Health and Social Care Bill

Baroness Armstrong of Hill Top Excerpts

Monday 7th November 2011 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I, too, should like to speak in support of this raft of amendments which are all designed, to use the words of the noble Baroness, Lady Murphy, to give greater teeth to reducing health inequalities. We have already heard various statistics from a number of noble Lords and those for life expectancy are generally the most stark. The statistic that means the most to me relates to London, probably because that is where I live; namely, that the life expectancy of men ranges from 71 years in one ward in the London Borough of Haringey to 88 years in one ward in Kensington and Chelsea. That is a huge difference of 17 years. It is worth also pointing out that even within Kensington and Chelsea, there is a difference of nearly 12 years in life expectancy across different parts of the borough.

As many noble Lords have said, there is a whole range of reasons for this, including the social and the economic. It is one of the things that underline the critical need in our debates to put more focus on public health interventions. I also very much welcome the establishment and the role of Public Health England, and the fact that the public health function at a local level will sit with local authorities.

In discussing the need to strengthen these duties, it is important to recognise and welcome that having explicit duties placed for the first time on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups is a landmark, representing a major shift from the current position. There is something very significant about the whole raft of these NHS reforms.

The phrase “have regard to” health inequalities for the clinical commissioning groups is not sufficient because we need to make sure that they act and behave to secure real improvements, which need to be in both access to NHS services and in outcomes. I want those CCGs to account publicly for their progress, not simply as part of normal accountability but as part of sharing good practice and workforce development, and in the training of NHS employees. It should become part of the everyday currency and language of the NHS, part of the DNA of the way in which the health service operates. I believe that this strengthening is necessary if the NHS reforms are to become a real game-changer for some of the most disadvantaged group in society—to borrow from the words of the public health White Paper, Improving the Health of the Poorest Fastest.

Perhaps I may give an example in relation to homeless people who experience some of the worst health inequalities of any group in society. They are more likely to die young, live with a long-term condition, have multiple health problems and have mental health or substance use issues. They are also far less likely to have regular contact with a GP or other health professional and are much more likely to access healthcare through A&E, which is inappropriate and, as we know, causes all sorts of problems for A&E departments. In short, they are the most likely to have very poor health and the least likely to benefit from what the NHS has to offer.

Of course, many services are needed to help homeless people to improve their outcomes, including housing, employment, family support and other things. But it is particularly important that the NHS is able to cater for the needs of these groups. Appropriate services are far more likely to be commissioned where clinical commissioning groups have a duty to take account of these health inequalities in their plans and reporting mechanisms and the standards to which they are held to account, and that they are ensuring that these arrangements are incentivised through the commissioning arrangements.

I very much support the principle of the amendments put forward and I look forward to hearing the Government giving an even stronger commitment to tackling health inequalities and to making this a key outcome of the overall package of reforms that we are discussing.

[Baroness Armstrong of Hill Top]

My Lords, I seek only to intervene briefly on this. The whole issue of how to tackle inequalities in health is an extremely complex and difficult one. When I was a Member of Parliament, I looked forward to receiving from the department reports on a regular basis on how inequalities had been addressed and how health had improved throughout the constituency. What was clear was that the more effective our public health interventions were, such as on reducing smoking, the more difficult it was to tackle inequalities. The people who automatically responded best to those interventions were those on higher wages, with better qualifications and who were likely to be in higher class groups than those in the poorest parts of the constituency. That could always be seen clearly in those reports. The amendments that support better information are very important because clinical commissioning groups in particular are not well placed instinctively to tackle inequalities. It is generally not part of the training of GPs to look at these issues and work out how to address them.

We have already discussed the second issue today, and it is important—the issue of access. Unless we open up access much more sharply to the disadvantaged we will not have a chance of addressing inequalities. The noble Baroness opposite talked about homelessness. I have discussed this issue with the Minister on a number of occasions, and I am not content that the Bill deals with it adequately. It is not fair to ask clinical commissioning groups to address this issue. Sometimes they will simply be too small to do so. Also, homeless people tend to be fairly mobile, so in London they will cross authority areas. From my experience in the north-east of England, a single PCT—or what will now be the smaller clinical commissioning groups—does not have the people available properly to offer the sort of services that are needed to open up access effectively to those who are not normally registered on a GP list.

I am also concerned that clinical commissioning groups may be responsible for areas with poor GP coverage and there will be a need to bring in salaried GPs. It will need someone other than a clinical commissioning group to address the issue of GP shortages—and it is always the poorest areas which have the poorest access to GPs. It is an issue that continues to have to be addressed time and time again. I was pleased when the last Government introduced many more salaried GPs, but we have to keep on top of that agenda.

I also support the amendments that look to the responsibilities of the NHS Commissioning Board. There will be occasions when the board has to come in specifically to address inequalities in a range of ways. I am not sure that it is really geared up to do that at the moment. But because I certainly do think that clinical commissioning groups are not going to be able to do this on their own, and indeed it would not be appropriate for them to address some areas of clinical commissioning, it is very important that the department, the Secretary of State and the Commissioning Board think about how they are going to do this effectively.

[Baroness Hollins]

My Lords, I particularly welcome the amendments which are designed to strengthen the duty to reduce health inequalities between people and communities, the emphasis here being on inequalities not between “the people of England”, but between individuals as well as groups. I draw attention to this because in 2008 the Department of Health drew up a policy on health inequalities, and I sat on the group which developed it. I was pleased when the document was published in June 2008 because it talked about the group that I am interested in, which is people with learning disabilities. I shall read out a short paragraph from the executive summary because it makes my point very nicely:

“Progress on health inequalities will be judged against how public services treat especially vulnerable groups. The recent Disability Rights Commission report made it clear that people with learning disabilities often receive a poorer level and quality of service from the NHS. If services and health outcomes are improving for people with learning disabilities, they are likely to be improving for other groups at risk of health inequalities”.

The report goes into some detail about the importance of measuring the improvement in health inequalities for particularly vulnerable groups. That is a good measure to measure progress in the NHS.