Health and Social Care Bill

Baroness Greengross Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Patel]

My Lords, I support these amendments and I have my name on two of them. I particularly associate myself with the comments that the noble Baroness, Lady Williams of Crosby, made on the need to address the issues within public health to reduce inequalities.

We must all be very encouraged to see the recommendations of the Health Committee in its report of 2 November on public health. One of the recommendations says:

“We do not understand why the Secretary of State’s new statutory duty to reduce health inequalities under the Bill appears to apply only to the exercise of his functions in relation to the health service. We recommend that the Bill be amended to make it clear that the Secretary of State’s duty to reduce health inequalities applies in the exercise of all his functions, including those applying to public health”.

The noble Baroness, Lady Williams, already referred to the inequalities in health that occur because of lifestyle-related diseases. In previous discussions we have noted that 40 per cent of acute admissions are related to lifestyle-related diseases. It must be right that the statutory duty of the Secretary of State includes functions relating to public health.

[Baroness Greengross]

My Lords, I will speak to Amendment 33 in my name. I am pleased to follow the noble Baroness, Lady Williams, and the noble Lord, Lord Turnberg, because a lot of my work is concerned with the sort of inequalities they have spoken about. The noble Lord, Lord Turnberg, mentioned Professor Sir Michael Marmot. I have been privileged to chair the advisory group for the longitudinal study on ageing that he established. I have done that since it started. It demonstrates so clearly the terrible, almost life-or-death sentences that health inequalities impose on different groups in terms of their life expectancy. This is really something that is quite impossible for us to continue.

My other role as the lead commissioner on age at the Equality and Human Rights Commission means that I hope very much that we can, if we amend this Bill, achieve more positive healthcare outcomes. The Bill, in order to achieve that, must be explicit that improvements have to be achieved across the whole population, not just some parts of it. We know that one group whose needs are currently very often underprioritised and underrecognised is older people, particularly within the NHS. Sadly, ageism persists in clinical practice—very often older people lag behind other groups in terms of better healthcare outcomes. I am very concerned that unless a clear obligation to demonstrate that improvement is being achieved across the whole population, the specific needs of older people will continue to lag behind those of other groups or sometimes to be ignored and similar existing health inequalities may even be maintained and strengthened.

My amendment would define the Secretary of State’s duties to reduce health inequalities against three different criteria: the definitions of equality contained in the Equality Act 2010; different parts of England; and different socio-economic strata. In any subsequent reporting of progress towards reducing health inequalities, the Secretary of State would have to demonstrate consistency in the progress made against the three criteria.

My amendment would clarify the Secretary of State’s duties in relation to reducing health inequalities. I am afraid that without this in the Bill health service improvement may not reach everyone. There may be a failure to improve services for specific groups such as those mentioned within the list of protected characteristics. Clause 3 currently requires the Secretary of State to have regard to the need to reduce inequalities between the people of England with,

“respect to the benefits that they can obtain from the health service”.

The amendment to this clause would ensure that access to health services and improving health outcomes were an intrinsic part of the Secretary of State’s duties. Without guaranteeing improvement in access to services, there is a risk that there could be high levels of variation in the kinds of services the NHS provides across the country.

I have listed the equality characteristics detailed in the Equality Act 2010 which is not necessarily Members of your Lordships’ House. Too often it has been the case that health inequalities exist in part because people belong to one of the groups listed here and there is actual discrimination against a patient. In relation to specific treatments, patients are treated differently not purely on the basis of clinical decisions but on the basis of one of the protected characteristics, particularly age. For example, despite improvements in cancer outcomes, a 2007 study of breast cancer patients in Manchester found that older women are less likely than younger women to receive “standard” management for breast cancer and less likely even after accounting for differences in general health and co-morbidity to have surgery for operable breast cancer.

My amendment will ensure that the Secretary of State’s duties are clear and specific and that people across England can be sure their access to healthcare and the quality of the healthcare they need will be assured regardless of who is providing the service. The areas where the Secretary of State can demonstrate improvement in reducing inequalities should be balanced and fair in their focus. The risk otherwise is that commissioners will be incentivised to invest their efforts in improving health outcomes for those groups where they believe they can make the easiest and quickest gains and some groups, including older people, risk being shunted to the sidelines. This must not happen.

[Baroness Murphy]

My Lords, I have a great deal of sympathy with those who want to beef up this duty on the Secretary of State. I want to ask the Minister to explain why the public health function was left out—it is very specific about NHS responsibilities. I suspect the answer is that public health is in relation to other departments of state. He is shaking his head so perhaps that is not the answer. Working in the NHS one cannot but be aware of these profound inequalities. Within the first week of going as chairman to the east London health authority, three facts hit me in the face. First, in Hackney, people had only a 25 per cent chance of referral for a hip replacement as per the norm for England. Secondly, in Newham, mortality rates for bowel cancer after treatment were 30 per cent worse than elsewhere. It clearly emerged that there was a failure of referral to access, for, particularly, certain of the ethnic communities. Thirdly, on a visit to the community podiatry service, every patient was white in an area where the population was 25 per cent black and minority ethnic. Simply, no one had ever asked them the relevant question. Addressing inequality seems to be profoundly difficult on the ground: you must have the information and the wit to discover whether there is a problem of access, referral or discrimination and treatment, or whether there are underlying features of the illness that make inequalities difficult to address.