HC Deb 20 July 1990 vol 176 cc1315-51

Question again proposed.

11.45 am
Mr. Alex Carlile

I am grateful for the opportunity to resume the sentence that I was in the middle of when we reached the statement.

I had been just about to commend the hon. Member for Ealing, Acton (Sir G. Young) for his well publicised energy on a bicycle. He has done much for the image of those hon. Members who strive to draw attention to the need for public health awareness. However, I fear that, like many cyclists, the hon. Gentleman finds riding a bicycle in central London a risky business not only because of traffic problems, but because of the incredible pollution that hits every cyclist as he tries to cycle along the roads of London.

Nevertheless, cycling is undoubtedly a healthy activity and everthing possible should be done to enable cyclists to use the streets of London in a far more congenial way than is available at present.

One thing about cycling concerns me on safety grounds. I am referring to the prevalent use of Walkmen by cyclists. I do not know whether the hon. Member for Acton listens to a Walkman as he cycles —

Sir George Young (Ealing, Acton)

indicated dissent.

Mr. Carlile

I am glad to see the hon. Gentleman shaking his head about that. It seems dangerous for cyclists to ride in the rush hour listening to loud music. which obscures the sound of the approaching traffic. Even as a car driver, I find it useful to hear the sound of the traffic around me, and I am sure that cyclists should find it even more useful.

This Friday morning, right hon. and hon. Members who are smokers are conspicuous by their absence—with one or two exceptions. I wonder whether they find that a four-day week is about as much as they can manage, whereas those of us who do not smoke can also leap to our feet in the House on a Friday morning.

We face an incredible number of hazards to our health, which are increasing daily. We have heard quite a lot this morning about tobacco advertising and about the sponsorship of sport by tobacco companies. It is extraordinary that a cigarette company should sponsor a grand prix for racing cars, for example, because if one were to light up a cigarette in the pits, I suspect that one might run the risk of causing a major disaster.

Equally, it seems extraordinary that the most energetic form of county cricket—not the form that I prefer, which is the slower five-day variety—is sponsored by a tobacco company. I doubt whether some of our more athletic young cricketers who score the largest amount of runs on a Sunday would find it easy to achieve their greatest successes if they were heavy smokers.

The increasing use of tobacco by young people, especially by those under 18, is a particular hazard to their health.

We have all heard the evidence about the number of young people in that age group who become alcoholics before they reach the age of 18. That is a shocking fact.

In my years as a criminal lawyer, I have noticed all too often how crime is committed by young people who have drunk to excess. It is committed not by people who are blind drunk—they are usually incapable of committing crime—but by people who have simply had rather more than they can safely manage which makes them, to use the psychiatrists' word, disinhibited, to the extent of committing crime. Such people tend to ask their lawyers to tell the judge that they were drunk, as if that was a mitigating factor.

Young people ought to understand that crime is just as serious if it is committed when they are disinhibited by drink as at any other time. The Government—indeed, all political parties and all groups with an input in education and which have contact with young people—should stress that alcohol leads to crime. There is a direct relationship between alcohol and crime. I am not talking about shop windows being broken. I am talking about the commission of offences such as rape and robbery as a result of young people becoming disinhibited by taking drink.

We continue to face increasing hazards to our health in the workplace as a result of industrial practices. The Health and Safety Executive, under its excellent chief inspector of factories Mr. Linehan, has done a great deal to improve the position. However, the funding of the Health and Safety Executive still leaves a good deal to be desired. I should like the executive to send factory inspectors out on a much more frequent random basis, particularly to smaller factories and workplaces. It is often in smaller workplaces that the worse practices are followed—for example with machine tools—which lead to many wholly unnecessary accidents.

I represent an agricultural constituency. Indeed, I believe that it is the most agricultural constituency. There are far too many agricultural accidents. A better funded agricultural safety inspectorate could do much to obviate that.

A more general issue affecting public health is town and country planning policies. They way in which they are operated causes a great deal of anxiety. Although there is a tendency to allow areas which were not traditional industrial centres to be developed—I commend the success of the Development Board for Rural Wales in my constituency and neighbouring areas on that score—town and country planning policies continue to concentrate jobs in conurbations. That compels huge numbers of people to travel to work on congested routes, which often leads to accidents, stress and consequent disruption of family life.

Those of us who sometimes drive alone in the rush hour from our London homes to this palace—I admit with some shame that I am one—are all too accustomed to the flash of anger which the rush hour can cause as one sits in one's car surrounded by other people who travel to work alone in their cars in this great city of London. I should like far more energy to be spent on finding imaginative ways of improving our public transport system. The state of London Regional Transport is very bad, as those of us who use it frequently can testify. The buses are unpredictable and infrequent—

Ms. Harriet Harman (Peckham)

And filthy.

Mr. Carlile

—and filthy.

The underground is unpredictable, sometimes infrequent, and filthy. Indeed, recent weeks have seen the virtual closure for several days of the District line, a line used not only by many Members of parliament, but, more importantly, by vast numbers of members of the public who try to lead reasonably well-organised lives in London. The consequence of that closure is that they all get into their cars and sit in queues in the rush hour suffering stress and anger with all the consequences to the health that that causes.

The hon. Member for Preston (Mrs. Wise) mentioned homelessness and the consequences for people's health. When I first came to the House in 1983, there was no homelessness in my constituency to speak of. There may have been a small handful of people who were homeless, but if people in need came to me and asked me to help them to obtain a house of flat, the Montgomeryshire district council or the Development Board for Rural Wales could generally help within a reasonably short period. That is no longer so.

Newtown is the largest town in my constituency, with about 11,000 inhabitants. There are at least 50 young people living rough there, many of whom have good, regular jobs in factories and service industries in Newtown. There is a waiting list for homes of between 400 and 500. That is only part of the constituency. It is a reasonably affluent rural area. It has low wages but low unemployment, so it is reasonably affluent, taken overall. We have a waiting list for rented accommodation of about 1,000 people: those are the ones we know about.

I have one of the smallest electorates in the House, although I have one of the largest constituencies geographically. If we have long waiting lists in Mongomeryshire, what on earth is it like in other places with much denser populations? From what I have read, it seems that, particularly in London, the problem of homelessness is desperate.

We know what homelessness does to young people, because we can see it for ourselves. There is a risk that young people who are homeless will be driven on to the streets, into crime, into drink and, in some cases, into prostitution. Of course, it does not happen to all of them;. but the real risk does not seem consistent with the housing policy of a Government seeking to promote public health seriously. If young people are to be healthy, it is vital that they are given a reasonable prospect of having a home.

I am also worried about the privatised water industry. Again I can relate the matter to my constituency. The privatised water companies have inherited a large and elderly sewerage burden. In Montgomeryshire, in the town of Welshpool there is an historic problem of poor drains and decrepit sewers. A further problem which affects areas such as mine must be tackled. A statutory responsibility has rightly been placed on the district council to ensure the cleanliness of private water supplies. I am willing to lay a substantial bet that most of the private water supplies in Montgomeryshire are a good deal more healthy than the public water supply yet it is right that we should be sure. I make no complaint about the public water supply as such, but there are some excellent private water sources.

In my constituency, over 4,500 dwellings have a private water supply. That is an extraordinarily high proportion when one considers that the area has a population of not much more than 50,000. To fulfil its statutory responsibilities, the district council will have to foot an enormous bill, running into hundreds of thousands of pounds. It cannot meet that bill. It simply cannot pay for its responsibilities unless the Government are prepared to devote substantial extra resources to it. I have written to the Secretary of State for Wales and he has set up a consultation exercise to deal with the matter. We await the result with keen anticipation.

I hope that the Minister and her colleagues in the Department of Health will pass on to the Secretary of State for Wales the view that it is extremely important that resources should be made available to enable a district council, such as Montgomeryshire, to test private water supplies, without detriment to the other services which it provides. In other words, extra money should be supplied for that purpose.

I join in the congratulations to the hon. Member for Chislehurst (Mr. Sims) on choosing this important subject for debate today. He and I have the privilege of serving together as appointed lay members of the General Medical Council. Although our appointment is fairly recent, I know that he, like me, already takes it seriously and regards it as extremely interesting and important. We have the opportunity to learn a good deal about the way in which modern general practice operates. Certainly, I did not know much about it before. Some of it has been a source of pleasant surprise, but some of it has caused me a good deal of alarm.

The health of the nation is not assisted by the prevalence of a substantial number of single-handed general practitioners, particularly in our cities. I do not want to run down every single-handed GP because undoubtedly, some are among the best. Generally speaking, a practitioner who is working on his own is forced to use contractual on-call services for night visits and days off, with all their unpredictability. Generally, they are unsatisfactory. He is not providing the same level of service to the community as a practitioner who operates in a group practice, which has duty doctors on call, most of the time at least, servicing the patients of the practice.

Mr. James Arbuthnot (Wanstead and Woodford)

As always, I agree with a great deal of what the hon. and learned Gentleman says. In my constituency, there is an abnormally high level of single-handed practitioners. One result is that constituents who are unhappy with the idea of going to a locum doctor if their GP is on holiday, spend far too much time going to the casualty departments of local hospitals. That is putting a huge strain on local hospitals. My constituents then complain that the waiting lists in casualty departments are too long. It is hardly surprising if the health service is misused in that way. That flows, at least partly, from the prevalence of single practitioners.

Mr. Carlile

I agree entirely with the hon. Gentleman. It is not merely casualty departments that are affected. Recently, the professional conduct committee of the GMC heard a case—in which, I hasten to add, the doctor was found not guilty—of serious professional misconduct. A family was anxious about the mother—the wife of the complainant. The patient, having had an unsatisfactory response from an on-call service, twice called out an ambulance. The family was uncertain whether to ask the ambulance to take her to hospital or to wait for a GP to turn up. The end result was detrimental to the patient's health.

There are two important aspects to this GP problem. First, it is a matter of sheer management common sense in relation to the organisation of a medical practice to have group practices. I speak with some indirect experience, because my late father was a GP. When I was a child he worked single-handed, and as I grew up he went into what is now a well-developed and successful group practice in the north-west of England. My friends in that practice undoubtedly offer a far better-organised service than was offered in the early 1950s. It is much better for the patients and more efficient for the doctors in management terms if they are working in a group.

The second aspect can be highlighted by an analogy with the Bar. The Bar is a collegiate profession, as are most modern solicitors' offices. Practitioners work together in groups and exchange ideas. We are sometimes accused at the Bar—my wife always accuses us of this—of being a gossipy profession; in a sense, that is true, but it is only a symptom of the fact that, when problems fall on to our desks, we share discussion of them.

It is certainly of great benefit to the client that we can bounce large numbers of ideas and problems off our colleagues. Senior colleagues have experience, and junior ones are full of ideas. Medical practice, particularly general practice, would benefit greatly from an increase in size of group practices, so that collegiate aspect of the learned profession of medicine could be more effective.

The personal relationship between the individual patient and the individual doctor has diminished, because it is often difficult to see the doctor on whose list one is registered. That does not matter greatly, unless a patient is seriously or chronically ill, in which case most practices ensure that one doctor sees the patient regularly. Much can be gained from allowing that one-to-one relationship to slip a little and replacing it with medical efficiency and patients' confidence that the doctors will know about the problems which they are asked to treat. That is important for all of us.

Over the years, we have seen a considerable shift of emphasis within dentistry. At one time one thought of the dentist as the person who pulled teeth; now he is the person who saves teeth. Dentistry has made enormous strides, from treatment to prevention. In the years to come, the same can be done with general medicine. The right place to invest money for the future, while maintaining a good treatment service, is in the prevention of illness. I urge the Government to invest ever greater sums in that direction.

12.7 pm

Mr. Toby Jessel (Twickenham)

The whole House has heard the hon. and learned Member for Montgomery (Mr. Carlile) with great interest. I warmly agree with his support for the concept of larger, joint general practices. They will come about increasingly and will assist in preventive medicine. I was interested in his reference to dentistry. Although he did not tell the House whether he was in favour of the fluoridation of water, I noticed that earlier in his speech he mentioned water, which is important in preventive medicine.

I warmly congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) on his motion on preventive medicine. The House and the country are in his debt. The central part of his motion is that this House recommends the adoption of healthier lifestyles to help protect against major disabling and premature death causing conditions such as heart disease, stroke and cancer". Our prime object must be to delay or defer death for as long as possible. In the Gilbert and sullivan opera "The Yeoman of the Guard" the character Fairfax, who was under sentence of death, began his famous song: Is life a boon? If so, it must befall That Death whene'er he call, Must call too soon. Fairfax, a young man when he sang that, was awaiting execution. One often hears the young say, "I do not want to live over 80". They may feel differently on reaching 79. [Interruption.] I hope that the hon. Member for Peckham (Ms. Harman) will chat to her hon. Friend the Member for Glasgow, Pollok (Mr. Dunnachie) a little more quietly because I am finding it distracting.

Enormous improvements in medicine have occurred this century, and particularly in the last 10 years. The Library informed me this morning that the average expectation of life for a child born in 1986—the last year for which accurate figures are available—was 721 years for a boy and 77.8 years for a girl. Apparently girls and women have an expectation of life five and three quarter years more than boys and men.

That differential has greatly increased in recent generations. For example, a boy born in 1932 had an expectation of life of 58.7 years, and a girl, 62.9 years. That gave an average difference of four years, where as today it is five and three quarter years. It is not clear why that should be the case, but it is clear that the expectation of life has improved substantially for both sexes.

There has been a remarkable improvement in the infant mortality rate in the last decade—and the Minister may have up-to-date figures. The trend given in the Library figures shows that in 1981, the infant mortality rate was 11.2 per thousand and in 1989, projected, it was 8.4 per thousand. It is remarkable that the infant mortality rate should have dropped by about a quarter in the eight years 1981 to 1989.

There have been other significant improvements in mortality rates. I note in the analysis of causes of death given in the official year book for Britain that, for example, in respect of bronchial disease, the number of deaths from pneumonia dropped from 54,000 in 1981 to 26,000 in 1988, a fall of more than half in the number of deaths from pneumonia in seven years. The number of deaths from bronchitis and emphysema dropped from 17,000 in 1981 to 9,000 in 1988, a drop of nearly a half. It seems highly likely that preventive health measures had much to do with that improvement.

My hon. Friend the Member for Ealing Acton, (Sir G. Young) who I am pleased to see has returned to his place, referred in his interesting speech to the wearing of seat belts. In 1981, the year when seat belt wearing in the front two seats of cars became compulsory, the number of deaths from road accidents was about 5,500. By 1988, that number had dropped to 4,500. I have no doubt that in the significant drop of 20 per cent. in the number of deaths from road accidents during those years the introduction of seat belts played a part.

One could go on giving examples of improvements, but there remain two great killers, cancer and heart disease. The number of deaths from heart disease amounts to nearly half of all deaths. In 1988, it was 268,000 out of 568,000. The number of deaths from cancer of all sorts totalled about 144,000, or about a third of all deaths.

We must all die at some time and from some cause, but undoubtedly those two areas of illness provide great scope for preventive medicine. That is why my hon. Friend the Member for Chislehurst is right to refer in his motion to heart disease and cancer. He is also right to advocate the widespread dissemination of advice and information in the context of the national health service.

In welcoming the increasing emphasis on preventive medicine I commend the excellent work of the Maddison clinic at Teddington in my constituency. It was founded by the late Dr. Maddison to enable elderly people to have regular health checks and be given information about, among other things, what to eat to protect their health. It is a highly popular institution which is widely patronised.

There are occasional rumours about the clinic closing. Such rumours were circulating seven years ago. We conducted a great campaign, and it was saved. There have been rumours in the past few months to the effect that it might close, but I am glad to say that the general manager of the Richmond, Twickenham and Roehampton district health authority has confirmed to me that the clinic will remain open.

I hope that the Minister will note what I have said about the valuable work done by that clinic and what the district health authority has said about it not closing. I emphasise that because some local general practitioners have shown a noticeable lack of enthusiasm for the clinic; they prefer patients to receive all the health checks from the GPs and not from the clinic. I repeat that the clinic is extremely valuable, and I hope and believe that it will long remain to serve this and future generations of elderly people resident in my constituency.

The concept of preventive medicine contains a large proportion of what can be done to reduce the incidence of premature death. I would not object to an element of compulsion, as occurred with seat belts, or as would be the case with water fluoridation. We need more discipline in preventive medicine, as well as compulsion, and we need more incentives. We should pay doctors more to achieve a high target of immunisation of babies against diphtheria and smallpox. That is part of the purpose of recent legislation, which we were right to pass, because it should be compulsory for babies to be immunised in that way. Parents who are so ignorant as to seek to prevent immunisation should be overridden by the law, as in the case of seat belts.

Mrs. Wise

Is the hon. Gentleman aware that vaccination against smallpox no longer takes place?

Mr. Jessel

Well then it ought to take place, and so should the immunisation against diphtheria because one never knows when such things will break out again. There should also be other vaccinations.

I can tell the hon. Member for Preston (Mrs. Wise) of the greatest episode of compulsory immunisation in recent times when I was on a delegation in 1971, 10 million refugees went from Bangladesh to India because they were being ill treated by the Pakistan army, based in West Pakistan. A massive number of refugees had to live in the most appalling conditions, in the ditches and fields in the open, when they went into India. The Indian Government wanted to feed those 10 million people, look after them and protect their health until they were able to get back into their own territory of East Bengal.

But there was a terrible threat of a cholera epidemic. The Indian Government insisted that every one of those refugees was injected against cholera and produce a certificate of inoculation before being entitled to receive a food ration card. That must sound tough, but it was toughness based on the motive of compassion. It forced everyone to have an inoculation against cholera before they could get food. That was done and in that way, the number of deaths from cholera was kept down to 3,000 out of 10 million refugees. Without that policy, probably hundreds of thousands of people would have died of cholera. That is what I mean by compulsion in preventive medicine. The Indian Government were right, and that episode made a great impression upon me. Ever since, I have believed that there is little place for freedom in preventive medicine, and there should be more compulsion, discipline and inoculations where necessary.

Mr. Arbuthnot

I am listening to my hon. Friend with increasing nervousness. About two centuries ago, if my hon. Friend's philosophy were followed, it would have been compulsory to have cupping and blood-letting of everyone as a matter of course. Medical science moves on, and from time to time things that are thought to be good are later thought to be bad. If such progress can be achieved through encouragement and incentive, that is all to the good, but doing it through compulsion makes me wary.

Mr. Jessel

I am sure that if my hon. Friend had been a Member of the House in the late 1970s and early 1980s, he would have voted against the compulsory wearing of seat belts. We had passionate debates on that subject when people who thought like my hon. Friend thought that it would be a monstrous interference with individual liberty for people to be compelled to wear seat belts and people should make their own decision about it. The other argument prevailed, and we are saving 600 or 700 lives a year, preventing 10,000 serious injuries a year and saving the National Health Service £8 million or £9 million a year from treating people who would have been severely injured on the roads and might, in some cases, have been human cabbages and taken up beds in national health service wards, which are now available, instead, to other people who need the treatment.

I am, at heart, as much of a libertarian as my hon. Friend, except in health matters. That may sound inconsistent, but my hon. Friend should remember the wise words of Emerson: A foolish consistency is the hob-goblin of little minds, and … Speak what you think to-day in words as hard as cannon balls, and to-morrow speak what to-morrow thinks in hard words again, though it contradict everything you said to-day. It is a most barren and foolish form of politics for people constantly to try to look for remarks, quotations or attitudes that are in conflict with what someone has said or thought in a different context or at a different time. We have to say what we believe is right at any particular time. It seems monstrous that young babies should not be protected against the risk of diphtheria because they happen to have a misguided mother. It is better to make a few mistakes than to make a lot.

I remind the House that a few years ago we were constantly being told that there were 2,000 deaths a year from cervical cancer in women and being asked why the Government and the House of Commons were not doing more about it. People said that something must be done about it. We have done something about it in the recent legislation. We have introduced targets for general practitioners to ensure that a certain percentage of women have checks, cervical smears and screening against cervical cancer. Now, those same people who were saying that we must do something about it are beefing and complaining, whining and whingeing—the usual lobby—saying that it is an interference with their professional liberty. We should disregard that sort of lobby and get on with what we believe to be right. It is wrong to pay too much attention to people who complain in that way. In public life, sometimes we must lead public opinion and not just follow it. It is right to do so in this matter.

My hon. Friend the Member for Chislehurst, who introduced the debate, was one of the supporters of compulsory seat belts, as was my hon. Friend the Member for Acton. If I may say so, I was also active in that. That was the right philosophy and I regard the prevention of accidents as part of preventive medicine.

Much of the speech of my hon. Friend the Member for Chislehurst was devoted to smoking. He is famous for the lead that he has given in that subject. He should have more backing from the House as a whole and from within my party. In an intervention in his speech, I mentioned that it is more difficult to book a non-smoking seat in a crowded aircraft than a smoking seat. I suggested that he should invite the Minister of State for Health to make representations to Ministers with responsibility for transport that there should be international co-operation among Transport Ministers from different countries to remind airlines that they should keep ahead of the public demand for that instead of lagging behind it, and ensure that there are more non-smoking seats available to meet that public demand in view of the decreasing proportion of people who habitually smoke when travelling.

There should be higher taxation on cigarettes. The tax on cigarettes should go up in every Budget systematically and regularly so that over a period of five or 10 years cigarettes become at least relatively twice as expensive as they are. Whenever they have gone up a little, due to tax changes introduced by successive Chancellors of the Exchequer, there have been complaints from tobacconists in my constituency, but never by more than three or four of them. People quickly settle down to a 5p or 10p increase in the price of cigarettes. The Government then have the extra revenue to spend on the health service or whatever they and the House believe to be right. I should like the tax to be increased progressively, year by year, until cigarettes become much more expensive. I agree with my hon. Friend the Member for Chislehurst that cigarettes should not be included in the cost of living index.

I am greatly concerned about the number of children who smoke, and particularly about girls at school, who seem to smoke more than the boys. I do not know why that is and I would be grateful if anyone could throw any light on it, but it is a worrying trend. I am glad to have heard from my hon. Friend the Member for Acton that the Home Office intends to tighten up its regime for the prosecution of shopkeepers who sell cigarettes to minors.

Cancer remains a major cause of death, and within the total figures there has been no significant reduction in the number of deaths from lung cancer. There were 35,000 in 1988, compared with 34,000 in 1981. That remains a great cause for concern because it is preventable to a large extent.

I turn now to heart disease. We are all told these days that we must cut down the proportion of cholesterol in our diets. My hon. Friend's motion refers to the widespread dissemination of advice and information. But in some respects there is not yet enough information about diet. I could not help noticing when there was anxiety about beef three months ago and about eggs 18 months ago—[Interruption.] I must ask my hon. Friend the Member for Billericay (Mrs. Gorman) to whisper a little more quietly as I find her distracting, too—

Mr. Irvine Patnick (Sheffield, Hallam)

That is a sexist attack.

Mr. Jessel

It is not. I am always interested to hear what my hon. Friend has to say—

Madam Deputy Speaker (Miss Betty Boothroyd)

But the hon. Gentleman would prefer to hear it when the hon. Lady takes the Floor and makes her own speech.

Mr. Jessel

Absolutely, Madam Deputy Speaker, and I am grateful for your assistance.

I could not help noticing when we heard so much about eggs in the winter 18 months ago or about beef in the spring of this year that hardly anyone mentioned that eggs and beef contain a high proportion of cholesterol, which enters into people's diets.

Fish are another area of diet. We are all told to eat more fish, but there is little reference to shellfish. It is far from clear whether a healthy diet includes shellfish in the same way as it includes flat fish, white fish or oily fish. At least one eminent heart specialist, who is a fellow of the Royal College of Physicians, has written that shellfish are just as healthy as white fish and that there is no reason why we should not all eat a large amount of them. But that is not reflected in the information put out by the societies that advise on diet, so there is a conflict of information.

We should remember that if we are told to reduce our intake of milk, cream, butter, cheese, eggs and meat, there is not much left that does not contain those foods. We cannot live all the time on kippers, cabbage and aspirins. If people could include a substantial proportion of shellfish in their diets that would add to the variety of what they can feel free to eat.

There are two main classes of shellfish: crustaceans and molluscs. Crustaceans are crabs, lobsters, shrimps, prawns and crayfish. Molluscs include winkles, whelks—which are described as sea snails on menus in France—clams, mussels, cockles and oysters. It is sometimes suggested that shellfish, whether crustaceans or molluscs, are luxuries, but I see the hon. Member for Peckham in her place, and I hope that she will not mind my mentioning that in 1964 I was the Conservative candidate for Peckham; indeed, I had been the prospective candidate there since 1960, which may well be before she was born. When I was there I had a drink in every pub in Peckham. They then numbered 117, and at least 20 of them had shellfish stalls outside. Peckham is not one of the richest areas in the country, as I am sure the hon. Lady would not deny. The consumption and enjoyment of shellfish was widespread throughout the whole of society in Peckham.

Of course there can be tremendous changes in relative food prices. We all know that salmon has come down in price. I was told by the main fishmonger in Twickenham, Mr. Ray Sandys, that the price of salmon last week was lower than the price of cod. That is absolutely astonishing: no one 10 years ago would have believed it possible. We all know that chicken is now much cheaper than beef, and 50 years ago it was the other way around. The same applies to certain shellfish.

When Lewis Carroll wrote "The Walrus and the Carpenter" in the 1880s, the oysters which feature prominately in that poem were a dish regularly and frequently eaten by working men in London. It would not have been surprising in those days for carpenters to eat oysters; these days, oysters are more likely to be consumed by yuppies. I believe that the wheel will turn full circle because, owing to improved fish-farming methods in Brittany and all along the west coast of France—methods which I hope will be extended to include places like Whitstable and Colchester in this country—the price of oysters has gone down. One can now buy 12 big ones at a fishmonger in Brittany for 20 francs, which is £2. I believe that it will not be long before some enterprising business man finds a way of importing oysters into Britain far more cheaply, so that their dissemination can be much more widely enjoyed among the population as a whole. In the context of preventive medicine, it is all the more important that we should know whether oysters are good for health and ought to be enjoyed as much as possible.

Next, I turn to eels. When we are told by health experts that we all have to eat more oily fish, they invariably mention herrings and kippers, but they make little mention of eels. Jellied eels are a traditional British dish, and they can be bought outside pubs in Peckham and outside a few pubs in Twickenham, which I have the honour to represent.

We should be told whether the consumption of eels ought to be encouraged to promote health, as well as that of kippers and herrings. They are high in calories—that is known—but they are a delicacy that is enjoyed less and less often than used to be the case, because so many people have a snobbish attitude towards eels. They think jellied eels in particular a proletarian dish, although smoked eels are considered more smart or eels in a green sauce, as one would eat them in Belgium or Holland. I want my hon. Friend the Minister for Health to obtain departmental advice, and to let me know in writing whether eels are as healthy as herrings and kippers. I shall make the result of this inquiry known in my constituency.

I now turn to lobsters. I spoke of food farming in relation to oysters which could make them much cheaper here. Recently I was on a visit to Canada, where I was representing the Council of Europe at a conference in Ottawa on global warming and the ozone layer. I flew back via Toronto. There is in the heart of Toronto a restaurant where one can eat as much lobster as one likes for 24 Canadian dollars, which is about £13. It is analogous to the carvery that one might come upon in a British restaurant, where people can eat as much pork or beef as they want for a certain sum.

I went into this place, and I must confess to the House that I ate seven lobsters for 24 Canadian dollars. I had never had more than half a lobster in my life before, so it was a tremendous treat to eat seven lobsters. They told me in that restaurant that the record was 35 lobsters. I did not aspire to emulate that; I might have expired if I had.

I have never felt better than I felt on that occasion. Lobsters have become much cheaper in Canada because there is farming of lobster taking place, either in Hudson bay or Newfoundland—I do not know where exactly. If it takes place there, presumably it can take place around the coast of Scotland and I think that lobster will become much cheaper here in future years. We should be told whether lobsters are a healthy diet so that in future we know, because if we are not told, we shall not know.

Mr. Arbuthnot

My hon. Friend has several times mentioned fish farming, but I wonder whether this is the best route to healthy eating. Some of the fish farming in Scotland produces, for example, salmon that are fatty because they do not have the proper lifestyle of wild salmon. They do not taste nearly as good, and presumably they are not nearly as healthy for us as wild salmon. I should have thought that the same would apply to lobsters. While I am sure that one and even two lobsters would be a healthy part of one's diet, 35 are probably not.

Mr. Jessel

I did not eat 35, I ate seven. I am grateful to my hon. Friend for his intervention because he raises an important point to do with whether farmed salmon are a healthy part of a diet in terms of preventive medicine. As I said earlier, the country has been advised by the Department of Health and oily and fatty fish are good for health, and it mentioned herrings and kippers. I asked my hon. Friend the Minister for advice about eels, but now my hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) asks about fatty salmon. He believes that salmon that are farmed are more fatty than salmon caught in the wild on the River Tay. In view of the fact that price of salmon fell last week below the price of cod, the public should be told whether salmon, albeit slightly fatty salmon, is as healthy as other types of salmon or other fatty fish such as herrings, kippers or, dare I say it, eel.

I think that I have said enough about fish and I now turn to the important subject of back pain. The national headquarters of the Back Pain Association is at Teddington, in my constituency, where it was founded by Mr. Stanley Grundy CBE, who happens to be the patron of my constituency Conservative association. He is an industrialist, and he is extremely fit. The Back Pain Association has been running for about 15 years. This is a subject in which my hon. Friend the Member for Bournemouth, East (Mr. Atkinson) takes a great interest, because he has the Anglo-European College of Chiropractic in his constituency.

I believe that much more can be done to relieve the country of the scourge of back pain, by preventive health measures. People do not usually do anything about back pain until they are hurt and afflicted by it. If only people learnt to bend in the right way when picking up heavy articles, and were trained at an earlier age in physical recreation and physical training classes at school, the incidence of back pain would be greatly reduced. Much can be done to prevent it.

For example, far too many nurses—I mention them in particular because this has to do with the national health service—suffer from back pain because, when they are lifting patients, they do not follow the instructions that they have been given on how to stand or bend their knees when lifting patients or turning stroke patients in bed. Back pain is not a glamour cause in the health service or in the charitable sector, but it afflicts a great many people, and I should like the Government to devote more of their time and resources, and more of their share of the preventive medicine budget, to the prevention of back pain.

Earlier I mentioned fluoride. I used to represent the Greater London council on the Metropolitan water board—when it was the forerunner for Thames Water. I took an interest in the fluoridation of water. I ask my hon. Friend the Minister to report to the House, either now or at some convenient time, what progress is being made. The great law suit in Strathclyde three or four years ago—a case to end all cases, which lasted for many months and took massive medical evidence—clearly established that fluoridation is not only safe but is the most effective measure that can be taken to protect children's teeth. Unfortunately, we are making rather slow progress. I hope that the whole process will be bucked up and that my hon. Friend will give us some information about it. I did not give her notice that I intended to raise the matter, so I should be content to accept a letter from her if it is not convenient for her to reply now.

Mr. Ian Taylor (Esher)

I am grateful to my hon. Friend and neighbour. Is he aware that the chairman of the anti-fluoridation campaign lives in my constituency? I listened with interest to what my hon. Friend said and I wonder whether he would like to receive correspondence from my constituent, rather than my constituent writing to me.

Mr. Jessel

No, I would not. I have had correspondence from the person in question for some 20 years.

Mr. Sims

Have not we all?

Mr. Jessel

Indeed we have. I admire the gentleman's tenacity, but he never seems to learn anything. He just churns out the same old stuff, and I see no point in reading it again. I do not want to hear from him. Indeed, I once had to threaten to sue him. I hope that the process of fluoridation will now proceed more rapidly.

I was pleased to hear the hon. and learned Member for Montgomery refer to water, because water is the basic foundation of health. A year ago, when water was still nationalised, some horrible green midges appeared in the pools of water waiting to go into the water supply at the waterworks at Hampton. Since water was privatised, those green weevils have not reappeared. That is an argument in favour of the privatisation of water.

I have one complaint about the water administration, and it is that the water pumping station—

Mr. Alex Carlile

Does the hon. Gentleman believe that there is a cause and effect relationship between the privatisation of water and the disappearance of those monsters? If so, can he explain why quantities of green algae have now appeared in water sources in Wales?

Mr. Jessel

The green things that appeared in my constituency were not algae; they were midge larvae. They wriggled, they were shown on television and they alarmed a great many people, even though they were perfectly harmless. I do not know whether the algae are harmless, but I am sure that they do not wriggle. They are therefore less likely to bring about fear, anxiety and despondency, and so are a less worrying matter.

I want the waterworks in my constituency to stop sounding a hooter at 9 am. It is a Victorian relic summoning people to work and it annoys those of my constituents who are still asleep—and there are a few. I hope that the chairman of Thames Water will stop the hooter noise forthwith, after which I shall cease complaining about it.

12.49 pm
Ms. Harriet Harman (Peckham)

It is a challenge to follow the hon. Member for Twickenham (Mr. Jessel), who has much in common with the green things that he found in his water supply: he too is perfectly harmless but frightens many people.

I am grateful to the hon. Member for Chislehurst (Mr. Sims) for taking the opportunity provided by his success in the ballot to debate such an important topic, and for drafting a motion with which I and many other right hon. and hon. Members agree. His speech was wide ranging and struck the balance interestingly between private and Government responsibility.

Every individual has a responsibility to take care of themselves, and it is the responsibility of every parent to care for the health of their children. The Government also bear a major responsibility in caring for the nation's health—to promote good health and to prevent ill health—but they are failing to meet it. There has been progress in cutting deaths from preventable disease, but it has been too slow. Heart and liver disease and lung cancer are still major killers, but many deaths from them could be prevented.

We know much more now about the causes of disease and of accidents, and about their prevention. We know of the link between alcohol and liver disease, smoking and lung cancer, poverty and ill health. That knowledge places a moral obligation on the Government, which they should discharge by setting targets for preventive medicine and formulating strategies that will meet them. They should also monitor progress. That will not happen by itself, so the Government must take the lead.

Of course there must be a partnership between individuals, local authorities, health authorities, industry, and the Government, but they must take the lead. The reason they are failing to do so is that all their health initiative and enterprise is bogged down and tied up with their efforts to press ahead with national health service reforms that the public do not want. If one goes to any district health authority or family practitioner committee, one finds it discussing not public health strategy but how it can manage to make ends meet and to implement the Government's ludicrous reforms.

A further obstacle to the Government being the real champion of preventive medicine and good health promotion is their hostility to planning and regulation, which, as other hon. Members have remarked, are a vital element in maintaining public health. Nor are the Government prepared to invest the resources necessary to improve it.

I shall mention some of the aspects involved, though I am afraid that I shall not range as widely as the hon. Member for Twickenham. I hope to shed more light on family planning than he was able to do, but I cannot compete with the hon. Gentleman when it comes to the price of lobsters in Toronto.

Lung cancer, which is caused by smoking, is a major killer. We know that smoking is also a major cause of disability and premature death. Recently, I visited a hospital in my constituency whose patients included those who had just undergone amputations as a result of circulation problems caused by smoking. I went from ward to ward seeing babies born prematurely because their mothers smoked, and adults struggling to breathe as they tried to talk to me about smoking. The toll that that habit takes on public health is intolerable. The facts and figures, as the hon. Member for Chislehurst said, are appalling.

We did not always appreciate how dangerous smoking can be, but we do now. I remember an advertisement from the 1950s which was shown recently on television. It was a public information advertisement to encourage people to go to see their general practitioner. A woman was invited into the GP's surgery but one could hardly see the GP for the cloud of smoke from the fag he was puffing on. He invited her to sit down and, in order to show how to take it easy in a GP's surgery, and how a GP can set patients at their ease, he offered her a fag, she lit up and the cloud of smoke deepened.

One of the people I met in hospital who had had an amputation said that he was given cigarettes as part of his rations in the armed services. He said that he had not chosen to be a smoker but had become addicted to smoking at a time when information about the link between smoking and ill health was not known.

Now that we have information about the effects of smoking and ill health, we must have clear and unambiguous policies to cut down smoking and prevent ill health. The facts are appalling. In its strategy document for 1990–95 entitled "Strategic Plan", the Health Education Authority says: Cigarette smoking is the greatest cause of preventable death and disability in this country. It is estimated that some 110,000 deaths each year in the United Kingdom are attributable to tobacco products. This is the equivalent of one million years of life lost annually. It is the equivalent of 300 people dying every day from smoking. Smoking causes 90 per cent. of deaths from lung cancer, 90 per cent. of deaths from chronic bronchitis and emphysema and 20 to 25 per cent. of deaths from heart disease.

Smoking rates are still much too high. A total of 32 per cent. of the British adult population are regular cigarette smokers. Worryingly, at the age of 15, 22 per cent. of girls—more than one in five—and 17 per cent. of boys are regular cigarette smokers. We have to act decisively on this issue.

We have to have a target. That target should be to reduce by the end of the century the number of adult smokers from 32 per cent. to 20 per cent. We should aim to cut to 5 per cent. or less the number of children under 16 who smoke. That would be a realistic target. I too support the Parents Against Tobacco initiative which is looking at new ways to deter children from smoking.

We need to have regular increases in the price of tobacco. We should have an advertising levy on tobacco promotion which could be used for health education. Really, we should abolish advertising for tobacco and tobacco products. We know that smoking kills. Why do we still allow advertisements for a product that causes major ill health and death? We should have a total ban on advertising and sponsorship. It is horrifying to see in toy shops toy cars with the name of cigarette companies all over them and during motor racing on television the cars whizz past with highly visible adverts. Cigarette sponsorship runs throughout sport.

Mr. Arbuthnot

Will the hon. Lady say the same about alcohol advertising? Is she saying that a Labour Government would ban advertising of both products?

Ms. Harman

I shall come to alcohol advertising shortly. If the hon. Gentleman reads "Looking to the Future", our policy document, which was quoted by my hon. Friend the Member for Preston (Mrs. Wise), he will see that we are committed to a total ban on advertising and sponsorship. We must be clear about that.

The ceiling for permitted tar yields must be reduced and there should be no Government subsidies, through any Department, for the production, import or manufacture of tobacco products. That will be hard, because the tobacco industry, including the manufacture, importing, sale and supply of tobacco products, accounts for many jobs in this country. However, the Department of Health should not have to pick up the pieces of illness caused by smoking while the Department of Trade and Industry is subsidising the tobacco industry in this country.

Mr. Jeremy Corbyn (Islington, North)

Does my hon. Friend agree that one of the most distressing problems at the moment concerns the export of high-tar tobacco products to poorer countries and the promotion by British companies of tobacco in Third world countries? Does she agree that those companies should be rapidly encouraged to adopt product diversification instead of promoting the sale of those dangerous tobacco products to poorer people in poorer countries?

Ms. Harman

I agree with my hon. Friend. The Government should have an honest and coherent approach to smoking across all Departments. Smoking cannot be dangerous in this country but safe in the third world. Different Departments should not be pulling in different directions.

There should be more resources for health education targeted at smokers and to prevent people from taking up smoking. We need more training in the risks of smoking for health professionals, and smokers who are trying to give up should be supported and receive counselling.

We also need legislation to control all public and workplace smoking, because that smoking involves a twofold problem. First, non-smokers are smoking passively and that is a problem for everyone, but particularly for people with respiratory diseases and for children. Secondly, workplace and public smoking seems to create the idea that smoking in public is somehow acceptable and that we can expect to see people on buses, in restaurants or at work smoking.

Smoking should not be allowed in day rooms in hospitals. It is an amazing irony that a mother who has given birth prematurely to a low birth weight baby with a health risk as a result of smoking can go and have a fag in the day room. We must have a public health strategy in which the Government take a lead in their role as an employer and provider of facilities and services. Cigarettes should not be sold on health service premises. Selling them there is a contradiction in terms.

The hon. Member for Ealing, Acton (Sir G. Young) made an interesting point about the sale of cigarettes bearing the House of Commons insignia. I would be interested to hear what the Minister for Health thinks about that.

The Minister for Health (Mrs. Virginia Bottomley)

indicated dissent.

Ms. Harman

The Minister is shaking her head. It seems that she is going to try to avoid that point. However, I hope that she will consider the matter.

There must be a named individual in each health and local authority to co-ordinate action. Smoking control plans should be part of every local and health authority's strategy.

There has been a great advance in child immunisation, as several hon. Members have said. However, there should be more stringent checks to discover whether children have had the correct immunisations. Those checks should be made when children enter school, because if children have missed out on immunisation before then, they can be caught and their parents can be encouraged to have their children immunised.

The Government must back that kind of service with resources. The Government took up on the excellent MMR vaccination campaign. Obviously, we should aim to stamp out rubella; it can have a terrible effect on a child if its mother had rubella when she was pregnant. That illness is entirely preventable. However, it is ironic that, when the advertising campaign for MMR was at its height, district health authorities were rationing the vaccine because they could not afford it. Parents were told to bring their children back on a different day because there was not enough vaccine available. They were told that, although their children were eligible for vaccination, they were not in the main target group and therefore they should bring their childern back on another occasion. We should take every oportunity to ensure that children have received their immunisations and vaccinations.

More and more stress is being placed on health visitors yet their posts are being frozen as a result of cuts and difficulties with health budgets. Health visitors play a vital role in promoting public health and in encouraging women to have cervical smears and to take their children for vaccinations. They must be an important part of any health promotion strategy. Their posts should not be frozen because health authorities are having financial difficulties.

I should like the Minister to respond to my next point, about vaccine-damaged children and their eligibility for compensation. As I understand it, a child is eligible for compensation only if he or she has suffered 80 per cent. disability. As the compensation scheme does not cost very much in any case—because vaccine damage is rare—it seems unfair that children who have been vaccine-damaged should not be eligible for campensation unless they cross the threshold of 80 per cent. disability.

We know that health inequalities relating to income are as deep as ever. The map of the variations in health and disease patterns shows that the picture remains largely unchanged since the Black report. Our health strategy and our targets for health promotion should focus not only on certain diseases, such as those caused by smoking or alcohol, but on the ill health that exists in different regions and individual cities. We need to set targets for cities and to encourage healthy city projects such as those in Liverpool and Sandwell, and the one that I have visited in Oxford. We need public health profiles so that the agencies concerned and the local community can join in setting and achieving targets to improve the health of their region or city.

Many hon. Members have referred to food safety. Our discussion has ranged across salmonella, botulism, listeria and the problems of a contaminated drinking water supply. Our knowledge of food safety and of the link between poorly stored food and ill health is growing as food science is becoming more developed and microbiology is telling us more.

The Government should not lag behind. They should see the research as an opportunity. They should not bring in controls reluctantly, only when everybody is screaming and shouting; they should look closely at what science can now tell us about food and ill health, which it could not previously, and be poised to cut the incidence of ill health caused by food.

The Government should not be dragged kicking and screaming to introduce new regulations. As my hon. Friend the Member for Preston has said, we need a sufficient number of environmental health officers to enforce the regulations, because regulations by themselves have only a limited value if there are insufficient environmental health officers to police them. No local authority has sufficient environmental health officers to ensure that the current law is being complied with, let alone to make the improvements in the regulations that we are seeking.

While I am dealing with food and nutrition, I must emphasise that the low level of breast feeding in this country is a scandal. All the evidence shows that the best food for a child when it is born is its mother's breast milk. However, the companies that produce artificial milk are still giving out free samples of their products in hospital maternity wards. Although that is against the regulations, it is still happening because the milk manufacturers have been clever and have recognised that maternity wards no longer give out packs to new mothers.

In the past, a new mother could take a nappy, some baby lotion or vaseline and some talcum powder from the hospital supplies. The national health service used to provide such things, when it was not so strapped for cash. That is one of the cuts that has taken place. Therefore, milk suppliers provide what are called "bounty boxes" for expectant mothers. In the bounty box there is stacks of commecial advertising material for artificial milk.

Despite the increase in the number of babies being born, the number of maternity beds has been cut. That has led to mothers being discharged sooner after they have their babies. The amount of time that women spend in hospital after having a baby is rapidly decreasing. One of the casualties of that is that women return home with a new baby without having established breast feeding with the support of the midwives in the hospital. The community support of the midwives is the hospital. The community midwife service is too stretched to enable mothers who have nothing wrong with them to establish breast feeding.

Mr. Arbuthnot

Will the hon. Lady give way?

Ms. Harman

We have an expert on breast feeding; I shall give way.

Mr. Arbuthnot

As the hon. Lady will understand, I am not an experienced breast feeder. Would she cope with the problem by banning the advertising of babies' milk?

Ms. Harman

A Department of Health regulation states that hospitals should not advertise babies' milk. I simply argue that that regulation should be enforced. I am sorry if I did not make myself clear. The Minister will confirm that it is already Government policy that milk should not be advertised in hospitals but that the regulation is not enforced. The milk companies encourage hospitals to break the regulation by offering free samples which hospitals stretched for cash take up.

Mrs. Wise

I agree entirely with my hon. Friend's point. Does she agree that the community midwife service needs to be strengthened and that it would be a good thing if new mothers were again given a home help so that they could rest more and give more attention to the baby? That would help in the establishment of breast feeding.

Ms. Harman

I absolutely agree with my hon. Friend. The home help service was introduced to assist mothers with new babies, but it is now almost entirely devoted to the elderly and people with disabilities.

I wish to touch briefly on maternity services. We must increase pre-conceptual care and promote understanding of the issues behind it, but we must also increase the number of women who come forward for ante-natal assistance and screening.

There is still an appallingly high toll from industrial illness and accidents at work. Many of those accidents simply should not happen. There is an unacceptable level of accidents among employees of cowboy builders. My hon. Friend the Member for Preston mentioned repetitive strain injury. Ill-health and disease is caused in the chemical and nuclear industries. Farmworkers are affected by chemicals and machinery used in agriculture.

We need a combination of openness, so that people know and assess the hazards in their workplace, and good inspection by the Government which is properly resourced, so that employers know that, if they breach regulations, there is a substantial chance that they will be discovered and fined. We need unionisation so that management can negotiate with strong unions acting in the interests of their members to ensure their safety.

I wish to touch briefly on ill health caused by poverty. A severe winter always brings an epidemic of hypothermia, which is preventable. The Scandinavian countries, which have far harsher climates, do not experience the increase in deaths by hypothermia that we have in Britain. If people had a decent income, if there were good incentives for insulation and if the cost of fuel was lower, we would not have that unacceptable Dickensian epidemic of death by hypothermia that arises every time that there is a cold winter.

We have too many accidents in the home. We need to have better regulations to ensure that unsafe toys and electrical goods do not reach the market. My hon. Friend the Member for Preston mentioned the safety of people in bed-and-breakfast accommodation. In her previous incarnation as a social worker, she will have visited families in bed-and-breakfast accommodation. Such accommodation lacks cooking facilities. The electric kettle is inevitably without a table because there is no space between the beds, and its wire snakes across the floor. That is of particular danger to children. Several families share the same toilet and inadequate washing facilities. They are prone to infectious diseases, such as gastroenteritis. It is a contradiction in terms to claim an interest in public health promotion when so many families live in these squalid, unhealthy hostels for the homeless.

As I came here today, I went down Haygate street in SE17 and saw a touching shrine of a little dog made up of flowers. Obviously, a child has been killed there recently.

Recently I went to Doncaster royal infirmary and chatted to two children who had been hit by a car. We have an unacceptably high level of road accidents. It is ridiculous that, when one argues on behalf of one's constituents for a school crossing, better enforcement of the speed limit or more school crossing attendants, one is told, "Yes, we recognise the need, but you will have to wait because spending restrictions mean that you are 50th in the queue."

We need improvements in public transport and deterrents to private cars—for example, road humps and parking restrictions. Hon. Members have talked about cycling, and it is welcome to see more people wearing cycling helmets. Sometimes cyclists wear elaborate masks because of the appalling pollution in central London and our other cities.

In any accident and emergency department there are people who have injured themselves by falling down when they were drunk. There are people, certainly in my constituency, with punch or stab wounds from being hit by someone who is drunk. As the hon. and learned Member for Montgomery (Mr. Carlile) said, in court people give as a defence, "I hit him because I was drunk." In every hospital there are people suffering from liver and other diseases caused by drink.

A cut in the volume of alcohol consumed, particularly high consumption, must be a target in improving the nation's health. Alcohol consumption should be cut by 20 per cent. by the year 2000. In particular, we must halt the increasing alcohol consumption by women, reduce consumption among high risk occupational groups and reduce the proportion of the population drinking more than the recommended number of units. The Government have a responsibility in that. Advertising plays an important part. We should have mandatory, clear labelling of alcohol content and the recommended limit on consumption on all containers. There is more information now that even small levels of alcohol can damage health.

Family planning clinics are an important health promotion and preventive medicine resource. The Government are wrong to allow hard-pressed, cash-starved, district health authorities throughout the country to cut those clinics because they are desperate to reach he end of the financial year without going over budget.

Research recently undertaken in Warwickshire showed that 45 per cent. of those presenting themselves for abortions had not used any form of contraception. In the light of that appalling figure, a strategy has been developed in that area with the aim of reducing the number of abortions by a third by the end of the century.

Family planning clinics and sex education are important in the prevention of unwanted pregnancies and it is wrong to reduce such services in the face of a possible epidemic of a sexually transmitted disease. Family planning clinics are a good base from which to conduct health and sex education and to provide people with information about sexually transmitted diseases such as AIDS.

There are about 180,000 abortions in Britain every year. If nearly half of those involve people who have not used contraception, it is clear that a major objective of the Government should be to reduce the number of people not using contraception.

Giving evidence to the Select Committee, the Secretary of State made an astonishing remark. He seemed to think that family planning had no relationship to contraception and that contraception had no relationship to unwanted pregnancies. He seemed to think that, in any event, none of that had anything to do with him.

It is difficult to have a sensible strategy to promote good health and prevent ill health when financial spending restraints are placed on the national health service in such a way that the service cannot improve in the way it should. People who are diagnosed as needing heart surgery must wait for that surgery and they become more ill all the time they are waiting. People requiring hip replacements are having to wait, and they suffer immobility and further disability while waiting for their operations.

The same is true of cuts in provisions for the menopause clinic in my constituency at King's College hospital. Menopause, pre-menstrual tension and post-natal depression services all have the aim of preventing situations from deteriorating. It is a false economy to cut their financing. A doctor recently told me, "Unless we can help women suffering the effects of the menopause, many of them will end up as in-patients across the road at the Maudsley." I am sure that the hon. Member for Billericay (Mrs. Gorman) will have more to say about that.

My hon. Friend the Member for Preston was right to talk about the importance of our commitment to abolish the charges for eye tests and teeth checks. Such checks are major preventive measures against glaucoma, diabetes, brain tumours and many other ailments. The hon. Member for Twickenham seems to appreciate that, if the price of a packet of fags goes up, fewer people will smoke. Yet he seems to think that, if a charge is slapped on eye tests and teeth checks, people will continue to go to the optician and the dentist. That does not make sense.

Does the Minister share my concern about the mushrooming of bogus advertisements for slimming aids, which clearly are not aids for slimming? Numerous magazine and newspaper advertisements urge people to spend their money on such projects, which would either not have any effect or, if they did, would harm people.

Likewise there are a growing number of advertisements for cosmetic surgery. We are constantly told, "Get your nose done," "Get your breasts fixed," "Have a slice taken off your thighs," and "Have a face lift." We do not want to go down the path that they have trodden in the United States, where one sees increasing numbers of elderly women with faces like a baby's skin, stretched thin. The Government should take a view on such matters. It is obscene.

The path that people are encouraged to take—cosmetic surgery for no good reason so that doctors in private clinics can make a fat profit—is wrong. I do not say that there is not a place for cosmetic surgery under the NHS. There are important uses for such surgery, but at present it is turning into a racket, and I promised to say that one need not have a face lift to look young. Look at the hon. Member for Billericay.

I should like the Minister to comment on the adverts about hair loss. There are increasing numbers of adverts encouraging people to spend money on hair transplants that will no doubt mutilate their scalps without making them look as though they have thick hair. Other adverts encourage people to spend money on potions that will allegedly thicken the hair shaft. There are also bogus adverts inviting people to spend money to deal with memory loss. There are many quasi-medical claims in those adverts. If they are to have a serious and scientific approach to educating people about health and what effects their bodies, the Government should take a stance on such adverts and do something about them because they are becoming a scandal and a rip-off.

The Government must also ensure that there are adequate resources for research. We are able to have a cancer screening service because the research has been done, so that we know how to detect the early signs of cancer and prevent it. We have made major breakthroughs in a number of cancers such as Huntington's disease and childhood leukaemia, but we still need more research to prevent ill health caused by cancer. We need an integrated, comprehensive, well-resourced health service, with local government working in partnership with health authorities, partnerships between unions and management, the Government acting to prevent environmental pollution, and above all, a determination to end the poverty that is the cause of so much ill health.

1.26 pm
The Minister for Health (Mrs. Virginia Bottomley)

I shall not follow the hon. Member for Peckham (Ms. Harman) by ranting about the shortcomings of the private sector and what basically sounded like the need for a national plan. I thought that even her party had abandoned the idea of such a salvation from the difficulties that we faced some years ago. I strongly support the sentiments expressed by many hon. Members who paid a most warm and fulsome tribute to my hon. Friend the Member for Chislehurst (Mr. Sims) for his motion and the manner in which he delivered it. I echo the words of my hon. Friend the Member for Ealing, Acton (Sir G. Young), who paid a tribute to my hon. Friend the Member for Chislehurst for his non-sermonising Jimmy Young style. That was an excellent description of the way in which my hon. Friend the Member for Chislehurst presented the motion and drew together its main strands.

I shall seek to describe the steps that the Government are taking and the reforms that are already under way in the health service, which for the first time will, we hope, achieve a health service rather than a disease service. It is a recognition of the emphasis that we put on health promotion that a major, central section of the leaflet that we distributed to every household in the country relates to health promotion matters such as looking after the heart and the importance of healthy eating. I must tell my hon. Friend the Member for Twickenham (Mr. Jessel) that I fear that it does not cover lobsters, shellfish or eels, but it covers smoking, alcohol and other matters of great concern. It explains in a clear and direct manner how the new reforms will lead to enhanced and better care for our people.

It is well known that health promotion has had a long history. The bible describes dietary laws to prevent disease and contains detailed passages on the control of leprosy. In the middle ages, communities took steps to avoid the plague. Quarantine later helped to control the spread of diseases such as cholera. Modern health promotion stems from the major sanitary revolution of the previous century. I suspect that plumbers, rather than pharmacists or physicians, had the largest part to play in the improvement of health standards of our and other nations. Sound engineering, the separation of sewage and clean water revolutionised health care and reduced mortality from water-borne diseases such as typhoid and cholera.

The hon. Member for Preston (Mrs. Wise) referred to housing. The revolutionary concept of having a sink inside the house led to a marked decline in food-borne killing diseases such as infantile diarrhoea. The gradual reduction in overcrowding reduced the airborne infections such as streptococcal disease, rheumatic fever and tuberculosis.

The second era, of medical intervention, dramatically increased people's opportunities of surgical and medical treatment. I refer to the remarkable development of antibiotics and then to the era of vaccination and immunisation, of which more in a moment. The result has been that polio, diphtheria and many of the killer diseases of childhood of the past are scarcely seen in our country any more.

The new challenge is to combat the diseases in which personal responsibility and individual action can play a major part. Heart diseases, strokes and cancers, the great modern killing diseases, are the areas on which so much of our debate today has centred. We know only too well that the key risk factors in strokes overlap with those for coronary heart disease—high blood pressure and cigarette smoking; we know less of the causes of cancer, but cigarette smoking is certainly the cause of 30 per cent. of all cancers in this country. My hon. Friend the Member for Acton spoke about the influence of smoking on other chest diseases, too.

My hon. Friend the Member for Chislehurst and others mentioned how the developments in the health service are for the first time placing responsibility on district health authorities for analysing and assessing the health needs of their populations. The Acheson report on public health made a major contribution to the way in which we analyse and study public health, as has the appointment of a director of public health in each district health authority with a crucial part to play in carrying forward the district health board's responsibilities to provide for health needs and to draw up contracts. Let no one underestimate the significance of the new and enhanced nature of the role of the district health authority or of the prominence that will inevitably be given to public health matters and the prevention of disease by analysing the needs of the local community and purchasing services to meet those needs.

My hon. Friend the Member for Chislehurst also mentioned the changed nature of the general practitioner's contract. There, too, there has been a marked shift towards recognising the importance of health promotion. I pay tribute to the Royal College of General Practitioners which, in its policy statement in response to our Green Paper "An Agenda for Discussion", said that many of the problems brought by patients to doctors are best understood by the doctors who know the patients as people, who understand their fears and feelings and who know the problems in their daily lives.

More and more the principle of healthy living and much of the management of chronic disease depends on people making changes in the way that they eat, drink and smoke. Personal preventive medicine is now a major feature of the modern health service, and it is logical for people to be offered preventive services in the same place and by the same team as offers them treatment services. Fusing prevention and treatment into comprehensive clinical care is an exciting development in modern practice.

As the House will know, we decided to make health promotion an explicit part of the GPs' new contract. I was interested in the remarks by the hon. and learned Member for Montgomery (Mr. Carlile); his role on the General Medical Council, like that of my hon. Friend the Member for Chislehurst, is an important new development. The hon. and learned Gentleman spoke about the collegiate ethos of the Bar and about how that could apply in general practice, thereby registering a point that was also picked up by my hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot). So often those who cannot gain access to single-handed practitioners might make excessive use of a casualty department.

Our reforms in the recent National Health Service and Community Care Act mean that doctors who choose to become fund holders can invest in their own practices. They can develop services, provide anti-smoking clinics and diet-exercise clinics, and they can make sure that health promotion becomes the key to their work. There will be extra help for the over-75s, who will be offered an assessment of their medical needs. There will be a requirement regularly to assess both current and new patients on doctors' lists.

We are already seeing in practice the effects of that important new work. The general practitioner service—the family practitioner service—is the gatekeeper to the national health service: it is where most people go first when they are worried about their health. It is essential that the key messages from the debate should be echoed by the general practitioners, and by the new groups of practice staff who have been able to join general practice thanks to the investment that the Government have made.

Throughout the health service all members of staff—doctors, for instance, and the health visitors to whom the hon. Member for Preston paid especial tribute—have a role to play. We have seen a dramatic increase in the number of health education officers, from about 200 in the mid 1970s to nearly 700 now. Their job is to ensure co-operation, and to ensure that the messages that are spread from the centre—from the Health Education Authority and others—are properly disseminated.

I should like to refer particularly to the appointment of Professor Michael Peckham as the new director of research and development for the national health service. I think that he will be able to inform and enlighten the service from the top to ensure that the latest research is properly evaluated, and that we draw on those lessons in carrying out our health promotion campaigns.

The major arm of Government, in health promotion and disease prevention, is the Health Education Authority. Since it was established as a special health authority, it has had a substantial increase in funding, and its work in carrying out health promotion is a force for good. Its recent strategic plan for the first half of this decade identifies seven key programmes as priorities for the next five years: HIV and AIDS prevention, and sexual health; "Look After Your Heart"; cancer education; smoking education; alcohol education; nutrition education; and family and child health. All those issues have been raised by hon. Members in the debate.

The plan identified key settings in which the programmes should operate—primary health care, schools and colleges and youth settings. I think that all of us would agree about the importance of education at school in encouraging health promotion. Health Education is a cross-curricular theme in schools. The chief medical officer has recently had discussions with the chairman of the National curriculum Council to discuss how that can be carried out further. If people can understand the importance of healthy living, of exercise and of avoiding smoking at an early age, it sets a good pattern for life.

The strategic plan for the Health Education Authority also identified the special needs of women and members of the ethnic minorities. We want good health to be available to all groups in our community. The other day I went with my hon. Friend the Member for Croydon, North-West (Mr. Malins)—my Parliamentary Private Secretary—to his constituency to meet a group from the Commission for Racial Equality, where we discussed what more could be done to ensure that the ethnic minorities were informed about, and had access to, high-quality health care and services.

Addressing the health needs of elderly people is of major importance, and Age Concern has carried out a considerable amount of work in that area. The Health Education Authority and my Department have been developing—in consultation with health professionals—the concept of a personal health record, which would be provided for GPs to issue to their patients. It is intended to organise a major consultation exercise to examine how those proposals can be implemented.

The idea of a personal health record is a powerful statement in itself. We have just taken through Parliament legislation concerned with access to medical records. It demonstrates a change in culture and attitudes that there is now an expectation that individuals should have their own personal health record. In the past, many felt that they were being denied access to vital information about their own health. That is a message about individual involvement and responsibility.

Many hon. Members spoke about coronary heart disease, prevention of which has to be a high priority for us all. In April 1987, the Department and the Health Education Authority launched a joint "Look After Your Heart" campaign, in response to concern about the high level of coronary heart disease. We know of the success of health education campaigns in other countries with initially far higher rates of death and disability from the disease. The original aim was to increase knowledge of the risk factors for coronary heart disease. In its first three years, the campaign enjoyed considerable success. Although there are other notable campaigns against coronary heart disease, we believe that ours is the first national campaign of its kind in the world. All Health Authorities have been involved in it. "Look After Your Heart" has sponsored more than 270 projects at a cost of over £500,000.

The involvement of the campaign with industry has been a great success. The hon. Member for Preston said that industry believes that it owns its employees body and soul. If that means that employers are increasingly aware of the contribution that they can make by promoting good health and passing on health education messages, that is a welcome development.

I know that this is an interest of my hon. Friend the Member for Bournemouth, East (Mr. Atkinson) and there is no doubt that, in the "Look After Your Heart" campaign, an excellent example has been set. Some 300 major organisations, with around 3 million employees, are actively involved in the campaign, both in the public and private sectors, including large organisations such as ICI and smaller organisations, the TUC and most Government Departments.

The "Heartbeat Award Scheme", which is run in conjunction with local environmental health officers, encourages not only good standards of hygiene but health menus and no-smoking areas in all eating places from canteens to restaurants. Although it was launched nationally only two months ago, already 40 per cent. of local authorities are taking part. Many of the remarks by hon. Members today lead me to think that they will welcome that development and that they understand how vital it is that people should take steps to promote healthier eating and to discourage smoking.

I have had any number of invitations to take up the issue of smoking on aeroplanes with Ministers in the Department of Transport. It would be less than generous of me to fail to do so after the strength of the remarks made on that subject.

The "Look After Your Heart" campaign has also been working with the food industry and last year developed a "Less Fat Fortnight". This year, it will be mounting a month-long promotion called, "Food For the Heart". These are all ways in which a campaign that is determined to meet with success can draw together people from the public and private sectors and from Government Departments. It is vital that they work successfully together. The campaigners have worked continuously with the National Forum for Coronary Heart Disease Prevention and the coronary Prevention Group to inform and enlighten their work further.

In that context, I am pleased to announce that we are able to give further section 64 resources this year to the Chest, Heart and Stroke Association, which we shall be funding to the tune of £35,000 this year and £36,000 in each of the following years for the important work that it does in promoting nurse facilitators associated with doctors' practices, particularly in the north of England, to make sure that the lessons on heart disease are fully incorporated and understood.

My hon. Friend the Member for Chislehurst mentioned the recent report of the standing medical advisory committee on whether opportunistic cholesterol testing can make a cost-effective contribution to combating heart disease. Copies of the report are available in the Library and a consultation period is under way. I hope that my hon. Friend and others will contribute to those consultations.

Another subject that has been the source of a great deal of comment today is smoking. The effects of smoking are devastating, as my hon. Friend the Member for Chislehurst made clear. Each year, it kills more than 100,000 people and costs the NHS around £500 million. What it costs in forgone earnings, and in personal misery and bereavement can scarcely be accounted for in terms of money. The habit accounts for millions of days of absence from work. It is a staggering toll in both human misery and cost.

There can be little doubt that if cigarettes were introduced today, their production and sale would probably be banned, but the habit has a 400-year history of acceptance and approval and it is too firmly established for a ban to be imposed now. However, when new tobacco products are introduced in the United Kingdom, we can consider a ban. Indeed, at the end of last year we responded to the evidence that oral snuff products were linked with mouth cancer by banning their sale.

We can and do use the law to protect children. Tribute has been paid to the "Parents Against Tobacco" campaign and discussions are taking place on how further we can strengthen the law to ensure that young children do not gain access to cigarettes and tobacco products. It is not only a question of the law; it is a question of public perception and social accountability. The more that can be done to make the sale of tobacco products to children unacceptable and offensive, the better. That is certainly an area in which the good will of the campaign is important.

Smoking harms not only the smoker. As hon. Members said, there is a growing rejection of the effects of passive smoking. There is an increasing demand for smoke-free areas, both in public places and in the workplace. We welcome that change in public attitudes. I shall take up the suggestion of my hon. Friend the Member for Acton and ask the Health Education Authority to accept his invitation to draw up guidance on passive smoking for general distribution.

Another important plank in the Government's response to the grave health risk posed by tobacco has been to strengthen and refine the system of voluntary agreement with the industry. As hon. Members will know, recent developments in the European Community mean that there must be changes, and we are still considering the implications of some of the latest directives. We are all committed to ensuring that smoking is reduced, that there are proper controls over advertising, and that needless deaths are avoided at all costs.

Nutrition has also been a subject for debate today, and it has been a long-standing debate over recent months and years. I cannot furnish my hon. Friend the Member for Twickenham with detailed replies on all the various products that he identified, such as eels, oysters, herring, kippers, salmon and so on. However, I can give him some good news. Next week the Department of Health, the Ministry of Agriculture, Fisheries and Food and the Health Education Authority will jointly issue joint guidelines for a healthy diet. They are intended to be exactly what hon. Members wish—a clear statement of guidance about healthy eating and the importance of nutrition, to try to develop a sense of coherence and understanding in an area that is easily moved to emotion rather than common sense. "An apple a day keeps the doctor away" is an old maxim. The importance of diet for health cannot be understated.

I want to speak briefly about the importance of alcohol. I agree with the hon. and learned Member for Montgomery, who spoke about the effects of alcohol not only in terms of disease and illness, but in terms of crime, and especially domestic violence. I am closely associated with a Minister who is committed to the eradication of drinking and driving. He has been most successful in making people think through the dangers of drinking and driving. We could spread the message more widely.

My right hon. and learned Friend the Lord President currently chairs the ministerial group on alcohol misuse. In launching "National Drinkwise Day" this year, he said most aptly that alcohol can either be a good friend or a bad enemy. We all know of the many circumstances in which alcohol makes a very bad enemy.

My right hon. and learned Friend co-ordinates that group, which draws together Ministers from different Departments to ensure that policies are developed and initiatives planned in a co-ordinated way. A report describing the progress that has been made in combating alcohol misuse will be published early next year. When sensible drinking rules are breached, that poses a serious threat.

In our proposals announced this week for phasing in the implementation of community care, a commitment was made to introduce a specific grant for the treatment of those with drug and alcohol misuse problems, which demonstrates the seriousness with which we view alcoholism. Alcohol Concern provides an important service in that regard. The Government are funding it to the tune of £500,000 this year, but by 1992–93 that figure will rise to £2.5 million.

Little mention has been made of the dangers of drug misuse, but we are committed to ensuring not only that supplies from abroad are reduced but that enforcement is effective, that there are strong deterrents, and that improved rehabilitation treatment is available. Above all, we want education and prevention to be spread as widely as possible.

My hon. Friend the Member for Twickenham, the hon. Members for Preston and for Peckham, and others, mentioned child health. We have seen a dramatic reduction in infant mortality, from 12.8 per 1,000 live births in 1979, to 8.4 in 1989. Perinatal mortality fell from 14.7 per 1,000 births in 1979 to 8.3 in 1989. The figures are now at an all-time low, and that achievement is a source of considerable pride. However, none of us is satisfied that we have gone as far as we can. We must encourage every group and community throughout the country to take every possible step to ensure that children benefit from all the advantages of modern health care.

Immunisation rates have also dramatically improved, from 85 per cent. to 89 per cent. between 1985 and 1990, provisionally, in respect of tetanus, diphtheria and polio. Immunisation against measles improved from 68 per cent. to 88 per cent. in just five years, and against whooping cough from 65 per cent. to 82 per cent. That is a remarkable and impressive achievement.

Our efforts will not stop there. Recently, we published a handbook, "Immunisation Against Infectious Disease", which has been sent to all doctors and health visitors. It reminds them of the continuing importance of the immunisation campaign. In September, we shall launch with the Health Education Authority a further publicity campaign, "Immunisation, the safest way to protect your child", which will carry forward that work. We have learnt the lessons of the past as to how easy it is to allow a campaign to become forgotten. The momentum must be kept up, and there is no better way of doing that than the commitment in the general practitioner contract to provide an incentive for GPs who go out of their way to ensure that the children on their lists are properly immunised. Again, we are seeing important and impressive results already, which will lead to further improvements in child health.

I take issue with the hon. Member for Peckham's remarks concerning maternity services, which have continued to show a considerable improvement. This week, I was pleased to speak at the annual conference of the Royal College of Midwives, when I emphasised that our maternity services provision is based, as it has been for the past 10 years, on the reports of the Maternity Services Advisory Committee, and that we recognise the importance of the continuity of the midwife's role and of a coherent and integrated service. Those are precisely the policies that we shall be pursuing. The process of contracting is being examined carefully in two areas—Maidstone and Lewisham. I have invited the Royal College of Midwives to discuss the effects on maternity services, to ensure that all the aspects about which it may have concerns are properly addressed.

To pay tribute to the midwives, only this week they launched a new video on "Rights and choice in maternity care" particularly intended to ensure that those from ethnic minorities receive the services and are aware of the importance of protecting their child as they approach childbirth and in the months afterwards. It was funded by the Department and is an excellent and professional video. It will be a force for good.

The hon. Member for Peckham mentioned breast feeding. We recognise the importance of breast feeding and have been involved in a joint initiative funding three voluntary groups. We are determined that the messages should be carried forward because, as the hon. Lady said, there is no doubt that breast feeding in the early stages can make an important impact on health, apart from the relationship that develops between the mother and child.

I should not be doing justice to the great programme of work that the Government have been undertaking if I did not refer to the important breast and cervical cancer screening programme. We are the first country in the Community to introduce a nationwide breast and cervical cancer screening programme based on inviting women by computerised call and recall. We have been setting the pace in terms of preventive health care for women.

There is no doubt that on the basis of the Forrest report on breast cancer screening and the inter-collegiate report on cervical cancer screening, early detection and intervention can mean that many lives will be saved. It is vital that throughout the country women should accept the invitation for a test and ensure that the family practitioner committee is aware of any change of address. They should ensure that in following up their invitation they encourage others to do the same. It is a waste of resources to have failed appointments but, my goodness, it may be a waste of years of a woman's life if she fails to take up the appointment. We know, sadly, that the vast majority of those who have died from cervical cancer have never been screened or have not been screened in the recent past. It is possible to save lives and to promote health.

Concern has been expressed by some about the availability of results. There has been a substantial increase in those going for cytology testing but I can assure the House that about 80 per cent. of results come through within the four weeks in which health authorities are asked to provide them. We are looking carefully at local authorities where there may be difficulties or delays.

This is an important programme, which is a force for good for women. It is backed up by the GP contract, where the incentive is such that we are going out of our way to encourage GPs to ensure that the women on their lists have taken advantage of screening. We have also asked the national co-ordinating network for the cervical screening programme to ensure that the lessons that are learnt in terms of the fast implementation of the programme are properly disseminated throughout the country.

Women are a particularly important group, not only in terms of the health issues that affect them, but in terms of their role so often as the communicators about the health service within their families. They are often the gatekeeper to the health service for their family. They are often responsible for their family's food habits and many of their social habits and the way in which they conduct their lives. It is right to make a special effort to inform and work with women's organisations to ensure that those messages are spread.

I regularly have meetings with a series of women's organisations to ensure that all those lessons are properly understood and that they take steps to inform their members. I have meetings with the National Council of Women for Great Britain, the British Federation of University Women, the Townswomen's Guilds, Women's Gas Federation, the Fawcett Society, the Business and Professional Women's Federation, the National Federation of Women's Institutes and the National Association of Women's Clubs. Not only are women so often the gatekeepers to the health service, setting the tone for their families, but the majority of health service workers are women, so they play a particularly important part.

I must briefly refer to a subject that has been strangely absent from our debate. More resources are spent on AIDS by the Health Education Authority than on anything else. It would be unacceptable for any Government to fail to recognise the great importance of that major modern threat to public health. For a disease for which there is no known cure, prevention and education—the theme of the motion before us—must be fundamental.

We are committed to a programme of prevention, to monitoring, surveillance and research and also to treatment, care and support. Dramatically and significantly, those in the groups most affected by AIDS seem to have been able to change their behaviour as a result of health education messages. It is easy for us to agree what the messages should be, but it is much harder to turn those messages into action in terms of diet, sexual behaviour, smoking or drug addiction.

We have launched a further publicity campaign about AIDS and HIV. It is important that we have introduced an anonymous screening programme and before long it will be possible to debate the subject on the basis of facts rather than fiction. Sometimes the debate on AIDS seems to suffer from too much heat and too little light. However, we continue to give AIDS a very high priority, working closely with the Health Education Authority.

I have not been able to respond to all the points that have been raised. If hon. Members feel that I have not covered their points, perhaps I can write to them. My hon. Friend the Member for Chislehurst asked about the progress that we are making on the European region of the World Health Organisation's "health for all by the year 2000 targets". We have been making good progress in several areas, particularly on cardiovascular disease and infant mortality. We are doing as well as any on accidents. The next formal response is due in 1993. However, those matters are carefully monitored by the Department's central health monitoring unit. I shall ensure that we look carefully to see whether there are any other ways in which the information can be provided before the next formal reporting date.

This has been an important debate, with many thoughful and considered contributions. I hope that I have left the House in no doubt that the Government take enormously seriously the challenge that confronts us. We believe that our proposals for reform in the national health service will ensure that health promotion and disease prevention are given the proper consideration that they deserve and that we will indeed well and truly have established a national health service.

2.3 pm

Mr. Simon Coombs (Swindon)

Since this debate started about four and a half hours ago, more than 100 of our fellow citizens have died of coronary heart disease. To put it another way, every day in this country a number equivalent to a Boeing 747 jumbo jet full of passengers die from that crippling disease.

I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) on moving his motion and I thank him for the opportunity to debate this subject. This debate has ranged widely over the whole question of health promotion and illness prevention. I shall concentrate on one aspect—coronary heart disease. It is particularly appropriate to discuss this issue now, just after the third anniversay of the establishment of the Health Education Authority, the "Look after your heart" campaign, the publication of its five-year plan, "Beating heart disease in the 1990s" and the recent publication of the report on cholesterol testing by the Standing Medical Advisory Committee, which has been mentioned by several hon. Members.

Much has been said in the debate and both inside and outside the House on many occasions about the incidence of coronary heart disease, what causes it and where it is likely to he found in the United Kingdom. The four countries of the United Kingdom have an appalling record with this disease. Of the top six countries in terms of the incidence of coronary heart disease, four are Northern Ireland, Scotland, England and Wales. The other two are Finland and Czechoslovakia. Naturally, I welcome the progress that has been made in the past three years, but we started late on the journey and we have a lot of catching up to do.

I should like to give the House one or two pieces of information about the incidence of coronary heart disease in this country. In Scotland, for example, the Scottish Medical Journal says that people in social classes 3, 4 and 5—especially men—are "closely associated" with a high mortality rate. Male unemployment is also strongly associated with coronary heart disease death rates. A Whitehall study of civil servants showed that men in the lowest grades, including messengers, had three times the coronary heart disease mortality rate of men in the highest grades, the administrators. The Health Education Authority has said that a man's unemployment is a strong predictor of his subsequent risk of getting coronary heart disease and that unemployment is more significant than any other risk factor. Coronary heart disease is more prevalent among manual rather than professional social groups. A man in social class 5 has nearly three times the chances of dying prematurely from coronary heart disease than a man in social class 1.

However, it is only fair to say that coronary heart disease death rates are falling fast in the younger age groups. Since 1972 death rates from coronary heart disease in England and Wales in the 35 to 74 age group have fallen by 18 per cent. for men and 11 per cent. for women. That seems good, until one compares it with the decreases in other countries such as the United States and Australia, where the decreases are three or four times greater than those which I have just quoted. In the past 15 years, reductions in coronary heart disease mortality rates for women aged 35 to 44 have been nearly seven times greater than for women aged 55 to 64, and two and a half times greater than the rate for men. It is undoubtedly true that mortality rates are falling faster in the younger age groups than in the ones that I have quoted.

Much has been said inside and outside the House about the location of high rates of mortality from coronary heart disease and about the north versus the south. According to the figures, Scotland and Northern Ireland have high incidences, with the north-east, the north-west, Merseyside, Yorkshire, the Trent area and the west midlands all having high figures; but so—it must be said—have the east end of London, Plymouth and Cornwall. We should not talk about a north-south divide in coronary heart disease, nor should we say that simply because someone happens to be of a certain age and class, he is certain to contract the illness.

However, what has to be said—I echo the comments at the beginning of the debate by my hon. Friend the Member for Chislehurst—is that it is up to the individual to decide whether to have a healthy life style. There is no reason why people on a low income, for example, should not eat wisely. The food that is harmful to diet is often more expensive than that which is good for the diet, but it is rejected.

I support my hon. Friend the Minister in saying that in 1990 we are more likely to perish of a self-inflicted disease than from a contagious disease. That is a complete reversal of the situation 100 years ago. In 1890 we were likely to die of cholera, typhoid or another of the water or air-borne diseases. That it is not so today is a triumph for technology, engineering and, as my hon. Friend the Minister said, plumbers. Today our lives are literally in our own hands, not in those of others or of the environment.

It has already been said that we spend a relatively small amount of public resources on prevention of coronary heart disease. We spend about £10 million a year in England and Wales. Let us set that against the cost of treating coronary heart disease, which is £500 million a year. Another even more alarming statistic is that 40.5 million working days are lost in Britain as a result of the disease. That represents 11.6 per cent. of all the days of sickness. That lost production costs £1.8 billion a year. Yet we spend only £10 million encouraging people to avoid the habits which lead to coronary heart disease.

The Public Accounts Committee in its report last year, just 13 months ago, said: We are concerned at the stark contrast between the levels of expenditure on the prevention and treatment of coronary heart disease. We conclude that our examination illustrates our predecessors' concerns about the Department's failure to evaluate the full potential for spending on prevention to save on treatment costs. I ask my hon. Friend the Minister, what more we can do to counter that charge? I listened with interest to what she said, of course, and I recognise that more is being done, but we are not yet doing enough to counter coronary heart disease.

There are two main causes of the disease—diet and smoking. There is a third cause—alcohol—but in view of the time I shall restrict myself to a few remarks on the first two. The major factor in diet is an excess of fat in the diet of ordinary British men and women, particularly of saturated fats. We were told six years ago by the Committee on Medical Aspects of Food that such consumption should not exceed 35 per cent. of total energy intake. But the figure remains above 40 per cent., despite all the best efforts of experts and politicians to advise people to reduce their intake of saturated fat.

There has been a slight improvement from saturated to unsaturated fat, but the total amount of fat in the diet is still far too high. It is true that people consume less butter, milk and red meat and have changed to semi-skimmed and skimmed milk. But when I hear people say, "Oh well, we cannot afford to eat the things that the experts tell us to eat", I look at the price of 250 grammes of butter. It is two and a half times the equivalent cost of 250 grammes of margarine. So it can be done.

Smoking accounts for approximately 20 per cent. of deaths from coronary heart disease in Britain. Those who have hypertension, are overweight or have high blood cholesterol are more likely to contract the disease than others. The risk is two and a half or three times greater for smokers than for non-smokers. In men under 45, 80 per cent. of heart attacks are due to smoking cigarettes.

It is even more appalling that schoolchildren aged between 11 and 15 are taking up smoking. In that age group 7 per cent. of boys and 9 per cent. of girls smoke regularly. There is tremendous public support for reducing the level of smoking. A recent survey showed that 82 per cent. of the population supported banning smoking completely in restaurants; 72 per cent. supported a ban in banks and post offices; and 70 per cent. supported a ban at work. Even 42 per cent. of the population said that they would support a complete ban on smoking in pubs. That is a substantial and remarkable figure. Seventy-four per cent. of hon. Members support bans on smoking on public transport, 63 per cent. support bans on smoking in school buildings and 60 per cent. support bans on smoking in shops. The will is there. We must translate it into action.

In 1987 "Look After Your Heart" produced a guide to healthy eating. It recommended the need to cut down on fat, sugar and salt and to eat more fibre-rich foods and plenty of fresh fruit and vegetables, to go easy on alcohol—a weak way of putting it—and to get plenty of variety in food. As my hon. Friend the Minister has already spoken, perhaps later she will let me know how many copies of the guide were produced and what happened to them. What monitoring was done to see whether they went to the people who needed to read them? Although a large proportion of people think about what they eat and try to eat healthily, a substantial proportion of them ignore advice and dismiss any suggestion as ludicrous. They are the ones who are at risk from this killing disease. Clearly, we must do far more to get the message across to those who, until now have been deaf to it or have refused to listen.

Unless we tell people the contents of food, it is unlikely that they can make the right choice of what they should eat. The Standing Medical Advisory Committee estimates that if every adult adopted its dietary recommendations, those needing clinical supervision due to elevated blood pressure would decrease by two thirds. Information on blood pressure and diet would influence public attitudes and behaviour, thereby influencing good manufacturers' approach to labelling.

Professor John Goodwin, the chairman of the National Forum for Coronary Heart Disease Prevention, recently said: To help achieve a healthy diet, we need compulsory food labelling so that people can put into practice the advice given in the healthy eating leaflets. How much longer will we talk about food labelling? Surely the time has come for action. We are in the middle of yet another consultation period, this time involving all the European Community countries. We should be taking a lead in those talks. For the benefit of producers, manufacturers and, most important, consumers, we need to bring the talking to an end as quickly as possible and make it abundantly clear to the population exactly what they are eating so that those who wish to make the right decisions can make them in the full-knowledge of what they are buying.

This month the SMAC published its report on blood cholesterol levels. It states:

An elevated level of blood cholesterol is one of the chief factors which lead to an increased risk of coronary heart disease…Some programmes of opportunistic blood cholesterol testing and treatment have the potential to make a cost-effective contribution to CHD prevention, whilst others are likely to perform less well. We have some decisions to make following the consultation and I hope that we make the right ones. The committee suggests that doctors give priority to high-risk categories, such as those with high blood pressure, smokers, diabetics, people with a family history of CHD or hyperlipidaemia, and those who already have CHD, and in particular that high priority should be given to people with more than one of those symptoms. The committee states: If blood cholesterol testing and treatment programmes are to remain cost-effective the proportion of prescribed drugs must be kept to a minimum by careful dietary counselling. I say amen to that. Let us not get into the position where GPs, faced with a patient who has a high level of blood cholesterol, simply prescribe pills to help get rid of it. This is crucial. We must not turn another group of people into pill pushers. The answer lies in the life style and the diet of the people, not in having people think, "I can eat, drink and smoke what I like because a magic pill will put it all right." Unless we get that right, the NHS will have another problem with its drugs bill.

To give an example of what it could cost, if the figures for people with high levels of cholesterol in their bloodstreams in this country are anything like the figures in the United States—the evidence suggests that, in all probability, the figures here are much higher than those in America—we could be talking about well over £1 billion a year for the drugs needed to bring blood cholesterol down to safe and acceptable levels. I cannot believe that such expenditure is the answer to the problem that undoubtedly lies ahead.

The opportunity to do the testing of cholesterol levels on GPs' patients must be grasped. We must ensure that GPs have the training to be able to cope with those who come to them presenting high levels of blood cholesterol so that they can give the right advice about the diet and life style necessary to bring down cholesterol levels.

There is no doubt that physical activity and exercise can help to reduce obesity, blood cholesteral and blood pressure. Again, men and women in professional groups are more likely to go in for physical activity in their leisure time than are men and women in unskilled manual groups. So the people who are eating the wrong foods are likely to be doing nothing about it in terms of taking exercise.

In socio-economic groups A and B, 15 per cent. said in a recent survey that they had taken no exercise the previous week, compared with 35 per cent. in group E, who similarly said that they had taken no exercise. Nearly twice as many people in socio-economic groups A and B went running or jogging than those in C2, D and E groups.

Younger people said that they exercised to feel fitter. Older people said that they exercised for health reasons. In either case, it was predominately the people who were already eating more sensibly who were taking more exercise, rather than those who were taking risks with their diets or life styles.

We must also consider the younger section of the population, those at school eating school meals. The national forum for CHD prevention has demanded national nutritional standards, and I support its call. School meals account for a third of children's energy intake, and 45 per cent. of that comes from fat, well above the levels recommended by the experts to whom we turn for advice.

Two years ago the Government introduced the FEAST—fun eating at school today—campaign, which was designed to promote healthy eating and attract as many pupils as possible to eat healthy, nutritious school meals.

The problem with a debate such as this—we are grateful to my hon. Friend the Member for Chislehurst for initiating it—is that it is answered by a Health Minister, and we are grateful for her presence. But we see no sign of Ministers from the Ministry of Agriculture, Fisheries and Food or from the Department of Education and Science, both of which have a key role in the promotion of healthy living. I hope that that message will be passed to those Departments, although I welcome on the Front Bench my right hon. Friend the Minister of State, Home Department; the Home Office is always anxious to see that we are looked after in every possible way.

The Minister of State, Home Office (Mr. John Patten)

I am obliged to my hon. Friend.

Mr. Coombs

It is essential to check what youngsters at school are eating and to make sure that they do not eat the wrong foods, and I hope that the message that was given to me last year by the former Under-Secretary of State, my hon. Friend the Member for Coventry, South-West (Mr. Butcher)—that the Government were anxious to see local authorities taking up the chance to participate in the FEAST campaign—means that that campaign continues and has the Government's support.

With regard to home economics and health education, it is crucial that the new national curriculum should take into account the need to teach children how to look after themselves when they grow older and have responsibility for themselves and their children. Having looked at the national curriculum guidelines, I am not entirely satisfied that the emphasis is sufficiently clearly placed on the need for healthy eating and cooking with unsaturated fats. I urge my hon. Friend the Minister to pass on the message to the Department of Education and Science about the need for action on that.

I congratulate the Government on what they have achieved so far. I hope that nothing that I have said in the past 20 minutes or so gives the impression that I do not welcome the progress that has been made. I believe, in concert with large numbers of people outside the House, that we still have a great deal to do to beat coronary heart disease. Other countries have tackled the problem and produced major reductions in the number of people suffering from CHD.

Last year, the Public Accounts Committee said: We are also concerned at the varying levels of local commitment to the heart disease prevention programme in England, and by the slowness of the Department of Health in obtaining essential monetary information from health authorities. We must continue to monitor the work of local health authorities in this matter because some of them are doing a great deal more than others. I pay tribute to my health authority in Swindon, which is well advanced. Not all the others have managed to achieve the same amount of progress in the past three years.

Mrs. Teresa Gorman (Billericay)

Will my hon. Friend give way?

Mr. Coombs

I shall stop in a moment, if my hon. Friend will allow me.

I welcome the large number of projects related to looking after the heart that are being undertaken, particularly the Allied Dunbar national fitness survey. That company, which is located in my constituency, has taken an important lead.

In relation to food and its impact on health, I hope that the Houston initiative on the common agricultural policy of the European Community will be given every encouragement to succeed—principally and ideally through the end of the CAP. It is ludicrous that we are spending 800 million ecu on community support for the tobacco industry in Europe, when tobacco is a killer drug.

The CAP does not mention food or consumers, only farmers. We must remember that there are more consumers in every constituency in Europe than there are farmers. They are the people who will count in the future. We need to promote greater consumer confidence in food safety. I welcome the National Farmers Union suggestion of an independent food assessment and monitoring body; it deserves careful consideration. I urge my hon. Friend the Minister to be unremitting in her efforts to secure more money from Treasury Ministers to enable the prevention of coronary heart disease to continue in the future, with an ever greater determination to beat that dreadful disease.

2.28 pm
Mr. Sims

With the leave of the House, Mr. Deputy Speaker, I shall speak again.

I thank all those who have spoken in the debate It has been time well spent. I appreciated the kind comments about my initiative in tabling the motion. I am sorry that our proceedings were interrupted by a statement over which we had no control, which has precluded two or three of my hon. Friends who were anxious to contribute to the debate from doing so. That is unfortunate, but that is how things happen in Parliament, and we have to take the rough with the smooth.

I hesitate to refer specifically to any of the speeches because all of them either picked up points that I had touched on or elaborated on others which simply due to lack of time, I had been unable to mention. I hope that the debate has brought home to hon. Members and the country the importance of preventive medicine and what we can do to promote our good health. I particularly appreciated the comprehensive reply by my hon. Friend the Minister, who covered a great deal of ground in a relatively short time. It will be interesting to hear whether she has more to tell us about the extraordinarily fishy speech of my hon. Friend the Member for Twickenham (Mr. Jessel).

I am grateful to all hon. Members who have supported me in the debate and I hope that the message that I was endeavouring to put across—that individuals have responsibility for their own health, and that the Government have a responsibility to take measures to promote good health and disseminate information—has got through to the House and to the country. I am grateful for the opportunity to have had this debate.

It being half-past Two o'clock, the debate stood adjourned.