Life Expectancy (Inequalities)

Debate between Anne Milton and Richard Bacon

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.

--- Later in debate ---

[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.

[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!

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[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.