§ Mr. William Hamilton (Fife, Central)The research working group on inequalities in health was set up under the chairmanship of Sir Douglas Black by the Labour Government in 1977 to review information about differences in health status between the social classes, to consider the possible causes of those differences and their implications for policies, and to suggest further research.
It was commonly accepted by Governments and Departments that the group had a gigantic task. It has been well known for many years that health inequalities in this country are great. Despite more than 30 years of the working of the Health Service, they show few signs of diminishing. Indeed, they may be increasing in some respects. The causes of the inequalities are deep-rooted and complex and Sir Douglas Black and his colleagues must be congratulated on producing such a splendid survey, which not only provides invaluable factual information but proposes 37 recommendations for the solution of the persisting problems of health inequality.
The report, produced in August 1980 by the Department of Health and Social Security, ran to 400 or more pages. It was clearly not designed for popular reading, for the Government priced it out of the market, perhaps deliberately, at £8 a copy. That was not exactly calculated to make it a best-seller. If the Government had been seriously concerned about these problems, they could have produced a short, cheap, popular version and ensured that it received widespread publicity and debate. In the event, the present Secretary of State made it abundantly clear in his foreword to the report that he had no intention of implementing its recommendations, now or in the foreseeable future.
The right hon. Gentleman estimated that the amount of cash involved
could be upwards of £2 billion a year".I do not know how he arrived at that figure. Perhaps the Minister will tell us. Did he take into account, for instance, the savings that might accrue from the implementation of the recommendations on preventive medicine? I accept that their implementation would cost a great deal of money, and that those who produced the report might be criticised for being too ambitious in their recommendations. But the fact that the recommendations would cost so much is an indication of the shortcomings of our health policies, not only in the NHS but in a much broader sense, encompassing such problems as child poverty, which is mentioned in the report, health and safety conditions at work, over-eating, our drinking habits, what I call the menace of the lollipop and fags society, about which the Government should be concerned, and a multitude of other factors that affect our health.At the outset I remarked on the amount of factual information in the report. Much of it occasions no surprise, but some of the facts should be put on the record. I take them at random from the report. The first is almost too obvious: a child born to professional parents can expect to live five years longer than a child of an unskilled manual labourer. Secondly, at birth and during the first month of life the risk of death among children of unskilled manual workers is double the risk among children of professional 1448 workers. Thirdly, mortality rates, arguably the best available indicator of the health of different social and occupational classes, tend to rise inversely with falling occupational rank or status for both sexes and at all ages.
The report also makes some interesting international comparisons. For example, in 1978—the latest year for which figures were available to the working group—rates of perinatal mortality were significantly higher in England, Wales and Scotland than in Sweden, Norway, Denmark, Finland and the Netherlands. France and Germany had rates similar to though slightly lower than this country's.
Deaths in the first year of life are considerably higher in England, Wales and Scotland than in the Nordic countries and the Netherlands, though it is fair to point out, as the group did, that there have been improvements in the United Kingdom rates since 1960.
One of the report's most crucial observations was made at paragraph 6.95:
early childhood is the period of life at which intervention could most hopefully break the continuing association between health and class.It is therefore critically important to concentrate on steps to reduce health inequalities in childhood. It will be interesting to hear what the Minister has to say about that.That brings me directly to the urgent need, especially in these days of acute financial stringency, to focus on the importance of preventive medicine. It is regrettable that after 30 years of the Health Service social class differences in health have actually widened in some respects. My conclusion—I suspect that it is also the Minister's conclusion—is that whether people remain healthy or become ill depends largely upon conditions outside the scope of the Health Service. The Government's future policies on health should be geared to that proposition.
Over many years, the eating of good, wholesome food and the provision of good housing conditions and good hygienic sanitation have done more to improve health than have medicine and medical services. Today, a large proportion of ill health arises from the problems of urban living and increasing industrialisation, as well as the consumption of over-large quantities of unsuitable food and drink. The abuse of food and drink, the overconsumption of starches, sugar and alcohol and the inhaling of cigarette smoke, petrol fumes and industrial dusts of all sorts are the biggest health menaces today. The preventive medicine proposals of the Black report are, therefore, by far the most important, not least because they can be effected without the expenditure of vast sums of money—which must appeal to the present mean Government.
Limitation of time prevents me from dealing with the proposals in detail and, in any case, many fall outside the direct responsibility of the DHSS. For example, the Black working group argues at length about the need for a comprehensive anti-poverty strategy. It points out that in 1966 it was estimated that 750,000 old-age pensioners were living below supplementary benefit standards—that is, below the poverty line agreed by the Government. Inevitably, if they are living below poverty level and are of advancing age, there must be a deleterious effect on their health.
The report states that
in 1967 a further report on a survey of families with children estimated that there were over 160,000 families with half a million children who were living under the new supplementary benefit scale rates"—1449 again, with health implications. If one is living below the poverty line, it follows that one has an inadequate diet, probably inadequate housing conditions, and so on. Table 6.2 of the report shows that, on the basis of DHSS estimates,in 1977 over 14 million people … had incomes of not more than 40 per cent. above the supplementary benefit level as laid down by supplementary benefit scales.Of those, over two-fifths were old-age pensioners. Among those folk there was, and still is, much evidence of multiple deprivation in diet, housing and environmental amenities such as open spaces, parks, recreational facilities and leisure activities of all sorts. All these contribute to the ill health or the inadequate health of millions of our people.The Black report made recommendations on the need for Government initiatives on diet, the over-consumption of alcohol, the provision of more recreational facilities in inner city areas, the encouragement of more television educative programmes on health education, more health education in schools and legislation to phase out all advertising of tobacco products. I notice that my hon. Friend the Member for Brent, South (Mr. Pavitt) is present. He has been active in successive campaigns in this regard.
The report also recommended the banning of sponsorship of sporting activities by tobacco companies. It is absurd arid a contradiction in terms for men and women to be seen playing games—whether tennis, cricket, football or whatever—to improve their health while killer advertisements are spread around the grounds. When the games appear on television it is often free advertising. The report also recommended annual increases in the duty on cigarettes in line with rises in income.
The report then proposed various other measures that should be taken outside the National Health Service. I do not expect the Minister to reply on these matters, but it is necessary to have co-ordinating machinery within the Government to make sure that all these recommendations are looked at in the round.
For example, I mentioned the need to abolish child poverty. If the question of children's health is to be tackled, a comprehensive attack should be made on child poverty. Black recommended that that should be adopted as a national goal for the 1980s. What more laudable objective could there be for the next decade? In my opinion, it is far more laudable than the projection of the Trident missile programme of £5,000 million in 15 years. In my view, and in the view of many other people, it would be infinitely better to spend £5,000 million on the attack against child poverty than on weapons of destruction.
Of course, that would require a redistribution of financial resources. I quote paragraph 30 on page 366 of the report, which says it will require
a redistribution of financial resources far beyond anything achieved by past programmes, and is likely to be very costly".Of course it is costly. All these programmes are costly, but they are no more costly than the programme on Trident. Nothing is more extravagant and destructive than that programme.I recommend paragraphs 24 to 27 relating to the increases in child benefit to 5½ per cent. of the average gross male industrial earnings. They say that larger child benefits should be progressively introduced for older children, that the maternity grants should be increased to 1450 £100, and that an infant care allowance should be introduced over a five-year period, beginning with all babies born in a year following a date to be chosen by Her Majesty's Government. Those are very ambitious proposals. The sky is the limit. Of course, no Government can accept proposals of that nature.
However, other recommendations in this part of the report would cost little or nothing. For instance, it is suggested that representatives of the DHSS, the Department of Employment, the Health and Safety Commission and the Health and Safety Executive, the TUC and the CBI should draw up minimally acceptable and desirable conditions of work.
In paragraph 9.81 on page 335 and elsewhere, the report calls attention to the inequalities in the death rate among people belonging to different occupational classes. Table 9.6 on page 377, in relation to males between the ages of 15 and 64, shows that death rates among people such as university teachers, company secretaries, office managers, Civil Service executive officers, Ministers of the Crown, Members of Parliament and senior Government officials are relatively low compared with those for coal miners, fishermen, labourers and other unskilled workers, including steel erectors and riggers. The report says, quite pertinently but not surprisingly:
There is still a tendency to accept poor working conditions as an inevitable accompaniment of particular jobs".One has only to visit a building site to see how primitive are the sanitary conditions, the canteen facilities, and even the safety of the job. Workers are far too ready to accept conditions of work which would not be acceptable among the professions that I mentioned.Recommendation 31 suggests that Government Departments, employers and trade unions should devote more attention to preventive medicine through work organisation conditions and amenities and in other ways. If we are to tackle our modern health problems in an effective manner, we need new Government machinery. It cannot be left to the Department of Health and Social Security. There must be greater co-ordination between Government Departments in the administration of health-related policies as outlined in chapter 9 of the report.
I end by making what I hope will be a constructive suggestion. I hope that within the next few months the Minister will, as part of his holiday task, draw up a detailed written response to the specific recommendations of the Black report, and especially those recommendations that are capable of being effected without the expenditure of vast sums of public money. During the past two years there have been two vital reports on health matters—the report of the Royal Commission on the National Health Service of July 1979, and the Black report on inequalities in health in August 1980. In addition, there was a comprehensive report by the Expenditure Committee in Session 1976–77 specifically on the subject of preventive. medicine.
There is no shortage of reports on the matter. There is no shortage of evidence of the vital need for a vigorous pursuit of preventive medicine policies. We have, however, been desperately short of a positive, vigorous and imaginative approach by the Government to the challenge that the reports present.
I hope that this short debate will have been an expression of the sense of urgency with which many hon. Members and many outside the House view these matters. I hope that the Government will take notice of it.
§ Mr. Laurie Pavitt (Brent, South)I rise briefly to make three points. First, I congratulate my hon. Friend the Member for Fife, Central (Mr. Hamilton). I underline his point that we must have a debate on the Black report at the earliest opportunity. Secondly, I wish to put on record my gratitude to the Minister, who undertook not to block the Bill on preventive medicine that I put before the House a short time ago. The Government did not block the Bill, nor did the Whips. It was blocked by the machinations of the tobacco industry.
Thirdly, I wish to underline the last point made by my hon. Friend. Because of the two reports, many of the working parties within the Department and a large number of research bodies set up within the Labour Party need not do their work again. There is sufficient material in those two reports for the implementation of a health policy that could put the NHS back on the road on which it originally started. They contain enough policies for the next four or five years. I hope that the various recommendations in the report receive the attention for which my hon. Friend has pleaded.
§ The Under-Secretary of State for Health and Social Security (Sir George Young)I have listened to the hon. Member for Fife, Central (Mr. Hamilton) speak many times about the National Health Service. His speech this afternoon was more restrained and persuasive than most. He and I can be accused of many vices, but over-eating is not one of them.
The Black committee comprised four distinguished people, who worked for the best part of three years and produced a mammoth 400-page report. At the end they concluded:
we do not believe there to be any single and simple explanation of the complex data we have assembled".The House will not expect me, within 15 minutes, to solve some of the persistent problems of inequality that the Black report and the hon. Gentleman mentioned.I am grateful for the opportunity to explain the Government's attitude to the report of Sir Douglas Black and his colleagues. I know that Labour Members pay considerable attention to the report's recommendations. My right hon. Friend and I have acknowledged that it contains much useful information. We have been pursuing a number of matters that are the subject of recommendations in the report. However, we have serious reservations, especially about its conclusion on the causes of inequality in health and some of the expensive recommendations to deal with them that are contained in the report.
The hon. Gentleman criticised the arrangements for distributing the report. My Department made it available for discussion in August last year. I understand that 2,600 copies have been sold by the Department. Except for a short period last year when stocks ran out, copies have been available to those who want them. The report is, of course, available to hon. Members.
The evidence in the report reveals that, in spite of a striking overall improvement in the health of the nation, there is generally little sign of health inequalities diminishing between social classes. As the hon. Gentleman said, there are some signs that they may even be increasing. The report proposes the expenditure of substantial sums to try to put matters right.
1452 I make two main criticisms of the report. First, there is no guarantee that if we implemented the recommendation inequalities would be eliminated. Sir Douglas wrote in a letter to the BMJ on 2 May 1981 that the persistence of inequalities in health was due
In the main to the very structure of our society.In a lecture earlier this year, Sir Douglas said that East Anglians, who in terms of average earnings and State funding have been about the poorest in the land for as long as reliable statistics have operated, had one of the lowest perinatal mortality rates, the greatest longevity and lower rates than the average for ulcers, coronary heart disease, drug addiction and alcoholism. That example points to the importance of factors other than economic ones in health.Even if we believed that expenditure would solve the problems, the resources are not available. My second criticism is that the report is much less forthcoming about the type of measures that might be implemented, given the constraints on public expenditure. I think that the Opposition have accepted that the report is somewhat unrealistic. It was discussed in the House on 27 October 1980. The right hon. Member for Salford, West (Mr. Orme) agreed that the Black proposals could not be
done overnight at a stroke. It would be impossible."—[Official Report, 27 October 1980; Vol. 991, c. 85.]The hon. Gentleman asked me about the costings. The research group prepared costings for only some of its recommendations and these are as follows: increase in child benefit £970 million, increase in infant care allowance £870 million, expansion of day provision £150 million, free school meals £200 million, universal allowance for disablement £24 million, special programme for deprived areas £30 million. The total is £2,244 million. That leaves out of account the costings of two other programmes—increasing the maternity grant and age-related child benefit. I have excluded some rather general recommendations that are difficult to quantify—for example, the cost of local authorities making provision for all types of housing need and other recommendations about standards of pay and welfare benefits.My Department has provided an up-to-date estimate based on November 1980 prices of the net cost, which is £3,683 million, to which one has to add an increase in the maternity grant, which would amount to £55 million, and age-related child benefits of £1,110 million. That produces a total of £4,848 million.
The research group proposed that some of its recommendations could be paid for by the withdrawal of the married man's tax allowance for families without children. One could do that. However, it would mean taking money away from one group and giving it to another. The Government have responsibilities for all members of society. They could not lightly take such a step. There are some recommendations that have little cost consequences, but the recommendations are not presented in such a way that enables them to be picked out in order of priority.
There are some problems with the methodology. I wonder whether mortality rates are the right way to measure health. I concede that they measure life, but I am not sure that they are the right proxy for measuring health. I also wonder whether it is right to look at the problem in terms of occupation and class rather than in terms of levels of income, housing and education. The working group suggested that there were inequalities in health care. The key problem is to relate health use to health needs.
1453 The lower income groups receive more health care in absolute terms, but the question is whether they receive more or less in relation to need. The working group based its conclusions on an analysis of the published tables from the General Household Survey. We have had another look at that and find that those on lower incomes do not receive less service than those in higher income groups in relation to need. There is some evidence to show that they receive more. A good deal more study of this complex problem is needed before we shall find the right answer. It would be a pity if the document came to be regarded as some sort of bible. The proper way to look at it is as a valuable mine of evidence and information.
We agree with some of the recommendations, particularly those on prevention, which the hon. Member for Brent, South (Mr. Pavitt) mentioned. We are reaching the point of diminishing returns as regards investment in acute medicine. If we want to see a substantial improvement in the nation's health, it will come about through preventive health measures and education. There are recommendations in the report on child accident prevention, health education, smoking, drinking and other matters. We attach great importance to this subject, and the guidance to health authorities, which we published in February—entitled "Care in Action"—devotes a whole chapter to ways in which health authorities can encourage prevention and healthy living.
Since the report was published we have issued, with the Department of Employment and the Health and Safety Executive, a discussion paper on "The Problem Drinker At Work". We have reached a new agreement with the tobacco industry on restricting the advertising of cigarettes. We have increased our grant to the Health Education Council by £1 million for special anti-smoking programmes, which are aimed at children and which feature Superman and Mr. Nick-O-Teen. I am glad to be able to announce that we are increasing our grant to Action on Smoking and Health by 40 per cent., to £112,000. ASH does excellent work, in partly neutralising the millions of pounds spent by the tobacco industry on persuading people to smoke. It is important to build on the change of opinion against smoking and to maintain the progress that has been made.
The vote on seat belts, which the House took on Tuesday, is evidence that, given the opportunity, the House would be prepared to legislate on matters that have traditionally been left to the individual. On a more controversial note, I invite the hon. Members for Fife, Central and for Brent, South to use their influence with their party. One of the Black committee's recommendations was that there should be regular annual increases in 1454 the duty on cigarettes, in line with rises in income, to ensure lower consumption. That is exactly what we did in the Budget and the subsequent measures. On 6 July, my right hon. and learned Friend the Chief Secretary said:
The real value of the duty on cigarettes has fallen substantially from past levels and this increase, together with the larger increase my right hon. and learned Friend imposed in the Budget, go only part of the way to restore the position. The duty…will be below the levels of 1974, 1975 and some earlier years."—[Official Report, 6 July 1981; Vol. 7, c. 74.]However, the Labour Party voted against the Budget increases and the subsequent increases in July. If the Labour Party will only accept the Black recommendations when they are expensive and will oppose them when they bring money in, it will take it a long time to implement the report. Perhaps we can see some consistency between the Opposition's Treasury spokesmen and their health spokesmen.I turn to the subject of pay and conditions at work. Most of the recommendations in the Black report fall to the Department of Employment. I should like to ask my hon. Friend the Under-Secretary of State for Employment to deal with the comments that have been made on that subject. I was asked to spend my holiday preparing a comprehensive response to the Black report. I had not anticipated spending my holiday in that way, and my family would be distressed if I did. However, I shall try to write to the hon. Gentleman and to explain how the Government will respond to the report's many recommendations.
The Government place a high priority on the nation's health. As my right hon. Friend the Prime Minister said on Monday, we have protected the National Health Service from the difficult decisions that we have had to take in other areas of public expenditure and we are proud of it. Moreover, we are complementing what the NHS can spend by encouraging private investment and expenditure on health. That is a slightly more controversial note. But we see that extra money coming in as being available for health care generally and perhaps taking some of the pressure off the National Health Service. I see the progress being made by encouraging health education, personal responsibility for health, and encouraging voluntary organisations to help in the personal social services and helping to complement the NHS.
That is the right way forward, given the difficult economic circumstances in which we find ourselves, rather than committing ourselves to the rather expensive solutions outlined by the Black report, which we are not absolutely convinced would deliver the goods.