"Health of the Nation"

HC Deb 08 July 1992 vol 211 cc335-51 3.31 pm

The Secretary of State for Health (Mrs. Virginia Bottomley)

With permission, I should like to make a statement about better health.

I am publishing today a White Paper, "The Health of the Nation", copies of which have been placed in the Vote Office. Last June, my predecessor, my right hon. Friend the Chancellor of the Duchy of Lancaster, published a Green Paper on the same subject, since when we have consulted extensively.

We made it clear before and during the election that a White Paper on health would be one of the first priorities of the new Conservative Government. Today, we honour that pledge.

The Government are committed to improving the health of the nation. The White Paper is the latest, but not the last, step in our strategy. The response to the Green Paper was impressive. More than 2,100 individuals and organisations responded directly. There has been a wide and productive debate at specially organised conferences and workshops, in newspapers and journals, and on television and radio.

That response reflects the growing interest in health matters as a whole. Hon. Members will know that people have become more conscious about what they eat, how much exercise they take and how they can generally improve the quality of their lives by becoming healthier.

We wish to build on that healthy trend. No responsible Government can be a disinterested observer of an unhealthy nation. There is an enormous cost to the national health service and to our economy of avoidable illness. It includes working days lost and expensive treatment given. We should prevent illness wherever we can. Prevention is better than cure. We shall be able to target health resources where they are really needed.

We are spending record amounts on the national health service. We must use resources to improve health as well as health care. We are seeking to improve the quality of life, and of individuals' lives, in the most cost-effective way.

One central message has emerged from the consultation exercise on the Green Paper—the wide backing for the overall strategic approach that it proposed. There is support from among policy makers, practitioners and politicians of all parties. The World Health Organisation welcomed our strategy, describing it as a model that other countries might follow. I am particularly pleased to launch the White Paper just one week into the United Kingdom presidency of the EC.

At the heart of the White Paper is the setting of targets in key areas. We have selected five areas—coronary heart disease and stroke, cancers, mental illness, HIV-AIDS and sexual health and accidents.

In each of these key areas we have set challenging but achievable targets. In some areas they are tougher than those proposed in the Green Paper. Those targets include a 40 per cent. reduction in deaths from coronary heart disease and stroke by the year 2000; a 30 per cent. reduction in deaths from lung cancer for men by 2010; reducing the number of people who smoke from one third of the population to one fifth by the year 2000; and cutting childhood accidents by a third by the year 2005.

Our task was to choose areas of greatest concern: where there is the most serious avoidable loss of life or handicap, and where the work needs to be done and can be done. The Department's chief medical officers have been closely involved in the work. We have drawn on a wide range of medical and other expert opinion.

Other areas do not cease to be important. In some cases, well developed initiatives to improve health already exist. For example, I announced last week that we have now achieved our 90 per cent. national target for immunisation against childhood diseases. We are now working to a new target of 95 per cent. by 1995.

In other areas, more development and research will be needed before national targets can be set. What we are proposing are not short-term measures. The strategy will grow and develop. To provide the knowledge and methodology for this to happen, the research and development strategy launched by my Department in April 1991 will play a crucial role. The White Paper identifies other possible target areas for the future. This underlines the fact that it represents a beginning, not an end.

I hope that the House will recognise and welcome the strategy. Coronary heart disease and strokes are the biggest causes of premature death and disability in this country. We have made considerable progress, but there is scope for more. Cancers account for a quarter of all deaths. Many of them can be prevented. Mental illness affects millions of people, with a high cost to the nation. There is still too often a taboo associated with it. Accidents are the most common cause of death in people under 30. Often they can be avoided. AIDS is the most significant new threat to public health this century. In improving sexual health generally lies the greatest scope for preventing HIV infection and the spread of this terrible disease.

We need targets for three reasons: they give us something real at which to aim, they provide a common focus for action, and they allow us to measure progress. To be respected, however, targets have to be tough. To be credible, they have to be realistic. It would be folly to set a target so out of reach that we would never get there, or one which is simply an extrapolation of existing trends.

Our comprehensive approach is unique. We have identified the broad strategies and the practical machinery needed to achieve targets. Everyone is involved. The White Paper is more than just the work of the national health service, vital though that is. It takes in the activities of every Department in Whitehall. It is for private companies and voluntary bodies, for local authorities as much as health authorities, for employers and trade unions, for organisations of -every kind, and for individuals of every age.

Working together, forming healthy alliances, is one of the central messages of "The Health of the Nation". The White Paper demonstrates the Government's commit-ment, first, by addressing a range of health issues which go well beyond the responsibility of the Department of Health; secondly, by highlighting the central role of the Cabinet Committee set up by my right hon. Friend the Prime Minister to oversee the development and implementation of the strategy—no other country has set up a similar structure at such a high level to take forward a health strategy—and, thirdly, by setting out a range of actions to improve health, which only Government can take.

While recognising the role of others, the national health service must be at the centre of the strategy. The publication of the White Paper today marks a major new landmark in the development of the NHS. It is the next logical step in the process of health reform. It provides new opportunities to raise our sights beyond the provision of health care—important though that is—to health itself.

The national health service was founded to secure improvement in the physical and mental health of the people and the prevention, diagnosis and treatment of illness. That was enshrined in the National Health Service Act 1946. This strategy carries those principles forward in a programme of work which will take us well into the next century.

The health reforms have enabled health authorities to take a more strategic look at the health needs of their local populations. The priority areas that we have selected and the targets that we have set match local needs and concerns. The NHS management executive will require health authorities to build the target-setting approach into all levels of local activity. The strategy will be central to the work of the NHS.

The NHS must also lead by example; it must be a healthy employer. Its 1 million employees must themselves play a part, helping themselves, their families and friends, as well as the patients for whom they care, to improve their health. We shall engage all NHS staff in making their own workplace a healthy place both for themselves and for patients. The NHS chief executive is working with the Health Education Authority to launch a special initiative on this later in the summer.

By many reckonings, we are healthy. In 1991, for the fourth successive year, perinatal and infant mortality rates fell to their lowest ever recorded levels. Our immunisation rates are high. We were the first country in the European Community to establish national screening programmes for breast and cervical cancer. In the past decade, life expectancy has risen by three years for men and by two years for women.

We have been adding years to life; the health strategy is about adding life to those years. Ultimately, it also means adding even more years to life. No one doubts that there are areas in which we can grow healthier as a people. The White Paper has identified those key areas and it has proposed real action for improvement.

The ideas in this White Paper will take root and grow. We have the potential to take this country to the top of the health league. I commend the White Paper to the House.

Mr. Robin Cook (Livingston)

There will be a broad welcome for the stress that the Secretary of State has rightly placed on promoting better health rather than just curing ill health. I offer a personal welcome for the toughening up of a target for a reduction in coronary heart disease which has been increased from 30 per cent. to 40 per cent. The Secretary of State will recall that when I pointed out to her predecessor that the original target meant that there would be no increase in the rate of reduction, he described that point as "facile" and "a misunderstanding". I express my pleasure that the right hon. Lady shares my misunderstanding and has acted on it.

It would be unfair not to recognise that the right hon. Lady has responded to the criticism that the Government's proposals on mental health were only about the closure of institutions. I congratulate her on coming up with a welcome range of targets for positive improvement in the mental health of individuals. These are all the more welcome as mental health does not always achieve the attention that it deserves in our deliberations.

The White Paper provides a bold target for cutting teenage pregnancies. In view of the trailers in the Sunday newspapers, I express some surprise that the Secretary of State made no mention of the target in her statement. Is that because she knows that the White Paper contains no new initiative on sex education and not a new penny for family planning? Will the right hon. Lady accept that, in this and in other measures, the reaction of many people to the White Paper will be that it has got the right diagnosis, but has not come up with the right prescriptions?

The White Paper identifies smoking as the largest single cause of preventable disease—a point stressed by the Secretary of State. Why, then, do the Government still duck a commitment to banning tobacco advertising? Does the Secretary of State appreciate that the offer in the White Paper of a review of tobacco advertising will be greeted with disbelief? Was she not listening during the year of consultation on the Green Paper? Can she name one submission from anyone in health promotion which did not support a ban on tobacco advertising? Does she not understand that it will be widely believed that the Government's failure to act now on the issue has nothing to do with the need to collect further information through another review and everything to do with the 2,000 poster sites supplied to the Conservatives by Imperial Tobacco in the general election campaign?

The White Paper stresses the need for a healthier diet. Will the Government therefore bring back the nutritional standards for school meals which they scrapped as soon as they came into office? The White Paper calls for a cut in road accidents. Will the Government accept the case for random breath testing to crack down on drink driving? The White Paper stresses people's responsibility to keep a check on their health. Will the Government scrap the charges for eye tests which dramatically cut the number of people coming forward for that check? What does the Secretary of State intend to do to ensure an NHS dental check for everyone who wants it when dentists are leaving the NHS in droves?

The Secretary of State claimed that her White Paper was comprehensive. I think that that was the word that she used in her statement. How can a White Paper on health promotion be comprehensive when it does not once mention poverty? Does the Secretary of State recognise that by doubling the number of children in poverty the Government have increased the number of children brought up on a poor diet? Does she recognise the link between increased homelessness and increased respiratory disease? Does she recognise the increase in suicides as a result of the increase in unemployment among young men?

Does the Secretary of State recognise that everyone knows that those links are missing from the White Paper because they would require the Government to admit that by increasing inequality they have increased ill health'? A White Paper which does not propose a single measure to combat poverty, homelessness or unemployment is not a White Paper which offers better health to all.

Mrs. Bottomley

I thank the hon. Gentleman for welcoming me to my position, but move on swiftly to say that I do not know whether this will be his swansong.

Having said that, I hope that by the time we finish today we shall have had a last opportunity to convince him on several matters and errors of debate in recent years.

The hon. Gentleman raised several points which were a vindication of the strategy. He raised issues which are the responsibility of my right hon. and learned Friend the Secretary of State for the Environment and my right hon. Friends the Secretaries of State for Education and for Social Security. That shows why it is so important to have a Cabinet Committee specifically to address the improvement of the health of the nation. I shall respond to the hon. Gentleman on matters for which I am responsible. He will understand that other matters are precisely those which need further debate.

The hon. Gentleman rightly said that the targets had been strengthened. Indeed, in his working group the chief medical officer identified the targets and sought targets which were not extrapolations—the point that the hon. Gentleman made on the last occasion—but were challenging yet achievable. We have strengthened the targets not only on coronary heart disease but on smoking among women and on mental illness. I thank the hon. Gentleman for recognising that we have included mental illness. We share the view that mental illness is the source of a great deal of disability and unhappiness and does not always get the focus that it requires.

The hon. Gentleman mentioned poverty. The Department of Social Security spends £1 billion a week —an extra £600 million—on arrangements for low-income families. When we have discussed aspects of deprivation in our health debates, the hon. Gentleman has sought time and again to make the point that GPs in inner-city areas should not be expected to deliver the high targets set for the rest of the country. We disagree with the hon. Gentleman. We believe that we should encourage all areas to do as well as the best. That is why this year we are driving forward improvements in perinatal mortality rates to ensure that the least advanced areas do as well as those which are striking ahead. Above all, when it came to the GP contract, our approach was not a lower target for inner-city areas. On the contrary, it was to provide for the first time deprivation payments for GPs in inner-city areas.

The hon. Gentleman also mentioned eye tests. As he will be aware, the number of tests has now reached the level that it was at when the charges were introduced. It is reasonable when allocating resources to expect those who can afford it to pay an average of 12p per week for their eye tests. As for dental checks, we have never had so much NHS dentistry at any stage of the national health service. There were 7 million more courses of adult treatment last year than in 1979.

The hon. Gentleman mentioned school meals. It is not our view that school meals should be controlled by central diktat, but we welcome the activities of local education authorities, which are working with nutritionists to produce healthy meals in their areas. One of the initiatives of the health strategy is healthy schools.

Smoking is an important area, and the hon. Gentleman will be aware that we have strengthened targets for smoking. We are unequivocal in our determination to achieve those targets. What the hon. Gentleman does not always say is that only one country in the European community has achieved a sharper reduction in tobacco smoking than this country, and that is the Netherlands. It is a curious fact that the majority of countries which support a ban on advertising also have nationalised tobacco industries.

When considering what influences people to take up smoking, the key factor is price. The hon. Gentleman may wish to reflect on the fact that under recent Conservative Governments the price of cigarettes has risen by 43 per cent. When Labour was in power, the price rose by a mere 1 per cent. That is the contrast. We recognise that advertising has a part to play, and that is why we have a stringent voluntary code. What is more, we have introduced the fiercest health warning labels on cigarettes of any EC country. The hon. Gentleman will be aware that the tobacco industry is busy taking the Government to court on the strength of that.

This strategy represents an important new landmark for the national health service. I hope that the hon. Gentleman will bring himself to a deathbed repentance and will admit that he was wrong about the GP contract and wrong about NHS health reforms, but that at least he is right to welcome in principle the "Health of the Nation" strategy.

Mr. Roger Sims (Chislehurst)

I welcome the publication of the White Paper and on behalf of my hon. Friends I congratulate my right hon. Friend on demonstrating that she is a Secretary of State for health and is not solely responsible for illness.

Can my right hon. Friend confirm that this year the Government will be spending nearly £36 billion on the treatment of illness and disease, a high proportion of which is avoidable? Does it not make sense, and is it not incumbent on us all and not just on politicians and medical people, to ensure by following the White Paper's proposals that we avoid illnesses and diseases which can be avoided?

My right hon. Friend mentioned a number of targets. Can she say a little more about the mechanisms proposed at Cabinet level and locally to progress how they are met?

Mrs. Bottomley

I thank my hon. Friend, who has for many years been a champion of the cause of health strategy. As he rightly says, the White Paper sets the agenda for the Department of Health to consider health as well as health care. The reforms enable us to take that strategic approach so that we can assess the health needs of local communities precisely and translate them into concrete actions. The White Paper sets the third leg of the health service—prevention—as well as treatment and rehabilitation.

The NHS will be setting, and seeking to secure, delivery of those targets—the chief executive through the priorities and planning guidance, the regions by setting targets with the districts, and the districts by implementing those targets in the contracts that they place. At the same time, the ministerial Committee will want to monitor the development of the strategy and to ensure that, if we need more stringent action in any area to meet the targets, that action is taken.

I assure my hon. Friend that we shall meet those targets, and we shall beat those targets.

Ms. Liz Lynne (Rochdale)

Does the Minister accept that there is more to health promotion than giving up chips and taking up jogging? Does she recognise that all Government Departments must be involved? Will she now demonstrate her commitment to health promotion by persuading the Government to ban tobacco advertising? Otherwise, people will assume that the Government are willing to profit from a person's addiction rather than do all in their power to prevent it.

Mrs. Bottomley

Certainly, I hope that the Department will practise what it preaches and that the NHS will practise what we preach. That is the significance of our initiative in ensuring that the NHS is an example of a healthy employer. As the largest employer in the country, it should certainly be a healthy employer. Our Department has been affected by the ministrations of my hon. Friend the Member for Derbyshire, South (Mrs. Currie) when she was at the Department and we have already taken a number of practical steps.

I must repeat our absolute commitment to meeting the targets to reduce smoking. Days lost, unnecessary costs to the health service and personal misery all result from needless smoking. We are determined that, by price, education, stopping the £1 billion subsidy to the growing of tobacco, preventing the example of tobacco smoking, and continuing to review the role of advertising, we shall ensure that this country is in the lead in the reduction of smoking. However, it is hard for us to take lessons from countries whose records in the reduction of smoking leave much to be desired.

Several Hon Members

rose—

Madam Speaker

Order. We have reached the point at which I must remind hon. Members to ask only one question. I also appeal to the Minister to answer briefly so that we can make progress.

Mr. Stephen Day (Cheadle)

Does my right hon. Friend agree that the White Paper, which is to be welcomed, would not have been possible without the health reforms which preceded it? Is it not about time the Labour party accepted the great benefits that those health reforms and the British Medical Association have brought to the health service?

Mrs. Bottomley

Following your instructions, Madam Speaker, I will simply answer yes.

Mr. Frank Field (Birkenhead)

Does the Secretary of State remember the time when she worked for the Child Poverty Action Group, when she lobbied the then Government to set health targets for all groups of the population but particularly for low-income groups? Does she recall that the official response to her then was that it would have been incautious of the Government to set such targets as they might be held to them? I congratulate the Minister on being less spineless than her predecessor. Does she also recall that when she worked for the group there were many data on the link between low income and ill health which current data still support? As the Government's figures show that since 1979 there has been an inexorable rise in the number of people and families on low incomes, what steps does the Secretary of State intend to take to prevent the Chancellor of the Exchequer's strategy from undermining her objective that poor as well as rich families will achieve those targets?

Mrs. Bottomley

The strategy is for the whole Government and the whole nation. I have made it clear that we already spend £1 billion per week on social security payments. The priorities of social security payments have been reordered so that additional money goes to low-income families. The hon. Gentleman is well aware that the challenge for us all is to generate wealth so that we can provide welfare. That is so whether the money goes into social security payments or the national health service. As for the resources available in the health service, we are determined to do all that we possibly can to encourage those sectors which have not acheived as well as those which are striving ahead. That is why, when it comes to immunisation, screening and every other health indicator, we are making it our business to ensure that the resources and skills of the health service are directed to the areas which need them most.

Dame Elaine Kellett-Bowman (Lancaster)

My right hon. Friend will be well aware that in Lancaster we have an outstandingly good health service, but we have one worrying problem? May I draw her attention to pages 69 onward of her White Paper in relation to skin cancer? Lancaster appears to have a higher incidence of all forms of skin cancer than similar districts. Will my right hon. Friend make inquiries to see whether we can get to the bottom of that problem and cure it?

Mrs. Bottomley

One of our new targets is to halt the spread of skin cancer by the year 2005. I have no doubt that representatives of the regional health authority will talk to those of my hon. Friend's excellent district health authority—to which my hon. Friend rightly paid tribute —to consider whether there are special factors such as a special health promotion campaign or other means to ensure that my hon. Friend's part of the country achieves the same targets as other districts.

Mr. Terry Davis (Birmingham, Hodge Hill)

If the Government are serious about improving the nation's health, why will they not tackle the problem of ill health caused by bad housing and low incomes?

Mrs. Bottomley

The document contains a great deal about the importance of housing. My right hon. and learned Friend the Secretary of State for the Environment played an important part in the document's preparation. I believe that he has welcomed the initiative as there are many sectors in which environment and health walk hand in hand. The document talks of establishing an institute to help set targets and study the links more effectively. Opposition Members are circling without knowing much about the detail, but those who have been involved in the development of estate action and urban programmes and channelling resources to the Housing Corporation all know that the Government do not shirk their responsiblities to improve the nation's housing stock and recognise the associations.

Mrs. Edwina Currie (Derbyshire, South)

I thank my right hon. Friend the Secretary of State for her kind remarks about me and reciprocate by saying that with this excellent White Paper she runs the risk of being the best Secretary of State for Health that we have had in a long time. If she is serious about reducing the number of adult smokers in this country, will she follow up the point that she rightly made about the price of cigarettes and encourage our right hon. Friend the Chancellor of the Exchequer to ensure that the real price of cigarettes—the most important element—goes up in this country year by year? Will she also ensure that we push hard in the Community, using our presidency, to ensure that the £900 million worth of subsidies towards tobacco production in Europe come to an end?

Mrs. Bottomley

I am grateful—very grateful—to my hon. Friend, who once again gets straight to the heart of the matter. Nearly £1 billion is spent on subsidising tobacco growing. However, of equal importance is the fact that we want other nations in the European Community to increase the price of cigarettes in their countries—and will take the opportunity of our presidency to push for that. If we do not, cheaper cigarettes could come into this country and undermine the policy. The price of cigarettes has increased by 43 per cent. while the Government have been in power. The White Paper reinforces that commitment to maintain the real price of cigarettes, which contrasts only too clearly with the record of the Labour party when in office.

Mrs. Margaret Ewing (Moray)

The Secretary of State will recognise that no one would oppose the broad principles which underpin her statement today, but does she realise that in conceding a clear link between poverty and ill health—whether that poverty manifests itself through bad housing, lack of employment opportunities or bad environmental conditions—she has said that she is prepared to argue the case for additional expenditure in those public sectors? In that context, in the interesting conversations which have taken place on public expenditure, has she argued that instead of commissioning a fourth Trident submarine the money should be used for housing, education and employment opportunities?

Mrs. Bottomley

While our party has been in power, life expectancy has risen by two years for women and by three years for men. Perinatal and infant mortality are the lowest ever. The Labour party should therefore keep its remarks in context. Our economic policies will improve prosperity at all income levels. The public have no confidence in the Labour party's economic policies or— dare I say it?—in its health policies.

This strategy is about improving the health of the nation. I shall discuss with all my colleagues how we can work together to improve the health of the nation.

Dr. Liam Fox (Woodspring)

I congratulate the Secretary of State on the proposals and targets for the mentally ill. Far too many work days are lost through mental ill health, and there are far too many suicides which would not necessarily have taken place if we had looked after those people better. The targets will be warmly welcomed. Does my right hon. Friend believe that they are attainable, and does she see a chink of light in the fact that they have at least temporarily stopped the sneering of Labour Front-Bench spokesmen?

Mrs. Bottomley

The targets that we set for mental illness are primarily associated with suicides. Nine per cent. of the life years lost by people under the age of 65 are due to suicide. Our concern is that many who have taken their own lives have been in touch with health or welfare professionals during the time before taking the fatal step, so it is extremely important, with the development of our mental health services, that we have better safeguards and a more effective and comprehensive service.

We have introduced a specific grant for mental illness. We are also working with nurses, doctors and other health professionals to ensure an effective and seamless service. I believe that we can meet these important targets.

Mrs. Audrey Wise (Preston)

Does the Secretary of State accept that the Department could make a contribution to giving babies a healthy and happy start in life if she accepted the report on maternity services issued by the Select Committee on Health? It includes a plea to the Department of Social Security to stop discriminating against the youngest mothers in the benefit system as they and their babies are the most vulnerable. Will the right hon. Lady take action on that?

Mrs. Bottomley

We shall be replying to the Select Committee shortly. I congratulate the hon. Lady and the members of the Select Committee on that important report, which I believe has changed the focus of the debate on maternity services. Having a baby in this country is a safe process now, and infant and perinatal mortality rates are at their lowest ever.

Mr. Nicholas Winterton (Macclesfield)

May I congratulate my right hon. Friend on the initiative that she has announced today and particularly on the targets that she has set for mental illness and mental health? I also congratulate her on the praise that she indirectly gave to the Select Committee, whose recommendations I think brought about the reduction in perinatal and neonatal mortality.

Will my right hon. Friend accept that some of us may have priorities additional to the five that she has identified? One of the greatest concerns in the health service and the social services is about whether community care will be effective and fully implemented in 1 April 1993. We are, after all, dealing here with the most vulnerable groups in society.

Mrs. Bottomley

I thank my hon. Friend; I can give him that commitment. A great programme of work is under way—my hon. Friend the Minister for Health will give more details of it soon—to ensure effective implementation and co-operation between the agencies. My hon. Friend has always sounded a note of caution about the exit of patients from institutions. As has been recognised already, the target involves the health and social functioning of mentally ill people, not just bricks and mortar.

Mr. Max Madden (Bradford, West)

Will the Secretary of State explain whether she accepts that there is a direct link between poverty and poor health? Yes or no will do.

Mrs. Bottomley

I believe that there is an association between a number of social factors and health. This health strategy is about how we can maximise the health of the nation; that, too, involves taking into account a great number of factors.

The hon. Gentleman may be surprised to learn that an inverse correlation governs some diseases and these factors. Breast cancer, it so happens, is inversely related to income—so the hon. Gentleman's assertion is not universally applicable.

Mr. Winston Churchill (Davyhulme)

I congratulate my right hon. Friend on the initiative that she is taking. Is it not a deplorable fact that hundreds and thousands of illnesses and deaths are self-inflicted and are largely preventable? If the situation could be changed in the years ahead, her efforts will have gained her much credit.

Mrs. Bottomley

We wish to make cost-effective improvements to health and it is clear that, by altering the focus, we can achieve real improvements in health, above all, by engaging and involving individuals, groups and employers in taking practical steps to ensure that the people for whom they are responsible make informed choices.

Rev. Martin Smyth (Belfast, South)

I congratulate the Secretary of State on the White Paper, but why are we targeting male smokers when younger women smoke more than younger men? Prevention is better than cure. Is there anything in the White Paper to encourage a shake-up in the royal colleges and prepare surgeons and others to deal with the new challenges of that age and to give women a proper role in medical and surgical care? In particular, will the Medical Research Council be doing anything to develop an understanding of myalgic encephalomyelitis, which is causing a great deal of concern and problems to many?

Mrs. Bottomley

Perhaps I can reassure the hon. Gentleman. The target for the reduction of smoking in women has been strengthened since the Green Paper. We want to ensure that men and women receive the maximum possible health gain. I am grateful to the hon. Gentleman for his comment about the role of women in the delivery of heatlh care. The national health service was the first Government department to sign up to Opportunity 2000 and we are determined to maximise the role of women in delivering health care throughout the service. ME is one of the many issues about which we received representations for inclusion. More work has to be undertaken as to what is an achievable target and what is effective intervention to achieve that target.

Madam Speaker

Mr. Warren Hawksley. No, I am sorry, Mr. Roy Thomason.

Mr. Roy Thomason (Bromsgrove)

Sometimes it is an advantage to be mistaken for others. My right hon. Friend has said that this excellent health strategy is from the Government as a whole and not just her Department. How will she extend it to the Government as a whole, operating through other Departments, and in particular to the Department of Education?

Mrs. Bottomley

The ministerial Committee which meets under the chairmanship of the Leader of the House will hold all Ministers to account to ensure that they achieve progress and meet targets. In many sectors, we have similar interests with the Department of Education, as my hon. Friend rightly said. We work frequently through the Health Education Authority on smoking, sexual education, drug addiction, healthy eating and the development of healthy schools.

Mrs. Alice Mahon (Halifax)

If the Minister is committed to prevention rather than cure, why does she not restore nutritional standards to the school meals service? Why does she not negotiate with her colleagues in other Departments to stop the persecution of local authorities? Why have her Government persistently brought in policies which have damaged the school meals service? Why does she not act on the Black report recommendation that youngsters should have access to a free school meal? That is the best way to prevent bad health in low-income families.

Mrs. Bottomley

We certainly support the education authorities' work locally to ensure that meals are healthy and appropriate. It is not our view that the right way to do that is by central diktat.

Sir Anthony Durant (Reading, West)

Does my right hon. Friend realise that many doctors thought that the immunisation and cancer screening targets were not achievable—as did the Opposition, who poured scorn on them when they were first introduced?

Mrs. Bottomley

I am afraid that I must remind the hon. Member for Livingston (Mr. Cook) yet again of his words in earlier debates about the general practitioner targets. He said that they were "too heroic" and "not achievable". In fact, nine out of 10 general practitioners are meeting the targets for immunisation and cancer screening, and three out of four are meeting the higher levels. That is a real credit to the family doctors and a real success in the health and welfare of women and children.

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

I am not sure what this expensive, pretty and ultimately superficial document is meant to reflect, but may I ask the right hon. Lady how the patients in my constituency will be helped by the quite clear distortion in the provision of health care by general practitioner fund holders? Not only is the right hon. Lady aware of that, but so is the whole of the health authority, which now has to deal with the problem.

Mrs. Bottomley

I find that a sad statement. The fund holders have made remarkable progress in innovating, developing and taking forward improved health care for their patients. Professor Glennister's report, which I recommend to the hon. Lady, makes it clear that the progress being achieved by fund holders is progress for the benefit of all general practitioners. It raises primary health care standards for all patients.

Mr. Ian Taylor (Esher)

Does my right hon. Friend accept that the very welcome targets can be effective only if there is a system under which we can analyse both the quality and the nature of the health care which needs to be delivered? Does that not go to the very heart of the Government's proposals for reforming the NHS? Do not the proposals answer the Opposition, who do not believe that we care enough about those who most require health care? Have we not provided, through deprivation payments and through splitting the contractor from the provider, the best way to deliver health care to those most in need?

Mrs. Bottomley

That is precisely the success of the health reforms. Health authorities have been freed to take a strategic view in assessing health needs, and they can now commission health care to meet those needs. They will be held to account for the targets that they have been set by the regions. For the first time, we have the mechanisms to deliver a health service which will truly achieve health gains rather than automatically deliver a health service.

Mr. Malcolm Wicks (Croydon, North-West)

To establish health targets, there must have been a great deal of departmental research and statistical estimating.

Would you be able to estimate how many people will die by the year 2000 because of your inaction—[HON. MEMBERS: "Order."]

Madam Speaker

Order. Let us have a little tolerance with new Members.

Mr. Wicks

How many people will die because of the right hon. Lady's inaction in banning tobacco advertising? Is it because the Tory party is now the tobacco party?

Mrs. Bottomley

A great deal of research has gone into smoking and the factors behind it, and I hope that there will be more. It is difficult to explain, in the hon. Gentleman's terms, why we have had a sharper reduction in the number of people smoking than any country except the Netherlands—which, like us, takes the view that the right way to control tobacco advertising is by a voluntary agreement. Price is a most important factor. When the Opposition were in office, the price of cigarettes increased by less than 1 per cent. We have increased it by 43 per cent.

Mr. Peter Bottomley (Eltham)

May I draw attention to the progress being made in beating by one third the targets set by another Secretary of State for reducing the number of people killed and seriously injured on the roads? I remind my right hon. Friend that the view echoed then was that the only way to reduce drink driving was to institute random breath testing; similar views are expressed now about tobacco advertising. The Labour party was wrong about that. Should not Labour Members look at the figures rather than the slogans?

Mrs. Bottomley

I believe that the Labour party was wrong and my close hon. Friend is right. Along with his ministerial colleagues, he did an enormous amount to change people's understanding of the effects of drinking and driving. Fifteen per cent. of life years lost by those under 65 are lost as a result of accidents; that applies not least to lives lost on the roads.

Mr. Andrew Miller (Ellesmere Port and Neston)

I am sure that the Secretary of State will know of the work done by Dr. Harvey Brenner and others on the correlation between unemployment and ill health, and the subsequent work done in this country by, in particular, Dr. Beale in the Wiltshire, North constituency—which, of course, is represented by the Minister for Trade. What provision is made in the White Paper to deal with the special category of people involved? I note that it is not included in the list of special categories towards the end of the document.

Mrs. Bottomley

I can only make it clear again that this is a Government strategy to achieve improvements in health. We have set challenging targets: we shall meet those targets, and we shall use all the means at our disposal for that purpose.

Mr. Peter Thurnham (Bolton, North-East)

The hon. Member for Livingston (Mr. Cook) has just scorned my right hon. Friend's welcome targets for a reduction in the rate of pregnancies in those under 16. Does she agree that he should take an extended tour—a Cook's tour, indeed —to Holland, where the rate of pregnancies in under-16s is twice as low as ours?

Mrs. Bottomley

The subject referred to by the hon. Member for Livingston (Mr. Cook) and by my hon. Friend is of great concern. I did not deal with it properly earlier.

In recent years, there has been a vast expansion in the provision of family planning services by general practitioners. Two out of three women now go to their GPs for family planning advice. However, that development has not been accompanied by a proper review of the appropriate role of family planning clinics. This year, one of the priorities of the NHS has been to review the provision of family planning clinics, and to ensure that they offer choice and a service for young people where that is appropriate. In supporting that work, we shall certainly take advice from Holland about how this worrying problem can be tackled.

Mr. Eddie Loyden (Liverpool, Garston)

Does the Secretary of State agree that the death rate as a result of accidents is intolerably high? Will she bear in mind that certain industries—notably the construction industry—involve a large number of such deaths and that little or nothing is being done to arrest that? Will she ensure that the matter is addressed as part of her strategy?

Mrs. Bottomley

I beg to differ with the hon. Gentleman. The accident record in this country compares favourably with that in other countries. The hon. Gentleman has made an important point, however. Along with the Health and Safety Executive, which has worked closely with us in implementing the strategy, we want to promote the initiate of healthy alliances, especially in the workplace.

Mr. Simon Coombes (Swindon)

If my right hon. Friend's targets are to be realised in future, millions of ordinary people will have to change their life styles dramatically. Does she recognise that the key to that is education, and that an increase in the resources available to the Health Education Authority and health education facilities throughout the country is a necessary prerequisite for the achievement of such targets?

Mrs. Bottomley

I thank my hon. Friend, who has been a great champion of the cause for many years. We work extremely closely with the Health Education Authority, which has been very much involved in our strategy.

The HEA's contribution is important, but so, too, is the role of other health professionals. Following the introduction of the new GP contract, a number of health promotion clinics have been set up. Using the work of GPs in spreading the necessary messages has been extremely effective. We must involve nurses, other health professionals and those in the wider area to ensure that people know and understand the sensible choices that they can make to improve their health.

Mr. Andrew Faulds (Warley, East)

As usual, my question will be brief and pithy. If these stringent voluntary advertising agreements with the tobacco industry are so effective, why is that industry now targeting young women through women's magazines, with the result that the number of young women who smoke is rising? Would not the health and lives of thousands of young women be saved if these voluntary agreements were even more stringent?

Mrs. Bottomley

All these matters are subject to continual review. The targets that we have set will be met. There is a particular rise in the target for a reduction in smoking amongst women. We are especially concerned about smoking among pregnant women, and in that regard there will be further initiatives. With regard to relations with the tobacco industry, the hon. Gentleman will be aware that that industry is currently taking legal action against the Government because the packet labels that we have introduced are the most severe.

Mr. Geoffrey Dickens (Littleborough and Saddleworth)

While we welcome the White Paper, the last thing we want is to frighten the nation to death. Can my right hon. Friend confirm that it is perfectly possible to enjoy a good lunch and a glass of wine and still live to a ripe old age? Does she agree that stress and tension, as demonstrated by the Opposition, are just as likely to cause heart disease as over-eating?

Mrs. Bottomley

With reservations, I confirm my hon. Friend's comments. On Saturday I went to a 100th birthday party. The person who had just become 100 years old ate moderately, drank little, had always taken a good deal of exercise and smoked not at all. I think that that indicates that the advice that we are spreading through our document should be followed.

Mr. Bob Cryer (Bradford, South)

Does the Minister accept that her cosy, vapid comments will entirely lack credibility so long as she fails to tackle the real problem of advertising with regard to the cancer-producing substances of tobacco? Could she not start by banning secondary advertising at outside sporting events, mainly through BBC television? There is clear advertising of cigarettes through that medium. The right hon. Lady could then go on to tackle the advertising of booze—alcohol products which cause an enormous amount of ill health in the nation. Or are the Tory Government simply in the pocket of the tobacco manufacturers and the brewers?

Mrs. Bottomley

The Labour party seems to be fixated on one means which it alleges can deliver an end. We are determined to achieve that end. Our aim is that this country should not just be the European Community member with the second greatest fall in tobacco consumption but should build further on that record and do even better by the end of the century. We shall use whatever means can achieve that end. As I have said before, I believe that price is important, that subsidising the growing of tobacco is important, and that advertising is important. In the case of advertising, that is why we have the voluntary agreement, which is constantly subject to renegotiation. Further powers have been taken to tighten control of the sale of cigarettes to under-age children. I take the view that, with regard to smoking, the worst effect on young children is produced by the smoking of parents.

Mr. John Bowis (Battersea)

My right hon. Friend's strategy is very welcome. Can she confirm that built into it is flexibility which will allow for the changing needs in medical science, such as growing awareness of the problems of younger Alzheimer sufferers, and for use of the whole range of medical science, including homeopathic medicine?

Mrs. Bottomley

The strategy is a beginning, not an end. We shall build on the targets. I hope that we shall develop them and broaden them and that new key areas will be introduced. We are working very closely with the director of research and development in the national health service so as to develop better mechanisms to set and achieve targets. I shall certainly bear my hon. Friend's remarks in mind as we carry the strategy forward.

Mr. Jimmy Boyce (Rotherham)

The Secretary of State has said today that she supports a voluntary code for the advertising of tobacco products. She also referred to the fact that the best way to curb tobacco smoking is an increase in price. Will she be kind enough to tell us what level of price increase she is prepared to support?

Mrs. Bottomley

I am not prepared to tolerate any increase in smoking. That is why we have introduced strict targets to reduce smoking even further. There has been a significant fall in this country which, as I have already explained, is greater than in any other country apart from the Netherlands, which happens to take our view on the banning of tobacco advertising. There is concern about particular groups. They are a source of concern to us, of course. We must make sure that we continue to take all possible steps that will effectively achieve that end.

Mr. Anthony Coombs (Wyre Forest)

I warmly welcome this further step in the development of the Government's preventive health policy, which I understand has already been described by the World Health Organisation as a model for other countries. Does my right hon. Friend agree that if we are to increase the targets for reducing coronary heart disease, it is vital to inculcate, particularly in young people, habits of exercise to promote good health? To that extent, will my right hon. Friend liaise with her right hon. Friend the Secretary of State for Education to ensure that physical education in schools is given much higher priority than it is at present, when all too often only one hour per week is allocated to this very important activity?

Mrs. Bottomley

I shall certainly speak not only to the Secretary of State for Education but also to the Secretary of State for National Heritage. I can confirm what my hon. Friend said about the World Health Organisation. Its director general, Dr. Nakajima, said: The health of the nation has international value. I. am sure other countries will benefit greatly from the approach England has adopted.

Mr. David Winnick (Walsall, North)

Is the Secretary of State aware that the continued price increases since 1979 for prescription charges, dental treatment and eye testing undermine and erode the whole concept of the national health service? Bearing in mind that fact and the Secretary of State's refusal to take any action over cigarette advertising, less hypocrisy from her on these issues would be welcome.

Mrs. Bottomley

I urge the hon. Gentleman to look at the facts more closely. On prescriptions, when the Labour party was in power, one item in three carried a charge. Only one item in five now carries a charge. Furthermore, life expectancy has increased by three years for men and by two years for women. Perinatal and infant mortality have fallen dramatically. According to a great number of criteria, the nation is healthier now than ever before. Our health strategy is about carrying that forward further and faster.

Mr. Jeremy Corbyn (Islington, North)

Is the Secretary of State aware that there is a disturbing increase in asthma and related problems among children, particularly those living in inner-city environments? Is she prepared to undertake a serious study of the link between asthma in young children in inner-city environments, the increase in pollution caused by traffic, and inadequate housing? Until now, in response to parliamentary questions from me, she has said that there is no central recording and correlation of these data.

Mrs. Bottomley

The director of research and development has made it clear that better research in the case of asthma is something that we very much want to take forward. There has been a growth in asthma among children. All the factors are not properly appreciated. More work needs to be done. However, I can give the hon. Gentleman a pretty clear undertaking that this will come forward as a key target area at a later date when we have more information.

Mr. Hugh Bayley (York)

I have a simple question for the Secretary of State: to what extent has the Department costed these plans? Is she aware that the Northern region costed the meeting of a coronary heart disease target in the Green Paper as between £1.6 million and £2.4 million each year until the year 2000? There are many other regions, including those in Scotland and Wales. What will be the total cost of the proposals? Will there be new money, or does the Secretary of State intend to raid existing NHS budgets and force cuts in other areas? Can she guarantee that there will be new money to fund all the targets?

Mrs. Bottomley

The purpose of the health service is to deliver high quality services and to achieve health gain. By concentrating on prevention in these areas, we can achieve health gain cost-effectively. That is our whole strategy for health—the result of our work in reforming the national health service. We spend £100 million a day on the NHS —we have never before put more money into it—and as more money goes in, so priority will be given to the key areas, chosen because through them we can most effectively improve the health of the nation.

Mr. Bryan Davies (Oldham, Central and Royton)

Would not a more appropriate title for the White Paper be, "The Health of Two Nations"? Has not a section of our population been so impoverished by the Government that they cannot afford the high quality diet recommended? Their children are not getting high quality food at school —and often come back to damp and inadequate homes, which reflects the local government cuts enforced by the Government.

Mrs. Bottomley

I do not have sympathy with those remarks. I have made it clear that, for example, one of the most important developments in the general practitioner contract was the introduction of deprivation payments for GPs working in inner cities. Throughout all the key areas that we are considering it is important to ensure that those areas which have not made the same progress as others catch up. That is where health resources are concentrated —the skill, effort and determination necessary to meet the targets and to ensure that we tackle variations wherever possible.

Several Hon. Members

rose—

Madam Speaker

Order. We must now move on.