Reducing Health Inequality

Meg Hillier Excerpts

Thursday 24th November 2016 Commons Chamber

[Judith Cummins]

That is an interesting point. I shall deal with some of those issues later in my speech.

According to the latest figures, 32% of children in Bradford—nearly a third—have not seen a dentist for more than two years. Ideally, as Members will know, children should be given a check-up every six months.

Dental and oral health has been and continues to be the Cinderella of health service provision. It is seen as being “nice to have”—to be tackled once the good ship NHS has returned to calmer waters—and due for its much-needed extra funding only when the financial black holes elsewhere in the NHS have been plugged. Such inequality in dental and oral health is plain wrong. It is an unspoken injustice in today’s society, and the task of tackling it cannot and should not be kicked down the road like the proverbial can year after year.

Tooth decay is an almost entirely preventable disease. It is a scandal, without exaggeration, that tooth decay is the No. 1 reason for hospital admissions of children between the ages of five and nine. It is a scandal not only because it causes our children needless pain and suffering, but because, in this time of austerity, it wastes countless millions in NHS resources. However, its impact goes much deeper than that.

In an increasingly globalised and competitive world in which our children are expected to succeed at school, improve their skills and excel in internationally benchmarked exams, they all need to be healthy and energised to face the school day. Too often, however, pain arising from poor oral and dental health hinders their school readiness, impairs their nutrition and growth, and cripples their ability to thrive, develop and socialise with each other. A recent survey sadly confirmed that more than a quarter of our young people feel too embarrassed to smile or laugh due to the condition of their teeth. For our teenagers, the injustice is no less when they need to succeed and make their way in a competitive job market.

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

In my constituency, I can tell the extent of someone’s poverty by the state of their teeth, so not only is there the issue of decay, but this is about not having the money to be able to get the necessary treatment—perhaps cosmetic treatment—which can then lead to embarrassment and a loss of confidence.

[Judith Cummins]

I thank my hon. Friend for making that valid and important point.

Disproportionate levels of poor oral and dental health, predominantly in deprived, low-income areas such as those in Bradford, hamper these young people from forging their careers. Survey after survey confirms that young people who suffer from poor dental and oral health face poorer job prospects. Dental and oral health plays, rightly or wrongly, an important part in selling ourselves in today’s competitive job market.

I have set out the depressing scale of the challenge, but what can we do—or, perhaps more accurately, what can and should this Government be doing—to tackle this scandalous health inequality? As I highlighted to the former Prime Minister Mr Cameron, when I challenged him about this inequality in my constituency and city, there are some simple steps that can be taken. The first of them is due to be implemented in the foreseeable future: a tax on sugary drinks. Although the Government’s final proposal was very much weaker than it should have been, it was nevertheless very much a welcome step in the right direction.

The Royal College of Surgeons faculty of dental surgery, a professional body that sees dental inequalities first hand in its day-to-day work, suggests a number of low-cost, easily deliverable measures that could readily be adopted by Government: tightening restrictions on advertising high-sugar products on television, for example by restricting advertisements before the 9 pm watershed; limiting price promotions in supermarkets for high-sugar foods and drinks, and excluding these products from point-of-sale locations such as checkouts and counters; and, most sensibly, limiting the availability of high-sugar foods and drinks in our school system.

Perhaps the most important measure that the Government could implement, as highlighted by the British Dental Association, would be to expedite changes to the current dental contract. Critical changes are long overdue, the first of which would be to incentivise preventive work through the contract. The second, and most important, would be to incentivise the dental profession to establish new practices in deprived areas. Such areas desperately need practices as people there typically face the least availability.

In my constituency, despite need being so high, there is a shameful shortfall of NHS dentist appointments. Very few NHS dentists have open lists, meaning that most people in search of dental treatment simply give up, and those who are determined end up finding a dentist outside the city boundaries. Surely that is not right. I understand that the Government hope to begin rolling out a reformed dental contract from 2018-19 onwards, but that simply is not soon enough.

I finish by asking a simple question: is it just and equitable that five-year-old children in Bradford, my home city, are four and a half times more likely to suffer from tooth decay than their peers in the South West Surrey constituency of the Health Secretary? I hope that the House agrees that the answer is no.

--- Later in debate ---

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

I join colleagues across the House in congratulating the hon. Member for Totnes (Dr Wollaston) and her Committee on their work in this area and on securing this debate. She brings a calm and clear knowledge to every health debate. We really do need a long-term vision in this area and I know that she, like me, wants to see that, whatever party is in government.

I speak today both as an MP for a constituency with large gaps in health, wellbeing and life expectancy, which are very much determined by place of birth, early years experience and poverty, and as Chair of the Public Accounts Committee, which in this year alone has published 10 reports on the national health service, some of which shine a light on this debate. Our reports show the huge pressures on the national health budget and the huge increases in demand on that budget. To take diabetes as an example, 4.8% of the population is currently diabetic, but that is set to rise to 8.8% in the next few years.

It is my role and the role of my Committee to look at funding. Specifically, our role is to look at the economy, effectiveness and efficiency with which the Government spend taxpayers’ money, so I will talk first about how we spend the money that is allocated to our health service and how that is key to tackling health inequalities. I will then turn to how we look at the impact of decisions, both in the health service and in other parts of Government, on health inequalities—what we in the Committee call “cost shunting”.

NHS budget spending is in the region of £110 billion a year. The Government are keen endlessly to remind us that they have injected £10 billion into the NHS over the six-year period to about 2016. At the same time, we see an ageing population, a large and increasing demand, including for specialised services, and a health service squeezed at each step of the journey. My Committee has heard evidence on general practice, specialised services such as diabetes and neurology, acute trusts and social care, all of which has shown the impact on the budget. That has all been caught up in what, sadly, has been a rather childish debate over headline figures and often very subtle changes in language from the Government about who is to blame. Ministers have moved from the mantra, “We’ve injected an extra £10 billion”, to saying, “The NHS has been given what it asked for”, as though they were scolding a naughty child, and, “We will manage this within the NHS”, as the Chancellor said yesterday when I asked him why he had not considered the NHS budget in the autumn statement.

In today’s Daily Mail there is an exhortation—this is quoting sources close to or in Government—that the NHS simply needs to manage its resources better and cannot endlessly be given more money. I am Chair of the Public Accounts Committee. This is taxpayers’ money. I do not think we should endlessly pour money into any Department without demanding quite a lot of it, and I am clear that there are always efficiencies to be found in a system so large and with such a large overall budget. Every pound saved is a pound to spend on something else. That is the key point. Every pound saved in the Department of Health budget can be spent on other things and ought to be spent on public health in particular. I will come on to that.

As I have highlighted, there are many pressures on the NHS budget. With all these discussions and figures being bandied around, we need to take a closer look. In 2015-16, the Department’s budget was projected to have a £2.45 billion deficit. The measures used in the last financial year to balance the budget were extraordinary and one-offs and led to an unprecedented three-and-a-half-page explanatory note from the Comptroller and Auditor General alerting all of us, particularly the Department, to his concerns that those were not replicable, long term or sustainable. He reiterated that point in a Committee hearing only a few weeks ago.

I will not spend too long on the budget figures—the debate needs to move on—but I will touch briefly on the overall figures this year for acute trusts alone. From April to September, trusts overspent by £648 million and the deficit for the first six months forecast to the year end is £669 million. This trend was increased largely because of the decision in 2011 to allow for 4% efficiency savings across the NHS by the then Chancellor of the Exchequer. Everybody in the system knew that that was not realistic on a long-term basis. People knew that there would be a problem with the budget two or more years out from the crisis in the budget settlement in the last financial year, yet there is no openness in discussing how we spend money in the NHS, what we spend it on and what we focus on.

That brings me to public health. Too often, public health budgets are raided to deal with day-to-day crises and money is taken out of NHS education. The plans for service transformation are not necessarily a bad thing, but the danger is, if they are done in the wrong climate and with the wrong tone, that they are seen as an excuse for cuts. They can be so much better for patients, especially if focused on preventive work and the more efficient spending of taxpayers’ money, but too often they will be driven by financial pressures. A lot of pressure was put on finance directors of acute trusts in particular at the end of the last financial year. Many were encouraged, for example, to move capital funding into the resources side of their budget in order to balance the books—a short-term measure that can lead to underinvestment in facilities that, if invested in, can actually save money and improve the patient experience.

This short-term, year-on-year, or even spending review period planning will not tackle health inequalities effectively. We need a longer-term approach. We need to prevent more ill health and treat fewer patients. As others have highlighted, the age of death is increasing—we have an ageing population—but the age of disability remains broadly similar. Public Health England released a report towards the end of 2015 highlighting some of these figures. The cost of treating illness and disease arising from health inequalities has been estimated at around £5.5 billion a year, and then there is the issue of cost shunting, which is a big concern.

If we do not tackle these things, it will not just be individual patients or their families who suffer, or the taxpayer funding these services; there is a wider impact on society. Productivity losses are estimated at between £31 billion and £33 billion per annum. Lost taxes and higher welfare payments cost in the region of £28 billion to £32 billion per annum.

To go back to what the hon. Member for Totnes said about smoking, if we tackle tobacco issues in my neighbouring borough of Newham alone, that would save about £61 million per annum. That would make a big contribution to the local health budget in east London. If we replicated that across just east London, just think what we could contribute to the NHS budget.

About 1.3% of workdays a week are lost to sickness in London alone, which is lower than in many parts of the country. All these things contribute to our productivity gap and have a big effect, so if we are to do what the Chancellor said yesterday and ensure that our workers produce in four days what they now produce in five, we need workers who are well and can work until the increased retirement age that is demanded. It is quite shocking that the hon. Member for Glasgow East (Natalie McGarry) and other colleagues from Glasgow represent a city where people will die before the age at which they qualify for their state pension. There are certainly many people in my constituency who face that, although they are not the average. That is a sign of the failure of preventive work to tackle health inequalities at the right point.

When it comes to joining up Government, we need to look not just at the silos in various parts of the health budget, but at ensuring a healthier wider society. Let us take, on the one hand, the land disposals that the Government are undertaking to provide public land to build new homes. My Committee has looked at that a great deal, although I will not divert the House today too much. In my area we have St Leonard’s hospital, the site of a former workhouse in Hackney. When the most recent reorganisation of the NHS took place in 2011, the site was moved to the central PropCo, the property company that the NHS holds centrally to manage its estate. We therefore no longer have local control of what to do on that site. Given the state of homelessness locally, if we could provide families with more good-quality homes on that site that were not overcrowded, we would do more for public health and health inequalities than a lot of the fiddling around we do over whether a service should be based here or there and all the treatment work we are doing.

Departments are now taking account of other “strategic objectives”, as they put it, in land disposals, but that is still ill-defined. My Committee will continue to push on this matter because from the perspective of my constituency, where we have extraordinarily high house prices, if we can release land and provide homes for key workers, that would contribute to the outcomes of those Departments. I am determined that the Government are clearer in their outcomes, because in constituencies such as Taunton Deane—or perhaps not, as the hon. Member for Taunton Deane (Rebecca Pow) highlighted—the need might be for green space or other facilities that would improve or promote health. However, if we do not have a wider view of what we are doing with our public assets, there is a danger that we will just sell to the highest bidder and lose the chance for several generations, because once land is gone, it is gone.

Finally on this issue, it is important to touch on the increasing challenge of homelessness, particularly in London and in my constituency. London households in temporary accommodation now account for around three in four of all such households in England. That is not a surprise, given increasing house prices and rents, and the impact of the benefit cap, which means that people cannot now rent a three or four-bedroom home on housing benefit anywhere in London or the south-east of England. I have people coming to see me now who even five years ago, and certainly 10 years ago, would not have come to me about their housing. They were managing okay, they were living in the private sector, they were paying their rent and they were working.

Now, one woman who came to see me had lost her job because she had been ill. She had hoped to go back to work. She had a good job with professional prospects, although not a well-paid job. She became ill and her rent went up, so she fell notionally into arrears while she was trying to find another home, as her rent was no longer covered because of the housing benefit cap. She tried to find somewhere in Hackney and the neighbouring six boroughs but could find nowhere, until eventually a landlord said he would take her in on benefits. However, because of the complexities in how housing benefit is allocated, he would not take her unless he had a guarantee a month before she moved in that she would be able to receive housing benefit. However, the system does not allow for that. As a result, a woman whose health was challenged anyway was suffering mental health issues through no fault of her own.

My constituent was of course very concerned, anxious and depressed about what was going to happen in her situation, and she is just one of many. This is the worst situation I have experienced in over 20 years as an elected member at local or national level. The stress of poor, uncertain and overcrowded housing has a huge impact on health. If someone is homeless, it increases by one and a half times the likelihood of their having a physical health problem, and it makes them 1.8% more likely to have a mental health problem, although it seems to me from my experience of speaking to people face to face that those figures are underestimates. Perhaps they mask the temporary housing problem, compared with the reality of what I am seeing. This has a huge impact, focused, yes, on the absolutely poorest, but also on people such as the woman I mentioned—people who have just hit a bit of a rocky patch in their life, where something has gone wrong and caused a spiral downwards towards homelessness.

There are so many hidden households in my constituency —families living on the sofa in the living room. It could sometimes be a family of an adult and two children in that situation while another family is living in the bedroom. For various reasons, they do not qualify for council housing, or they are on the waiting list—a bit of a misnomer when people wait a lifetime for a council property. Sometimes they cannot afford, on their income, to rent privately and they have no other options.

Temporary accommodation is now costing Hackney council about £35 million a year. I commend the Hackney Gazette, which has done a lot to highlight the conditions in temporary accommodation hostels in my borough and across London. We have the Homelessness Reduction Bill, which is passing through Parliament, but that is only part of the picture. Saying that councils must accept people who are homeless is fine, but unless we have the homes available to provide to those people at an affordable level, we will not solve this problem.

[Rebecca Pow]

I believe that the Government provided £10 million yesterday for homes, particularly in London, so things are being done and they are on the move. I just wanted to put that on the record.

[Meg Hillier]

The hon. Lady pre-empts my next point. I welcome the fact that the Government have begun to make some moves on housing, particularly taking away the “pay to stay” provisions. I am making sure that all my local housing associations are not going to buy into this on a voluntary basis—I hope they would not in London. The autumn statement freed up housing associations to use Government money for affordable housing as defined locally, rather than as set nationally. The idea that in my constituency affordable would be 80% of private rents is nonsense; it is well out of the range even of people who are well above the minimum wage. Most young people in Hackney share a home, because they could never afford to rent somewhere privately and they certainly cannot get on the housing ladder. It is going to take a generation to solve this housing problem, so although I welcome what the Government have done, much more could have been in their six years of office.

I am pleased that we now have a Housing Minister who is a London MP and who understands London issues. We London Members often speak about housing here, and it is as though we are in a different world from others. However, we have this very big problem of homelessness, overcrowding and excessive use of temporary accommodation.

Let me finish with a story that should never be true in our world. It is a story of a woman who was living with her toddler and her husband in a hostel because she was waiting to get some council housing. Even three years ago, I used to say, “Hold on and hang on in there for six months, and we’ll find a home for you.” Nowadays, it is increasingly a year or 18 months. The woman went into hospital to give birth and had to come back, with her new-born baby, her toddler and her husband, to that one room in the hostel. The people living in that hostel are among the most vulnerable—not an ideal environment in which to bring children home. Many people with a lot of problems are crowded into one place, without the support they need. This is not, I am sure, what any Member wants to see. We must tackle the issue, because the health problems that that spins off for the next generation of children are immense. I add a plea from my local constituency perspective as well as from my national perspective as Chair of the Public Accounts Committee—tackling homelessness is a vital issue to tackling health inequalities.