Life Expectancy (Inequalities)

Diane Abbott Excerpts

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.

--- Later in debate ---

[Mr Bacon]

That is right: people will do what they are paid to do. One criticism I have also heard is that the more we treat people like employees, the more they will behave like employees. In recent years, a lot of GPs have felt more bossed around, so they act like employees, rather than people who are running their own organisations.

[Ms Abbott]

Is it not also the case that in inner-city areas, such as the east end of London, large numbers of people who are reservoirs of disease are simply not on GPs’ lists? As we move to GP commissioning, it will be important that GPs commission for the population, not just for the people who happen to be on their lists.

[Mr Bacon]

The hon. Lady makes an important point. One issue is the number of GPs in deprived areas, and a chart in the report shows the variation in those numbers. At one extreme, we have about 110 or 115 GPs per 100,000 of population, although that figure is an outlier, and the rest of the figures start at about 80 GPs and go down to an average of about 59 or 60. At the other extreme, in Redcar and Cleveland, the number of GPs per 100,000 of population is only 25. In other words, there is a fivefold differential between the best and the worst. Even if we cut out the extreme outliers, the figures still go from just over 40 to about 80, which is double. If there are not enough GPs in a given area, it will be that much more difficult to identify and get on to the GP list all the people we should—those whom the hon. Lady calls reservoirs of disease. That is an important public health problem, as well as a policy problem in terms of where GPs sit.

If the Minister does not mind, I would like her to comment on single-practice GPs. Although the proportion of such GPs has dropped from 34% to 22% in the most deprived areas, there are still 371 single-handed practices. All other things being equal, a single-handed practice is almost certainly not a good idea. There may be good reasons why one exists in a particular locality, and it is certainly likely to be better to have a single-handed practice than no practice, although Dr Harold Shipman comes to mind. There is also the fact that a GP is much more likely to work well if they are with a group of people than if they are by themselves; most of us work better in groups than we do wholly by ourselves. I would be interested to hear the Minister’s comments on policy on single-handed practices and where the Government think we are heading on that. As I mentioned, I should also like to hear her comments on the proposed outcomes framework, and how she thinks the changes in the GP contract will make the kind of difference that is needed, both in getting GPs into the right areas, and in making sure that they focus enough on health inequalities.

The third part of our report applied the lessons to the wider NHS. There is of course considerable discussion and controversy about the Government’s health reforms. We are not a policy Committee, so our report does not address whether the GP consortia reforms are a good idea. People have different views on that. I have my own, and instinctively I have always been in favour of giving more authority and power to GPs, for one simple reason, which is to do with what happens whenever, in the 10 years in which I have been a Member of Parliament, I have sat down with a group of GPs. I accept that what happens may be because, although South Norfolk is not economically very prosperous, it is not massively deprived either, and it is a pleasant place to live. Some might even call it leafy, but we have plenty of socio-economic problems, and employment problems. I do not want to gild the lily, but it is not in most respects a deprived area compared with many others, so perhaps the GPs I meet are a biased sample. None the less, every time I sit down with general practitioners, from whichever practice in my constituency they come, I always walk away thinking, “My, what a sensible bunch of people. If only they were given more control and power in the running of the health service. Things would almost certainly work better.” Of course, the Government’s proposals are in that direction, so my instincts are to support what they are doing.

My experience of 10 years on the Committee, however, is that whenever the Government try to change anything of any kind, anywhere, they always underestimate the risk and over-egg the benefits. There are considerable risks to the change, including the fact that it is a change. All change, particularly when it involves big management change, raises risks. It is likely, I think, that the best of the people working in the primary care trusts, if they are good at managing health consortia, will be hired to do the job. If things works out as well as we all hope, we shall probably end up with better management, and fewer and better-paid people doing a sharper, leaner job than has happened with primary care trusts. In addition to lots of meetings with GPs over 10 years, I have had plenty of meetings with the primary care trusts in my constituency. When I was first elected, there were six PCTs just for my constituency, which was then one of eight in Norfolk, with a total population of 800,000. Each had its own finance director on a six-figure salary, and not all were particularly well qualified, which may be one reason why the PCTs began to get into serious financial trouble a few years ago, despite the fact that the NHS was receiving record funding increases.

I have probably dwelt on the issue a bit too long, and I am not trying to make a political point. I merely say that I instinctively have a degree of support for what the Government are trying to do in the context, but it still gives rise to a series of questions. I was quite surprised when I heard that public health would be moving away from the health service towards local authorities, because, on the basis of my experience of my local hospital, which is a good and fairly new acute hospital built in the past 10 years, and based on my experience of general practitioners, I would sooner that those responsibilities were left with clinicians than that they were given to the council.

When I see the proposal for health and well-being boards, I think “What if?” Let us think back to 1997, as the sun came up over the Thames and the then new Prime Minister Tony Blair said, among other things, that the Government were going to put reducing health inequalities at the heart of tackling the root causes of ill health. What if he had said after a couple of years, “I know; here’s another thing we’re going to do. We’re going to have something we will call health and well-being boards, and because we are in favour of democracy we’re going to give them to local councils”? What if we had then watched as not a lot happened for the next 10 years? I am just making this up, because it never happened, but say those bodies had been established, and had not achieved quite as much as we hoped: I can see that we might have gone into the general election saying, “As for those health and well-being boards run by the council, well you’ve all read about them in the Daily Mail and we’ll be getting rid of them on day one.” I am sure it will not work out in that way, and that my hon. Friend the Minister is well aware of the risks and has them under control.

I was interested that the Department told us that the money for the public health budgets would be ring-fenced. Paragraph 22—the final paragraph of our report—said:

“The Department told us that action for improving population-wide health and reducing health inequalities would be funded from a ring-fenced public health budget.”

One of the questions I have for my hon. Friend is, “When is a ring fence not a ring fence?” I have had meetings with my local council, which is rather eager to get hold of the £11.7 million coming its way for its public health budget. It is not its impression that it will be spending it all on public health. Some of us think that it may have other priorities in different areas, which have nothing to do with public health, but which it seems to believe have merit, and for which it can make a strong case—and, indeed, many of my constituents would make a similarly strong case. I want to understand exactly what the health and well-being boards will do, and what leverage they will have over the GP consortia, to ensure that they deliver the priorities they are supposed to—or what other methods there will be to make sure that the consortia deliver those priorities.

That all comes back to what I was saying earlier to my hon. Friend about the need for greater clarity about ensuring that the outcomes framework and the new GP contract deliver what they are supposed to. I do not care whether it is health and well-being boards who do it, or whether they exist. I care that it should happen, and it is not abundantly clear to me that there is yet a picture with all the dots joined up, so that we can be sure that if health and well-being boards are carrying out that task either they will have the correct leverage over GP consortia or there will be other mechanisms in place, through the outcomes framework or the new contract, to achieve what the Government, like the previous Government, say they want to do about health inequalities.

[Ms Abbott]

It has been my experience in my present Front-Bench role that local authorities throughout the country believe, broadly speaking, that what they call public health is public health, and that they can spend the money on that. As I said earlier, they can spend it on environmental health, social care or leisure services. I am concerned precisely with the point he made: when is ring-fencing ring-fencing? Because I do not believe that the money can be effectively ring-fenced for what we would recognise as public health expense.

[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.

--- Later in debate ---

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

I congratulate the Public Accounts Committee and the NAO on an important report that sheds light on a lot of health policy issues. I read with care the Government’s response to the report and it seemed that although it was well-meaning, it was sketchy. I hope that we will get some more detail on the points of concern to everyone who has spoken in the debate.

I cannot address the issue without repeating what the PAC has said: under my Government, inequality widened. I would not want to resile from that. I hope that the new Government can build on our achievements in fighting health inequality—there were substantial achievements—and learn from our mistakes. That is what the PAC is trying to point towards in its report. In its report summary, the PAC states:

“It is important that tackling health inequalities does not slip down the Department’s agenda.”

I will try to refrain from commenting on the drama and excitement surrounding the Government’s health reforms. However, in that drama, excitement and Sturm and Drang—as the Germans say—it would be very sad indeed if the progress made was lost sight of and the need to deal with health inequalities in practice and in a targeted fashion slipped down the agenda. One of the most important points made by my right hon. Friend the Member for Barking (Margaret Hodge), the Chair of the PAC, was that we can have all the good will in the world but unless we are focused on the issue and there is a targeted policy approach, the outcomes that we all want to see will slip away.

Health inequalities are an international issue. In the United States, research shows that if black Americans had the same mortality rates as white Americans, there would be 800,000 fewer deaths over a decade. Even in one of the richest countries in the world, they have not been able to tackle the blight of health inequality. If we consider other countries, we will see that life expectancy for women in Zimbabwe is 42 and in Afghanistan it is 44. In contrast, that figure is 86 in Japan.

Probably the greatest single contribution to tackling health inequalities was made by Clem Attlee’s Government under the leadership of Aneurin Bevan in establishing a national health service. We were given a health service that is comprehensive, universal and free at the point of access. There is no question but that the nation’s health has improved massively since the introduction of the NHS. Yet since the 1930s, despite the creation of the NHS, vast social reforms and colossal scientific advances, the gap in mortality between professional and unskilled men has more than doubled. We need to pause and reflect on that because it shows the difficulty of engaging with inequalities.

I think it was more than 30 years ago that Julian Tudor Hart wrote about the inverse care law and pointed out that the availability of good medical care tends to vary inversely with the needs of the population that is being served. That accounts for the very low numbers of doctors in some parts of the east end of London and so on. As we touched on earlier, people in the poorest areas of London, Manchester or Glasgow will die seven, 11 and, in Glasgow, 28 years earlier than people living in the same urban conurbation.

We have heard in the debate about what a Labour Government tried to do on health inequality. From the glittering eminence of my right hon. Friend’s position as Chair of the PAC, she said on the issue that the previous Labour Government were good at policy papers but not so good at implementation. As a humble Opposition Front Bencher, I would not dream of saying that, but I repeat what she said because it might be of interest to people who are following the debate. Of course, there is a lesson there for the Government and all of us concerned with public health. I would like to make this point about Labour’s time in government. The decline in public health outcomes did not begin with a Labour Government—or certainly not the last Labour Government. In the early 1970s, the mortality rate among men from the lower socio-economic groups was twice as high as those in the top professional groups. By the early 1990s, that was three times higher.

The then Health Secretary, my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), commissioned the Black report and we instituted a programme for action, which, as we heard, in some ways fell short. Let us not forget the advances that were made, however: shorter waiting times, many more operations, greatly improved infection control, and better survival rates for cancer and heart disease. Those advances were not just about figures. The most recent Ipsos MORI poll on voter satisfaction with the NHS showed that it had risen from when the Labour Government came in from 55% to 71%—the highest ever reported.

We did make some advances, and some of them specifically related to health inequalities: on cardiovascular disease, the gap closed by almost a third; on cancer, it closed by an eighth, and the trend should be for it to close even faster; life expectancy and infant mortality rates have improved; and last year, statistics showed that the rate of teenage pregnancies was at its lowest for a decade. We put £21 billion into early years education and child care and we have gone from having no Sure Start children’s centres in 1997 to more than 3,000. Overall, we raised total health expenditure on public health, as hon. Members said earlier. By the time we left office, we were spending 4% on public health. None the less, the gap remains.

On this side of the House, we accept the PAC report, but there are specifics in the Government’s response on which I would like to hear more information. The Government partially agree with the report’s first conclusion, which is that the gap in life expectancy is continuing to widen. However, it is not clear what the Government will do to narrow the gap more quickly than the previous Government. The second conclusion relates to cost-effective recommendations. As has been said, there are three specific recommendations: medicine for blood pressure, medicine for cholesterol, and smoking cessation. It is not clear from the Government’s response how they will embed those specific targets and strategies into the system that they are building. They talk about the Department embedding health inequalities in the emerging system, but they do not say how. The Government’s response states:

“Duties will be placed on the NHS Commissioning Board to reduce inequalities in access to outcomes from healthcare.”

That does not state how. That does not say what the targets will be. That does not say what the penalties will be if those duties are not met.

One of the most important points, which my right hon. Friend the Member for Barking spoke about, relates to GP shortages and the existence, still, of some single-handed GP practices, which are not the best. All the Government have to say on that is:

“The Government is committed to addressing these issues…following discussions with the BMA General Practitioners Committee.”

For anyone who knows Government and who knows the BMA General Practitioners Committee, that does not say very much at all. Again, I would like a little bit more detail on how the Government are going to battle with the BMA on that one.

No. 4 in the conclusions and recommendations section of the report states that

“GPs fail to focus their attention sufficiently on the more deprived people registered with their practices”—

and I would add, as an east end MP, those people who are not registered at all. Tuberculosis and malaria are big issues in the east end for populations who are largely not registered. I am not against more GP involvement in commissioning in principle, but one of my fears is that it would be all too easy for GPs to commission for the list. It would be disastrous for public health and health inequality to do that in the east end of London. For all sorts of reasons, we have large populations of people who are not on the list, not least because historically people in the east end would just rock up at Guy’s, Tommy’s or Bart’s and get treated—they did not bother to register. We therefore have to understand how, under the new system, the GP commissioners will be able—will be forced, actually—to commission for the population, and not the list.

I read what the Government have to say about making GPs focus more attention on deprived people. I have read it several times and I still do not understand, because if the GPs can make a decent living while not focusing on the most deprived people on their lists, which is what they have done hitherto, what is to make them change their habits?

Another concern is the numbers of PCTs. That will change with the reorganisation, but the fact is that areas with the highest deprivation still do not get the money due to them under the Department’s funding formula. We hear about the health premium, which sounds reassuring, but I know, from examining how the education premium will work in Hackney, that it will not leave us a penny better off. I would like to know how a health premium will help to get extra money to areas of high deprivation.

One issue of most concern is that when the PAC report states:

“The NHS spends 4% of its funding on prevention, although individual commissioners’ spending on prevention is not readily identifiable”,

the Government respond by stating:

“The Department does not believe it is for central Government to require Directors of Public Health to benchmark the costs and effectiveness of their public health activity—this will be a local responsibility.”

All that is well and good—in Hackney there some activist and committed GPs who came to Hackney because they are committed to fighting health inequality. I worry, however, that it will leave some of the most vulnerable members of our society entirely at the mercy of what their local authority thinks it is able to deliver in public health. I am very concerned about the unwillingness of the Government to benchmark costs and effectiveness and to find a way to promote the simple activities on blood pressure medication, cholesterol medication and smoking cessation.

In conclusion, the Government have said some encouraging things about public health in a general sense, but if there is one lesson to learn from the PAC report it is that having good intentions in a general sense, and even having wonderful policies in a general sense, is not the same as having targeted mechanisms to deliver improved public health outcomes for the very poorest. The Government set a lot of store by a more informed population going online, comparing statistics and choosing—the market, really. In the part of London that I come from, it is not reasonable to expect the poor, the elderly and the very young to universally have access to computers and, at a time of crisis and illness, to be comparing figures and doing sums on their laptop computers.

If the Government are serious about public health, they must first learn from the mistakes of the previous Government. Secondly, they simply cannot leave it to the vagaries of local authorities and the interests of local GP consortia to deliver the overall consistency in public health that will give us the narrowing of health inequalities that we want to see. I can stand on the top floor of my house in Hackney and see the towers of the City of London, but I might as well be in another country. It would be a tragedy if, despite the challenges that the Minister will no doubt tell us about, in one of the wealthiest countries in the world we cannot deliver the mechanisms to narrow that gap. That would be very sad indeed and I await with interest the Minister’s response to the debate.

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[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.

--- Later in debate ---

[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.