Reducing Health Inequality

Peter Bottomley Excerpts

Thursday 24th November 2016 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

I beg to move,

That this House calls on the Government to introduce and support effective policy measures to reduce health inequality.

In her first speech at Downing Street, the Prime Minister referred to the “burning injustice” of the difference in life expectancy between the richest and poorest in our society, and to her determination to tackle it. The purpose of this debate is to try to assist the Government in making that a reality, but I also urge her to look at the gap in healthy life expectancy. Based on Office for National Statistics data from 2012-13, the healthy, disability-free life expectancy of a woman born in Tower Hamlets is 52.7 years of age, while that for a woman born in Richmond upon Thames is 72.1 years of age. That is a gap of about 20 years. The social gradient for disability-free life expectancy is even greater than that for mortality. I ask the Under-Secretary of State for Health, my hon. Friend the Member for Oxford West and Abingdon (Nicola Blackwood), to consider the issue not only as one of social justice, but as one that adds hugely to NHS costs and to economic costs more widely. There is a compelling economic and social justice case for tackling it.

What should the Minister do? In a nutshell, she should follow the evidence and start immediately, beginning with the very youngest in society—in fact, she should start with them even before they are born—and take a whole life course approach, following all the wider determinants of health. She should also take a cross-Government approach, with leadership at the highest level of the Cabinet. She needs to take the long view—many of the benefits will become evident in 20 or 30 years’ time—while not ignoring the fact that there will also be quick wins. She needs to look at everything that needs to be done to tackle the situation.

I hope that this will be a consensual debate. I congratulate the Labour Government on the work that they did to tackle health inequalities, which is starting to pay dividends. I also pay tribute to Sir Michael Marmot for his groundbreaking work; the blueprint that he set out in 2010 holds true today and it should be the basis of everything that we do. It is about giving every child the best possible start in life and allowing people of all ages to maximise their capabilities and exercise control over their lives. It is also about fair employment and good work, healthy environments and communities, standards of living and housing.

It is about preventing ill-health as well, and that is what I want to address, because I know that many Members across the House will speak with great expertise about the wider determinants of health. Tackling the issue starts long before people come into contact with health services, but that is still an enormously important part of tackling health inequalities. As Chair of the Health Committee, I will focus on those aspects.

On preventing early deaths, we need to look at lifestyle issues, including smoking and obesity, and at preventing suicide, which is the greatest single cause of death in men under the age of 49. Public health plays a critical role. The “Five Year Forward View” called for a radical upgrade in prevention in public health. Cuts to public health budgets are disappointing and will severely impact on the Government’s ability to tackle health inequalities. The Association of Directors of Public Health surveyed its members in February and found that the cuts to the public health budget were affecting issues such as weight management, drugs, smoking cessation and alcohol, which are key determinants that we need to tackle. In my own area, part of which covers Torbay, cuts of about £345,000 to council public health budgets will result in the decommissioning of healthy lifestyle services. Those budgets affect education and active intervention, and support a network of fantastic volunteers. I regret that those cuts to public health are going ahead, and call on the Government to stop them.

I want to tackle a few key areas. First, smoking is still the biggest cause of preventable death in the United Kingdom. Every year, 100,000 people die prematurely as a result of smoking. In her closing remarks, I hope that the Minister will update the House on the tobacco control plan.

[Sir Peter Bottomley (Worthing West) (Con)]

About 25 years ago I took an interest in how many death certificates mentioned smoking, and the answer was four. The figure may be larger now, but we should encourage medical practitioners to say that the person had been an active smoker, even if it was not the primary cause of death, so that at least people can become more aware of the issue.

While I am talking about this, I will mention two other things, which my hon. Friend may be going to cover. One is nutrition at the time of conception, and the second is that we should learn the lessons of how we cut the drink-driving deaths, which was not by public programmes, but by people doing the things that actually made a difference—that cut down the incidence and cut down the consequences and cut down the deaths.

[Dr Wollaston]

Those are extremely important points. The Government can introduce policies and make sure that there are levers and incentives in the system to make that happen. The drink-drive limit is a very important example.

We are not likely to make a difference to the gap in disability-free life expectancy without tackling smoking, which is a key driver for health inequality and accounts for more than half of the difference in premature deaths between the highest and the lowest socioeconomic groups. Without tackling it, we will not make inroads.

I would like briefly to touch on obesity and on the Government’s obesity strategy, which the Health Committee has looked at. To put the matter in context, the most recent child measurement programme data show us that 26% of the most disadvantaged children leave year 6 not just overweight but obese, as do 11.7% of the least deprived children. Overall, of all children leaving year 6, one in three is now obese or overweight. The situation is storing up catastrophic lifetime problems for them, and we cannot continue to ignore that.

In our report, the Committee called for “brave and bold action”. Although I really welcome many aspects of the childhood obesity plan—such as the sugary drinks levy, which is already having an impact in terms of reformulation—it has been widely acknowledged that there were glaring deficiencies and missed opportunities in the plan.

I would like to have seen far greater emphasis on tackling marketing and promotion. Some 40% of food and drink bought to consume at home is bought under deep discounting and promotion, and that is one of the potential quick wins that I referred to. We often focus in this debate on what people should not do, and this is an opportunity to look at what they should do. Shifting the balance in promotions to healthy food and drink would have been a huge opportunity for a quick win, because one of the key drivers of this aspect of health inequality is the affordability of good, nutritious food. This would have been an opportunity to tackle marketing and promotion, and I urge the Minister to bring that back into the strategy. I also urge the Government to extend the sugary drinks levy to other drinks, including those in which sugar is added to milky products, because there is no reason why it should be necessary to add sugar to such drinks.

I also welcome the mention in the plan of the daily mile, which has been an extraordinary project. I have met Elaine Wyllie, who is one of the most inspirational headteachers one could meet, and she talked about the strategy and about how leadership from directors of public health makes a real difference. I hope that the Minister will update the House on how that will be taken forward. We should think not just about obesity, but about physical activity and health promotion, and about the benefits that they could bring to all our schoolchildren.

The Health Committee stressed in our report the importance of making health a material consideration in planning matters when money is so restricted. I do not think that to do so would be a brake on growth; it would be a brake on unhealthy growth, and it would give local authorities the levers of power when they are making licensing decisions and planning decisions for their communities. That is something that Government could do at no cost, but with enormous benefit.

The Health Committee is actively considering how we reduce the toll of deaths from suicide. The Samaritans have identified that men living in the most deprived areas are 10 times more likely to end their life by suicide than are those in the most affluent areas. Many factors contribute to this—economic recessions, debt and unemployment—but when we try to tackle health inequality, we will not make the inroads that we need to make unless we look at the inequality in suicide, particularly as it affects men. Three quarters of those who die by suicide are men. I hope that the Minister will look carefully at the emerging evidence from our inquiry as the Government actively consider the refresh to the strategy, and that they will do so at every point when they look at how to tackle health inequality.

I would like the Minister to look at the impact of drugs and alcohol on health inequality. The fact that there are 700,000 children in the United Kingdom living with an alcohol-dependent parent is a staggering cause of health inequality, which has huge implications for those children’s life chances and for the individuals involved. Again, alcohol has a deprivation gradient; the two are closely linked.

There is evidence about what works, and we have had encouraging news from Scotland. The Scottish courts, I am pleased to say, have ruled that minimum pricing is legal, although I am disappointed that the Scotch Whisky Association has yet again taken the matter to a further stage of appeal. As soon as those hurdles are cleared, I think it would be a great shame if England undermined the potentially groundbreaking work being done in Scotland by failing to follow suit and introduce minimum pricing at the earliest possible opportunity; if we failed to do so, people would be able to buy alcohol across the border.

--- Later in debate ---

[Alan Johnson (Kingston upon Hull West and Hessle) (Lab)]

I rise to express my enthusiastic support for the work of the Health Committee under the superb leadership of the hon. Member for Totnes (Dr Wollaston). I also pay tribute to the Prime Minister for her description of health inequalities as a “burning injustice” and for placing the issue at the top of her agenda, which was virtually the first thing she did as Prime Minister of this country.

This is an unusual debate. Usually in this Chamber, Back Benchers press the Government to take something on as a priority, but this is more of a top-down issue. The need to tackle health inequalities has been forcefully expressed by the Prime Minister, and through this debate we are trying to translate those words into effective action. For those of us who have grappled with the nuts and bolts of trying to tackle the obscenity—that is what it is in the 21st century—of health inequality, the Prime Minister’s words were, as the hon. Lady said, enormously encouraging, because they demonstrated the leadership that the issue requires if the awful statistics are to be properly addressed.

I want to set the matter in its historical context to demonstrate the difference in approach that spans the 37 years between the appointments of Britain’s first woman Prime Minister and its second. Although health and life expectancy improved dramatically for everyone following the creation of the NHS in 1948, there was a strong suspicion by the 1970s that persistent health inequalities existed and that they were defined largely by social class. There was, however, an absence of easily understood statistical evidence on which to base a clear assertion. In 1977, the then Health Secretary, David Ennals, commissioned the president of the Royal College of Physicians, Sir Douglas Black, to chair a working group that would report to Government on the extent of health inequalities in the UK and how best to address them. The report proved conclusively that death rates for many diseases were higher among those in the lower social classes. Stripped bare, it was the first official acknowledgment that the circumstances into which a person was born would largely determine when they died. That remains the thrust of the argument expressed by the Health Committee’s report, except that it has quite rightly added the new dimension, which was highlighted by the Marmot indicators of health inequalities in November 2015, of the difference made by the number of years spent in good health. There is an extraordinary gap between the most and the least disadvantaged of almost 17 years.

By the time the Black report was published, a new Government had been elected. They displayed their enthusiasm for tackling health inequalities by reluctantly publishing fewer than 300 copies of the report on an August bank holiday Monday in the depths of the summer recess. In his foreword to the report, the new Health Secretary could not even raise the enthusiasm to damn the report with faint praise; he simply damned it and virtually ignored it, and that remained the case for 18 years.

This is important because people assume that health has improved for everyone since the 1940s—it has, by and large—yet during those 18 years, many of the problems that Black highlighted actually got worse. For instance, in the early 1970s, the mortality rate among young men of working age in unskilled groups was almost twice as high as that among those in professional groups; by the early 1990s, it was three times as high. The most awful statistic—this began to emerge in the 1980s—was that the long-term unemployed were 35 times more likely to commit suicide than people in work. It would be inconceivable today for a Health Secretary to be as dismissive of an issue that is so critical to the life chances of so many.

We are also more aware today than we were then that healthcare is only part of the problem. Indeed—the Minister has a difficult job—it is a minor part: the proportion has been calculated at between 15% and 25%. The epidemiologist Professor Sir Michael Marmot, the world’s leading expert on this subject, has established the social determinants of health. The Acheson report of the late 1990s explained:

“Poverty, low wages and occupational stress, unemployment, poor housing, environmental pollution, poor education, limited access to transport and shops”—

and the internet—

“crime and disorder, a lack of recreational facilities…all have an impact on people’s health.”

Beveridge’s five giants—disease, want, ignorance, squalor and idleness—were a more pithy and poetic way of describing the problem. Beveridge’s brother-in-law, the historian and Christian socialist R. H. Tawney, set the template that we should follow. He said the issue was

“not…to cherish the romantic illusion that men are equal in character and intelligence. It is to hold that…eliminating such inequalities as have their source, not in individual differences, but in its own organization”.

The Marmot report, which I commissioned as Health Secretary in 2008 to inform policy from 2010 onwards—unfortunately, the electorate decided that we would not be in office to carry this out—recommended six policy areas on which we should focus: the best start in life; maximising capabilities and control; fair employment and good work; a healthy standard of living; healthy and sustainable places and communities; and a strengthened role for and provision of ill-health prevention. Marmot advised that those six areas should be focused on with a scale and intensity proportionate to the level of disadvantage, which he called “proportionate universalism”. The coalition Government accepted all Sir Michael’s recommendations. However, they responded with a policy— “Healthy Lives, Healthy People”—in which the focus was on individual lifestyle and behavioural change. That, as Sir Michael has pointed out, is only one facet of the problem, just as the NHS is only one part of the solution. Moreover, the only piece of cross-Government co-ordinating machinery, the Cabinet Sub-Committee on health, was scrapped in 2012.

The Health Committee’s report on public health and today’s debate, together with the Prime Minister’s pledge, give us a fresh opportunity to capitalise on the brilliant work done by Sir Michael Marmot and his Institute of Health Equity at University College London, and on the political consensus that I am pleased to say now exists on this issue, by forging a fresh and dynamic response across the Government to tackling health inequalities. One of the Committee’s recommendations, as has been mentioned, is that a Cabinet Office Minister should be given specific responsibility for leading on this issue across the Government. I have a more radical suggestion: the Prime Minister herself should take personal responsibility for this issue. The Prime Minister is also the First Lord of the Treasury and Minister for the Civil Service, and previous Prime Ministers have taken on other ministerial positions—Wellington was also Foreign Secretary, Home Secretary and Colonial Secretary, and Churchill was Prime Minister and Defence Secretary. It would set a wonderful example if the Prime Minister followed up her words by saying, “I’m going to lead on this. I’m going to chair the cross-Government Committee that tackles health inequalities.” That level of leadership is needed, because only then will there be meaningful cross-departmental work to tackle these inequalities.

I echo the Health Committee’s view that devolving public health to local authorities was the right thing to do. Not everything in the Health and Social Care Act 2012 was approved by Opposition Members or many other people, but that change was the right thing to do. The cuts in authorities’ budgets—£200 million of in-year cuts—must be restored and I suggest that the ring fence is extended at least to the end of this Parliament. With local government having so many problems, I fear that breaking the ring fence for public health will mean that the money goes elsewhere and is not focused on these issues.

As I have said, only a minority of health inequality issues involve the Department of Health, but I want to highlight one that quite certainly does. The biggest cause of the hospitalisation of children between the ages of five and 14 is dental caries: 33,124 children went into hospital to be anaesthetised and have their teeth extracted in the past year. Incidentally, that is 11,000 more than for the second biggest cause of the hospitalisation of children, which is abdominal and pelvic pain. Believe it or not, it was the 12th highest cause of hospitalisation of tiny children below the age of four.

This is a health equality issue. Almost all the children who went into hospital were from deprived communities, including 700 from the city I represent. There is a safe and proven way dramatically to reduce tooth decay in children, and it also has a beneficial effect on adults. It involves ensuring the fluoridation of water up to the optimum level of 1 part per million. The cost of fluoridation is small. For every £1 spent there is a return to the taxpayer of £12 after five years and of £22 after 10 years. The evidence—from the west midlands and the north-east, and from countries across the world—has now existed for many years. A five-year-old child in Hull has 87.4% more tooth extractions than one living in fluoridated Walsall. The whole medical profession, the dental profession, the British Medical Association and the Department of Health have recognised that for many years.

In Hull, we intend to fluoridate our water as part of a concerted policy to tackle this element of health inequality. We need the Department of Health to show moral leadership by encouraging local authorities in deprived areas to pursue fluoridation, and supporting them when they do. The Health Secretary retains ultimate responsibility for public health, including ill-health prevention. This is one issue on which he can begin the process of reducing hospital admissions by encouraging preventive action and, in terms of health inequalities, giving poor kids prosperous kids’ teeth.

[Sir Peter Bottomley]

I completely agree with the right hon. Gentleman. Has he or anyone else solved the problem of how to protect water supply companies and businesses so that they do not find themselves facing unjustified claims or difficulties?

[Alan Johnson]

I had actually finished my speech, but I will answer the hon. Gentleman’s intervention as my conclusion. I have talked to Yorkshire Water, and my understanding is that putting the focus on local authorities changes the whole dynamic of how the various conspiracy theorists can attack on this issue.