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Lucy Allan (Telford) (Con)
I beg to move,
That this House has considered legal duties on the Secretary of State to reduce health inequalities.
It is a pleasure to serve under your chairmanship, Mr Hollobone, and I am delighted to have secured this debate and to raise this important issue.
In 2016, the Health Committee Chair, the hon. Member for Totnes (Dr Wollaston), led a thoughtful and important debate on this issue, noting that in the Prime Minister’s first speech in No. 10 Downing Street she had put reducing health inequalities at the top of her list of priorities. But July 2016 is now a very long time ago, and since that date we have heard a great deal less about that injustice. During that time, inequality of health outcomes between those in affluent areas and those in areas of deprivation has persisted.
That injustice has been obscured by improvements in overall health outcomes—and, of course, by all the other business that has been going on in this place and distracting us from the reasons that so many of us came to Parliament. As the Government unveil the NHS 10-year plan, it is right that we make a conscious effort to revisit the question of health inequalities. I want to do so in particular because I can see unequal health spending by local clinical commissioners in my area. While decision-makers may pay lip service to tackling health inequalities, it is not the driver that it is meant to be under the law.
Of course, the primary causes of health inequalities are complex and varied, from unemployment to poor housing. While no one would suggest that healthcare spending is the answer, we must ensure that all healthcare decision-makers understand their duties and the importance of their obligation to provide access for, and direct spending toward, those most in need. Healthcare spending is the one part of the mix that Government can control, and it is right to expect healthcare spending to be focused on tackling both unequal health outcomes and unequal access to healthcare.
The allocation of funding to local commissioners, which the Minister will probably touch on, rightly includes an adjustment for health inequalities based on the mortality rate. An area with a higher mortality rate, such as my borough of Telford and Wrekin, will get more funding per head than an area with a lower mortality rate, such as neighbouring Shropshire, but that is not the end of the matter, particularly when it comes to major hospital reconfigurations, which are happening in so many places across the country.
While funding may be allocated to separate clinical commissioning groups on the basis of need, when it comes to a major reconfiguration, CCGs will group together to form a joint CCG, bringing widely disparate areas under their umbrella. The funding and resource decisions are then made by the joint CCG, without considering health inequalities between those disparate areas. That is exactly what is happening in my area.
Telford is a post-war new town, created on the east Shropshire coalfield, and it has areas that are among the most deprived in the country. It has, by every measure, significantly worse health outcomes than Shropshire, a county that has better health outcomes than the national average, and significantly better outcomes than Telford, by almost every indicator.
We are experiencing just such a hospital reconfiguration. Telford and Shropshire have combined, and funding for hospital care is allocated to the area as a whole. What we have seen is a joint CCG, representing those disparate areas, deciding to direct the bulk of its funding to the more affluent area, and to move existing resources there from an area of deprivation. That is a clear failure of the duty to narrow health inequalities.
The national health service database has the figures there for all to see. When it comes to health outcomes, Telford and Shropshire are at different ends of the spectrum. For someone living in Telford, the premature mortality rate is 25% higher than for a person living in Shropshire. Children in Telford are far more likely to suffer from obesity or to be hospitalised for dental decay. Tragically, rates of suicide and cancer in Telford are significantly higher than in Shropshire. Smoking rates, inactivity in adults and other such indicators show the very same disparity. The truth is that a shire town in rural England is healthier than a new town built in a former mining area on the east Shropshire coalfield, and NHS spending allocations are required to recognise that greater need. It is that simple—yet in practice, that is not what is happening.
The Health and Social Care Act 2012 makes it clear that there is a requirement to move towards greater investment where levels of deprivation are higher. Under the Act, that is a legal duty on the Secretary of State, NHS England and CCGs. The guidance makes it clear that inequalities
“must be properly and seriously taken into account when making decisions”.
As a former non-executive director of an NHS trust, I know that the NHS constitution requires the NHS to pay attention to sections of society where improvement in health and life expectancy do not keep pace with that in the rest of the population.
It is not enough for the Government or NHS England to hand over the cash to a joint CCG and then say, “Job done,” as far the health inequality duty is concerned. CCGs also have a duty to narrow health inequalities and, if they are not complying—as in my area they are not—I ask the Minister how we can hold them to account. What steps can be taken to enforce that requirement?
This is happening not only in Telford. Across the country, from Lewisham to Huddersfield, the NHS is carrying out controversial restructurings of hospital care similar to the one in Telford, where funding and resources are being targeted toward a single area. If what is happening in Telford is happening elsewhere, decision-makers are ignoring their duties to address inequalities—or maybe they are merely paying lip service to them. It is all very well to commit to narrowing health inequalities, but that commitment is manifested only on a spreadsheet when we do our allocations to CCGs; it is not happening in practice when it comes to spending that allocation of funding.
Stephen McPartland (Stevenage) (Con)
I am grateful to my hon. Friend for securing this important debate. In my area, East and North Hertfordshire CCG is being forced to merge its management and executive teams, but so that it does not have to consult with local people, it is going to keep three separate boards. As a result, we are concerned about how decisions will be taken going forward and, although the spending will be going to the three separate CCGs on paper, in reality one committee will be making those decisions and getting the boards to ratify them. The concerns she is raising in her area are repeated around the country.
Lucy Allan
I thank my hon. Friend for his intervention, and I am aware of the position he sets out. He is absolutely right; these problems are happening elsewhere with the combination of CCGs coming together and not being able to meet the needs of the individual areas that are receiving the funding.
In Telford, the local hospital trust serving both Telford and Shropshire announced in January, after five years of bizarrely convoluted and contorted deliberation, that it was pleased to announce its investment of a total pot of £312 million in a state-of-the-art critical care unit in the leafy, affluent shire town of Shrewsbury in Shropshire, 19 miles from Telford. In addition, the trust announced that it was pleased to say it would transfer Telford’s women and children’s unit and emergency care from Telford to Shropshire.
I have repeatedly asked the revolving door of hospital management over the past five years to explain how that proposal narrows health inequalities, how that decision improves the health outcomes of the most disadvantaged groups in the area they serve and how it improves health access for the most disadvantaged group if it is moving their provision 19 miles from its current location.
The response to my questions over a significant period has been to take no notice whatever. As an MP I have found, and I know from talking to them that many colleagues have also found, that local hospital trusts and CCGs feel no obligation whatever to respond to or even take notice of elected representatives. Indeed, my right hon. Friend the Member for Hemel Hempstead (Sir Mike Penning) noted in this place just last week, in an excellent debate on his local trust, that he had “absolutely no influence” on any decisions made by the CCG in his area.
As the Shrewsbury and Telford trust felt no obligation to respond to questions on this incredibly important issue, I asked the then Secretary of State if he could seek a response on my behalf. However, even that did not bring so much as an acknowledgement that reducing health inequalities is an important issue for the hospital trust or the CCG when making spending decisions.
The trust seems to feel entirely unaccountable to anyone. The Department of Health and Social Care says that it is accountable to NHS England, and NHS England says that the trust board is accountable to the trust chairman. In reality, there is no accountability. This subject has been raised with me over and over again by local residents who strongly oppose this reallocation of funding from a disadvantaged area to a more advantaged area.
Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)
My hon. Friend will be aware that there are health and wellbeing boards at play in local authorities. How effective has her local health and wellbeing board been at holding the CCG and other parts of the NHS to account, not only for their spending decisions but for how those decisions impact on frontline patient care?
Lucy Allan
I thank my hon. Friend for sharing his expertise in this area. My local council and health and wellbeing board have equally not been listened to on this issue. It is a Labour council, but it has tried extremely hard; if there was an opportunity to suggest otherwise, I would perhaps take it, but that is not the case. Both tried hard and have not been listened to. Most frustrating has been that the voice of local people has not been heard. Who do we expect to enforce this statutory duty? We cannot expect constituents to crowdfund a legal process because we want to hold CCGs to account.
Dr Philippa Whitford (Central Ayrshire) (SNP)
Does the hon. Lady share my concerns on integrated care providers? Those should be statutory bodies and not in any way open to being private companies, which can hide behind commercial sensitivity, for exactly the reasons she says.
Lucy Allan
I thank the hon. Lady for her comment. There was an interesting debate on that issue on Monday night in the Chamber. This is an important issue, and I have a lot of sympathy with what she says.
On the injustice of unequal health outcomes, I said at the outset that that is of course not about spending more, and that poor health is not only about healthcare but is a much wider issue. However, if the NHS overlooks its statutory, constitutional and moral duty to properly consider health inequalities when making major spending decisions, the Secretary of State has a legal duty to act; he cannot just sit on his hands and say it is down to local clinicians. That response is all the more frustrating in my case because all six voting members of the Telford CCG voted against the transfer of resource from an area of deprivation and to an area of relative affluence, whereas all six voting members of the CCG in the more affluent Shrewsbury naturally voted for the funding resource to be transferred to their area.
In our case, Telford CCG was made to vote again until it came up with the right answer and allowed that transfer of funding. [Interruption.] That is very topical, yes. This whole issue reminds me exactly of Brexit. I wish I had not come on to that point; this should be a Brexit-free zone, for a change, so that we can all maintain our sanity. However, it is similar in the way that those in power have not been listening to the people. It is extremely important to note that, if we give that sort of funding to relatively affluent areas and take resource away from the most disadvantaged, we are doing something wrong. No Government could think that that was a good idea. I am grateful to the new Health Secretary, who came to Telford to visit our Princess Royal Hospital earlier this month and took the time to see for himself the fantastic work being done in the very areas that the management is seeking to close and to transfer 19 miles away to Shrewsbury hospital.
I would like to get something else off my chest, to further illustrate the problem of unequal health spending. Six months ago the Government gave the Shrewsbury and Telford Hospital Trust £3 million for winter pressures. The trust decided to spend all of it in Shrewsbury—all of it—despite there being no evidence that the decision reduced health inequalities between the areas that it serves and not even an indication that it had considered health inequalities when making that decision.
No Government could possibly condone transferring resources from an area of need to an area of greater affluence and better health outcomes. The Government have a legal responsibility to ensure that that does not happen. Everyone in this room will agree that NHS funding decisions must focus on the areas of greatest need, and where that is not happening, we cannot ignore it. The trust has been able to forge ahead with a plan that has never made sense to local people, that was roundly opposed by a consultation that took place, bizarrely, two years after the original decision was made, and despite MPs and councillors vocally pointing out the plan’s shortcomings and its failure to address health inequalities. The hospital trust and CCGs carried on regardless. It cannot be down to local people to enforce the Act. I can only conclude that decision-makers perhaps do not understand their duty to narrow health inequalities or—of more concern—that they do not understand the extent of the need, disadvantage and health inequality in the area they serve.
The flat-out refusal to even discuss the reconfiguration’s impact on health benefits and outcomes for the most disadvantaged has been extraordinary. I have written letter after letter for a considerably longer period than the consultation lasted and I have not received any answers. My trust treats the issue as if it was entirely irrelevant to its reconfiguration plan. If it is not able to show how its plans narrow health inequalities, it must think again.
I know that once the Secretary of State receives the relevant documentation from my local council, he will carefully consider whether to call in the Telford proposal for review by an independent reconfiguration panel. For that, I am most grateful. I hope the panel will look closely at the failure to address need and disadvantage and, on those grounds alone—there are many others—throw out the scheme. If the Government are committed to reducing health inequalities and not only focusing on better health for all, they need more than just warm words. I ask the Minister to remind hospital trusts and commissioners generally, and the Shrewsbury and Telford Hospital Trust and its commissioners specifically, to give due regard to their duty to demonstrate how their spending decisions narrow health inequalities.
In conclusion, I ask the Minister to keep focusing on this issue. It is so easy to lose sight of the reason we all came to this place, and it is too easy for the Department or the Minister to believe that health spending is allocated and targeted towards need, and that we do not have to look beyond the spreadsheet. We have to ensure that it is happening in practice on the ground. We cannot simply say that we have done our bit and that there is no need to look any further. Health inequalities are a shameful injustice of unequal lives and unequal life chances. I know that the Secretary State wants to ensure that no NHS decision-maker allocates funding in a way that exacerbates this injustice, whether in Telford or any other area.
Mr Philip Hollobone (in the Chair)
The debate can last until 5.30 pm. I am obliged to call the Front-Bench spokespeople no later than 5.07 pm. The guideline time limits are five minutes for the Scottish National party spokesperson, five minutes for Her Majesty’s Opposition’s spokesperson and 10 minutes for the Minister, with the mover of the motion having two minutes at the end to sum up the debate. The next 18 minutes will be for Back- Bench Members. You can all contribute if you speak for no more than four and a half minutes each.
Jim Shannon (Strangford) (DUP)
I congratulate the hon. Member for Telford (Lucy Allan) on bringing this issue to the House. I am always very pleased to support her on any issues that she brings to the House. They are always ones that I am interested in, and that is why we are all here—because we are all interested in this issue.
The issue of health inequalities is of grave concern to me, as I hail from what too often feels like the poor relation when it comes to health issues—Northern Ireland. Our NHS is stretched beyond capacity and without access to many services that the UK mainland has. I suspect that when we hear from the spokesperson for the Scottish National party, the hon. Member for Central Ayrshire (Dr Whitford), she will tell us how things are progressing in Scotland, and I always feel envious of things that are being done there. I wish that we could replicate them in Northern Ireland.
People in Northern Ireland do not have access to children’s heart doctors. Parents and their sick children have to fly to the mainland or travel to the Republic of Ireland. Over the years, a number of my constituents have fallen into that category. It is because we do not have enough demand on paper to keep a paediatric cardiology team in place, yet in practice far too many children are having to travel, with no family support, out of Northern Ireland to London or to the Republic of Ireland. They are treated unequally because, let us be honest, they come from Northern Ireland. The access that they have is not the same as people have on the mainland. The fact that they are going to London or to the Republic of Ireland is an indication of the problem.
Then there are those who suffer from rare diseases, who feel the inequality of suffering from something that is not common enough for there to be a focus on it or for funding to be put into it. That is heartbreaking. When we consider that 54% of UK cancer deaths are from rare and less common cancers, we suddenly realise that it is so wrong that there is such inequality in funding across areas including policy, services and research. In particular, symptoms of rare and less common cancers can be less well recognised or vague and, as a result, too many people are diagnosed late or through a presentation at an accident and emergency department, which generally means that outcomes will be much poorer.
I am not sure whether anyone here reads The Times, but there is a lovely photograph on the front of that newspaper today of a wee lassie who went to America to get proton beam therapy. It was a success, and that was one of the first ever examples of this. It is one of those heart-warming stories. It gives us encouragement when technological advances are made and there is an opportunity for health services elsewhere in the world to progress in such a way. It was good news that that young girl, who is now nine, was able to be back home with her family and her cancer was away.
We must address training on symptoms and publication and awareness of information to stop the inequality for those who know what to look out for with breast cancer but have no idea that the early symptoms of fast-spreading pancreatic cancer can seem like gallstones. Sometimes the issue is diagnosis and knowing the right symptoms. We must address the inequality of coverage and funding for rare diseases in the UK.
Those are not the only areas where I see inequality. I recently asked a further question regarding concerns that I have. I asked what steps the Department of Health and Social Care was taking to ensure that provisions relating to health inequalities and the life expectancy of people with learning difficulties and autism were included in the prevention Green Paper. It is important to address inequalities for those who have complex needs. Every one of us, as an elected representative, is each and every day impacted by cases involving complex issues—constituents who have not one ailment or problem, but multiple problems. That is the life we live. This was the response from the Under-Secretary of State for Health and Social Care, the hon. Member for Winchester (Steve Brine):
“The ambition of the Green Paper focuses on both reducing health inequalities and increasing healthy life expectancy. We are currently considering policy options, and will be mindful of impacts on people with learning disabilities and autism.”
I look to this Minister to perhaps provide more enlightenment on that question.
We need a more proactive approach for vulnerable people and more of a focus on the inequalities that exist for those who are slightly different healthwise and who process things slightly differently. It is safe to say that currently we operate in a postcode lottery for health. I understand the budgetary constraints and they are a fact of life, but it is imperative that there is UK-wide access to healthcare that is not impacted by someone’s address, illness or ability or inability to communicate. I say this gently to the Minister: simply put, we must do better.
Derek Thomas (St Ives) (Con)
I congratulate my hon. Friend the Member for Telford (Lucy Allan) on securing the debate. This is such an important subject. A Cornish MP absolutely understands health inequalities and the lack of funding to target them. In Cornwall, there is no shortage of examples of health inequalities. I will mention just a few issues: vascular disease, including diabetes, kidney disease, dental health problems, skin cancer, diagnosis times for people with severe conditions, including ankylosing spondylitis—I chair the relevant all-party parliamentary group for that—and mental health services. It is clear that in Cornwall there are inequalities in all those areas.
My hon. Friend was right to address the need to allow funds to be targeted towards health inequalities. As a Member for Cornwall, which has long been underfunded compared with the rest of England, or at least the English average, I fully support that. However, in the short time that I have this afternoon, I would like to address a different aspect of health inequality—dementia. Dementia is a disease, but it is not primarily treated by the NHS. It is a Government commitment to provide NHS services free at the point of use. If someone has a stroke, heart problems, cancer or flu, the NHS will treat them free of charge. If someone has dementia, a recognised disease, it can cost tens of thousands of pounds—I learned today that it can cost up to £100,000—to get the care that they need.
I am suggesting that it would be in the interest of the Government, the Department of Health and Social Care and certainly those who are concerned about social care budgets to make dementia an NHS problem, rather than a problem for social care. According to the Alzheimer’s Society, which is about to launch a call for a fund for dementia, 50,000 avoidable hospital admissions happen simply because we do not adequately care for those with dementia or for those who care for them. Failing dementia care services could be avoided. According to independent reports, 23% of all services for dementia are failing. That sounds quite dramatic, and it is dramatic when one sits with a person who has cared for a loved one and who has also been in hospital because she cannot cope with being awake every night and trying to ensure that her husband does not turn on the stove, fall out of bed or fall down the stairs. Where we have failing services, because the issue is not properly dealt with within the NHS family, we really have problems and we cannot fully understand how severe the problems are.
People who treat dementia patients would be adequately trained if this disease were brought within the NHS window, the NHS envelope. We would be able to ensure that everyone who cared for someone with dementia was adequately trained. Independent reports say that 38% of carers who care for people with dementia have not been trained in the disease or all the things associated with Alzheimer’s or dementia.
I have welcomed and am so pleased with the commitment to the 10-year plan for the NHS. It is time, and this is an opportunity, to address health inequalities and to treat dementia as a disease within the NHS and one to be treated by the NHS. I would therefore like us, as we develop the plan, to create a recognised pathway of care for those with dementia and to ensure that all those providing care are adequately trained in dementia care and all that goes with it. Clearly, that will have a cost, but I believe that it is the right way to care for people, many of whom have served this nation for such a long time during their lives.
My father-in-law suffered full frontal dementia for many years—for 10 years—and it was such a battle to get the support that he needed. Even when he was completely dependent and could not do anything for himself, he was still cared for within social care and not the NHS. That was the case right up to the day he died, even though he died of pneumonia. That was a few years ago, but it is one example of how we do not fully understand dementia. Stories are hidden at the moment, but by dealing with dementia within the NHS as a disease, we could really help people to reduce so much of the harm and the inequality that we have talked about. We could do something fantastic and make better use of the money that is available to care for those we all care about.
Debbie Abrahams (Oldham East and Saddleworth) (Lab)
It is a pleasure to serve under your chairmanship, Mr Hollobone.
I congratulate the hon. Member for Telford (Lucy Allan) on securing the debate. She was absolutely right to say that, as important as our NHS is in treating and caring for us when we get ill, reducing health inequalities —in my Oldham East and Saddleworth constituency, there is an 11-year life expectancy gap between rich and poor—goes beyond the NHS and the Government’s 10-year plan.
The term “health inequalities” refers to the increasing mortality and morbidity that occur with declining socioeconomic position. This is the systematic, socially reproduced, differential distribution of power in relation to income, wealth, knowledge, social status and connections. There is overwhelming evidence that those factors are the key determinants of health inequalities, influenced by written and unwritten rules and laws across our society. Those things, rather than biological and behavioural differences, drive these inequalities. No law of nature decrees that the children born to poor families should die at three times the rate of children born to rich families, but that is the reality in 21st-century Britain.
Given that those health inequalities are socially produced, they are not fixed or inevitable. If the Government were committed to tackling these burning injustices—let us face it, what could be more unjust than knowing you are going to die earlier because you are poor?—a starting point would be to tackle their regressive, unfair economic and social policies.
Countries that have a narrow gap between rich and poor have not only higher life expectancy rates, but better educational attainment, social mobility, trust between communities and so on. Fairer, more equal societies benefit everyone. Unfortunately, the concentration of power in tiny elites is happening more than ever in the UK.
Just four weeks ago the Office for National Statistics published data with more evidence that these inequalities are on the increase, with income inequalities increasing in 2018. The average income of the poorest fifth of the population after inflation contracted by 1.6% in the last financial year, while the average income of the richest fifth rose by 4.7%. This followed “fat cat Friday” in January when it was revealed that top executives were earning 133 times more than their average worker—up from 47 times more in 1998.
At the same time we are seeing increases in both infant and child mortality, which—as shown in the latest study, just 10 days ago—correlate with increasing child poverty. These increases, the first in 100 years, mean that four babies in 1,000 will not see their first birthday in the UK, compared with 2.8 in 1,000 in the EU.
Two weeks ago life expectancy estimates were revised downwards by six months by the Institute and Faculty of Actuaries in its latest mortality projections model. The institute now expects men aged 65 to die at 86.9 years, down from its previous estimate of 87.4 years, while women who reach 65 are likely to die at 89.2 years, down from 89.7 years. Public Health England’s investigation into flatlining life expectancy revealed—as many of us, including Sir Michael Marmot, have said for a number of years—that austerity has wrought misery and poverty, and ultimately an early death for too many of our citizens.
As analysis from the Institute for Fiscal Studies and others has shown, since 2015 the lowest income decile has lost proportionately more income than any other group as a consequence of personal taxation and social security measures. Last autumn’s Budget had only marginal impacts on the household income of the poorest, while reducing the number of higher rate taxpayers by 300,000. Last week’s spring statement followed that trend. There was nothing for the 8 million working poor, the 4 million children living in relative poverty or the two thirds in working families, and nothing for the 4 million disabled people living in poverty.
These health inequalities are socially produced, so they are not fixed or inevitable. They can be changed, and that should give us hope.
Sir Kevin Barron (Rother Valley) (Lab)
Thank you for calling me, Mr Hollobone. I am pleased to be here this afternoon and that the hon. Member for Telford (Lucy Allan) has brought up this matter of health inequalities. She mentioned the Health Committee of the previous Session. I chaired the Health Committee under the last Labour Government, which looked into health inequalities and found that there are great difficulties in moving on from that.
In 2010, the Marmot review on health inequalities was published. Since then, we have had legislation. I was on the Committee for the Health and Social Care Act 2012. I was really pleased that health inequalities and population health was a big issue, and it was put in statute that those things needed addressing. I am sad to say that I have not heard a murmur from Ministers since then in relation to reducing health inequalities.
As my hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams) said, Sir Michael Marmot was a leader on this matter. He is now involved in the Institute of Health Equity, which, in September last year, released a fascinating publication. In conjunction with that publication, Sir Michael Marmot wrote on his blog about the complexity of health equalities, a point recognised by the hon. Member for Telford and my hon. Friend the Member for Oldham East and Saddleworth. Sir Michael Marmot wrote:
“There has been a contradiction at the heart of recommendations for action on health inequalities. No one is more concerned with health than those of us in the health sector. But the key determinants of health inequalities lie outside the health care system. It is not so much what doctors do, or don’t do, for patients that cause health inequalities, but the conditions in which people are born, grow, live, work and age.”
That is absolutely true. To be fair, the coalition Government tried to bring in legislation that would help people to recognise that, not only in the health service, but in the wider world.
The report published last September, “Reducing Health Inequalities Through New Models of Care: A Resource for New Care Models”, is really worth reading. Sometimes I despair when I hear Members of Parliament saying that we do not want new models or changes in the health service, because this is what happens and that is how it should be. In fact, the Institute of Health Equity provides some great guidance that we could all learn from, in terms of what should or should not be done.
One issue highlighted in that report is that the Public Services (Social Value) Act 2012 came into force in 2013, across the public sector. The report says:
“The Act states that for public bodies procuring service contracts over a certain threshold”—
both examples given are below £200,000—
“the authority must consider: ‘a) how what is being proposed to be procured might improve the economic, social and environmental wellbeing of the relevant area, and b) how, in conducting the process of procurement, it might act with a view to securing that improvement.’”
That is exciting, at one level. However, on the next page, regarding take-up of those considerations, the report states:
“Social value contracting is still relatively underdeveloped within the NHS, even though it is a legal requirement. Only 13 per cent of CCGs were able in recent research to evidence active use of the Act.”
Under those circumstances, it seems to me—it is not just the NHS, but the rest of the public sector—that we need to concentrate our minds, as a nation, on how we get through this issue. It is an issue not only of health, but of many other things.
The report talks about using
“social prescribing to create action on social determinants”.
The Minister—in her life before being elected—comes from close to the borough of Rotherham. Rotherham Social Prescribing service has won national awards for how it works with different communities. Voluntary Action Rotherham also works with different voluntary groups—not groups that deliver health services as such—to ensure that people get the help that they need now. Social prescribing, in my view, is a way to get away from the health service and into the wider communities, and it is an avenue that this House should encourage. I hope the Minister agrees with that.
Dr Philippa Whitford (Central Ayrshire) (SNP)
Obviously, we are discussing the duty to reduce health inequalities, but as other hon. Member have mentioned, the increase in life expectancy is stalling and healthy life expectancy is falling. There is an exact linear correlation with deprivation. Women in poorer areas will have 26 years of poor health compared with 13 years for the least deprived. That all generates health pressures in the health service and in social care. Last year, the Scottish Government passed the Fairer Scotland Duty, which puts an obligation on all public bodies to work towards reducing inequality.
There are different aspects to this issue, including access to healthcare, which the hon. Member for Telford (Lucy Allan) talked about. In Scotland, we now spend £185 a head more on health and £113 a head more on social care than in England. That allows us to offer free personal care, which allows people the luxury of staying at home if they need the support mentioned by the hon. Member for St Ives (Derek Thomas).
A key issue of access to healthcare is free prescriptions. They are not available in England, other than for a very limited number of conditions, not including asthma. Asthma UK has conducted surveys showing that, at some point, half of all patients have not collected their prescription, and that three-quarters of asthma patients struggle to pay for their prescription. Of those who did not collect their prescriptions during that period, 13% were admitted to hospital. That is not cost effective.
The long-term plan talks about access to a digital GP, video access and healthy people being able to buy genomic testing. I am sorry, but all that will feed the inverse care law of increasing demand from the better-off instead of tackling unmet need among poorer people. Those are the people who do not attend appointments for screening, who live far away from services and who do not have access to decent healthcare.
On the public health and prevention side, obviously Scotland was the first to enact the smoking ban, followed by England. We have introduced minimum unit pricing to try to tackle alcohol, which is another one of the scourges. That policy has yet to be enacted here. I welcome the UK Government’s sugar tax, but I would like to see some action on advertising junk food to children before 9 pm. Scotland has also signed up to the World Health Organisation’s global action plan, which tries to improve physical activity and participation in sport, particularly among women, girls and the elderly.
It is particularly important to invest in children and we try to do that in Scotland through the Best Start grant, the Baby Box and the fact that our early years education is available to all children and does not just depend on parents’ circumstances or work pattern. If we do not invest in children, we inevitably end up spending more later to pick up the pieces.
As has been said, Professor Marmot highlighted in his report the fact that increasing poverty means increasing inequality. The welfare cuts, particularly the benefit freeze, have driven an increase in every group in poverty over the last number of years. Poverty in England is at 22%, it is 24% in Wales and it is down at 20% in Scotland. However, if we look at the disabled, pensioners and children, we see that they are particularly vulnerable. Child poverty was falling, but the Institute for Fiscal Studies says that it will climb by another 7% before 2022. In England, child poverty is now over 30%, in Wales it is 28% and in Scotland we had got it down to 21% but it has climbed to 24%. That is due to the impact of welfare cuts on families.
For the last several years in Infant mortality has risen England. That is a measure that we use to look at health on a worldwide basis in developing countries. The Scottish Government mitigate policies such as the bedroom tax, and they have measures such as the Scottish welfare fund, which is why we have the lowest levels of child, disabled and pensioner poverty. However, in all those classes poverty is still increasing and we are having to use £100 million a year on it.
The Government talk about tackling worklessness, but 70% of children have a working parent. What we have is the working poor. The International Monetary Fund says that a more equal society is a healthier society, which brings better economic growth, so what we need to do is promote the real living wage, to make work pay. We need to tackle poverty. It is the biggest driver of ill health, which means we need a “health in all policies” approach. The NHS alone cannot fix this problem.
Mrs Sharon Hodgson (Washington and Sunderland West) (Lab)
It is a pleasure to serve under your chairmanship today, Mr Hollobone.
This has been an excellent debate, and I start by thanking the hon. Member for Telford (Lucy Allan) for securing it and for her excellent contribution. Sadly, many areas across the UK face similar issues to those affecting Telford, as we have heard. As we know, our NHS was built for everyone. The original leaflet explaining the NHS to households across the country read:
“Everyone—rich or poor, man, woman or child—can use it or any part of it.”
Seventy years on, we cannot forget that ethos, which is why this debate is so important. I also thank all other hon. Members for their contributions to the debate. Due to time, I will not name them all.
Health inequalities are avoidable, but they still persist so clearly, both nationally and locally, within our communities, as we have heard. It cannot be right that in England men and women from the most disadvantaged 10% of areas on average now die 9.3 and 7.3 years respectively sooner than those in the 10% least disadvantaged areas. And those living in the most deprived areas not only die much earlier than those living in the most affluent areas but they also live much longer in bad health. For example, between 2014 and 2016 women in the most deprived areas could expect to live for 51.8 healthy life years, meaning that their remaining 27 years would be spent in bad health. That is compared, for instance, to women in the least deprived areas, who could expect to live for 70.7 healthy life years, with only 15.5 years in bad health.
It has to be said that there is also a persistent north-south divide in both life expectancy and healthy life expectancy, with people in the southern regions of England on average living longer and with fewer years in poor health than those living further north. For example, 2015-17 figures show that men and women in the north-east—my region—have the lowest life expectancy at birth in England, at 77.9 years and 81.6 years respectively. That is compared to the south-east, where men can expect to live for 80.6 years and women for 84 years.
However, health inequalities also exist within local authorities. For example, the longest life expectancy in the country is in the richest borough, Kensington and Chelsea; I am not surprised. Nevertheless, the most disadvantaged people in that London borough can expect to live for 14 years less than their most advantaged counterparts. Such a stark difference is completely unacceptable.
Also, children living in poverty are more likely to die before the age of one, become overweight, have tooth decay or even die in an accident. Parents living in poverty are also more likely to smoke, experience mental health difficulties, be a young parent, be a lone parent, experience domestic violence and other negative outcomes, all of which also increase adverse childhood experience risk factors that impact children’s health, too.
So, after a century of decline the number of deaths in childhood in the UK has risen for two consecutive years, with the highest mortality rates evident in the poorest communities. Life expectancy in the UK had always increased slightly, year on year, for over a century, largely due to improvements in nutrition, hygiene, housing and control of infectious diseases. However, it seems that that is not happening any more.
What are we going to do? Labour is committed to a new health inequalities target, to improve life expectancy, mortality rates and children’s health. The target would be independently assessed, and as the hon. Member for Telford called for, the Health and Social Care Secretary would be held accountable to Parliament and would produce an annual health inequalities report.
The four biggest risk factors that affect health—smoking, excessive alcohol consumption, poor diet and lack of exercise—also affect the poorest in our communities. Public health services support those people. However, there have been public health cuts to the tune of £800 million between 2015 and 2021, and local authorities have been put in untenable positions, where they have to make difficult decisions.
I believe that the Government already have a moral duty to ensure that health inequalities are reduced, but unfortunately they have not taken that duty seriously enough, so I would like the Minister not only to set out her commitment to reducing health inequalities but to lay out details of how the Government will reduce them, and I urge her once again to reverse the cuts to public health budgets.
Mr Philip Hollobone (in the Chair)
If the Minister concluded by 5.28 pm, that would allow Lucy Allan time at the end of the debate to sum up.
The Parliamentary Under-Secretary of State for Health and Social Care (Jackie Doyle-Price)
It is a pleasure to serve under your chairmanship, Mr Hollobone, and to respond to the debate. I feel that it is a major challenge and an absolute responsibility for Ministers in the Department to do everything we can to tackle inequalities. Frankly, that is why all of us got involved in politics and stood for public office, because we want to do the best for everyone in our society.
I pay tribute to my hon. Friend the Member for Telford (Lucy Allan) for her very persuasive argument in opening the debate. She has been an absolutely fantastic champion for her constituents, at a time when difficult decisions are being made about how to reconfigure health services in her area. She has not been backward in coming forward to make her case, because this is the second time that I have responded to her on it. I know that she will continue to make her case.
I will just say something about some of the concerns that my hon. Friend has raised. When the NHS makes decisions on how best to deliver health services for a local community, clearly those decisions are made locally and should be locally responsive. However, it is equally the case that the public become very nervous about the potential downside of any decision. It is therefore absolutely crucial that engagement is constructive, with dialogue and transparency, so that the public can have confidence that the right decisions are being made.
My hon. Friend articulated her case with clear reference to inequalities in the area that is served by that configuration. It is important that we have a way of addressing those points, because there is a perception that the pointy-elbowed middle classes are better at fighting for themselves than everyone else is. We all have a duty to ensure that everyone can have confidence in the decisions that are made. I encourage my hon. Friend to continue to give challenge, because it is only when we provide her with answers that she can give her constituents reassurance. I know that she will continue to give that challenge.
On that basis, I would give a gentle prod to some organisations within the NHS. We often find that some areas are better at consultation than others, but we are elected representatives who are here to give challenge on behalf of our constituents, and I would like to send a message that the NHS needs to be more transparent in its decision making throughout.
I thank all Members for their contributions to this debate, and I will try to address most of the points that have been raised. Turning to the legal duties on the Secretary of State, we have regard to the need to reduce health inequalities. That requires concerted effort across all our health services. That is a priority for us, and it is a particular priority for me. Clearly, other factors contribute to poor health outcomes and inequalities, which go beyond the gift of the NHS and the Department of Health and Social Care, meaning that we need to take a cross-Government approach to the problem. Housing is clearly an issue; we know that poor-quality housing can be a driver of ill health and health inequality. We have heard about employment and income, and clearly education is a factor as well. We need to equip everyone with the tools to live a healthy lifestyle and look after themselves well. Equally, this issue is about access to services, and we know that there is much we can do within the NHS and the wider healthcare system.
Debbie Abrahams
Is the Minister aware that there was an interdepartmental public health group specifically to look at the wider determinants of health and how each Department could do its bit? Would she consider re-establishing that group to address the important issues that have been raised?
Jackie Doyle-Price
We have a number of inter-ministerial groups looking at particular areas of inequality, such as rough sleeping and the first 1,001 days. The hon. Member for Central Ayrshire (Dr Whitford) spoke about the importance of early intervention; if we could get that right, that would be a real way of addressing inequality. My short answer to the question asked by the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) is that we pick up public health in a number of ways, but my priorities are the first 1,001 days and particular pinch points where there are real inequalities. We will continue to look at those areas, not least because supporting those individuals is not just better for them, but makes financial sense. If we can tackle some of these issues earlier, not only do individuals live longer and healthier lives, but there is a reduced cost for the health system.
Dr Whitford
Many of us have spoken about the fact that poverty drives ill health. Can the Minister tell us whether any discussion is taking place between the Department and the Department for Work and Pensions about the impact of welfare changes over the past few years, and how to tackle them?
Jackie Doyle-Price
I have been in close consultation about that issue with the recently departed Minister of State for Disabled People, Health and Work, my hon. Friend the Member for Truro and Falmouth (Sarah Newton). She has really challenged the DWP to look after people who are vulnerable, and put in place safeguarding policies for them, so I confirm to the hon. Member for Central Ayrshire that that discussion is taking place.
My hon. Friend the Member for St Ives (Derek Thomas) raised the issue of dementia. Clearly, dementia has a big impact on the number of years in which people can enjoy a healthy life, and we must get that right. For that reason, we have introduced the ageing society grand challenge, which is focused on narrowing those inequalities. My hon. Friend is right that we must have better integration with social care; there have been a lot of moves towards better integration between local authorities and the NHS, and that must continue.
The hon. Member for Washington and Sunderland West (Mrs Hodgson) referred to public health cuts. We have tackled those through the NHS forward plan, and have said that this is an area in which we expect the NHS to focus and work collaboratively with local government, specifically highlighting health visitors and the wider public health agenda. My answer to the hon. Lady’s point is “watch this space”, but we recognise that we spend less if we spend wisely, which has to be about getting the system to work better.
Jackie Doyle-Price
I have limited time, and I would like to get through this.
We have made it clear that the long-term plan will be focused on reducing inequalities. The hon. Member for Strangford (Jim Shannon) mentioned people with learning disabilities and autism, and I can tell him that those people are a real priority for me. When we consider inequality, the life expectancy of people with those conditions is massively less than it ought to be, and we need to fix that. This year we expect all local health systems to set out how they will reduce health inequalities by 2023-24 and by 2028-29. Through that, we are targeting specific areas. NHS England will highlight areas in which it can do specialist commissioning. One example is people who are rough sleepers, who have low levels of life expectancy.
I absolutely agreed with what the right hon. Member for Rother Valley (Sir Kevin Barron) said about social prescribing. How we deliver health services depends not only on medicalised professions and clinical support; when tackling inequality, a lot of the wrap-around and de-medicalised support can deliver better health outcomes. I am very excited to hear about what is happening in Rotherham, so I might pay a visit next time I go to see my mum. That would be quite nice.
Turning to the specific points made by my hon. Friend the Member for Telford about her local trust and the impact on inequalities, she has clearly articulated the issues that she is concerned about. The decision is clearly a local one, but it is within the gift of the council to make an appeal to the Secretary of State, and I gather from my hon. Friend’s comments that that will happen. I obviously cannot prejudge the outcome of that case, but I assure her that when it arrives on the Secretary of State’s desk, he will consider it impartially. She has articulated the concerns from her constituents’ perspective extremely well.
I am under no illusion about the fact that tackling inequality requires commitment and leadership, energy and focus, and national and local accountability. Let us look at the plans that come from clinical commissioning groups later this year and interrogate them to make sure that they will tackle inequality. We will make sure that we stand fully behind them to ensure that they deliver.
Lucy Allan
I thank all Members for participating in the debate this afternoon. I am grateful to have heard not only their contributions but their passion for the subject, which I share. The Minister has been very kind in making a commitment to transparency and better communication by decision makers when it comes to major changes in local areas, and I will hold her to that commitment.
Health inequality is such an important issue, which we do not talk about enough in this place. We must do better, as the hon. Member for Strangford (Jim Shannon) said. I loved that the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) mentioned that there is hope for improving life chances and opportunities for those most in need. We all have to keep focusing on this issue and keep it on the agenda, despite the whirlwind of everything else that is going on around us. It has been refreshing to talk about something that we are all passionate about and will change lives. I again thank the Minister. I will gladly continue to work with her to ensure that the issues in Telford are addressed.
Question put and agreed to.
Resolved,
That this House has considered legal duties on the Secretary of State to reduce health inequalities.