Strategy for Health

HC Deb 04 June 1991 vol 192 cc155-72 3.31 pm

The Secretary of State for Health (Mr. William Waldegrave)

I am today publishing a Green Paper "The Health of the Nation" setting out the Government's proposals for the development of a strategy for health for England. In the light of responses and consultation, I shall publish a White Paper early next year setting out our definitive proposals.

This is the first time that an explicit health strategy has been proposed for England. At its heart is the proposal to set challenging health objectives and targets to improve the overall health of the nation. Their scope reflects the fact that my task as Secretary of State is to focus on better health just as much as better health care. The Green Paper enshrines that wider health objective. I am happy to tell the House that our approach has been endorsed in warm terms by the World Health Organisation whose "Health For All by the Year 2000" programme started the production of such strategies world wide.

The NHS contribution to such a strategy is derived from the NHS reforms, which require local and therefore national health strategies to be explicitly discussed and adopted. Debate in recent weeks has focused on one aspect of the changes—the role of the providers. We are convinced of the benefits to patients that will flow from the clear separation of responsibility for commissioning health care by health authorities on the one side and, on the other side, the provision of health care by hospitals and others. That separation is already producing better management in directly managed hospitals and services and in NHS trusts. Freeing hospitals from unnecessary interference in day-to-day management produces obvious benefits. Equally important, however, are the benefits flowing from the new and strategic role for the health authorities and indeed for the Department of Health itself.

In the past, both the Department of Health and health authorities have been preoccupied with issues of day-to-day local management. That has been to the detriment of the need, locally and nationally, to take a far more strategic view of what is needed to improve health. What is more, the reforms put in place a clear mechanism by which that strategy can be turned into reality. The new contracting process provides for the authorities an open and powerful means by which they can specify and check the content, the quality and the quantity of the health services for which they are paying. Concentrating on their strategic role allows health authorities to base those contracts on a proper assessment of what is needed both by way of services and by way of other action to improve the health of the local population.

However, our administrative and financial reforms of the health service are a means to an end—better health and better health care—not an end in themselves. We now have in place district health authorities and family health service authorities, together with fund-holding general practit ioners, whose duty is to identify local health needs and then to deploy their money in the best way to meet those needs. Most priorities will quite properly be set locally —though, of course, I remain accountable as Secretary of State for seeing that those local health strategies are comprehensive and set in a reasonable way. But it is also right that some national priorities should be set where it is obvious that England as a whole has a common interest in a nationwide improvement.

Clearly a health strategy needs to go wider than the NHS, and wider than my own immediate responsibilities as Secretary of State for Health. The Green Paper addresses these wider health issues and responsibilities. It builds on other recent developments such as the recent reforms of food safety laws and last year's environment White Paper.

However, if this strategy is to work it cannot be just for Government and the NHS; it must be for the nation as a whole. In achieving our targets, we shall ask all those with a concern for health to play a part—the NHS in health promotion, treatment and rehabilitation; schools in educating young people on health and encouraging physical activity; local authorities across a range of statutory services.

In addition, there are the vital roles of voluntary groups, community health councils, employers, trade unions and the media. They can help to get across to people the facts about, for example, how to avoid coronary heart disease, and giving them opportunties to put knowledge into practice. A lot of what needs to be done is for the citizen individually to do—stopping smoking, having a healthy diet, taking the exercise that we need. The strategy must therefore command widespread support if it is to work. Such support and involvement will be crucial to its success. That is why we are consulting widely.

The proposed approach has two main elements: first, the selection of key areas for health improvements—these will be causes of significant preventable and premature death or ill health; secondly, the setting of clear objectives and targets in each key area, and monitoring progress.

The health of the people of England is already very good. Life expectancy is now 73 years for men and 78 for women, compared to 44 and 47 only a century ago. There has been an increase of two years in life expectancy in the last decade alone. This means that we have already met the WHO target for life expectancy for the year 2000. Perinatal and infant mortality rates—key indicators of any nation's health—are steadily improving. Both have fallen dramatically since 1979, again enabling us to meet the WHO target. That is what we have achieved so far. It shows what we can do. Our task now is to improve still further our record in these and other areas.

"The Health of the Nation" examines the key areas for further improvements. They range from major causes of premature death such as coronary heart disease, cancers, stroke and accidents through risks to health such as smoking, unhealthy diet and drinking too much, to major causes of ill health such as diabetes, asthma and mental illness. The Green Paper also looks at other areas of importance such as the health of pregnant women, infants and children, rehabilitation services, and food safety.

The discipline of target setting is central to the strategy. In each key area the Green Paper discusses targets, both national and local. They cover such things as a 30 per cent. reduction in death from both coronary heart disease and stroke below age 65 by the year 2000; a one third cut in cigarette smoking by the year 2000; and a 95 per cent. target for childhood immunisations by 1995. There will also be quality of service targets. In particular, health authorities must set targets to meet hospital appointment times.

Although we have taken care to suggest a range of objectives which we believe will win support from most professionals, it is essential that it is understood that today's Green Paper is the beginning of an intensive five-month discussion process. It is aimed at achieving, as nearly as possible, national consensus. Simply to impose a shopping list of proposals without true consultation will not work. Success will depend not only on the commitment of Government, the professions and the 1 million staff whom we employ in the NHS, but on real commitment by the public.

Following the consultation period, which will last until the end of October, we shall publish a White Paper setting out a definitive statement of strategy. It will set out what we will do to meet the targets. We hope to receive a wide range of suggestions about how different fields of activity can contribute to the strategy. [Interruption.]

Mr. Speaker

Order. These matters are of considerable concern to those who listen to our proceedings. The Secretary of State should be given a fair hearing.

Mr. Waldegrave

As the strategy develops, more key areas will be added. It is important that we begin with a manageable and achievable list of targets. To be successful, we must be realistic. I intend to make sure that there is a clear lead from the centre. This strategy must be backed by a firm commitment from Government as a whole and from the Secretary of State for Health in particular. I—along with my colleagues in the many other Departments that have a key role to play—will give it that unequivocal backing.

My role as Secretary of State for Health, having launched the strategy process, will be to assess what needs to be done, monitor progress and ensure action. To help me to drive forward the strategy and secure strong support for it, I shall be establishing an English health strategy steering group with a wide membership from both outside and within the NHS. It will be supported by various working groups, including membership from across Whitehall. They will begin work during the consultation period, and continue after the White Paper to help to implement and monitor the strategy.

Finally, let me return to my earlier point. Getting the organisation of the NHS right has been vital. But the final yardstick must be the quality of health care that the NHS provides—and, even more, the health of the nation it serves. Those are the ultimate tests that must be applied to our policies as a Government; it is on them that we shall gladly be judged.

The production of a strategy for health set into motion by this Green Paper, and the action that follows, will secure further improvements in the country's health. It complements our commitment to high-quality health care with a wider commitment to the nation's health. This health strategy is an important new undertaking—the first ever strategy for England. The Government are determined to make it a success. I commend it to the House.

Mr. Robin Cook (Livingston)

Let me begin by welcoming, on behalf of the Opposition, the Government's decision to set targets for health promotion. As the Green Paper fairly admits, the Government have come to that task later than many other countries, but it is all the more welcome because of that. There will be broad support, not just in the House but outside, for a health strategy that embraces health and not just disease.

The Secretary of State, however, will want today to mark the beginning of a debate on his proposals, not the end. May I therefore press him on three aspects of his statement?

First, can the right hon. Gentleman tell us how he arrived at the targets? So that we can judge how challenging they really are, will he tell the House what reduction in the incidence of heart disease and strokes he expects, judging by current trends? Is he aware that his figures, in his Green Paper, show that his targets for heart disease and strokes are lower than the reduction in the past decade, when there were no targets? The Secretary of State shakes his head. His own annex, however, shows that., in 1980 and 1989, coronary heart disease went down by 28 per cent.—an annual rate of more than 3 per cent. The Secretary of State proposes a reduction of 30 per cent. between 1988 and 2000, which is an annual reduction of 2.5 per cent. Similarly, his own annex shows that in 1980 and 1989 there was a 31 per cent. reduction in the incidence of strokes—an annual rate of 31½2 per cent. He proposes a reduction of 30 per cent. between 1988 and 2000. That is not only less than 31 per cent.; it is an annual rate of 2.5 per cent.

Britain has one of the worst heart disease records in Europe. Is the Secretary of State really satisfied with those targets, which set a lower rate of reduction than is currently being achieved?

Mr. Richard Holt (Langbaurgh)

It is a mistake. [Interruption.]

Mr. Speaker

Order. It is not permissible for our proceedings to come to a stop in the middle of the response to a statement.

Mr. Cook

It is a matter of great regret to me that we cannot hear the explanation of the hon. Member for Langbaurgh (Mr. Holt).

Secondly, is the Secretary of State aware that, although the setting of targets will be welcomed, there will be disappointment that the Green Paper proposes no new Government action to achieve them? If it is a strategy for health, it needs both targets and policies to match. If Ministers want people to give up smoking, will they give up Britain's resistance in Europe to tougher controls on tobacco advertising? Will the Secretary of State confirm that today—the very day on which he is talking about targets on smoking—the Under-Secretary of State for Health in another place is speaking out in Luxembourg against precisely those tougher controls on tobacco?

If Ministers want people to adopt a healthier diet, will they begin at the beginning and bring back nutritional guidelines on school meals, which they scrapped? If Ministers want to cut down on alcohol abuse and preventable accidents, will they now accept the case for random breath testing? If Ministers, especially the Secretary of State, are serious about screening targets, will the right hon. Gentleman bring back the free eye test and drop the charges that, in two years, have stopped 5 million people getting that health check? Will the Secretary of State recognise that it is not enough to urge the public to change their life style if the Government are not prepared to change their policies?

Thirdly, a gaping hole in the statement was the absence of the word "poverty". Does the Secretary of State accept that his own tables in the Green Paper show that, as long as people remain poor, they are likely to remain in poor health, that those on the lowest incomes have more chance of a heart attack and that children in bed-and-breakfast accommodation have higher rates of respiratory disease? Will he study with care the shaming report published yesterday which confirmed that many children on income support go hungry and that all of them have a poor diet? Will he tell his colleagues at the Department of Social Security that the health of those children needs a better response than it got yesterday from Ministers who blamed the children's mothers? Cannot the Government admit that, in doubling the number of children in poverty, they have damaged the health of those children?

I want to end on a note of consensus by congratulating the Secretary of State on his decision to publish the document as a Green Paper for consultation. Does he now recognise that if the Government had been prepared to consult on their proposals for the NHS, he might not have run smack into so many of his problems of the past couple of months? As this is a document for consultation, may I assure the Secretary of State that we will strengthen his targets with our policies when we announce our response as the next Labour Government?

Mr. Waldegrave

There is an easy answer to the hon. Gentleman's facile first point. As one makes progress, it becomes more difficult to maintain the trend. That is not a difficult concept for the hon. Gentleman to understand. I can assure the hon. Gentleman that the targets that we propose are challenging, and would not be met simply by present trends on the best predictions. That is a straightforward answer to his question. It is not difficult for him to understand that it is easier to make the first step to progress and that it gets more difficult as one goes on.

The hon. Gentleman then quoted from the rag-bag of uncosted old policies which Labour raked up again yesterday to make a number of points. The fundamental point about Labour's rather feeble document is that it does not address the World Health Organisation's targets. It contains no objectives and no targets; it simply collects together a number of uncosted policies of dubious merit.

The action on our targets is related to the whole structure of the reforms that we have introduced. For the first time in the history of this country, we have a capacity to set health strategies and to enforce them. There is nothing in the hon. Gentleman's half-baked proposals which would enable him to deliver any health outcome.

The hon. Gentleman asked a question about tobacco advertising. The German, Dutch and Danish Governments today, with us, have put it to the Greek Commissioner concerned that it ill behoves the country that lobbies for the maintenance of subsidies for the growing of tobacco to lecture the rest of us about tobacco advertising. There is no correlation whatever between the countries in Europe that have banned tobacco advertising and progress on diminishing smoking—rather, the contrary—so I think that the hon. Gentleman's hasty advocacy of that policy will turn out to have been badly based.

I believe that serious civil liberties issues are involved with random breath testing. The authoritarianism of the Labour party is showing itself again. I served on the Select Committee on Home Affairs with many Labour Members who argued passionately against the sus law, and the ability of the police to stop people at random. Yet now the Labour party is arguing for exactly that policy.

As the House knows, 40 per cent. of people are exempt from the charges for eye tests and there is no evidence of a long-term drop in referrals to eye hospitals as a result of our policy.

The hon. Gentleman's final substantial point is in one sense correct. Everybody knows that an increase in wealth is generally good for one's health—although with one or two diseases, such as breast cancer, the correlation is the other way round. We, like other countries, have been making progress throughout the income levels—for example, on perinatal mortality—but we, and they, still have more to do. Sweden is among the countries in Europe which spend the most—it employs 9 per cent. of its GDP and 10 per cent. of its total work force in health—yet it has widening disparities in health, according to the latest evidence. It is true that differences still exist, but such discrepancies are profoundly difficult to attack.

It is clear that the Conservatives stand for more successful economic policies, which over the lifetime of Governments always increase wealth far more speedily than do those of Labour Governments. In the NHS we now have the capacity, which the hon. Gentleman opposed in every respect, to target health resources towards deprived areas. The hon. Gentleman opposed the GP contract, which enables us to do that, and every other similar step in our health reforms.

We have specifically targeted £500 billion to the poorest families in the past two years. Since the survey that the hon. Gentleman mentioned, there has been an 8 per cent. increase in support for the poorest families. Families in difficulty have even greater need of the help which we can give through better education, information and support for a healthy diet.

The hon. Member for Livingston (Mr. Cook) has, as so often, failed to rise to the scale of the challenge offered to him today.

Several Hon. Members

rose—

Mr. Speaker

Order. I remind the House that the Second Reading of the Child Support Bill is to take place today, and there is a great demand to take part in that important debate. I ask hon. Members to confine themselves to asking questions rather than making statements about a document, which as the Secretary of State for Health has said, is a Green Paper to which we shall doubtless return on numerous occasions.

Dame Jill Knight (Birmingham, Edgbaston)

As none of the steps on health would have been possible without the work on the reforms and on the doctors' contract, which have led to so much immunisation and checks on older people, does not my right hon. Friend the Secretary of State find it strange that not only the Opposition but the medical profession have fought both the reforms and the contract tooth and nail for a long time?

While my right hon. Friend's mind is on the question of preventive medicine, please will he think again about the Government's policy that has led to so many people not going for eye tests? Already hundreds of thousands of old people simply cannot afford to have their eyes tested. Early signs of cancer, heart disease and a number of other conditions are being missed. Will my right hon. Friend please think specifically about bringing back free eye tests for older people?

Mr. Waldegrave

My hon. Friend is right. It would be impossible to talk sensibly about developing a health strategy for England if we did not have in place the reforms that we have introduced. It would be simply to whistle in the wind if we did not have the delivery mechanism that we now have through the local health strategies and local health contracts between purchasers and providers. The hon. Member for Livingston probably knows that because in his rag-bag document there is a sort of acknowledgement of it. He says that he would have performance contracts, or something of the sort, in what he calls a medical market.

My hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) has been a doughty campaigner for eye tests. The £100 million which has come back into the health service is being better applied in other areas than if it was spent on the 60 per cent. of people who no longer receive free eye tests. As I said, 40 per cent. of people are exempt from the charges. I believe that the other 60 per cent. can afford the small charge for eye tests. The trends in the numbers attending for eye tests are now up again.

Mr. Charles Kennedy (Ross, Cromarty and Skye)

The objectives which the Secretary of State outlined have more potential to achieve cross-party consensus than the institutional changes in the health service which are being carried out at present. When the Secretary of State promises wide consultation, does he mean consultation with other political parties, as happened, for example, on the poll tax? Does he understand that many people in other political parties would take his promise of wide consultation more seriously if he had displayed willingness to listen to the overwhelming evidence on the institutional changes in the health service? The consultation on the institutional changes produced an emphatic no to the Government's proposals.

What are the implications of the statement for Scotland? How do the Government propose to follow the approach outlined today within a Scottish health context?

Mr. Waldegrave

My hon. Friend the Minister of State, Scottish Office, who is on the Bench beside me, is pursuing parallel initiatives.

On the institutional changes, it is typical of the hon. Gentleman's party to oppose what it takes to be the unpopular aspects, which are necessary. If we are to shift priorities, there will have to be changes in the institutional arrangements. We are putting in place mechanisms to make a reality of what I have talked about today. Under the present system, it would not be possible to make a reality of the health strategy that I have proposed. But the hon. Gentleman supports the objectives. If one supports the objectives, one must support the means to make them a reality.

Mr. Conal Gregory (York)

I welcome the Green Paper. Will my right hon. Friend confirm that there are two principal matters? The first is the resources which go into the national health service. Will he confirm that the resources have increased by some 50 per cent. since the Labour years up to 1979? Secondly, and even more importantly, the number of patients going through the hospitals underlies the strategy. Will my right hon. Friend confirm that the number has increased by 41 per cent. in the York health authority and by 40 per cent. in the Yorkshire region since Labour was in power? Do not those two local and regional examples stand well in the light of the paper that my right hon. Friend presented to the House today?

Mr. Waldegrave

My hon. Friend is entirely right. It is worth remembering that we have increased by a full percentage point the proportion of gross domestic product spent on health. In 1978–79 the proportion was 4.7 per cent. and in 1991–92 the proportion of GDP put into the NHS is 5.7 per cent. The proportion fell by 0.1 per cent. under Labour when it was last in office.

My hon. Friend the Member for York (Mr. Gregory) is also right about the excellent performance of the health service in increasing treatment in recent years. It is in order to maintain that progress that we need further to improve the organisation of the health service.

Mr. Ken Eastham (Manchester, Blackley)

In his statement the Secretary of State made special reference to the importance of diet. We readily concur with that sentiment. As a result of his statement, will instructions go to the Department of Education and Science to provide once again adequate midday meal for hundreds of thousands of schoolchildren who have been denied that facility for several years? Many school kitchens have been closed down. For a start, will the Secretary of State at least make a move in that direction to ensure that children do not go outside school and buy bags of crisps and so on for lunch but receive a balanced meal planned by a dietician?

Mr. Waldegrave

Local authorities employ dietary advisers and many schools provide very good, healthy meals. However, I do not believe that many of the traditional school meals would score highly according to modern dietary reckoning.

Mr. Jerry Hayes (Harlow)

Does my right hon. Friend agree that the general practitioners' contract is the major step forward in terms of monitoring, health promotion and protecting the frail and the elderly? Is he therefore surprised that the Labour party wants to abolish it? Is that because it is more eager to win the battle of the headlines rather than the battle for health?

Mr. Waldegrave

I thought that the Opposition's document was rather a damp squib because, as the newspapers knew, it had all been published before and it did not address the issue in question—the production of World Health Organisation-type health objectives. My hon. Friend is right to remind us that the Opposition's record on health objectives and making them real is extremely bad. They opposed the GP contract, saying it could not be done—they were wrong. We are now discussing whether we should raise further some of those targets, for example, a target of up to 95 per cent. for immunisation. We are putting the mechanisms in place to make those health gains real.

Mr. Kevin Barron (Rother Valley)

Does the Secretary of State accept that many people at present working in primary health care will think that his statement is nothing more than party-political hype?

Recently the director of public health in the Rotherham borough published his second annual report, which was drawn up through the family health services authorities and in conjunction with the area health authority and the community health council. That report clearly outlines the problems in terms of the need for primary health care, but the authority does not have the resources to do things about the high incidence of heart disease and other illnesses in South Yorkshire. When will the right hon. Gentleman's Department resource the current health service so that it can do many of the things that I do not believe a committee in Whitehall can do?

Mr. Waldegrave

I have the advantage over the hon. Gentleman of already having talked to a large number of senior health professionals about this matter. He will find that he is wrong. I applaud the fact that strategies of the kind that the hon. Gentleman described are being identified—which is because of the reforms that we have put in place. We shall now have the mechanisms to make a reality of the improvements that are needed. Those improvements would not be possible under the old system that the Labour party is defending.

Mr. Steve Norris (Epping Forest)

Does my right hon. Friend agree that, now that the country has two documents before it purporting to set out the strategy for primary health care, the country is entitled to judge their relative merits? In that regard it is worth contrasting that, whereas there are no objectives set in the Labour party's document, that of my right hon. Friend courageously sets specific objectives for health improvement. It is also worth remembering that, although capital expenditure under this Government has risen by 62 per cent., under the Labour Government it fell by 16 per cent.

Mr. Waldegrave

My hon. Friend is right. We are serious about improving the mechanisms for the delivery of health care and about producing, for the first time, a commitment across Whitehall, involving all Government Departments, to improve the health of the nation. It is obvious to anyone who looks at the two documents that that produced by the Opposition is not a WHO-type document. It would not be received as such, and it would not contribute much to discussions of this issue.

Mr. Joseph Ashton (Bassetlaw)

May I remind the Minister that it is now more than three years since I introduced a Bill to compel public houses to have no-smoking areas? It was approved by a vote. Since then successive Ministers for Health have done nothing about it, including the hon. Member for Derbyshire, South (Mrs. Currie). Will the Government now give an assurance that, in common with restaurants, planes, trains and the tube, pubs will be compelled to have no-smoking areas—or will the right hon. Gentleman still listen to his paymasters, the brewers, at the next election and refuse to introduce such areas?

Mr. Waldegrave

Today we are concerned with setting objectives; we shall then move on to discuss the best means by which to achieve them. Great progress has been made by means of voluntary agreements in the sensible direction for which the hon. Gentleman argues. Whether that needs statutory back-up will need analysis. We shall then see whether or not we can achieve the objectives we have agreed.

Mrs. Edwina Currie (Derbyshire, South)

Is my right hon. Friend aware that he has made me a very happy lady today? He is on exactly the right lines. I warmly congratulate him, and I will support him in all his efforts to improve the health of the nation. Does he agree that Labour Members have it all wrong about the main diseases, in dealing with which we lead the world, such as heart disease? Does he further agree that they are diseases not so much of poverty but of affluence, which will be amply demonstrated later today in the bars and restaurants of the House as hon. Members proceed either to celebrate or commiserate, whichever is their preference, with cream cakes and double brandies?

Mr. Waldegrave

It gives me great pleasure to have given pleasure to my hon. Friend. I welcome her support. She is correct to say that some of the issues—for example, alcohol abuse and smoking—cannot be correlated with poverty. I urge her to agree also that another real issue —there is no point in denying it—is that if we can maintain progress in the economy so that people are better off, all the indications are that general health will also improve against most, though not all, diseases.

Mr. Michael J. Martin (Glasgow, Springburn)

I am disappointed that the Minister has not said that many people can contract heart complaints and hearing and breathing difficulties as a result of their occupations. If he is serious about prevention rather than cure, he will take his health team into factories where, in this day and age, men and women are having to work with asbestos, near welding techniques which can give them emphysema, where there is excessive noise and where sometimes they must handle oils and other substances which give them dermatitis. It is clear that the men who died on Piper Alpha died because of lack of safety. If the right hon. Gentleman is concerned with the health and longevity of the people, he will want to examine some of the factories in which they have to work.

Mr. Waldegrave

The hon. Gentleman should not be disappointed in that respect because he will be happy to find, on reading the document, that we have given a high priority to occupational health and discuss the objective of an accident avoidance target, a complex issue about which we are serious. Let us not forget that a Conservative Government took decisive action against asbestos, and the numbers of health and safety inspectors are set to increase rapidly in future months.

Sir Anthony Grant (Cambridgeshire, South-West)

My right hon. Friend rightly identified heart disease as a major health problem for the nation. He will have noticed, as the House did, the deplorable hilarity with which the matter was dealt with by Opposition Members when it was raised. Does he agree that it is essential to preserve the excellence of hospitals, such as the world famous Papworth hospital in my constituency, in dealing with the situation? May we have an assurance that nothing in the policy is likely to cause the break-up of those excellent institutions, with their work being passed on in some other way?

Mr. Waldegrave

I appreciate that my hon. Friend takes a particular view of any proposals that might be made for the reorganisation of Papworth, and I note his advocacy yet again. The performance of Opposition Members today has been shoddy—[Interruption.]—and I suggest that even some Labour Members believe that to have been the case. The puppies yap as the caravan passes on.

Mrs. Rosie Barnes (Greenwich)

Will the Secretary of State undertake, as part of his review, to pay particular attention to the correlation between damp and black mould in homes and health? I believe it to be a contributory, if not a major, factor in cot and infant deaths, a problem in many parts of the country.

Mr. Waldegrave

The tragedy of cot deaths still baffles scientists to some extent. The hon. Lady will welcome the fact that in the document—the first time that it has ever happened in this country—we are presenting a strategy that runs across Government, with a major contribution from the Department of the Environment. It is difficult to set targets related exactly to housing, but the concentration of resources on improving the worst housing must be part of a general strategy for health.

Sir Michael McNair-Wilson (Newbury)

I welcome my right hon. Friend's statement about a strategy for the nation's health, looking to the future. That, in turn, must raise the profile of health education. My right hon. Friend will not be surprised to hear that I am a little disappointed that kidney patients, particularly elderly ones, are not mentioned. I am even more surprised that we do not yet feel that we can do anything for AIDS patients on the basis that more information is required. Will my right hon. Friend fill out that point?

Mr. Waldegrave

On my hon. Friend's first point, it is vital to emphasise that the comprehensive nature of health care must be maintained, including the care of kidney patients. We are dealing with priorities because, in some areas, compared with other countries, Britain needs to do better and in others, although we are doing well, with reasonable extra efforts we could do even better. Road traffic accidents are an example of the latter.

The Government are spending large sums on the terrible disease of AIDS. The difficulty about setting the objective to which my hon. Friend refers is that, with science as it is, we do not yet know what would be a sensible objective in terms of eradicating that disease. It may be sensible to develop subsidiary objectives to care for those who have the disease.

Ms. Mildred Gordon (Bow and Poplar)

Is the Minister aware that there has been a huge increase in the number of cockroaches and ants in this country, perhaps because of the introduction of central heating? Will he look into the question of the extermination of such insects and the use of chemicals for extermination which will not damage the people who handle them or those whose houses are affected?

Mr. Waldegrave

I remember from my time as Minister for Housing the problem of pharaoh ants and other insects—

Mr. Graham Allen (Nottingham, North)

That was probably when the problem started.

Mr. Waldegrave

It was not caused by my presence in that office; it was due to the reasons referred to by the hon. Lady. I cannot give a full response from the housing department to that point today, but I shall draw it to the attention of my colleagues.

Mr. Tim Devlin (Stockton, South)

Given the fact that a royal commission established under a previous Labour Government found that, even if 100 per cent. of GDP was spent on health, there would still be unsatisfied demand, and given that the Labour party is not offering one penny more for health should it come to power, is it not a valuable exercise for consumers to be consulted about t he future direction of their health service and the targets that should be set? In that way, they can not only judge the system but see how well it is delivering the service for the first time since its inception.

Mr. Waldegrave

My hon. Friend has put his finger on the most fundamental point. After the reforms, there will be not only a requirement but a need for an explicit health strategy, locally and nationally. That will derive from the reforms. We are discussing that matter today to begin to deal with the problem. The matter is of great importance in the long-term history of the national health service and in the country.

Mr. Robert N. Wareing (Liverpool, West Derby)

The Secretary of State said that the charges for eye tests bring in £100 million. Will he admit that that figure tells us nothing about the people who cannot contribute to that figure—those who are too poor but are not exempted from the charge? Would it not be better for the Government to recoup the £100 million by abolishing the eye sight test fees and the tax relief that was given to people such as the Secretary of State, who can afford private health insurance?

Mr. Waldegrave

I have not yet retired, so I do not benefit from that relief. The arguments that I put to my hon. Friend the Member for Birmingham, Edgbasi on (Dame J. Knight) seem to be powerful. The charges are small and 40 per cent. of the population are exempt. Evidence shows that the number of people having eye tests is now up again. There seems to have been no falling off in the number of referrals to eye hospitals in the past year. I know that the hon. Gentleman, like my hon. Friend, has been a campaigner on those matters.

Mr. Henry Bellingham (Norfolk, North-West)

I congratulate my right hon. Friend on his extremely impressive statement, which was in stark contrast to the hot air that we heard yesterday. Does he feel that, within his health strategy, there is a role for alternative medicine, and above all for the study of allergies?

Mr. Waldegrave

I should not want to make those matters a primary objective of health care. However, as a constituency member representing the Bristol homeopathic hospital, it behoves me to make available—in that case on the national health service, if possible—the treatment required by many people.

On my hon. Friend's second point, may I warn the House that, true to form, in about a month's time, the Labour party will once again publish the document that it has published three times before and the BBC will, yet again, fall for it as a news story.

Mr. Eddie Loyden (Liverpool, Garston)

Does the Secretary of State accept that there is a relationship between poverty and ill health? Does he also accept that the high unemployment suffered in this country during the past 11 years has contributed in many towns and cities to the deterioration in the health of many families? Will he convey that message to his right hon. and hon. Friends in the Departments of Industry and Employment to ensure that that aspect of ill health is considered?

Mr. Waldegrave

I have already spoken about inequalities in health. The hon. Gentleman represents a party that wins a remarkable double in such matters. A Labour Government have never left lower unemployment or lower waiting lists than they found, so I think that some modesty on that issue might be in order from the Labour party.

Mr. Geoffrey Dickens (Littleborough and Saddleworth)

May I congratulate my right hon. Friend and his team on this brilliant initiative? Not only is it sheer common sense to set targets and objectives that can be measured, but the spin-off that will occur in coming months as we roll on with the debate will cause many people to think and perhaps use a bit of self-discipline. I might cut down my weight, so watch this space.

Mr. Waldegrave

The hon. Member for Livingston (Mr. Cook) and I would welcome more congruity in shape with my hon. Friend the Member for Littleborough and Saddleworth (Mr. Dickens), but we would not want to lose his contributions to our discussions in the House. I am grateful to my hon. Friend for his welcome. Now that there is a proper management structure in the health service, it is sensible to set objectives towards which the service can work to enable the I million people employed in the service throughout the United Kingdom to begin to feel that the service has aims.

Ms. Dawn Primarolo (Bristol, South)

In the past few days, the Secretary of State will have received from the district health authority that covers both his and my constituencies an identification of the crisis in health care in south Bristol—high mortality rates, very high infant mortality rates and a remoteness from the national health service. Indeed, on every criterion geared to identify health care, Bristol, South scores the highest. As a result of the reorganisation, there have been cuts in the numbers of intensive care beds and budgets, and a refusal to build the new Bristol, South hospital; and now there are to be redundancies. Will the Secretary of State explain to the people of Bristol how the document that he has presented today will improve their access to health care when it is built on reforms that have made access more difficult, not easier?

Mr. Waldegrave

The 30 or 40-year-old battle for a major hospital in south Bristol is the only factor that unites the hon. Lady and her predecessor. The hon. Lady should make the point that when we consider the distribution of health resources throughout the country —about which we hear a lot from Opposition Members —we realise that the Government are taking steps to ensure the fairer distribution of such resources nationally. That is partly what our travail is about. She should welcome that.

Mr. John Greenway (Ryedale)

The setting up of the health strategy steering group is the most positive of the measures announced today. Will the group include members of the dental profession? Given that diet can play such a large part in improving our health and that without teeth one cannot eat, surely dental practitioners have a major role to play in improving the nation's health by giving advice about diet.

Mr. Waldegrave

My hon. Friend is entirely right. Contributions from dentists will certainly be included. The document also considers setting objectives for child dental caries. That is not because this country's record on that issue compares poorly internationally—in fact, we do well —but because we believe that it would be relatively easy to make further progress in that sphere and attach a high priority to it.

Mr. Bob Cryer (Bradford, South)

The Minister spoke about the incidence of ill health in factories. Does not he realise that factory inspections are at an all-time low and that the Department of Employment does not even enforce the notification of occupation of factory premises? The Secretary of State seems to be obsessed with changes in the institutions. Will it benefit the people of Bradford when Bradford NHS trust makes 300 people redundant and closes the baby unit at St. Luke's hospital and two other hospitals in Bradford? Surely that denies people access to medical facilities.

In terms of more NHS trusts, will the right hon. Gentleman assure the House that in his consultation process he will agree to a ballot of local people? If he is not satisfied with that and is convinced about the marvellous nature of his proposals, will he have the guts to tell the Prime Minister to have a general election about them?

Mr. Waldegrave

That was a characteristic contribution. The hon. Gentleman should realise that our capacity to look across the board at the health needs in his constituency and city has enabled us to make great advances in primary care in Bradford where there has been a dramatic reduction in lists. Health care in Bradford or Bristol, or anywhere else, cannot be improved simply by concentrating on acute hospitals. There must be a comprehensive local health strategy, and resources must be deployed across the board.

Mr. Richard Holt (Langbaurgh)

I welcome my right hon. Friend's statement. I am sure that it will not take long for him to write a short note to the hon. Member for Livingston (Mr. Cook) giving an exposition of the law of diminishing returns because, plainly, the hon. Gentleman does not understand that law.

Will my right hon. Friend help me with a small problem which landed on my desk today? As a diabetic, I received a letter from consultants in diabetes telling me that the Government have withdrawn the free medical facilities that were previously available to all diabetics, even those who were not receiving medication. A confirmed diabetic being treated by diet alone was able to obtain the necessary testing equipment free. I am now told by the consultants who have written to me that you have changed that arrangement. If that is true, will you please reverse it?

Mr. Speaker

Order. The hon. Member must not address his question to me.

Mr. Holt

I am sorry, Mr. Speaker. Will my right hon. Friend confirm that what the consultants have said in that letter is correct, in which case will he reverse his decision? If it is incorrect, the consultants should be ashamed of writing such a letter.

Mr. Waldegrave

The hon. Member for Livingston (Mr. Cook) understands the law of diminishing returns, because each time he publishes the same old proposal it seems to get less coverage.

It would have been helpful if my hon. Friend had given me notice of his question about his letter from consultants. I shall he happy to discuss it with him. He will be pleased to discover that the document states that we wish to develop targets for diabetes and asthma. I shall certainly discuss the consultants' letter with my hon. Friend and discover what lies behind it.

Mr. Dennis Skinner (Bolsover)

Has not the Secretary of State got the intellectual capacity to understand that for 12 years the Government have undermined the national health service, and spoken against intervention in a public service? He is electioneering to the British people and is substituting waffle for resources. Tory Members may be conned by that, but he can rest assured that people outside are not. It is time that he took his hook back to the senior common room and took all his Front-Bench colleagues with him.

Mr. Waldegrave

Of course electioneering is the last thing that the hon. Gentleman would do and would regard it as a disreputable activity. He seemed to betray one of the finest of the old Labour traditions, which was to value education. Perhaps I should not rebuke him for that.

Mr. John Butterfill (Bournemouth, West)

When my right hon. Friend consults on targets, will he please take no account of the appallingly low expectations of the Labour party? Does he recall that the chief Opposition spokesman on health said when we were negotiating the GP contract that the demands on doctors were so heroic that most of them would give up trying? Can my right hon. Friend confirm that four out of five of them have now succeeded in meeting those targets on child immunity? How many children might have died or now be suffering from crippling diseases if the Labour party had been setting the targets?

Mr. Waldegrave

That is a fair point. The Labour party is still standing by its ridiculous position that it will repeal that contract. It will allow the standards of immunisation and the targeting for cervical smears to go backwards and that will put many people at risk. That is very irresponsible, and my hon. Friend the Member for Bournemouth, West (Mr. Butterfill) is right to continue to rub the nose of the hon. Member for Livingston (Mr. Cook) in it. By making a very short-term alliance with the British Medical Association at the time, the hon. Member for Livingston has got himself hooked on a very irresponsible policy, just as he did in an alliance with the drug companies when he opposed the limited list. He was wrong also on that.

Mr. Tony Lloyd (Stretford)

Given that the Secretary of State mentioned tobacco as a serious factor in relation to deaths and ill health in this country, why is he not prepared to take on the tobacco lobby specifically when we know that the tobacco companies have, in advertising terms, successfully targeted young people and especially young women? Is it not time that we took action against that advertising? Why will the Department of Health and the Government be opposing an EEC-wide ban on tobacco advertising? When drugs are such a scourge among young people, why has there been scarcely a mention of a proper attack on drugs in our society or of the need to provide a proper health programme for young people?

Mr. Waldegrave

I do not know whether the hon. Member was in the Chamber earlier when I answered a question about advertising. The issue is more complex. .A further aspect that I did not mention earlier, but which I will refer to now, is that the countries that are in favour of a total advertising ban are among those with nationally controlled monopolies in the production of cigarettes. Some people believe that the suppression of advertising is not unconnected with the fact that they wish to protect those monopolies. There is no connection at all between those countries which have banned advertising and those which have done well in diminishing smoking. As I said earlier, the first thing for the European Community to do is to withdraw its subsidies from the growing of tobacco. That would be a much better first objective.

Drugs may be an area which should be targeted and perhaps the hon. Member for Stretford would propose that. We have not included drugs among the initial main targets in our discussion document because—and I make this point to everyone who wants to add additional targets —if we make everything a priority, then nothing is a priority.

Mr. James Paice (Cambridgeshire, South-East)

My right hon. Friend deserves widespread congratulation on having the courage to lay down targets so that we can assess later in the decade how well the Government are progressing towards achieving what my right hon. Friend has set out today. Is it not significant that the Opposition have refused to set out any targets not only so that they can simply snipe at the Government's targets, but, more importantly perhaps, because they are pledged to repeal the structural reforms which would be the only way to assess whether they had ever reached those targets?

Mr. Waldegrave

That is absolutely true. The connection between the reforms and the kind of targeting procedure that we are now undertaking must be emphasised. Unless we have the capacity to deliver, it is no good talking about objectives. The Labour party must have realised that it was in some danger here or it would not have gone to all the trouble of regurgitating its document yesterday and giving it to the press.

Mr. Simon Coombs (Swindon)

At last the Government have produced a strategy for health promotion and have offered the nation targets by which that strategy can be judged. That action will be widely welcomed both inside and outside the House. Nevertheless, does my right hon. Friend accept that a large proportion of the population of this country is frankly suicidal in the sense that they will ignore all the advice of the Health Education Authority and health education officers and advice that they should moderate their diets, intake of alcohol and cigarettes and advice about healthy exercise? Given that the Government are not in favour of a nanny state, how does my right hon. Friend propose to meet the targets in the light of that opposition from such a large proportion of the population?

Will my right hon. Friend also consider the targets for eating and drinking? The Green Paper states that those targets should be reached by the year 2005. Will he consider aiming to reach those targets by the year 2000, as that is important? Also, why is there no target in respect of the level of cholesterol in that range of targets?

Mr. Waldegrave

On the latter point, in the discussion we shall certainly consider whether those targets should be brought forward, raised or lowered. That is exactly what the discussions are now meant to do. We have issued a report about cholesterol testing and surveying.

My hon. Friend is a long-standing campaigner on these issues, and I pay tribute to his contribution. It is true that in a free country we cannot compel people to good health. I made that clear at the beginning of the Green Paper. There are some pressures, however, that both sides of the House regard as legitimate, and one of those is price. In relation to cigarettes and alcohol—this relates also to the question by the hon. Member for Stretford (Mr. Lloyd) —we must ensure that the European Community, by the harmonisation of taxation levels, does not lower the levels of taxation on cigarettes and alcohol in 1992.

Mr. Robert G. Hughes (Harrow, West)

Does my right hon. Friend agree that the welcome targets that he has set today will be achieved only if there is a full partnership between the Government, local government, employers and voluntary organisations, and that, for that partnership to be meaningful, they can play their full part only if they have targets and objectives to which to work? Is it not a fact that the Labour party's document which was published yesterday, without such targets and objectives, was designed to be meaningless, is meaningless and, like the rest of its health policy, means absolutely nothing to anyone?

Mr. Waldegrave

That is true. That document was not a great contribution to the debate, and I do not think that it will be long remembered. I agree with my hon. Friend. I specifically mentioned voluntary organisations in my statement. If the strategy is to work, it will not be done simply by Government or simply by the national health service. It must be done by persuading people in a range of organisations and by persuading individuals that it is worth doing. That is why it is worth having a proper consultation period and having discussions throughout the country to get people committed to the kind of targets that we are proposing.

Mr. Patrick Nicholls (Teignbridge)

In the consultations that are to take place on these excellent proposals, will my right hon. Friend reject some of the more facile and easy solutions that are sometimes offered? Does he agree that it is not an adequate response to the fact that many epidemiological surveys show that smoking is associated with various lung conditions and that other lifestyle factors may be every bit as relevant? Should not that sort of thing be borne in mind as well, otherwise merely to opt for the easy option of a total ban on advertising may miss some factors that are every bit as relevant?

Mr. Waldegrave

In my scepticism about the effectiveness of a general ban on advertising, I would not want to mislead the House into thinking that I did not believe that a continued, rapid fall in smoking would not be one of the best things that we could do for health. It would be one of the best things that we could do for health. Nobody knows the exact causation between lung cancer and smoking, but no one now doubts the absolutely clear statistical evidence that one goes with the other. It is central to our strategy to set a challenging target for the further diminution of smoking and to see that it comes about.

Mr. Ted Leadbitter (Hartlepool)

Is the Secretary of State aware that his hon. Friends are wrong in suggesting that he has courage in deciding on targets? They are 12 years too late. Will he have the courage, however, to deal with one target, and that is the practice of health service consultants saying to patients that they must wait 12 months or more for treatment, but end up treating them if those same patients go private?

Mr. Waldegrave

Everything that we are doing in the reorganisation of the health service is aimed at getting more health care for the money—the increasing amounts of money—that we are spending. Our record on health spending and on the number of people treated stands easy comparison with that of the hon. Gentleman's party, which, as I remind him once again, has never left waiting lists lower than it found them.

Sir Ian Lloyd (Havant)

If, as I believe, the health of the population is the result of the careful and considered application of science, medicine, compassion and resources, is not the population much more likely to be served by the calm and courteous rationality that my right hon. Friend has exhibited this afternoon than it is by shouting and leering and the kind of intellectual nonsense that has been exhibited by the hon. Member for Bolsover (Mr. Skinner)? Perhaps one day the hon. Gentleman will become a fellow of All Souls. I shall look forward to that day.

Mr. Waldegrave

My hon. Friend is very kind. I am sure that the House would not want to miss the contributions of the hon. Member for Bolsover (Mr. Skinner). My hon. Friend must be careful because it is more dire an insult for him to describe the hon. Gentleman as "an intellectual" than for my hon. Friends to describe me as such.

Mr. Robin Cook

No doubt through oversight, the Secretary of State omitted to give us the figures, on current trends, for the reduction in coronary heart disease and strokes by the year 2000. Will he now tell the House those figures?

Mr. Waldegrave

I shall write to the hon. Gentleman with those figures, but of course they will be speculative. However, I assure him that the targets that we are setting are challenging. That is what challenging means. They are not simply predictions.