London has a GP crisis, which needs addressing. That should be done by consulting the GPs rather than by imposing solutions in the face of their rising workload and shrunken workforce. One local practice in Ealing had architect costings and planning permission to renovate their premises to bring it up to scratch to accommodate the rise in their patient numbers—from 3,000 to 9000 in a decade. However, under current regulation, although the practice is at capacity, it is not allowed to refuse anyone and NHS Estates says it cannot pay the rent. One partner there said:
“Frankly, there is no estates strategy, we’re just being asked to ‘suck it up’ at full capacity until reaching breaking point… In the meantime, our landlord could serve us notice at any time, putting nearly 10k patients at risk.”
Point six is to look at the profile of disease and trials and recognise that the woman in the white coat can know better than the man in the grey suit. Dr Christiana Dinah, NHS consultant ophthalmologist of those aforementioned vision-threatening conditions in Ealing, Brent and Harrow, conducts award-winning research, but she has a problem in that the BAME population are under-represented in the clinical trials. If only the white well come forward, that gives an incomplete picture, and it jeopardises the chances of the results being applicable and the treatments effective in all the target populations. There is work that could be done there.
We have seen local services withdrawn, including maternity, paediatrics, stroke and mental health beds gone from Ealing. I am familiar with the bureaucrat’s argument that people do not need a facility at the end of their street if there is a much bigger and better one slightly further away, but even if we accept that, let us remember that when facilities get “consolidated”—that is the language—it is no good if there is no public transport to get there, and conduct mandatory mapping.
My penultimate message is to stop blaming individuals, as Government messaging sometimes tends to sound as though it is doing. We are the most obese nation in western Europe, and Sir Simon Stevens once said that obesity threatens to bankrupt the NHS, yet the official rhetoric presupposes that that is a choice. If someone is time and cash-poor, feeding multiple mouths and working multiple jobs, the ultra-processed, high fat, sugar and salt, unhealthy choice tends to be the most convenient and the cheapest. We could look at incentivising buying organic and fresh food, so that the healthy choice becomes the easy choice, and we could do so by taxing and pricing, as we have seen with the sugar tax and, historically, the decline in smoking due to the tax regime.
Lastly, we could recognise the joined-up nature of policy intervention. A mixed-ability comprehensive school that I was at the other day, which not long ago was in the “requires improvement” category, noticed such a glut of obesity among pupils post lockdown that it now provides a free breakfast for all, a free Chromebook for all and voluntary basketball at 7.30 am. The take-up on all three has been enormous. It is expensive, the head said, but it is worth it: the school is out of special measures and even has record successful Oxbridge acceptances. Sadiq Khan’s free school meals for all primary pupils from next year is another visionary and bold scheme. It sounds a bit Oliver Twist, but I say, “More please, Minister!”, so that we can do it nationally.
In short, I would say, “Be unafraid—be very unafraid—of intervention.” Health inequalities arise from overlapping factors, from commercial to cultural, but also from politics and policy. Covid-19 illustrated how disadvantaged communities experienced proportionally higher morbidity and mortality, but before coronavirus hit, who would ever have thought that the Government would foot the nation’s wage bill while we were all locked up for months on end, or preside over the biggest ever mass vaccination programme? We can do things when we put our mind to it, and the pandemic was meant to be a reset moment, was it not?
In this country, we are mostly all—to paraphrase Bruce Springsteen—born in the NHS, but divergence starts at birth. It is a scary sign of rampant inflation that baby milk is now theft-alarmed in supermarkets. Professor Michael Marmot recently stated in the i newspaper that a proper start in life is so fundamental that the powdered formula should be free on prescription for those forced to shoplift it. It is an idea; I do not think it has been taken up by any political party, but it is a thinking-outside-the-box solution.
Another issue we could address, at the other end of the life cycle, is loneliness, which stereotypically, but not exclusively, affects the elderly, and is said to be as bad for health as smoking 15 cigarettes a day. Let us think of ways around it. Apparently, loneliness is even worse and more isolating for BAME communities, despite the stereotype about them living in extended families. The north-west London data shows that it is really bad there, but it is bad everywhere.
Although the Government have attributed unprecedented food and fuel prices to Putin, in reality the perma-crisis that we inhabit flows from political choices—more than a decade of austerity and the chronic underfunding of public services starved of cash by Cameron and Osborne—but we are beyond that now. To repeat myself, strategising should not equal stigmatising people and implying that they are the problem.
When we drill down, it is difficult to find issues that do not contribute to health outcomes. I do an advice surgery every week, and people come and show me pictures of mould and damp. At the end of last year, I think mould was, for the first time, mentioned on a death certificate, and air quality has been identified on a death certificate as well. Well-designed quality and affordable housing directly impacts on physical and mental health, as does access to green spaces and play spaces.
We have longer than we thought because it is not yet 10 o’clock. I do not know if anyone else saw, but there was half a page in a Murdoch newspaper today attacking little old me in connection with a proposed housing scheme in Ealing that is not going ahead now. It is quite a bizarre article—a whole half-page rant about me—and I did not know that it was coming. Everyone here knows that MPs do not decide housing applications or policy, but in that particular developer-led scheme, the private developer pulled out because it would not pay for the post-Grenfell fire safety measures that are now law—it did not want to foot the bill for that. As a west London MP in a borough neighbouring Kensington and Chelsea, I think that, after that enormous and avoidable loss of life, we should never scrimp on fire safety.
Anyway, I said that I was going to conclude. I did not even get to the removal of maternity functions of Ealing Hospital in Southall, or the fact that pre-term deaths in pregnancy are experienced four times as much by black mums as by the population at large, and that poorer communities living by main roads breathe more polluted air—plus, in north-west London we have Heathrow airport, which is ever hungry to expand despite the climate crisis. I did not get on to any of that because the debate could have gone on and on, but I will say that acting on health inequalities improves lives and livelihoods, cuts costs to the NHS, to the benefit of wider society, prosperity and the economy, and it would save the Exchequer billions in lost productivity through long-term sickness.
We should be bold. We should act and think beyond eye-catching short-term targets aligned to electoral cycles —me in particular, as I have seen so many snap elections in my lifetime; it does not work to think in terms of normal electoral cycles any more. Let us think more long term and be honest with people, not treat them like idiots. Let us take a multi-pronged approach to levelling up—the Government’s watchword. In the meantime, if anyone has any clue about where the £350 million per week that was promised on the side of the Brexit bus is, please inform our local NHS folk. I took a wide range of soundings to come up with this content, but no one says that they have seen that money.
I look forward to the Minister’s response—I know that he is a good man. I do not think it beyond the wit of man to do this. We can do it.
The Parliamentary Under-Secretary of State for Health and Social Care (Neil O’Brien)
Well, how to follow that? I pay tribute to the hon. Lady for securing this important debate and for her wide-ranging speech. It was so wide ranging that I think I will struggle to follow or match it, but I will do my best. It was a speech with everything from Tina Turner and Bruce Springsteen to loneliness and ethnic minority participation in clinical trials. Let me try and structure my response by starting with the health service, working back to primary care, and then addressing public health.
The first and most central thing is, of course, to have a high standard of healthcare. That is why, between 2010, when we came into office, and the end of this Parliament, we will have increased spending on healthcare by 42%, even when adjusted for inflation. That has enabled us to hire about 37,000 more NHS doctors than there were in 2010, and 52,000 extra nurses. That is a huge increase in resource and people, enabling us to start hacking through the covid backlog. We have already eliminated the two-year waits and have very nearly eliminated the 78-week waits. We are now moving on to eliminate shorter waits as we work through and cut the NHS waiting lists.
Of course, that is downstream—that is secondary care, hospitals and treating disease—and we all agree that the name of the game is to try to prevent disease and to treat things upstream, which is why we made further investments in primary care last week. In general practice, we have about 2,000 more doctors than we had in 2019 and about 25,000 more other clinicians. Compared with 2017, total spend on general practice is nearly a fifth higher. So more resource is going into that primary care.
We also see primary care doing more than ever. GPs are doing about 10% more appointments every month than they were before the pandemic, in 2019. That is the equivalent of about 20 extra appointments per practice per working day, which is a huge increase in output. That is partly because of the extra resource and partly because GPs are working extremely hard, and I pay tribute to everyone in general practice for doing that. That activity in general practice is a big part of the prevention story, helping people to stay healthy and to stay out of hospital.
However, as the hon. Lady alluded to, a lot of health is about the social determinants of health and about getting further upstream and tackling the underlying causes of the disparities that she talked about with great passion and understanding. Taken together, the public health grant, the drugs grant and the Start for Life grant will grow by about 5% in real terms after inflation over the next two years, enabling us to do more, particularly on problems such as drug dependency and drug addiction, which are particularly serious across all of London.
Part one is to have the funding there for those streams, but we have also been making major institutional changes to public health. We have set goals to increase healthy life expectancy and to the narrow gaps between different parts of the country. We have created the Office for Health Improvement and Disparities, and we and the NHS have created the Core20PLUS5 framework, which is a way of thinking about and tackling disparities. We have also put a new duty on integrated care boards to have due regard to disparities and to try to tackle them.
In quite specific ways, we have been taking action—this is of course relevant to north-west London—to tackle the problems of particular ethnic minority groups. In particular, we have been driving up vaccine uptake, particularly in groups where there is a degree of hesitancy, through targeted advertising and outreach to faith groups and local community groups, and I pay tribute to everyone who has been involved in that in the NHS.
We have been tackling the challenges thrown up by energy, which I will come back to, and by social housing—the hon. Lady was quite right to raise that issue in relation to west London. I pay tribute to my right hon. Friend the Secretary of State for Levelling Up, Housing and Communities for the vigorous action he is taking to tackle some of these challenges through the Social Housing (Regulation) Bill and extending the decent homes standard to the private sector, and the action he is taking to make developers pay to clean up the mess they have caused and to make sure we never have a Grenfell again.
So action is being taken across a wide range of areas. Let me just delve into a few of them in the time remaining. On drugs, the Home Office, the Ministry of Justice and the Department of Health and Social Care are investing about £900 million extra in the drugs strategy, which will grow local authority funding for treatment by about 40% between 2021 and 2024-25, and create about 50,000 extra places in treatment. As well as that investment in more treatment for people with drug addictions, we are increasing access to naloxone, which helps treat overdoses, and looking at spreading new technologies and new treatments, such as slow-release buvidal. When I visited a health centre in Brixton I saw the effect that some of these new drugs can have on improving treatment for those who have serious drug dependencies.
However, again on the point about getting upstream, our Start for Life programme is a major investment in new and expanded family hubs in about 75 local authorities. Its universal offer in those areas combines peer support for breastfeeding, help for those who are difficult to help and lots of face-to-face support with issues such as mental health. Right from the very start, as the hon. Lady mentioned, this is about trying to improve the disparities that emerge at an early stage.
Across the course of life we are taking action to prevent some of the most important major conditions, and our major conditions paper, which succeeds the health disparities White Paper will say more about this. The NHS long-term plan already announced the ambition to prevent 150,000 heart attacks, strokes and dementia cases by 2029. We supplied about 220,000 blood pressure monitors to those with high blood pressure. We are modernising and updating the NHS health check and creating a digital version. We have already pretty much got back to pre-pandemic levels of health check. We will be setting out more about the prevention of these major conditions in that forthcoming paper.
Dr Huq
The Minister is giving a constructive response with a lot of numbers in it. Is there a date for the major conditions strategy? I have asked him before and we have sparred on this question. At the time of the health disparities White Paper, the Secretary of State at the time—just two Secretaries of State ago—said that we should level up health as well as levelling up economically. The strategy does feel like a watering down, and it is yet to see the light of day. Do we know when it is coming out?
Neil O’Brien
There is not actually a date for that paper yet, but it will be out relatively shortly. We are tackling the major conditions because these health disparities that we are all concerned about are not mediated by magic; they are mediated by physical things that happen. First among them is probably smoking.
Smoking rates are highest in the poorest places, and that is a powerful driver of all of these other major health problems. I am proud to say that we have the lowest rate of smoking on record in England—just 13%, down from 21% in 2010—and that has happened because we have doubled duty on cigarettes and introduced the minimum excise tax on the cheapest cigarettes, and we have recently announced measures to go further. We are offering a million smokers help to “Swap to stop”, as they say, by giving them free vape kits, because that is so much less harmful, and we will also be introducing a financial incentive to quit, worth about £400, for all women who are pregnant and smoking. A shocking number of people still smoke in pregnancy, particularly in areas of higher deprivation. That builds on some of the things that the NHS is already doing, including the roll-out of carbon monoxide testing for people who are pregnant and smoke, and some of the innovative things that have been done at a local level.
The other big way that these health inequalities are mediated is through obesity. There are much higher rates of obesity in poorer places, for the reasons that the hon. Lady set out. She already mentioned some of the things. She talked about the so-called sugar tax—the soft drinks industry levy, as not a single person ever calls it—which has cut average sugar content in affected drinks by about 46% since we brought it in. We have introduced calorie labelling for out-of-home food in cafés and restaurants, and brought in location restrictions for less healthy food from October 2022. We are bringing in an advertising watershed in 2025. We spend about £150 million a year on healthy food schemes, such as school fruit and veg, nursery milk, Healthy Start and so on. We spend about £330 million a year on school sport and the PE premium. Through the youth investment fund, we are spending about £300 million on 300 new facilities for youth activities. We are also investing about £20 million a year on the national child measurement programme, which is all about trying to note these problems at an early stage and nip them in the bud.
In the hon. Lady’s speech, she talked about the challenges thrown up by the Russian invasion of Ukraine and the effect that has had on the cost of living. Again, we are taking decisive action. We are spending about £55 billion to help households and businesses with their energy bills, which is among the highest and most generous support plans in Europe, paying about half of people’s bills over the winter. On top of that, we have action directly to help with the cost of living for people who are less well off, including the £900 cost of living payment for about 8 million poorer households and the largest ever increase to the national living wage for 2 million workers. In total, we are spending about £26 billion on cost of living support next year. We are taking action on energy, but also at the same time taking further action both to improve the quality of rented and social housing through the Social Housing (Regulation) Bill and to invest more in energy efficiency so that people’s homes are cheaper to heat.
I have tried to tackle some of the subjects that the hon. Lady raised in her speech, which I thought was really interesting to listen to and covered many subjects. I will not be able to tick all of them off this evening, but it was a pleasure to hear about some of her thoughts and ideas, and a pleasure to commend to the House some of the action we are taking.
Question put and agreed to.