Life Expectancy (Inequalities)

Nick Smith Excerpts

Thursday 3rd March 2011 Westminster Hall

[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.

[Nick Smith (Blaenau Gwent) (Lab)]

When we discussed the role of GPs in public health, I was disappointed to discover that they were not incentivised by GP contracts to treat public health issues seriously and put resources into them. If they had been, that would have made a difference.

[Margaret Hodge]

I agree entirely with my hon. Friend. I understand that the Government have said in their Treasury minute that they intend to try to renegotiate the GP contract, and to increase the focus of the quality and outcomes framework on prevention, with 15% of the outcomes centred on it. I am really interested in hearing what the Minister has to say about that. We have to provide incentives in the system, but we also need to ensure that GPs do not cherry-pick. There must be incentives to ensure that GPs focus on the hardest-to-reach groups—on those people who do not automatically go to their doctor when they feel ill.

Finally, what will the Government do to support the health service to do what works? One of the most depressing findings in our report was in this area. We know that most health inequalities arise because of issues that are outside the control of the NHS, but 15% to 20% of them come about because of the quality of the health service that people experience, and their access to it. We also know that two thirds of the difference in life expectancy is due to people dying from respiratory and circulatory illnesses, and from cancer. I have no doubt that the hon. Member for South Norfolk will want to draw attention to the report on cancer that we published this week, which talks a lot about the fact that if we got better at early identification of cancer, particularly in poorer areas, we would be more successful in reducing health inequalities. We also know, from the Marmot review, that if we do not get better at reducing people’s propensity to develop such illnesses, the additional associated treatment cost to the NHS, and therefore the cost of dealing with health inequalities, will be £5.5 billion. There is a fantastic financial incentive as well as an ethical incentive to spread practice that we know works in a much better, more structured and more defined way.

Our inquiry found three cost-effective interventions. They are so simple that we were all slightly gobsmacked that they are not more widely used. The first is giving anti-hypertensive drugs to lower blood pressure, the second is giving statins to lower cholesterol levels and the third is dealing properly with smoking cessation. There is probably a class bias involved. I cannot think of middle-class people who are not aware of those preventive interventions for respiratory and circulatory illnesses and who do not take them almost before they need them. However, poorer communities lack the same understanding and self-advocacy, which would support a reduction in health inequalities. Our inquiry also found that it would cost a mere £24 million—I say “mere,” but it is relatively small in NHS expenditure terms—to ensure that those three interventions were properly implemented in the spearhead areas. At present, those spearhead authorities spend £3.9 billion each year on treating people who develop the illnesses that arise through lack of preventive action.

We also found that our record on reducing health inequalities varied across the country. London, for a change, did relatively well, whereas Yorkshire and Humberside did particularly badly. However, the Department of Health had not developed any proper understanding of why such differences existed, and therefore had not decided how to use the data to lever action.

Probably the most shocking graph in our report involved smoking cessation. There is a lot of evidence that one-to-one sessions do not particularly help people to stop smoking, whereas putting them into groups where they are influenced and encouraged by their peers tends to have a better impact, yet PCTs were putting nearly all their money into one-to-one sessions and very little into group sessions. That seemed an absurd waste of investment and a failure of those empowered to take decisions to do the right thing with their money, which could have had much more impact.

What are the good and bad things that we know so far about how the country will perform on health inequality under the reforms? The Government have said that reducing health inequality remains a key priority, and I welcome that, as we all should. I welcome the fact that the NHS commissioning board will have a duty to reduce inequality, but that in itself is not enough; we must understand how the board will focus on it. I welcome the fact that central Government will make information about good practice available, but I worry that the implementation of that good practice will not be directed more from the centre, if not mandatory. What does the Minister have to say about that?

I worry that there will be no central benchmarking of cost-effectiveness in reducing health inequalities. I welcome the commitment to move towards fairer funding between areas, but I worry about the rate of change. Will the Minister comment on that? I welcome the fact that the Government are seeking to renegotiate the GP contract and are minded to give greater weight to local health needs in that regard. I welcome the fact that they wish to change the quality and outcomes framework, and that health premiums will be available to local authorities that reduce inequalities.

However, there are risks, to which my hon. Friends have alluded, in relation to the public health proposals and local authorities’ capacity properly to meet their requirements for reducing inequalities. I worry that the health premium will reward disadvantaged areas only if they make progress, and will disadvantage such areas further in the distribution of resources if they fail to do so. That would mean that people living in poor areas, who are likely not to live as long as people elsewhere, will be disadvantaged by a failure of the institutions that we have established.

How do the Government intend to ensure that local bodies work cost-effectively to reduce inequalities and provide value for money in their work? What powers, if any, will the Department, the NHS commissioning board or local health and well-being boards have to direct local GPs and providers who are not reducing health inequalities or are doing so in a way that gives bad value for money? What measures, if any, will be taken to ensure that the £20 billion in savings will not lead to short-sighted cuts to prevention budgets?

If the Minister can answer some of those questions, hopefully the good report that we as a Committee have put together can support the shared national endeavour to tackle this hugely difficult problem, which is so important in the life of our society.

[Mr Richard Bacon (South Norfolk) (Con)]

It is a pleasure, Miss Clark, to join under your chairmanship this debate on my favourite subject, the Select Committee on Public Accounts, along with the right hon. Member for Barking (Margaret Hodge) and other Committee members, as well as one of my favourite Ministers, the Under-Secretary of State for Health, my hon. Friend the Member for Guildford (Anne Milton). This three-hour debate is sparsely attended. I was a little worried that we might not fill the time, but then I reflected on the old maxim by Fidel Castro that a speech less than three hours long cannot possibly do anyone any good. Although I will not take off my jacket, I am prepared to be expansive should the need arise.

To be serious, although I do not plan to take up too much time, I think that the report is valuable. It points to something much broader than the single issue of health inequality, although that is an interesting and important issue. We begin our report by pointing out that in 1997, the new Labour Government announced that they would put reducing health inequalities at the heart of tackling the root causes of ill health. That was stated as a clear policy—it is not particularly politically controversial; most people would support it—yet many years later, here we are.

When my right hon. Friend the Work and Pensions Secretary was in opposition and doing a lot of work with his think tank, the Centre for Social Justice, he drew attention to health inequalities in Scotland. They are, strictly speaking, outside the terms of our report, but many people were shocked to learn—Scottish MPs probably knew this, but I did not—that the life expectancy in parts of Glasgow is lower than in the Gaza strip. My right hon. Friend did a lot of work on that issue in opposition, and he is now in a position in the Department for Work and Pensions to help others, including my hon. Friend the Minister, do something about it.

The issues are difficult and vexing, but they are not massively politically controversial, although the report shows that the gap between asserting the intention to do something and actually delivering it is often huge. That is the experience I have had many times in many different areas during the 10 years I have served on the Committee. Often, when Ministers are expanding on any number of subjects, my hon. Friends talk as if everything will be okay, just because it is our political party that is now discussing these things. When the Government make announcements of any kind, I think that, in a few years, we will be getting a National Audit Office report about all the things they forgot to do, all the things that went wrong and the eight common causes of project failure that they failed to observe.

My attention was drawn to a comment by the new hon. Member for Walthamstow (Stella Creasy), who is a new member of the Committee. She brings a lot of extra intellectual firepower to the Committee; indeed, she has a PhD from the London School of Economics. My right hon. Friend the Member for Barking—I will call her my right hon. Friend in this case—and I are also alumni of that fine institution. I believe, however, that the hon. Lady did not pay a large management consultancy to do her fieldwork for her, in the way that this morning’s newspapers say Saif al-Islam did. That aside, she said in a recent debate:

“Governments should not just start projects or policies—the public expect them to be able to finish them too. Essentially, implementation is as important as ideology in politics.”—[Official Report, 16 December 2010; Vol. 520, c. 1134.]

The interesting thing is that we are not even talking about an area where ideology is that important. There is general agreement that changes would be a good thing, but it has still proved extraordinarily difficult to make the progress that we would all like.

The report is divided into three sections. We started by looking at the weaknesses in the approach taken by the previous Government. One of the most shocking things for me was that, in a period when life expectancy overall has improved, the gap between the national average and what we term the spearhead areas has actually widened, as the right hon. Lady said. Under the previous Government’s approach, more than half the local authority wards in the bottom fifth for life expectancy were outside the spearheads, so there was not the slightest chance they would be covered, even though they had some of the worst figures. In fairness, the Department has recognised that its targeting and leadership were not adequate and that it was slow to put in place the right priorities.

There is considerable scope for the Department to take further the model of a national clinical director, which has been applied with considerable—I will not say unqualified—success to areas such as the cancer reform strategy. As the right hon. Lady said, we took evidence on that strategy and published a report on it this week, and it showed, in addition to some success and improvements, that there were still quite shocking variations. For example, there was an eightfold variation in the preparedness of GPs—I nearly said MPs, as well—to refer patients to cancer specialists, and that variation cannot be explained by socio-economic factors. In that respect, we had a fascinating hearing earlier this week with, among others, the King’s Fund, the chair of the Royal College of General Practitioners and a general practitioner running a consortium covering 180,000 patients in Essex. The fact that they took quite different views of the Government’s proposed reforms and GP consortia led to a fruitful dialogue, and the process of creative tension and debate meant that we got quite a lot of extra information that we might not have got if all the witnesses had believed and said the same thing.

It is clear that there were weaknesses in the approach that was taken, and I would like to hear more from the Minister about what proposals the Government have to make specific improvements and whether the idea of a clinical director should be taken further. I say that especially in the context of pushing public health budgets out to local authorities, because there will potentially be more stools for things to fall between. The Department of Health will presumably drive any national clinical director programme, but the influencing will be done with people in local authorities.

The second issue that the report looked at was the role of general practitioners. The hon. Member for Blaenau Gwent (Nick Smith) is right that, according to the Department, the GP contract does not give GPs enough of an incentive to focus on the neediest groups, although part of me wonders why there should need to be an incentive. I know from my experience of talking to GPs that people who go into medicine and general practice take a very holistic approach to their patient group. They will ask some patients to come in once every three or four weeks for no other reason than to keep an eye on them. They are fearful for such patients because they come from certain socio-economic groups and probably need an extra eye kept on them. However, let us take it at face value that the Department believes that the GP contract in its present form is not adequate.

[Nick Smith]

I am struck by the hon. Gentleman’s point about GPs. Every GP I have met absolutely throws themselves into their job, and, with very few exceptions, usually does a fantastic job. However, after the evidence session, I could not help thinking that people will do what we pay them to do. If we get the incentives right and we are clear about the targets and the benefits of the activity that the Department, health board or primary care trust has emphasised, we will get better results. We need GPs absolutely to focus on the important topic before us.

[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.

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[Nick Smith (Blaenau Gwent) (Lab)]

I am pleased that you have called me to speak in this debate, Miss Clark, following the terrific contributions of the Chair of the Public Accounts Committee, my right hon. Friend the Member for Barking (Margaret Hodge), and my fellow PAC member, the hon. Member for South Norfolk (Mr Bacon). As a new Member, I feel privileged to serve on the PAC, given its powers to review all areas of Government spending and to assess whether individual programmes are good value for money.

In the report, we looked at how the Department of Health delivers action to reduce the inequalities in life expectancy that we find in each of the nations of the UK, not just England, although the report looked at England specifically. On the day that we took evidence for the report, I went away with a very heavy heart. I was hugely disappointed that the Government and public policy had failed to make a real dent in this crucial area. I am sorry to say that I was convinced of the failure of senior politicians to drive the issue harder over 10 years, and of senior national health service managers to implement good practice and policies. That is just not good enough.

It is with a mixture of sadness and anger that I must report that adults in my constituency of Blaenau Gwent have life expectancy rates of just 75.6 years for males and 79.1 years for women. Blaenau Gwent has the 10th lowest life expectancy at age 65 in the whole of the United Kingdom. Worryingly, figures released recently by Save the Children revealed that 20% of the children in my constituency—2,000 youngsters—could be living without basic necessities. It is the highest rate in Wales. We are talking about children whose parents skimp on food so that their home can be heated and the youngsters can be fed, and children who are more prone to infections, colds and accidents. That deprivation is likely to have an impact on their health and their life expectancy. These young children are our responsibility and we must do better.

It is because I see the consequences of deprivation in my own constituency that I was absolutely incensed to learn how the Department of Health has been failing families living with poor health in similar constituencies in England. After all, it is more than 30 years since the Black report set out the scale of health inequality in the UK. I do not want to be partisan—this has been a good debate—but that report was buried by Margaret Thatcher, so in 1997 the new Labour Secretary of State for Health, my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), asked Sir Donald Acheson to update it. Subsequently, the Labour Government set a target of narrowing the health inequality gap by 10%.

Colleagues have already said that tackling health inequality is complex. Acheson flagged up a number of initiatives, such as better housing, higher child benefit, and pre-school investment, which he urged the Government to adopt. A number of those things have been done and have made a difference. The 2008 World Health Organisation inquiry by Professor Marmot was equally radical. It identified low incomes, bad housing and a failure to curb junk food as some of the factors that contributed to poorer life expectancy. He also advocated a higher minimum wage, which we will be pushing for in the future, difficult though it may be.

It is important to set the context of the PAC inquiry, because action by the Department of Health is by no means the only action needed to tackle health inequalities. I am sympathetic to a degree with the idea of involving local authorities in the task. We all remember gas and water socialism, whereby local authorities played a big part in ensuring that we had a cleaner environment and gas to heat our homes. Having said that, I am keen for health authorities and GP practices to keep an eye on the issues that make a big difference in public health.

The wealth of reports, information and good practice on public health that were already in the public domain should have galvanised the Department into early action on matters upon which it could deliver. Tackling health inequalities was, after all, one of its key objectives in 1997. As my right hon. Friend the Member for Barking has said, in 2004 the Department set the task of reducing the gap in life expectancy between 70 spearhead areas and the population as a whole. However, although national life expectancy has improved, the gap between the spearhead authorities and the national average has widened. What a depressing fact that is. By looking at why the Department of Health failed in its objective, the PAC was keen to identify pointers, and they will, I hope, enable us to make progress on reducing life expectancy differentials, particularly because no target has been set at present.

The PAC is keen to promote best value, which is very important at all times, but particularly so in the straitened economic circumstances in which we now find ourselves. As NICE has said:

“Public Health interventions are extremely good value when compared with the costs of clinical interventions.”

In our investigation, the PAC found that the Department was slow to get off the starting block and to utilise NHS resources effectively. I stress that this was a priority for the Labour Government in 1997, but it took nearly 10 years for it to be implemented on the ground by PCTs. It should have been a fantastic opportunity to make a difference in a key area for Labour that is representative of our core values. Targets were adopted in 2004, but reducing health inequalities did not make the Department’s top six until 2006, and it took another year for PCTs to be fully involved, which is way too long.

As early as 2002, three key cost-effective policies were identified to help to meet the objectives. My right hon. Friend has pointed them out, but I think they are worth repeating. They should be part of national initiatives, despite the Government’s localism agenda, and should be given emphasis in the future. The first was medication to control high blood pressure, the second was medication to reduce cholesterol, and the third was help for people to stop smoking. Those three things alone would have a marked effect on the agenda.

However, it still took five years for the Department to advise on the best way to implement those policies and to monitor what PCTs were going to do in their patch. Some extra funds were transferred to the spearhead areas on the basis of higher need, but they only trickled through. The spearhead authorities did not reach their target funding levels. If we set public health objectives, we have to deliver the funding. Hon. Members’ comments this afternoon on the need to be clear about what money will go forward and precisely how it will be spent are really important for this agenda.

Like other hon. Members, I shall turn to the role of GPs in tackling health inequalities. We all know that GPs are a fantastic and unique asset but, unsurprisingly, the spearhead areas did not have enough of them. It is as blunt as that. There just were not enough GPs. The reality is that the Department has failed to secure sufficient GPs for poorer areas, despite some good initiatives, which my right hon. Friend has mentioned. The Department has failed to make a difference and to negotiate a GP contract that gives an adequate incentive to focus on patients with the greatest need. I am absolutely clear that people will do that if they are paid to do it. That needs to be promoted and pushed as simply and as hard as possible.

The record also shows that few preventive services have been commissioned by GPs under the practice-based commissioning system introduced in England in 2004. That is a fact. Unfortunately, that does not inspire confidence in the Government’s plans to move to an NHS in England where services are predominantly GP commissioned. If there are not enough GPs in the first place, it is just not going to happen in a lot of areas. The new health and well-being boards, which will be set up by local authorities in 2013, will scrutinise how local commissioners are reducing health inequalities. However, what teeth—or sanctions—will they have? What budget will there be for public health and what exactly will that include? We must get to the bottom of that, otherwise more wasted years lie ahead of us. I hope that the Minister will address those points this afternoon.

A recent review and study of the impact of the economic downturn on health in Wales considered my constituency and concluded:

“In Blaenau Gwent, the recession has hit hard and was felt to have exacerbated the existing long term problems of the area.”

Things were bad already and, with unemployment, they will get worse. The study found that young people are the age group most likely to suffer in the long run

“as the transition from education to employment, further education or training is pivotal for long term secure employment and health”.

Given the current high levels of youth unemployment—we read about that in this week’s papers—I am afraid that the Government are storing up a large health inequalities problem for the future. The study recommends the development of leisure services to help those distressed by job loss, extra resources for debt counselling and access to affordable loans to help to reduce the anxieties associated with loss of income and low incomes. We need to look at the wider agenda and be mindful of that, as public health discussions go forward. In a nutshell, public health outcomes have to be addressed by all levels of government.

Finally, as the Minister responsible for public health is here, I cannot pass up the opportunity to comment on the Department’s plans to help people to stop smoking. Certainly, the NHS must assist individuals to give up smoking using local resources such as nurses, pharmacists and GPs. All of that is terrific. However, the Government must also implement the ban on tobacco displays in newsagents. Such actions may deter young people from smoking in the first place. I commend the Welsh Assembly’s tobacco control action plan, which continues to deliver smoking prevention programmes in our schools in Wales. In terms of the economic picture, that should be rolled out across the UK—certainly in areas such as mine.

Another of my public health priorities is alcohol pricing. Some commentators have predicted that the continued squeeze on family incomes will lead to a reduction in alcohol consumption. However, the Government could be much bolder on minimum pricing. VAT plus duty is not enough and if the NHS spent less on treating the consequences of alcohol misuse, we would have more money to invest in public health and improving life expectancy for the poorest in our society.

Thank you, Miss Clark, for calling me to speak. I am grateful to the National Audit Office for producing a fantastic report and to my fellow PAC members for adding value to it. I hope that the Department of Health and others will act on it soon.

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[Anne Milton]

The right hon. Lady is right to raise that point. I was trying to stress that the healthiest areas will not necessarily be those that receive the most money. In theory, those areas that start from the lowest base should have the greatest opportunity to get those rewards.

Perhaps I can connect the right hon. Lady’s point with that made by the hon. Member for Hackney North and Stoke Newington. This debate is slightly premature because a consultation on the outcomes is currently under way, and we are also looking at the finances, at how much each local authority will have and at the size of the health premium. We are acutely aware—as I am sure are all Opposition Members—of the problem of unintended consequences.

Let us take an obvious example of A and E waiting times. It is right to want people not to wait in A and E for very long, and indeed they did not. If that is given as a target, the health service is good—as are most professionals—and it will fulfil that target. It will get people out of A and E. However, what was never measured was whether people got the care they needed. Did they get better or were they just transferred up to a ward sooner than they should have been? It is important to look at that. To some extent, this matter is a work in progress and we are keen to learn and listen to what people have to say. It is important not to have perverse incentives but to put in place the levers that we need to produce the right results in areas where there is possibly poor capacity, or areas that need building up or contain inequalities.

In some areas there are difficult cultural issues. To return to the issue of domestic violence, sometimes those working in the health service will collude with some of the men who perpetrate that violence. It gets very complicated and we need a system that takes account of all those issues.

[Nick Smith]

I commend the Minister’s emphasis on the directors of public health. The director of the Aneurin Bevan health board in south Wales is terrific and I will meet with her in a few weeks’ time. She has a good action plan together with her comparable officer in the local authority, and I hope that they will build a good partnership working together on public health. Will the Minister let us know how negotiations are going with the British Medical Association, and whether as part of the contract with GPs, public health will be given enough attention and emphasis?

[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.

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[Anne Milton]

There is a question of whether the GP is listening and of whether the levers exist to make the GP listen.

This is a nebulous point to make, but I have to make it. Improving public health is about changing a mindset. We always underplay the importance of not only ministerial but parliamentary leadership on issues such as this. I am talking about a shift of focus on to public health, ensuring that the professions involved in health service delivery and the professions involved in the delivery of other services that affect people’s health receive a clear message that that is now a priority for the Government. When we talk to people who work on the ground, particularly at senior management levels, we see that that message is heard very clearly by them; it does filter down. Ministerial leadership is required, as is leadership from all of us on our individual patches.

[Nick Smith]

Does the Minister anticipate growth in the number of GPs in areas of multiple deprivation, which therefore have high levels of health inequalities? That has emerged from this afternoon’s debate as one of the big issues that need to be addressed. How easy will it be for practice-based commissioning to allow for growth in GP numbers in those areas, which are suffering the greatest health inequalities?

[Anne Milton]

As many people have pointed out—the Public Accounts Committee report focused on this—access to GPs is a major issue, and not just in urban areas such as Redcar but in rural and isolated communities. I will come on to that.

Subject to parliamentary approval, because the Health and Social Care Bill is in Committee at the moment, the NHS commissioning board and GP commissioning consortia will be duty bound to have regard to the need to reduce inequalities in access to and the outcomes from health care. That does not make it happen, but the duty is in the Bill and will be important. GP commissioning consortia will have to keep on improving the quality of their services, reducing geographical variations in standards. To increase the democratic legitimacy of health services, health and well-being boards will have elected councillors to represent the views of local communities.

To be truly successful, we need to be sure that the most vulnerable groups experience the most pronounced benefits. That is an obvious thing to say, but it is important. We are therefore driving ahead with the “Inclusion Health” programme, to focus on improving access and outcomes for the most vulnerable groups. Those are often the groups of people who are not registered with GPs or who are homeless. It is important that the really hard-to-reach groups get that additional focus, because they are not necessarily swept up by the other things that we are doing. We need to keep an eye on that.

I apologise if I am incorrect, but I believe that the life expectancy of the average Traveller is 59 years. The figures for the most excluded groups are truly shocking. Therefore, I fully welcome the Public Accounts Committee report and its recommendations. They were formally responded to in the “Treasury Minutes” dated 16 February. I know that many questions remain, but those minutes give a flavour of how we propose to embed the recommendations in the reformed health care system.

We need to ensure that the GP-patient relationship is as effective as possible. If we are not talking about a family who perhaps have contact with health care services only when they have a baby, the GP is the most important point of contact. On average, families with children under the age of two will visit their GP eight times a year. That is a massive opportunity to put additional emphasis on information and action to improve the health of families. We want to renegotiate the GP contract. The idea is to ensure that disadvantaged areas get the right level of access to GPs. The way to do that, as has always been the case, is to provide incentives to make it happen.

GPs need to improve the health of vulnerable people, not cherry-pick the easiest ones at the top of the pile. They need to encourage the uptake of good-practice preventive treatments. Changes to the quality and outcomes framework prevalence adjustment reward practices in a fairer way, particularly because deprived communities often have a higher prevalence of many of the QOF conditions.

I urge my hon. Friend the Member for South Norfolk to exercise some caution when talking about single-handed GP practices. His point was well made, in that practitioners who practise independently—single-handed—do not necessarily have the best outcomes, but in saying that, we should not exclude the very good single-handed practices. I saw one such practice recently. The GP there has recently been accredited for training and was serving his community absolutely brilliantly.

We have also proposed that at least 15% of the current value of the QOF should be devoted to evidence-based public health and primary prevention indicators from 2013. That answers a point raised by the right hon. Member for Barking. The funding for that element of the QOF will be within the public health England budget.

As the Public Accounts Committee report says, the most cost-effective interventions to improve life expectancy have been developed. Now we need to ensure that they are rolled out as far and as effectively as possible. The report of the review by Professor Marmot has helped us to understand the steps that we need to take, and we shall take them. The public health White Paper adopts the review’s framework of lifelong attention, which will mean a truly cradle-to-grave approach.

In thinking about public health, we must not forget that that is not just about physical health. It is also about people’s mental health and well-being. We need only consider some of the difficult issues that surround young people when they are growing up. We can consider the incidence of sexually transmitted diseases. In the last year for which there were figures, there was a rise of 3%. There has been good progress on unwanted pregnancies and abortions. There has been some progress on unintended conceptions among under-18s, but there are still 36,000. There are still 189,000 abortions every year, of which one third are repeat abortions. We can consider the figures for drinking and young people and the fact that 320,000 young people take up smoking every year. We have a lot to do with regard to young people’s health.

We can split health services into NHS services and public health. We can split public health further, into preventive work and curative work. What do we do when people have started to smoke or drink or have had sex when they should not have done? Then we can consider how to prevent that. There is no doubt that we need to do a great deal to ensure that young people have the skills, the self-confidence and the self-esteem that mean that they are equipped to make decisions about the difficult issues that they face.