Life Expectancy (Inequalities)

Anne Milton Excerpts

Thursday 3rd March 2011 Westminster Hall

[Mr Bacon]

I am interested in the hon. Lady’s comments. Of course, if we made sure that every schoolchild got a tangerine every day as part of their five a day, it would not be difficult to make a strong case for that being in the interests of public health. It would not be necessary to be a member of the tangerine growers association to make that argument.

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

I hesitate to intervene at this stage, because I will have an opportunity to speak later, but I must say, as it is such an important point, that the fact that the child gets the tangerine is not the point. The point is, does the child eat it?

[Mr Bacon]

I am pleased to say that my son would eat it, if given a chance, but he has been indoctrinated by my wife to think that fruit is the best thing going. However, to go back to what the right hon. Member for Barking said earlier, that is what happens in middle-class households, where children have lots of fruit and vegetables. My son is three and one of the things he loves the most is cucumber; he adores it. I am sure it is full of the right nutrients, although I think it is 99% water. The point is that we must make sure that those messages are getting across.

When I think about a cross-section of the population of my constituency, and ask whom I would most trust to persuade a little boy to eat tangerines—the local councillors or the general practitioners—I am not sure that I would immediately plump for the councillors, particularly given the fact, as the hon. Member for Hackney North and Stoke Newington (Ms Abbott) has said, that councillors have a lot of other pressures on them and have other priorities. I asked when a ring fence is not a ring fence, but of course there is another question about whether there should be one. One thing that we apparently feel unable to admit is that if we take off the ring fences and tell people, “We mean it when we say that you at the local authority will decide what happens,” the natural concomitant will be variation between different parts of the country. The rhetoric and the argument is that it is down to local people and if they do not like it, they can choose a different councillor.

I attended a meeting with a senior Minister in the Cabinet Office. It was just after the general election and he had been to a meeting with local councillors from across the country. He relayed a story about how a group of Conservative councillors had asked him, “Right, Francis”—that gives away who I am talking about—“we have won the election, or partially won it, at least. What do you want us to do?” He replied, “I want you to stop asking that question.” In other words, the Government seriously want to give local authorities the power to make these decisions. The obvious concomitant, however, is that there will be differences in different parts of the country. If that is the case—and in the light of the fact that, even when we have tried to have a co-ordinated strategy to get the same outcomes and reduce health inequalities, we have managed simultaneously to improve life expectancy and to widen the gap between the best and the worst—how much more likely is it to go wrong when we have this degree of local autonomy?

These things always come in waves—localism and centralisation have gone backwards and forwards. Some may remember Tony Crosland saying in 1974, “The party’s over,” and I am sure that we will come to a “party’s over” moment, although it is probably a few years away yet. I am interested in what happens on the ground to achieve change, and it sounds like my hon. Friend the Minister is as well. I shall not speak for much longer, because I am keen to hear her response.

I shall conclude with one further point to make my hon. Friend’s job a little easier, although no one pretends that this is easy. Indeed, we say in conclusion 7 of our report:

“Addressing health inequalities is a complex challenge requiring sustained and targeted action. The Department’s experience to date shows that greater focus and persistence will be needed to drive the right interventions.”

That is about strong leadership, as we go on to say in that paragraph. That is why the examples from other areas, such as Professor Sir Mike Richards’s cancer strategy, may have something to tell us about what we ought to do about reducing health inequalities. We all agree on the ends, but there still seems to be a lot of confusion about which means will work best. It is important for the whole country that we sort out that confusion and start seeing improved results.

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[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

It is a pleasure to be here this afternoon serving under your chairmanship, Miss Clark, for what I think is the second time.

I will endeavour to answer all the issues that have been raised in the debate. I welcome the report from the Public Accounts Committee. There is no doubt that health inequalities belong to another age and certainly have no place in modern society. Anything that brings this issue to the fore is entirely welcome. As the right hon. Member for Barking (Margaret Hodge) said, health inequalities are terrible, and it is shocking that they exist to such a great extent. I shall deal later in my remarks with the questions that have been raised. If Members wish to intervene, I will be happy to take interventions, but if they hang on, I will get to all their questions in time.

The hon. Member for Hackney North and Stoke Newington (Ms Abbott) was absolutely right to say that lessons should be learned. The problem with government generally, at every level and irrespective of political party, is that people tend to turn up bright-eyed and bushy-tailed but do not take any notice of what has gone before. In fact, the Government and politicians should have the humility to recognise that if things were not achieved earlier, it was not necessarily because of the incompetence of the previous incumbents but because sometimes it is difficult to do something, and this is one area where that applies. As was said earlier, this is not a partisan issue. It is something that we need to act on across the board. The important thing is truly to understand what we are talking about when we talk about public health.

I do not think that, strictly speaking, I have to register an interest, but I should mention that my husband is a public health physician, although not working as a director of public health. It is extraordinary that we have had this discussion this afternoon without yet mentioning the public health profession or directors of public health—members of the public health profession will be somewhat disappointed, because they are pivotal to many of the changes that we want to introduce.

My Government want to improve the health of the poorest most quickly. If we are to achieve better health outcomes, particularly compared with other countries, that must be more than a pipe-dream. My hon. Friend the Member for South Norfolk (Mr Bacon), who is, indeed, my favourite member of the Public Accounts Committee— [Interruption.] This is a love-in. He mentioned that it is extremely easy to assert things, but we do not want assertions but real action. That must be a fundamental part of our strategy in health care and in other areas such as housing, education and social care. We believe that the more devolved health system that we are developing will enable a sharper focus on disadvantaged areas across the country.

The Government want to provide far more opportunities for local people and organisations, including statutory organisations, to plan and run health initiatives specifically tailored to their communities. We have set out proposals to reform the delivery of health services in England. They are contained in two White Papers, which I am sure Members are familiar with: one is for NHS services, and the other is for public health. Reducing health inequalities must, and will, be embedded in the reformed architecture that we propose.

[Margaret Hodge]

I believe that, in principle, all of us would support devolution of power, but I draw to the Minister’s attention constituencies such as mine—this is more a constituency point than a general point. My constituency, which is a working-class area, is quite uniform in class structure. The whole public service infrastructure is weak, whether one looks at education, health, public health, GPs or the voluntary sector. If there is devolution to the poorest areas with poor infrastructure, it will be extremely difficult for them to grow from within themselves the necessary capabilities to tackle some of these deeply entrenched problems. There is a role for the centre, through Government, to intervene and try to build capability so that we can achieve an impact. I am concerned that if the whole mantra is about devolution, we will leave large areas of the country with concentrations of poverty and need struggling to achieve the kind of outcomes that she and we would want.

[Anne Milton]

I thank the right hon. Lady for that intervention. She is absolutely right to mention capacity building. There are areas where there is weakness across the board, and that is certainly something that we need to address. However, it is quite interesting what local areas can do with good leadership and the right levers and safeguards in place. I believe that it was out her way that I visited a scheme in an area with a high incidence of domestic violence. The local authority connected the council’s noise nuisance helpline and the domestic violence team, on the basis that where there is noise from neighbours there will probably be violence in the home. After a certain number of calls about a certain address, the domestic violence team is alerted and then goes in—a simple intervention, and a kind of capacity. Some of that is down to the confidence of the people working in the area, some of it is to do with expertise, and some of it—general practice has been mentioned quite a lot—involves putting in incentives to ensure that we get people with the skills that are needed to build that capacity.

I was not going to mention this, but we have made, for instance, a commitment to increasing radically the health visitor work force. One of the modules in health visitor training that we are looking at is about teaching new health visitors how to build capacity in communities. It is a nebulous thing, but it is important that we understand it. There is no doubt that communities, Governments and even empires have struggled for donkeys’ years with the question of how to improve public health. The hon. Member for Hackney North and Stoke Newington mentioned that in 1948, the NHS itself was a major public health advance. It secured health services for all, regardless of ability to pay. I make no apology for giving a history lesson. I am not a history scholar, but it is important to take on board the history of public health. At the same time, local authorities were given responsibilities for the health of children and mothers, and for the control of infections. At the same time, they retained their role in planning, sanitation and overseeing the health of their local population through medical officers of health.

In the NHS reforms of 1974, further unification of health services resulted in the transfer of some of those health functions from local government to the NHS, including many that we would recognise as public health functions. I draw Members back to the comments of the hon. Member for Hackney North and Stoke Newington about the status of public health. One of the reasons why the medical profession at that time pulled public health out of local authorities was to do with status, and the clout that they felt they had. Clearly, if one looks at what we are doing now, that was probably a mistake, but there were issues to deal with. The Government have to be clear about how we want the public health profession to look.

That period coincided with advancing knowledge that allowed us to identify the causes of chronic disease and health inequalities. All of those things needed to be tackled as they became apparent. The hon. Member for Blaenau Gwent (Nick Smith) mentioned the Black report, which was published in 1980. It showed that although there had been a significant improvement in health across society, there was still a relationship between class and infant mortality, life expectancy and access to medical services. It is shocking that one could write the same thing today, 31 years on.

That report was followed by the first public health White Paper, “The Health of the Nation”, which recognised that there were considerable variations in health by area, ethnic group and occupation. A new public health agenda was set, and it provided a foundation for action over the past 30 years. There has been a great deal of work, with the best of intentions. I do not doubt the previous Government’s intentions. As I said in my opening remarks, it is important to have some humility and understand that the intent was there. However, we did not get the results that everyone wanted.

We need a new approach, and that is backed up by recent data from the London Health Observatory and from the Marmot review team, which show that although life expectancy is increasing in all socio-economic groups, it also reinforces inequalities. The data also show the variation in life expectancy at birth between men and women and between local authorities, and the pronounced inequalities even within local authority areas including, for example, Westminster, which has the widest within-area inequality gap, at just under 17 years for men: a man born in one part of the borough can conceivably expect to live almost two decades longer than his friend born a short distance away.

I do not apologise for using figures, because when we talk about health inequalities, people glaze over and are not terribly sure what it is about. They think it is something to do with obesity, smoking or something like that, but the figures tell the real story. The smallest inequality gap for men is in Wokingham in Berkshire, at less than three years, and for women the smallest gap is in Telford and Wrekin, at slightly less than two years—so we all know where to move. It is worth repeating that those are the smallest differences in the entire country, so even in the areas with the best outcomes, we are still talking about differences in years.

It stands to reason that a community in Lancashire, for example, might face different health problems from one in Hackney, where I used to work. The public health White Paper therefore sets out a new way of working. It gives a different flavour to how we view public health, looking at our lifecycles and highlighting the points where we can intervene to make a difference. It is a way of working that shifts power away from central Government and into the hands of communities.

We had a short discussion about devolving power, and it is a brave Government who devolve authority for something for which they will be held responsible in the end. That is why I disagree with my hon. Friend the Member for South Norfolk, who said there has been a yo-yo between local devolution and centralised power; there has not. All Governments like to centralise things and keep control, because at the end of the day at a general election they will be blamed or otherwise for what has happened. It is quite brave to devolve power, but sometimes it is the right thing to do.

The new way of working will enable local areas to improve health throughout people’s lives, reduce inequalities and focus on the needs of the local population. The White Paper also underlines the priority we have given to tackling inequalities in supporting the principles of the Marmot review, which is important. The White Paper recognises the value of an approach that sees the importance of starting well, even before a child is born. Life chances are set well before someone pokes their head out into the world.

The new body, Public Health England, will have an important role. It will bring together what I suggest is a rather fragmented system and will span public health; it will improve the well-being of the population, targeting the poor in particular; and it will protect the public from health threats, which have not been mentioned, but they are an issue. There are inequalities in public health threats and, without a doubt, there are inequalities worldwide. Public Health England will need to work closely with the NHS, to ensure that health services continue to play a strong role and that NHS services play an increasingly large part in that mission. There has been a tendency for NHS services to see themselves simply as services to cure an immediate problem, rather than as part of a wider, more holistic approach to improving individuals’ health.

[Ms Abbott]

The Minister spoke about enabling communities, which is one of those things that sound very nice. How could one disagree with it? My right hon. Friend the Member for Barking made a point about how social infrastructure in some communities has never been robust, but there is also a point about the social capital of some of those communities. Many of them are simply not socially homogenous. Representing Hackney, my fear is that enabling communities is all well and good, but it will enable the parts of the community with more social capital and confidence, who are generally noisier, at the expense of socially excluded groups.

[Anne Milton]

The hon. Lady is right to raise the issue. That is what has happened. On a more general point, cherry-picking is a problem. It is very easy to get certain people to lose a couple of stone—[Interruption.] Actually, sometimes it is quite hard to get them to lose a couple of stone and go down the gym. To be rather crass and non-specific, it is easier to get the middle classes to go to the gym and to eat a better diet.

The hon. Lady is absolutely right to highlight the fact that some areas are very disparate and disconnected. I am an optimist, and I believe that there is social capital. Central Government are very poor at delivering in local areas. I have worked in the most deprived part of the country and lived in the most affluent, and there is a world of difference. It is extraordinary to see—they could be different planets. Central Government is a clumsy tool to deliver something that is very difficult to bring about on the ground, so we must ensure that we have levers and build social capital.

I mentioned health visitors as an example, and a universal health visiting service is extremely important. When we think about hard-to-reach communities, we forget just how hard to reach they are. For some people, the only interaction they have with any health or social service is when they have their baby. Their kids might not go to nursery school or might frequently play truant from school, and they are extremely difficult to get hold of. To be honest, a universal health visiting service is probably the single most important measure we have announced, because it will get hold of those families who are so difficult to reach.

There has been talk of increased health funding. I will not deny that the previous Government put a significant amount of money into health, and I welcome the rather cross-party approach in this debate to acknowledging that that did not always produce returns, certainly not in public health. One problem was that the budget was not ring-fenced, but it will be ring-fenced now. I will return to some points made on ring-fencing and localism and the tension between them. It is important that local government be given the responsibility and freedoms to make a major impact on improving health, backed by ring-fenced budgets.

The right hon. Member for Barking gave an interesting example about the ineffectiveness of one-to-one smoking cessation programmes. More generally, she said that it is extraordinary that we do not drive or back up with evidence what we do in health, which to most people is a science-based discipline with science-based professions. I may have a higher opinion of local government than my hon. Friend the Member for South Norfolk. I think that local government knows a lot about its local area and is often better at dealing with evidence than health services are.

The size of the ring-fenced grant will be important, because when the money was not ring-fenced it was an easy pot from which to pinch. The trouble is that the tabloid newspapers—I hesitate to mention one in particular—do not come out screaming about the poverty of the public’s health, although they come out screaming when services go. It was too easy to pinch the money, which is why it needs to be ring-fenced. It must also be based on relative population health need and weighted for inequalities, so that the areas with the greatest need will get the most.

Directors of public health will lead on action to address health inequalities. Public health physicians have done tremendous work. The public health observatories have done fantastic work, but they have tended to work in a cupboard and do not feel that they are getting their message across. Locating them in local authorities will bring together the threads that influence health, not only health care itself, but other determinants such as housing, transport, employment—the causes of the causes of poor public health, if you like.

There will be financial rewards for progress, and greater transparency so that people can see the results achieved. The new health premium will provide an incentive to reduce health inequalities and reward progress. That does not necessarily mean cherry-picking the easy cases. The programme will be designed to reward instances where progress has been made, and those places that have seen the greatest impact in areas with a poverty of outcomes in reducing inequalities. Almost by definition, those will be the areas where health inequalities are greatest.

[Margaret Hodge]

I understand the thinking behind the incentives and rewards, but my point was about the other side of that coin. Will there be penalties for those high-need areas with huge health inequalities that fail to perform? Although it is good to reward the good performers, that does not help people living in communities where there are bad performers. What are the Government’s intentions on that point?

[Anne Milton]

The right hon. Lady is right to raise that point. I was trying to stress that the healthiest areas will not necessarily be those that receive the most money. In theory, those areas that start from the lowest base should have the greatest opportunity to get those rewards.

Perhaps I can connect the right hon. Lady’s point with that made by the hon. Member for Hackney North and Stoke Newington. This debate is slightly premature because a consultation on the outcomes is currently under way, and we are also looking at the finances, at how much each local authority will have and at the size of the health premium. We are acutely aware—as I am sure are all Opposition Members—of the problem of unintended consequences.

Let us take an obvious example of A and E waiting times. It is right to want people not to wait in A and E for very long, and indeed they did not. If that is given as a target, the health service is good—as are most professionals—and it will fulfil that target. It will get people out of A and E. However, what was never measured was whether people got the care they needed. Did they get better or were they just transferred up to a ward sooner than they should have been? It is important to look at that. To some extent, this matter is a work in progress and we are keen to learn and listen to what people have to say. It is important not to have perverse incentives but to put in place the levers that we need to produce the right results in areas where there is possibly poor capacity, or areas that need building up or contain inequalities.

In some areas there are difficult cultural issues. To return to the issue of domestic violence, sometimes those working in the health service will collude with some of the men who perpetrate that violence. It gets very complicated and we need a system that takes account of all those issues.

[Nick Smith]

I commend the Minister’s emphasis on the directors of public health. The director of the Aneurin Bevan health board in south Wales is terrific and I will meet with her in a few weeks’ time. She has a good action plan together with her comparable officer in the local authority, and I hope that they will build a good partnership working together on public health. Will the Minister let us know how negotiations are going with the British Medical Association, and whether as part of the contract with GPs, public health will be given enough attention and emphasis?

[Anne Milton]

I will give a politician’s answer and say that we are currently having a constructive dialogue with the BMA. I cannot give the details of that and I am not personally involved. However, it is important to get that matter right, and I am sure that details will emerge. The Health and Social Care Bill is currently in Committee, and some of the details about how the mechanisms will work have been considered during that process. The negotiations are ongoing, and we will let hon. Members know.

[Ms Abbott]

Everybody always has a constructive relationship with the BMA.

[Anne Milton]

I was not being ironic.

[Ms Abbott]

Neither am I. My point is that some parts of the GP profession may be resistant to hearing anything from a local authority director of public health because they might see that as local authority bureaucrats telling them what to do. There may be some parts of the GP profession that think they know what public health is. They think that it is about injecting people and about cash money per hundred. It must be clear in the contract negotiation that GPs are signed up to public health in the sense that we in this debate understand it, rather than in the way that some of them have historically understood it.

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[Anne Milton]

I am sure that those GPs are few and far between, but it is important to acknowledge that point. I say to the hon. Lady that the world just changed. The NHS has a key role to play in helping to reduce inequalities that affect disadvantaged people, and GPs are part of that. I know that there has been a lot of debate and discussion about the issue, and bringing decision making closer to home for GPs will be an extremely important part of levering-in better commissioning and focus on public health. Services are often commissioned because people’s health is poor. GPs will be faced with the consequences of poor public health every day, and they will commission services to deal with those consequences.

The White Paper set the proposals for the establishment of the independent national health service commissioning board and the new NHS outcomes. The proposed outcome frameworks for the NHS and public health will have the promotion and protection of equality at their heart. That aim underpinned everything when the frameworks were developed and it is no less relevant now.

As the hon. Lady said, the Health and Social Care Bill introduces specific duties on health inequalities that are enshrined in law for the first time. I share her cynicism a little. Governments often enshrine duties in law, but what matters is who holds them to account. The Secretary of State will be held to account, but Parliament has a role. Although this debate is not attended by many people, it is part of that process of holding the Government to account.

[Mr Bacon]

I was interested in that exchange and the intervention by the hon. Member for Hackney North and Stoke Newington (Ms Abbott). I draw her attention to the evidence taken by the Committee on Tuesday morning from the GP running the consortium in Essex. Together with the chair of the Royal College of General Practitioners, we were exploring the fact that there is great variation among GPs that cannot all be explained by the health variations and socio-economic conditions one would expect.

It was acknowledged that there are serious and challenging questions that need to be put to GPs. The GP from Essex is involved with teaching and improving the capacities of the consortia, and he has conversations with other GPs as he goes around his patch to look at the variations. I asked him how important it is during those conversations that he is also a GP and a clinician. He said, “It is essential. I would not be able to have the conversation otherwise.” I listened to the intervention by hon. Member for Hackney North and Stoke Newington with some interest. When that conversation between the director of public health and the GP takes place, the question will be whether the GP is listening.

[Anne Milton]

There is a question of whether the GP is listening and of whether the levers exist to make the GP listen.

This is a nebulous point to make, but I have to make it. Improving public health is about changing a mindset. We always underplay the importance of not only ministerial but parliamentary leadership on issues such as this. I am talking about a shift of focus on to public health, ensuring that the professions involved in health service delivery and the professions involved in the delivery of other services that affect people’s health receive a clear message that that is now a priority for the Government. When we talk to people who work on the ground, particularly at senior management levels, we see that that message is heard very clearly by them; it does filter down. Ministerial leadership is required, as is leadership from all of us on our individual patches.

[Nick Smith]

Does the Minister anticipate growth in the number of GPs in areas of multiple deprivation, which therefore have high levels of health inequalities? That has emerged from this afternoon’s debate as one of the big issues that need to be addressed. How easy will it be for practice-based commissioning to allow for growth in GP numbers in those areas, which are suffering the greatest health inequalities?

[Anne Milton]

As many people have pointed out—the Public Accounts Committee report focused on this—access to GPs is a major issue, and not just in urban areas such as Redcar but in rural and isolated communities. I will come on to that.

Subject to parliamentary approval, because the Health and Social Care Bill is in Committee at the moment, the NHS commissioning board and GP commissioning consortia will be duty bound to have regard to the need to reduce inequalities in access to and the outcomes from health care. That does not make it happen, but the duty is in the Bill and will be important. GP commissioning consortia will have to keep on improving the quality of their services, reducing geographical variations in standards. To increase the democratic legitimacy of health services, health and well-being boards will have elected councillors to represent the views of local communities.

To be truly successful, we need to be sure that the most vulnerable groups experience the most pronounced benefits. That is an obvious thing to say, but it is important. We are therefore driving ahead with the “Inclusion Health” programme, to focus on improving access and outcomes for the most vulnerable groups. Those are often the groups of people who are not registered with GPs or who are homeless. It is important that the really hard-to-reach groups get that additional focus, because they are not necessarily swept up by the other things that we are doing. We need to keep an eye on that.

I apologise if I am incorrect, but I believe that the life expectancy of the average Traveller is 59 years. The figures for the most excluded groups are truly shocking. Therefore, I fully welcome the Public Accounts Committee report and its recommendations. They were formally responded to in the “Treasury Minutes” dated 16 February. I know that many questions remain, but those minutes give a flavour of how we propose to embed the recommendations in the reformed health care system.

We need to ensure that the GP-patient relationship is as effective as possible. If we are not talking about a family who perhaps have contact with health care services only when they have a baby, the GP is the most important point of contact. On average, families with children under the age of two will visit their GP eight times a year. That is a massive opportunity to put additional emphasis on information and action to improve the health of families. We want to renegotiate the GP contract. The idea is to ensure that disadvantaged areas get the right level of access to GPs. The way to do that, as has always been the case, is to provide incentives to make it happen.

GPs need to improve the health of vulnerable people, not cherry-pick the easiest ones at the top of the pile. They need to encourage the uptake of good-practice preventive treatments. Changes to the quality and outcomes framework prevalence adjustment reward practices in a fairer way, particularly because deprived communities often have a higher prevalence of many of the QOF conditions.

I urge my hon. Friend the Member for South Norfolk to exercise some caution when talking about single-handed GP practices. His point was well made, in that practitioners who practise independently—single-handed—do not necessarily have the best outcomes, but in saying that, we should not exclude the very good single-handed practices. I saw one such practice recently. The GP there has recently been accredited for training and was serving his community absolutely brilliantly.

We have also proposed that at least 15% of the current value of the QOF should be devoted to evidence-based public health and primary prevention indicators from 2013. That answers a point raised by the right hon. Member for Barking. The funding for that element of the QOF will be within the public health England budget.

As the Public Accounts Committee report says, the most cost-effective interventions to improve life expectancy have been developed. Now we need to ensure that they are rolled out as far and as effectively as possible. The report of the review by Professor Marmot has helped us to understand the steps that we need to take, and we shall take them. The public health White Paper adopts the review’s framework of lifelong attention, which will mean a truly cradle-to-grave approach.

In thinking about public health, we must not forget that that is not just about physical health. It is also about people’s mental health and well-being. We need only consider some of the difficult issues that surround young people when they are growing up. We can consider the incidence of sexually transmitted diseases. In the last year for which there were figures, there was a rise of 3%. There has been good progress on unwanted pregnancies and abortions. There has been some progress on unintended conceptions among under-18s, but there are still 36,000. There are still 189,000 abortions every year, of which one third are repeat abortions. We can consider the figures for drinking and young people and the fact that 320,000 young people take up smoking every year. We have a lot to do with regard to young people’s health.

We can split health services into NHS services and public health. We can split public health further, into preventive work and curative work. What do we do when people have started to smoke or drink or have had sex when they should not have done? Then we can consider how to prevent that. There is no doubt that we need to do a great deal to ensure that young people have the skills, the self-confidence and the self-esteem that mean that they are equipped to make decisions about the difficult issues that they face.

[Mr Bacon]

Before the Minister finishes speaking, will she give way?

[Anne Milton]

I have not quite finished yet, but I will happily give way. I will not keep my hon. Friend long!

[Mr Bacon]

I mistook what the Minister was saying for her peroration; it was the dulcet way in which she was speaking. On single-handed practices and particularly because she mentioned mental health, I want to say for the record that I do not doubt for one minute that there are some superb single-handed practices. The point that we made in our report, at paragraph 13, was this:

“A contributory factor to low levels of GP coverage has been the presence of single-handed GP practices.”

I was also making the point that people generally work better together, and it is better for someone’s mental health as a worker if they are working with people rather than alone. I speak from experience, having worked in a large agency in London with 200 employees and then having set up my own business and worked solus. What surprised me most—apart from my clients, of course—was the amount of contact that I had in the workplace, which was much lower. That was quite an unexpected aspect of it. All other things being equal, surely it must be better for GPs to work in groups than to work alone. That is in addition to the effect that it would have on overall levels of coverage.

[Anne Milton]

My hon. Friend is right to say that it is better to work together. Peer support is important, as is peer review. The identification of children at risk in A and E is important, but it is often junior paediatricians who see such children when what is actually needed is access—it can be by phone—to someone who has been doing the job a lot longer so that they can run through with them the signs and symptoms that they have seen at A and E. That sort of support is invaluable. A single- handed GP might well miss out on that. Where there are good single-handed GPs, we should encourage them to work together—not necessarily in the same practice, but perhaps in the same building. What matters to me, and my hon. Friend mentioned it earlier, is not how things happen, but doing what works.

The right hon. Member for Barking spoke about evidence, which is crucial. She rightly highlighted the issue of cancer, which was the subject of a recent Committee report, and the need for early diagnosis and early intervention. I accept what the hon. Member for Hackney North and Stoke Newington said about not everyone having access to computers or other fancy communications equipment, although most people can text these days, so there other ways of communicating. However much the Government do and whatever is done locally by GPs on early diagnosis, at the end of the day, we rely on people going to the doctor with their symptoms.

For instance, when it comes to bowel cancer, we are not very good at talking about what is in our knickers or underpants, and men are particularly bad at it. The problem with bowel cancer is that men do not go to their doctor when they have symptoms. We need to get the information out there, but improving the public’s health is largely about giving people the information, levering them into settings and giving them lots of opportunities to do so.

The right hon. Lady said that some things are much easier to do than others. For instance, it is easier to do things on which figures can be collected. However, smoking is still difficult to deal with. We and, I think, Canada perform better than almost any other country. We have made huge progress on that front, but there is a great deal more to do.

I have probably touched on most of the matters raised during our debate, but I wish to say a final word about public health. Public health goes back a lot further than people might think. The first report into the health of the working man was the Chadwick report of the 1840s. Many remember John Snow and the Broad street pump in 1854, and the outbreak of cholera that killed 500 in the first 10 days. Then we had the London sewers in 1858 and the Royal Sanitary Commission of 1871. Interventions in public health go back a long way, but it is important to remember that most of them derived from local authority action. Public health is not just about the health service.

I sit on many committees, including two Cabinet sub-committees—one on social justice and one on public health. The one on public health is particularly successful. It brings all Departments together because it recognises that public health is everybody’s business. It is a transport issue, an environment issue, a local government issue, and an education issue. It spans all the Whitehall Departments. It therefore has to span all the ministries. One of the challenges for the Department of Health is to ensure that every Department is taking whatever action it can to improve people’s health.

I know that the matter is well suited to local government. Everyone loves to hate the local council, particularly at this time of year, but they are complex organisations, dealing with a multitude of things and they know the local community well. I want to get to the day when, instead of seeing local councillors in the council chamber arguing about whether Mrs Smith at 17 Acacia avenue puts an extension on the back of her kitchen, they are saying things such as, “It’s a disgrace that the people who live in your ward live 17 years longer than those in my ward.” That would be a real success. I look to local councillors to take up the baton and to fight for public health in their areas.

We know what we need to do in the short and long terms, and we know that it can be done. Indeed, some disadvantaged areas are already narrowing some of the gaps in health outcomes. I know that our proposed reforms will put incentives in place to drive delivery at a local level, allowing local authorities and the NHS to work together.

There are health imperatives and there are financial imperatives, but there is also a moral imperative. We in Government can spend a lot of time legislating and making regulations. A lot of things are going on at the moment; we have a very difficult economic climate, and foreign affairs are now exercising us. We have to remember sometimes that there are strong and ever-present moral imperatives to take action and to improve public health.