Life Expectancy (Inequalities)

Debate between Baroness Hodge of Barking and Diane Abbott

Thursday 3rd March 2011 Westminster Hall

[Margaret Hodge (Barking) (Lab)]

I welcome the opportunity, despite the sparsity of Members in the Chamber today, to debate one of the many reports that we have published since July, when we were established as the new Public Accounts Committee for this Parliament. I take the opportunity to thank the members of my Committee who, although many have not stayed for the debate this Thursday afternoon, do a fantastic job in coming to grips with all the issues on our hugely busy and diverse agenda and in holding the Executive to account over a vast range of areas. I thank the staff of the House, particularly our Committee Clerk and his staff, for working incredibly hard to keep up with the volume of work, and the National Audit Office, which always provides us with excellent material as a basis for our investigations into this vast range of Government business.

Health inequality is the most awful and terrible thing. People who live in poorer wards can expect to die seven years earlier than people who live in the most affluent wards in this country. Furthermore, they spend, on average, 17 years of their lives with a disability. That is unacceptable in a free, democratic, fair and compassionate society. Let me give some reality to those statistics. Some 3,000 more individuals die than otherwise might have done as a result of the dreadful inequalities between the richest and poorest areas. My own personal passion for tackling inequality comes, in part, from the knowledge that I have of how it impacts on my own constituency. The estimates say that, if someone lived most of their life in Barking and Dagenham, they are likely to die eight years earlier than a person who lived most of their life in Kensington and Chelsea.

[Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)]

Is my right hon. Friend aware that there are twice as many doctors in Wandsworth as there are in Barking and Dagenham, and that for every stop further that a person lives on the Jubilee line between Westminster and Canning Town, their life expectancy goes down by at least a year?

[Margaret Hodge]

My hon. Friend makes a hugely important point, and I want to spend quite a lot of my contribution talking about the distribution of general practitioners, and the relationship between that and health inequalities.

As a Committee, we believe that addressing health inequality should be at the heart of every Government. All MPs from all political parties share the desire and commitment to work towards eradicating those inequalities. It is because it is a shared ambition that our report makes particularly depressing reading. The previous Government came into power publicly committed to reducing health inequalities, so there was a strong political commitment to achieve progress in the area. During the 13 years of that Government, there was a huge injection of money into the health service, which resulted in welcome improvements for everybody, including increases in life expectancy among the whole population. We now have life expectancy for men of 78 years and for women of 82 years. In our session on pensions yesterday, we received evidence from the King’s Fund that showed a massive improvement in life expectancy over the past decade or so, whereas in the last century there was hardly any improvement.

Given the general positive trend, it is horribly depressing to see that, while the health of the nation as a whole has improved, the gap between the richest and poorest, as measured by life expectancy, has widened. If we compare the life expectancy of men in the spearhead authorities—the most deprived authorities, in which a quarter of the population live, that were selected by the previous Government—the absolute gap and the relative gap increased between 1998 and 2007-09. In absolute terms, the increase was 8.6% and in relative terms it was 4.6%. If we look at the same statistics for women, the absolute gap increased by 9.3% for women and the relative gap by 6.5%.

What is so worrying about those statistics is that the gap between the richest and poorest women is growing at a faster rate than the same gap between the richest and poorest men. As yet, we do not have any good answers for why that is—unless the Minister can help us—except that women are smoking more today than they were a generation ago and are, therefore, more prone to diseases such as lung cancer that then kill them. I urge the Government to do some better evidence collecting so that we can understand what is happening and see whether we can take appropriate action to improve the figures.

Given our real determination to tackle health inequalities, why have we failed so far, and what should this Government do to improve performance and therefore close those unacceptable inequalities? We all understand that this is a hugely difficult area, and it is not just an issue for the health service; inequalities arise from socio-economic factors. If we consider the evidence, most of the inequalities—between 80% and 85%—come from socio-economic factors, such as income, education and housing, and probably between 15% and 20% arise from poor access to good-quality health services. It is important, therefore, that the health service does what it can. If it performed better, we would reduce that gap, but on its own it cannot tackle the problems of life expectancy that arise from whether someone is rich or poor or where they tend to live.

If we accept the importance of those wide socio-economic factors, it is vital that we have a comprehensive and coherent approach across Government. Integrating health inequalities into the wider agenda of tackling poverty inequality becomes hugely important. Without wanting to be politically partisan, I have to strike a warning note about the proposed cuts in public expenditure, which look as though they will hit the poorest hardest. If that is the case, I have not yet seen anything that provides me with the comfort that the direction of travel will reduce inequalities. In fact, quite the contrary, inequalities could be intensified. Will the Minister address that issue in her response to the debate?

I urge the Government to keep a focus on health inequalities as part of their agenda of tackling poverty and general inequality, and to judge all the actions that they take by how they will impact on health inequalities. That focus is hugely important.

[Margaret Hodge]

Absolutely. I am grateful to the hon. Gentleman, who took through our recent inquiry into cancer. That inquiry demonstrated that, if there is that focus, outcomes will improve, although we can always do better. Having set the context in my opening remarks, I was going to make that point: access to and the responsiveness of the health service are hugely important. We need to do a lot of work to improve those things.

Tackling health inequality must be a real priority for everybody involved, which is the first lesson that we learned from our inquiry. It is not just about the politicians, for whom it has always been a priority. It must be a priority for the Department of Health, the new NHS commissioning board, GPs and all health service providers, local authorities, pharmacists and all others who have an interest in ensuring that we are healthy and live longer.

There is a criticism to be made of the previous Government. They were good at writing policy papers, but less good at following through those policies with specific actions. There were plenty of papers. We had the commitment in 1997, when the Government came in. We had the Acheson report in 1998. We had a target in the comprehensive spending review in 2000, which was pretty general but was about reducing inequalities. We had a refined target in 2002, which was more specific but perhaps a little less ambitious, and was aimed at reducing inequalities by 10% in the 20% of health authorities where there was the lowest life expectancy. We had a plan of action in 2003. That is an interesting point to pause at, because that plan of action had 82 so- called commitments. I do not think that our Committee looked at the plan in detail. I certainly have not done so. By December 2006, the then Government claimed to have met 75 of those 82 commitments, but we know from the statistics that the outcomes grew worse in terms of inequality. So there is something to be learned from the focus of that plan of action.

In the 2004 comprehensive spending review, the then Government revised and revisited the target. Again, we focused on it. We made it slightly less ambitious but more specific by focusing on 70 spearhead areas of the country. However, there is a danger with that approach, because more than half of the people who have an unequal life expectancy outcome at present do not live in those 70 spearhead areas. Inevitably, therefore, by concentrating action on those areas, we were leaving out far too many people.

Finally, in 2006—nine years after the previous Government came into office—reducing inequalities became one of the top NHS priorities. I think that it was at that point that we started to get things right. One of the lessons to learn from that is that, if we are not specific and focused, and tackling health inequality is not a high priority, we will not deliver, despite having the best intentions. In 2007, we got the primary care trusts to report on the progress that they had made on health inequalities.

Therefore, the view of the Committee is that reducing health inequality must be an explicit priority throughout the system and that it must be measured. I hope that the Minister will agree with that comment and I look forward to hearing her response to learn how she will ensure that the agenda on reducing health inequality is taken forward by this Government.

[Ms Abbott]

I have listened with great care to my right hon. Friend, who has had the opportunity to study these matters in detail. Does she agree that one of the problems in tackling health inequalities is that it does turn on good public health, which has never had the glamour or the immediacy of acute care in hospitals?

[Margaret Hodge]

I agree and I will develop that point a little later. However, the previous Government almost doubled the expenditure on public health, from an incredibly low base: it was 1.9% and it increased to 3.6% of NHS spending. I hope that the present Government will do even better in that regard. However, spending on public health is still a minute part of NHS resources, especially when it is an area that would prevent a lot of the health inequalities from emerging. Having conducted a study on cancer, both my hon. Friend the Member for Blaenau Gwent (Nick Smith) and the hon. Member for South Norfolk (Mr Bacon) would agree that the earlier that one can diagnose a condition the better the outcome. That was a key finding of the report that our Committee published this week on cancer.

I move to the issue of resources and I will talk about it in three contexts. First, I will talk about the resources—the actual money—that are distributed between geographical areas. Secondly, I will talk about the distribution of general practitioners. Thirdly, I will talk about the expenditure on prevention.

On resources, our study made it clear that at present there is an inequitable distribution of resources. The report showed that, in 2010-11, 68%—more than two out of three—of the spearhead PCTs were still not receiving the money that they should have been receiving on a needs-based allocation formula. That meant that more than £400 million of NHS money was diverted from those neediest areas to other parts of the country.

From the response of the Government in the Treasury minute, I know that they will continue to try to redistribute resources, but I would be grateful if the Minister gave us some indication of a time frame within which she would hope that there would be a much fairer distribution of resources to reflect need and therefore at least to give our neediest areas the capability and capacity to tackle health inequality.

I also note from the response of the Government in the Treasury minute that responsibility for the distribution of resources will go to the NHS commissioning board. What comfort can the Minister give my Committee about the instructions that the Department will give to the commissioning board regarding the action that it needs to take to ensure that there is genuine equity in the distribution of funding? Again, I know from my own borough that there is a real need for political commitment and drive to achieve that redistribution of resources. Obviously, there is a limited cake, we are in difficult financial circumstances and we are trying to see how we can cut that cake differently.

I and some of my colleagues in our local PCT area had to work extremely hard with Ministers in the previous Government to achieve a fair distribution of resources for Barking and Dagenham. That was the one area where we did okay. Obviously, that work was very local and it is not a pattern that we observed when we carried out the study across Government. So that is the first issue—a proper distribution of resources to poorer areas.

On the issue raised by my hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott), we must spend money on prevention. The issue of public health investment is crucial, because we know that other key causes of health inequality are what are known as “the risk factors”: obesity, smoking, drinking, diet and lack of exercise.

In that regard, the previous Government did well. They increased the spending on public health, doubling it from an extremely low base to a pretty low level of 3.6% of NHS spending in 2006-07. I think that the members of my Committee would say that we need further progress in that sector to ensure that we prevent people from developing the illnesses that limit their life expectancy.

Under the present Government’s reforms, we will have the new health and well-being boards, and they will receive resources. However, there are huge pressures on local authority budgets. Local authorities are probably having to absorb more cuts than any other part of the public sector. I have particular concerns about what mechanisms will be in place to ensure that local authorities spend the money they have, and prioritise expenditure on public health facilities and policies.

The commissioning board will have the responsibility to ensure proper expenditure on prevention, but the evidence given to the Committee showed that the problem with expenditure being devolved to GPs, who one would think were best placed in the health economy to think about investing in prevention rather than cure, is that their record in pursuing such investment is poor. GPs who have already been commissioning, and who control their budgets, do not have a good record of ensuring that they properly spend on prevention.

Finally on this point, the national health service has to find between £15 billion and £20 billion of expenditure savings, and while I accept that that money will be redirected within health, it is easiest to cut that which is most difficult to measure, which is investment in the prevention of poor health outcomes. In a climate in which the health service is trying to identify the very challenging savings that the Government have asked it to find—I accept that the savings were initiated by the previous Government—I fear that investment in preventive health measures will fall to the bottom of the agenda. How will the Minister and the Government ensure that money is properly spent on prevention?

[Ms Abbott]

Is my right hon. Friend aware that even now local authorities and primary care trusts are cutting public health expenditure, for example on community midwives and smoking cessation? Such expenditure is non-statutory, and it is going. Although one appreciates the intentions of Ministers in giving local authorities ring-fenced moneys, the danger is that those authorities will, under force majeure, use the money to backfill expenditure on environmental health and social care, and I have even heard of authorities believing they can spend their public health money on leisure services.

[Margaret Hodge]

I have a rather depressing example from my own area. We have had an effective smoking cessation service, but the regional health body looked at the expenditure both there and in Waltham Forest, which is spending far less, and instead of considering the impact and effectiveness of that expenditure, asked, “If Waltham Forest can do it for less, why can’t Barking and Dagenham?” That very effective intervention is now being cut because the comparison made by the regional health body was on the basis of inputs rather than outcomes, and that is a depressing trend that we will see mirrored elsewhere in the country.

Thirdly on resources, we need to ensure that there are the right GPs in the right areas. All the statistics that were provided to the Committee on that make for extremely depressing reading. The least deprived areas of the country have on average 64 GPs per 100,000 people, and the most deprived have 57. In Barking and Dagenham we have only 40 GPs per 100,000 people. I hope those statistics are right—I got them only the other day—because it is shocking if they are. The previous Government tried to tackle that issue locally, and the Committee was given evidence about what they did nationally. For example, in 2007 we had the £250 million programme to establish 112 new practices and 150 GP-led health centres in areas with the fewest primary care clinicians. I assume that that programme is coming to an end and that most of those facilities have now opened, but perhaps the Minister can confirm that.

In my borough, we have had a paucity of GPs, and a concentration of single-person practices and very poor environments and, try as we might, we still have this very challenging problem. Over the past 10 to 12 years I have been engaged in encouraging innovation, including having salaried GPs, and linking our GPs to universities as an incentive, and we were the first borough to try to encourage private providers to come in. One of them was successful, but the health authority has, I think, closed the other one’s contract. We have new health centres and practices, but the problem is that GPs are essentially independent providers and can choose to work wherever they wish. That is a hugely important point, and not just in tackling health inequalities, because if the Government cannot make the situation better, there will be much greater pressure on accident and emergency units and hospitals, and resources will be driven into the acute sector at the expense of community services.