Health Inequality

HC Deb 25 February 1998 vol 307 cc281-300

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Jamieson.]

9.34 am

Ms Joan Walley (Stoke-on-Trent, North)

I am grateful for this Adjournment debate because never has it been more important for the House to debate inequalities in health. After 18 long years when the divide between those in good health and those in bad health got worse than ever, for the first time we now have positive action from the new Labour Government and a commitment from the Minister for Public Health, my hon. Friend the Member for Dulwich and West Norwood (Ms Jowell), whom I am pleased to see in her place this morning, to do something about health inequality.

I have spent 11 years representing North Staffordshire, so it is not surprising that, along with my colleagues from the area, I want us to address the issue of health inequality. I want the Government's actions to mean something and to make a real difference to my constituents' lives. That is why I asked for this debate.

It is also fitting that, 150 years after the first public health Act and 50 years after the birth of the national health service, we now have a public health Green Paper, "Our Healthier Nation". We have until 30 April 1998 to submit our comments, so we need a countrywide debate on public health. That would be a first step towards improving the nation's health, and I hope that this morning's debate will stimulate that debate.

I want people in both the urban and rural areas of my constituency to discuss public health, and I want the debate to take place at local level: at work; in schools; in youth clubs; in voluntary organisations—I have received many representations from voluntary organisations about the importance of this morning's debate; in the community; in councils and in parish councils in rural areas; in sports halls, churches, halls, clubs, pubs and working men's clubs; in doctors' surgeries and clinics while people wait for treatment; and wherever people get together.

I welcome the four main categories set out in the Green Paper: heart disease and strokes; accidents; cancer; and mental health. It is important to debate the targets for those categories. I spent many years as president of the West Midlands Home Safety Council, which, along with many other organisations, such as the Royal Society for the Prevention of Accidents, has long pressed for more to be done by local authorities to prevent accidents in the home. Obviously, more also needs to be done to prevent road traffic accidents, and accidents and disease at work.

I welcome the targets to reduce heart disease and strokes by a third, cancer deaths by a fifth and suicides by a sixth. I doubt whether anyone would challenge or question those laudable objectives and I hope that they will be discussed at length as the debate about public health takes place throughout the country.

I am concerned that, while the Government get on with changing the structure and framework of the NHS through the new NHS White Paper, I do not want them to lose sight of the important, all-embracing, over-arching concept of sustainable development, which recognises that the principles behind public health are part and parcel of all aspects of public policy. I welcome the White Paper, as it lays the foundation for beginning the process of modernisation and especially accountability, so that we can deliver uniformly high standards of health care. It consults, and puts a clinical focus on the four main targets.

This is a challenge for us all, and we must support our Minister for Public Health, no matter which side of the House we are on. We must help her in her co-ordinating role to ensure that the comprehensive spending reviews that are taking place across all Departments recognise the importance of public health policies. The Advisory Committee on Resource Allocation must tackle real needs, and the new health improvement programmes, which identify and meet local needs, must have the resources to do what is necessary.

I shall mention some of the consultation documents that are being discussed across the country. The Department of the Environment, Transport and the Regions has produced a White Paper, "Building Partnerships for Prosperity"; a review of planning guidance and of planning for the communities of the future. The housing conditions survey is important, as housing is crucial to health. A consultation document on contaminated land is due shortly, and a review of water charging is currently out for consultation.

The DETR has also produced a document on opportunities for change and a new strategy for a sustainable future. There are reviews of the crucial matter of national air quality and of regulation strategy, which are being undertaken by the Department of Trade and Industry, and new lottery legislation will bring in many bids across the country. All are integral to the promotion of an enhanced quality of life and improved public health.

The public health Green Paper makes many healthy references to the need for local authorities to work in public health partnerships with NHS trusts. A duty on local government and health trusts to work together to produce local health improvements is proposed. However, we must not fragment public health provision by leaving councils with insufficient means to close the huge health gap between the rich and the poor.

Health inequality is tied up with domestic metering of water and disconnections; energy efficiency in the home; the fact that the worst sewers are often in the oldest parts of urban areas; poverty wages, low-income households and the condition of people's homes; and a lack of sports facilities. Many schools in my constituency lack proper sports facilities: how can people take up healthy, active life styles without them?

Health inequality is also tied up with poor diet; unsound agricultural practices, such as the use of untreated abattoir waste as fertiliser for crops and the risk of that getting into the food chain; polluted air; stress; and low educational achievement—we know all about that in North Staffordshire. Unemployment also has an effect, and, in parts of my constituency, people are on a four-day working week. We must also urgently address the failing child support system.

I speak as the vice-president of the Institute of Environmental Health Officers. Environmental health officers often do not get the recognition that they deserve: they come a poor third in health authority partnerships. Indeed, a MORI survey for the Anchor Housing Trust showed that only 56 per cent. of health authorities consulted environmental health departments when putting together plans for 1998–99.

Just as Edwin Chadwick—an engineer, not a doctor—inspired medical officers of health and developments in public health, we must, as the millennium approaches, recognise the importance of public health to all areas of policy if we are to reduce ill health and health inequality. Ordinary people, just as much as doctors and clinicians, can contribute to improving public health.

That over-arching framework is as relevant to Europe as to the United Kingdom. I urge the Minister to press urgently for wider European Union public health competence through an extension of article 129 of the treaty of Rome when she chairs the European Union Health Council. The Institute of Environmental Health Officers would welcome the opportunity to work with the Government to achieve that.

The truth is that the previous Government failed to recognise the effects of their blatant cumulative under-resourcing of local authorities through the standard spending assessment formula and the abandonment of the resource allocation working party, which did much to redress the balance. Those of us who have been around for a while know that RAWP attempted to iron out the health inequalities that left people in many parts of the country suffering appalling ill health. Such people lived in rundown inner-city areas which traditionally depended on heavy manufacturing industry, but there were pockets of deprivation in rural areas, too.

Ill health reduces daily living to a remorseless and painful struggle for survival. Month by month, our national health services are merely firefighting. Hospital waiting lists are unacceptably long; efficiency savings to pay for treatments have to be made despite our injection of extra money; and litigation costs have to be paid because underfunding has meant that services cannot be provided.

We could start to improve the service if we were able to prevent ill health. The Green Paper will help, but the reality, at least for many of my constituents, is a world apart. That brings me to the second part of my speech—why I want the House to discuss these issues.

Health, good or ill, depends largely on where people live and on their circumstances. I do not think that it should. We in North Staffordshire consider ourselves fortunate. We are a proud community, and we look after one another as best we can. The performance of the Staffordshire ambulance service trust is such that an ambulance arrives at life-threatening emergencies after an average wait of six minutes 11 seconds. The average in all other cases is seven minutes nine seconds. That performance is not bettered anywhere in the United Kingdom; I doubt whether it is bettered in Europe.

In this financial year, the Staffordshire ambulance service trust has responded to 90.28 per cent. of life-threatening emergencies in eight minutes, 97 per cent. in 14 minutes, and 99.36 per cent. in 19 minutes. That is excellent, but there the good news ends. The bad news is that, in an area of 1,000 square miles, the trust had responded to 48,285 emergencies by 20 February this year.

We must learn the lessons of best practice from the trust, and recognise its experience and the improvements that it has made. That must be fed into the review. But the downside is the high death rate from chronic heart disease, which must be treated in the short term, and prevented in the long term.

In my constituency from 1981–92, the odds of people dying before their 65th birthday were 25 per cent. higher than the British average for someone of their age and sex. Furthermore, those odds were more than 75 per cent. higher than in Esher and Walton and in South Cambridgeshire, the constituencies with the lowest rates of premature mortality.

Hon. Members know that people can use statistics to show whatever they want. Whatever figures I consult, however, I receive the message that North Staffordshire, and Stoke-on-Trent in particular, rank highly in terms of relative deprivation. The public health common data set figures show that, in regard to most causes, Stoke has a standard mortality rate of more than 100. In the case of heart disease in men, the rate is 123, 23 per cent. above the average. That makes us 30th out of the 358 local authorities in England. In terms of accidents among women, we rank 23rd.

As for premature and infant mortality, in 1996 there were 5,597 perinatal deaths in England and Wales; there were 689 in the west midlands, and 57 in North Staffordshire. Since 1983, our rate has been consistently higher than the average, and consistently higher than the west midlands rate and the west midlands rate trend, never falling below 10 per 1,000.

Contributory factors include poor nutrition, social deprivation, teenage pregnancy—there is a high risk of teenage pregnancy in North Staffordshire—smoking and drinking alcohol during pregnancy, and inadequate standards of obstetric and paediatric care. Such inadequate standards have been identified as causes of some deaths in confidential inquiries throughout the United Kingdom, and North Staffordshire is clearly no exception.

It is not just infants who start off with reduced life expectancy. The Association of Retired Persons over 50 campaigns for the rights of older people. I am sure that many of us who are present today, if we have not quite reached 50, are not all that far from it.

The North Staffordshire pensioners convention and North Staffordshire Healthwatch campaign for improved services for older people, believing that discrimination on the basis of age rather than need leads to the delivery of inappropriate treatment and, in some instances, the complete absence of effective care. They are worried about the widening gulf between the treatment of older people and the treatment of those under retirement age. I do not want that to happen in my constituency.

Screening for breast cancer in women over 60 is a matter of special concern. I know that the House has discussed the issue before, but I want to flag it up briefly today. There is also a lack of adequate preventive treatment for osteoporosis and prostate cancer. I am especially concerned about health issues affecting women, because I think that women's health care is very important.

In North Staffordshire, we have a particular problem. It is no accident that we have a relatively high number of long-stay continuing-care beds. In our area, older people cannot necessarily afford private health care. Despite an extensive campaign to keep our NHS long-stay beds, 37 beds are mothballed at Stanfield hospital, and so far no progress has been made on a proposed private finance initiative bid for reprovision of beds at Westcliffe hospital, although it has already been formally agreed through consultation.

There is a good deal of fear and anxiety, because the legacy of underfunding—not just of the health service, but of social services—has left us short of resources for community care. I feel that I have a debt of honour to my elderly constituents. We must plan for the long term and the short term, and also plan transitional arrangements.

I have been inundated with briefings from a number of organisations that want to hammer home to the House just how unfair the system is to those who happen to live where services are insufficient, and whose particular illnesses are not given the priority allocated to them in other parts of the country. We have had another campaign in Stoke-on-Trent to prevent the proposed closure of the fertility unit by the health authority. Although we have had a minor victory, in that the unit has been reprovided, it has been reprovided in a private clinic. There is not enough money from the national health service to pay for treatment there. Those living elsewhere have access to fertility treatment, but there is a definite ceiling on the amount of money available in North Staffordshire.

Dental care is another problem. It is barely possible to gain access to a dentist at present. We currently have applications for extra bids to help the provision of dental care on the NHS in North Staffordshire. Our children have the worst dental health care record in the west midlands—hence our bid.

There are many indicators relating to coronary heart disease, strokes, lung cancer, schizophrenia and suicide. In every instance, the North Staffordshire rates are worse than the west midlands rates, and worse than the rates in England and Wales. I hope that the Minister will have a chance to examine the figures.

There are even worse figures. The extent of ill health in North Staffordshire is illustrated by data showing an increased use of health services in Stoke-on-Trent and North Staffordshire. In 1996–97, there were 170,230 finished consultant episodes at the two NHS trusts in North Staffordshire. That represents about 360 per 1,000 of population, compared with 230 for England as a whole.

The problems that my constituents face daily are illustrated by the fact that the average GP list size in North Staffordshire was 2,077, higher than the England average of 1,881. That average was the highest in the west midlands, and the ninth highest in England, as of 1 April 1997, according to statistics from the NHS executive.

Yesterday, I received a telephone call from a constituent aged 74, who had hardly ever had any NHS treatment. He, his wife and his son—who has had a stroke—have all been struck off by their GP, who does not have to give a reason. We have a shortage of GPs.

Not enough trained GPs are being provided, and, in an area without a medical school, we cannot train the people we need.

I do not like painting a black picture, and I do not intend to do so this morning. We all live with the position daily in North Staffordshire, and we know how urgent is the need to deal with it. Some 10 years ago, the city council published a report called "Health of the City", which remains a blueprint for action, and confirms what I know from my surgeries.

It is clear that there are pockets of extreme ill health and deprivation in North Staffordshire's health authority area that urgently need to be tackled. The key indicators of risk of poor health in certain wards have led to their being designated health action areas. We are making progress, and doing a great deal to offset the problems. The designation of health action areas is a result of joint action that Stoke-on-Trent city council and Staffordshire Moorlands district council have already taken with the health authority. In those health action areas, the Jarman score is unacceptably high, but it is clear that we are making progress.

The problem is that many people cannot wait to be treated, no matter how much we are doing to put in extra money. Many cannot easily see doctors or dentists, and many must wait too long for social work support. Many cannot easily reach clinics. I am currently doing my best to stop the closure of a clinic in Fegg Hayes. We are hoping for a joint initiative to retain clinics in areas where they are needed, to provide family planning and other services.

It is obvious that there are not enough services to meet the needs of people in North Staffordshire. That may lead the House to conclude that our trusts, councils and voluntary organisations are not doing their best, but nothing could be further from the truth: they are doing the best that they can in very difficult circumstances. I want the Minister to know that. They are working in partnership to reduce health inequality in North Staffordshire, especially in those pockets of deprivation where health is worst.

The Green Paper sets out targets relating to specific illnesses, and calls for local initiatives jointly to tackle specific local problems.

We have already started that joint work in our health action areas, but we could do much more. There is a new unitary local authority in Stoke-on-Trent, and it could also do much more. As a result of wanting to do more, it has submitted a proposal for a health action zone. I want that bid to succeed, because it shows that we have the will and the vision and that there is local co-operation to address our specific problems.

I understood that need would play a large part in determining the areas that would succeed in being designated as health action zones. We in North Staffordshire are convinced that our bid is based on need, and we want it to succeed. We are concerned that the panel that is advising Ministers seems already to have excluded our bid. Only three of the six bids from our region are being forwarded with a regional office recommendation for consideration. There will be a decision at the end of March, and I fear that North Staffordshire will not be chosen, because our bid has not been forwarded. I urge the Minister to look in detail at our needs and our bid. We should be pleased to co-operate if she wishes to arrange a meeting.

I am unaware of the criteria under which bids have been reviewed by the NHS executive, because that information has not been made public. In the spirit of openness and accountability, I urge the Minister to consider carefully how she can assist us. If our bid has demonstrated the need for a health action zone but falls down in its detail, I ask the Minister to show some flexibility and offer us advice so that we can redraft our proposals and intensify our present action to address health inequality.

By asking for this debate, I could be accused of building false optimism and unreasonable short-term expectations. The Government warned us against that on page 82 of the Green Paper. North Staffordshire people are realistic and understand that they need long-term, sustained and co-ordinated effort. We realise that there are no quick fixes, but we want an understanding of how much there is to do, and a Government commitment to support us in our efforts.

10.2 am

Mr. Jonathan Sayeed (Mid-Bedfordshire)

I congratulate the hon. Member for Stoke-on-Trent, North (Ms Walley) on securing a debate on a thoroughly important topic that affects the lives of many people. The publication of the White Paper on the national health service and the Green Paper on public health, both of which build on the considerable achievements of the previous Administration, means that the debate is timely.

The hon. Lady spoke about a range of inequalities in health care. I hope that she will understand when I say that I shall speak on only one—cancer care provision in the United Kingdom. Cancer remains our greatest medical problem. One in three people suffer from some form of cancer; one in four will die of it, and demographic changes mean that, by 2020, one person in two will get some form of cancer.

It is essential for the Government to support the previous Government's recognition that cancer is one of the main challenges facing our health service. The previous Government commissioned a report on a strategic plan for cancer services. It was published in 1995 and became known as the Calman-Hine report. It is one of the best reports that I have read in the past 20 years. It was practical and focused, and it has already led to considerable achievements in the provision of cancer care. However, there is still much to do.

The aim of the Calman-Hine report was to ensure that all patients received a consistently high level of service regardless of where they lived. It highlighted variations in recorded outcomes of treatment and advocated that all patients should have access to a uniformly high quality of care in the community or hospital". Much work was carried out under the previous Administration to make that strategic plan a reality, but much remains to be done. I urge the Government to take the opportunity that is presented by the Green Paper on public health to make fair and equal access to specialist, high-quality cancer care their priority.

Perhaps I may be allowed a short commercial. For some years, I have worked with the Cancer Macmillan Fund, which is a superbly run charity. It does not waste money, but does what it is meant to do, which is to help people. It does that in a number of ways, one of which is by working with the NHS and with Government. It does not spend its time complaining but gets on with the job. My commercial is that those who are thinking of giving money to charity should put the Cancer Macmillan Fund on their list.

That charity has made it clear to me that there are significant variations in the availability and quality of services—the so-called cancer lottery. I congratulate the charity on its work with the NHS, which has benefited many patients. Much of its pump-priming work will be known to the House. It is the only charity that works with the NHS and others to provide cancer patients with expert nursing and medical care. It also provides a service that is often lacking in the NHS because it offers emotional and practical support from the point of diagnosis onwards, so that patients and their families may continue with productive working lives.

There are many examples of health care inequalities in tackling cancer, but I shall give just a few, because I know that other hon. Members wish to speak. Fewer than 50 per cent. of cancer patients are referred to a specialist for treatment, and only a fraction have access to clinical nurse specialists such as Macmillan. There is considerable evidence that some black and ethnic groups and older people are less well served than other members of the community. For instance, there is a low uptake among the Asian population for screening and palliative care, and there is a chronic shortage of information in languages other than English.

People in rural areas also have limited access to specialist services. I have not even touched on the widely differing arrangements for different types of cancer. For example, lung cancer patients often receive what is coyly called sub-optimal treatment whereas breast cancer patients rightly have a fast-track diagnosis.

One fundamental element links all those issues, and it is the lack of appropriate patient information on the types of services that are available, on the nature and course of the disease and, most importantly, what patients have the right to expect from those who are caring for them. Such information is not expensive to produce, but it is critical if we are to deal with what is already a scourge and will get even worse. Patients can demand better services only if they have access to the most basic information on their condition. Too often, that information is lacking.

The Government have made some welcome commitments in their recent White Paper and Green Paper, which I hope will end those forms of health inequality. However, fine words have to be supported by action and backed by resources. There is—to give one specific example—a considerable shortage of clinical and medical cancer specialists. The Government have given a pledge: to ensure that everyone with suspected cancer will be referred to a specialist within two weeks of their general practitioner recommending that course. That will be achieved only if action is taken now to recruit and train new postholders—otherwise, it will not happen.

I urge Ministers to seize this opportunity to work with the national health service and with voluntary organisations, such as Macmillan, to make Calman-Hine—one of the best reports of the past 20 years—a working reality.

10.10 am

Mr. Gareth R. Thomas (Harrow, West)

I congratulate my hon. Friend the Member for Stoke-on-Trent, North (Ms Walley) on introducing this debate on health inequalities—an issue that Ministers in the previous Government completely failed to address properly. One of the most disappointing features of the debate following the Green Paper's launch by my right hon. Friend the Secretary of State for Health was the continuing inability of Opposition Front Benchers to recognise the clear links between ill health and poverty, ill health and unemployment, and ill health and poor housing.

The London Research Centre—one of many research bodies working in the subject—has published many excellent reports, which have consistently highlighted the link between ill health and deprivation. Mortality rates in London are consistently worse in areas of deprivation. In the most deprived inner-London boroughs, mortality rates are up to twice as high as in some outer-London boroughs.

Therefore, one of the most positive aspects of the recent Green Paper on public health is the Government's commitment to improving health for the worst-off in our society and to narrowing the obvious health gap. Other positive features of the Green Paper are explicit recognition of the link between childhood injuries and social deprivation; of higher mortality rates for coronary heart disease and cancer among men of working age in the bottom social classes; and of rising incidence of poor mental health, particularly among the socially disadvantaged.

It is frustrating that it has taken so long for Government health policy to address health inequalities. As far back as 1980, the Black report concluded: much of the evidence on social inequalities in health can be adequately understood in terms of specific features of the socio-economic environment. We should not have had to wait until 1998 before the Black report's conclusions were listened to and acted upon.

The failure to acknowledge and address the socio-economic factors affecting health was the most serious omission of the 1992 document "The Health of the Nation". The document's only reference to those socio-economic factors was made in section F of the appendix, which mentioned variations in health status between different socio-economic groups". Sadly, it went on to conclude: the reasons for these variations are by no means fully understood". In cold light, such apparently wilful ignorance of the causes of health inequality is astounding. I do not believe that those who drafted "The Health of the Nation" simply did not know or understand the causes of health inequality. The previous Administration—who were responsible for great increases in poverty and inequality—simply did not dare to admit that growth in the numbers of those on low incomes might have wider social consequences. They chose instead to focus almost entirely on individuals' own behaviour, failing completely to own up to the consequences for the nation's health of economic policies that generated increasing poverty, poorer-quality housing and higher unemployment levels.

As the Green Paper clearly states, poverty and unemployment can result in problems in keeping the home warm, may inhibit healthier life styles and increase the likelihood of accidents. The Government's welfare-to-work programme to tackle unemployment by offering a new deal to young people, the long-term unemployed and lone parents will be crucial—with the introduction of a national minimum wage—in beginning to tackle immediately those two key causes of inequality: low incomes and lack of employment opportunities.

Establishment of the Prime Minister's social exclusion unit—focusing on the needs of those on low incomes, who face a combination of social problems—will generate welcome longer-term initiatives to tackle health inequalities.

In my constituency, my local authority is due to receive next year about £2.3 million under the capital receipts initiative—part of a national programme that will, over the next two years, provide almost £800 million to enable a much more ambitious programme of repairs and improvements to our housing stock than would have been possible had the previous Administration's plans been continued. The measures will help tenants in social housing—who are usually the least well-off and most vulnerable to ill health—to be able to live in healthier domestic environments, free from the twin spectres of damp and overcrowding that not only damage our lungs and our respiratory system but increase the likelihood of accidents, sleeplessness and the spread of infections.

Increased energy efficiency programmes will be deliverable by the Energy Saving Trust now that the threat of a £5.5 million funding cut has been lifted by the Deputy Prime Minister and the Chancellor has cut value added tax on energy saving materials. Those programmes and the resources provided under the capital receipts initiative will be crucial in tackling the health problems of the least well-off that are caused by living in cold homes.

The Government have begun the task of confronting the inequalities in income, housing and job opportunities that are also the causes of major health inequalities. We have to ensure that international, national, regional and local partnerships for health improvement are developed by all key stakeholders. Such partnerships must be sustained and rigorously monitored to ensure that they are appropriately targeted and successful in narrowing—and eventually eliminating—health inequalities.

The success in Europe of my hon. Friend the Minister for Public Health in securing European Union agreement on ending tobacco advertising and sponsorship is one positive example of international action to reduce the greater incidence of smoking in low-income families. If our targets are to be achieved, it is essential also that effective work across Departments—which has already started, as the Green Paper demonstrates—continues.

Focused and co-ordinated policies in delivering long-term reductions in health inequalities will be crucial also at a regional and particularly at a local level. I look forward to a London regional development agency and a Greater London strategic authority focusing on health inequalities across the London region.

Too often, public health has been the cinderella service for health authorities, to the chagrin of many of the staff working in those authorities. Public health has not been singled out for development and has often been the first service to be targeted for service cuts. I welcome the important development of primary care groups, which will rightly shift health authorities' thinking to focus much more on improving health and away from concentrating on episodes of illness.

I look forward to my own Brent and Harrow health authority developing—in tandem with the council, local voluntary groups and other statutory bodies—a health improvement programme to help achieve the Green Paper's national targets and to tackle local priorities. Health action zones are a particularly welcome initiative in the Green Paper to focus investment and to generate impetus in tackling health inequalities in areas of considerable deprivation. The zones must generate long-term and sustainable strategies to confront those health inequalities.

Despite my constituency's relatively wealthy image, it has some significant pockets of poverty and poorer health. Just as Harrow will benefit from the health authority's—I hope successful—bid for a Brent health action zone, so we must ensure that best practice in the health action zones that are established is quickly identified and disseminated to all health authorities.

The most effective initiatives to date in tackling health inequalities have been born out of partnerships between a range of agencies and groups of local people. As my hon. Friend the Member for Stoke-on-Trent, North recognised, new duties on local authorities and NHS bodies to work together to promote well-being in their areas will help to deepen and cement the effective local joint working which is crucial to the success of the Green Paper.

The desire to improve health must also be at the core of regeneration initiatives in our inner-city areas and on rundown estates and part of the Government's wider drive to make urban areas more attractive and healthier neighbourhoods in which to live.

An integrated transport policy—for example, the provision of safe cycling and walking routes—will help to ensure better air quality, improve levels of fitness and lead to fewer accidents in areas of deprivation. In many such areas, banks and shopping facilities have been withdrawn, making access to the cheapest and most nutritious foods difficult. Credit unions, food co-operatives and local exchange trading systems all have a role to play in improving access to a range of services that tackle inequalities.

As regional development agencies work to increase investment, I hope that they will focus specifically on areas of high deprivation and will have a strong public health dimension to their work.

Measures to make sport and physical activity in general more accessible are essential components of a healthy environment, whether at school, in the workplace or in the wider community. Research by the English Sports Council clearly shows the link between unemployment and a sedentary life style. I share the concern of my hon. Friend the Member for Stoke-on-Trent, North about the lack of decent sports facilities in many areas. In my constituency, a number of key communities are a considerable distance from proper sports facilities, and this problem needs to be tackled.

I congratulate some of our major sporting governing bodies, such as the Rugby Football Union and the English Sports Council, on targeting some of their development work on areas of great deprivation. I hope that the White Paper, when it appears after the consultation period, will encourage increased partnerships between sporting clubs and their communities to tackle health inequalities. The decision to stop the sale of school playing fields is a crucial step in the development of healthier schools, where pupils take regular exercise and are encouraged to participate in sports.

I especially welcome the proposal for a network of healthy living centres, funded by £300 million from the lottery, to complement the drive to focus statutory bodies on the health of their communities. Healthy living centres will be an important boost in tackling health inequalities in areas of deprivation. They will enable local communities to have access to a range of health-related programmes appropriate to local needs in areas where, perhaps, existing health and fitness facilities are either off-putting or, as in my constituency, difficult to get to.

At last we have a Government who are focusing on the key link between inequality of income and inequality of health. The nonsensical idea that poverty and poor health were not related has at last, thank goodness, been discredited and discarded. Using the tools in the Green Paper, I look forward to working with the Government, the new Greater London authority, and, especially, stakeholders in my constituency to tackle health inequalities in Harrow.

10.22 am

Dr. Peter Brand (Isle of Wight)

I congratulate the hon. Member for Stoke-on-Trent, North (Ms Walley) on her wide-ranging and comprehensive introduction to this important debate. She clearly showed that there is inequality in health, and I think that every hon. Member could have made a similar speech, perhaps using different examples.

The problem is that we have no longer a national health service but a fragmented one. What one can expect depends not on one's clinical need but on where one lives—it is a lottery by postcode. We need the Government to declare what they will deliver to users of the health service and what people's core entitlements are. If we cannot deliver a comprehensive entitlement, let us be honest about it. It is wrong to leave it to clinicians to cover up for politicians who are not prepared either to raise the money or to suppress the expectations of the people who rely on the health service.

Mention has been made of the allocation of resources. We can make wonderful speeches about what we are trying to achieve, but without resources we cannot do anything. We need to look again at how resources are allocated. RAWP, the resource allocation working party, went a long way, but it was very insensitive. We must have a system that considers not only patients' profiles—including age, incidence of illness and social and economic deprivation, which are important factors in determining the input of resources to a particular area—but the cost of delivering care.

It is more expensive to deliver comprehensive core services in an isolated area. I know that the Government are examining rurality as one aspect of this problem, but I make a special plea for those who experience a unique aspect of isolation—those who live in island communities in England. Such communities in Scotland are recognised as having a greater need, and I hope that there will be a similar recognition south of the border.

The hon. Member for Stoke-on-Trent, North made a very good case for partnership and the encouragement of partnership. I welcome the health action zones that the Government have introduced as pilot projects. I hope that they will be bold and choose a wide range of pilots. It is sad that they are restricting themselves to 10 to 12, and I hope that they will have a rethink.

We are getting messages telling us that we may or may not be successful in respect of the pilot projects, but I hope that the Government will encourage local enthusiasm where it exists, because enthusiastic people tend to deliver, no matter what the resources. If one thing has kept the NHS going in spite of all our concerns, it is the commitment of the people working in it. It is for the politicians to encourage that commitment, and a wider acceptance of health action zone bids will go some way to fostering that.

10.26 am

Mr. Patrick Nicholls (Teignbridge)

I too congratulate the hon. Member for Stoke-on-Trent, North (Ms Walley), not only on securing the debate, but on introducing it in the way she did. As is clear even from this debate, we might have different views and different suggestions as to how to tackle the problems, but there is no doubt that there are inequalities in health provision.

The hon. Lady drew on her constituency experience as a starting point, but the figures for her constituency also tell a wider tale. She referred us to the public health common data and the standardised mortality ratios. They show that Stoke is below the national average only in cerebro-vascular disease. That is bad news: I am not saying that Stoke is a terrible place to live, any more than she did, but it clearly concerns her.

However, the picture is mixed, because the same figures show that Stoke is below the national average when it comes to infant mortality rates, with about 5.5 deaths per 1,000 live births compared to 6.1 per 1,000 in England as a whole. That brings us to the "gap" about which we have heard so much today.

In 1995, the age-standardised death rate per 100,000 of the population in Stoke-on-Trent was 860, compared with 1,056 in 1985. Both those figures for Stoke were higher than the averages for England in those years, which were 748 and 894 respectively. Interestingly, if one compares the average rates in 1985–87 with those for 1993–94, one finds that, in percentage terms, the reduction has been greater in Stoke than nationally. One could ask, "Is my glass half full or half empty?" I accept that one could say that there was more room for improvement in Stoke, so the decline would be greater. That is a perfectly fair point, which needs to be made.

If the health gaps between social classes widened in the 1980s, that must be seen in the context of a declining mortality rate for all classes. For men aged 35 to 64, age-standardised death rates fell by 32 per cent. for classes one and two between 1976–81 and 1986–92. The highest fall—44 per cent.—was experienced by socio-economic group three, whereas there was a 21 per cent. fall for groups four and five.

The hon. Member for Stoke-on-Trent, North reminded us that we all use statistics to back our particular cases, but I mention those figures because they show how careful one must be in using the gap as a measure of success or failure. I suspected that the hon. Lady—I hope that she will take this as a compliment—was going to make more of the gap, as the hon. Member for Harrow, West (Mr. Thomas) did, but she was right not to.

The gap is a relevant fact and indicator, but what matters more is the absolute standard of treatment that the poorest and most disadvantaged members of society receive. We could, for example, imagine a situation in which the gap had narrowed even though the absolute position of the poor had worsened. No one would regard that as a measure of success. It is too simplistic to argue—as people often do—that the continuing gap between the rich and poor must mean that the situation is worsening. I compliment the hon. Member for Stoke-on-Trent, North on not overplaying that argument.

In the debate, there has been more than a hint of the great cry, Four legs good, two legs bad". It was suggested that everything that happened under the previous Administration was bad, whereas everything that will happen under this Administration will be good, and that the previous Government allocated insufficient resources, whereas things will be much better now. I do not think that the figures substantiate that argument.

Ms Walley

I made it clear that the setting up of the health action areas has made a significant difference. I want us to address the current situation.

Mr. Nicholls

I am sure that the hon. Lady is absolutely right in that, but it is not the case that, when the new Government took office, they found that the previous Government had applied manifestly inadequate resources. I shall not blind the House with statistics, but the previous Government spent some £80,000 every minute on the national health service. One can always cry, "Even more should have been spent," but that was a substantial sum.

The third progress report on the "Health of the Nation" project, which was published in July 1996, showed that progress had been made on 18 of the 21 targets. The death rate from coronary heart disease for those under 65 had fallen by 19.2 per cent. and by 12.5 per cent. for those between 65 and 74. The death rate from breast cancer in women aged 50 to 69 had fallen by 9.6 per cent. The death rate from strokes among those aged between 65 and 74 had fallen by 14.3 per cent., and the death rate from lung cancer among men aged under 75 had fallen by 13.9 per cent.

We are debating this subject against a background of substantial improvement in the nation's health. As the hon. Member for Stoke-on-Trent, North said, we do no good by saying that the position is worse than it is.

Numerous studies have made the connection between poverty and ill health. The hon. Member for Harrow, West seemed to take the view that the wicked old Tories had always said that there was no such link. I am not trying to avoid a good argument—I am always in favour of one if necessary—but the hon. Gentleman is wrong. People sometimes advance the view that the cause of ill health is poverty, and that ill health will disappear at a stroke if poverty is abolished. That is an attractive view, but numerous studies show that it is not so.

The Minister may mention—or we may hear about them in the continuing debate—the various reports that are cited as evidence that poverty causes ill health. Sir Douglas Black's report is the most famous; it is often cited as showing the linkage beyond doubt. However, the Black report said that the argument is much more subtle and complicated. For example, it found that health inequalities related not so much to poverty as to the way in which different parts of the population used health services. It suggested that the lower occupational classes made greater use of general practitioner services, but that their use of preventive health care was markedly lower than that of higher occupational classes. That argument was confirmed in a study by the King's Fund in 1995.

There are other factors that are not directly related to poverty. The Policy Studies Institute report on aspects of health inequality, which received some publicity, argued that the differences between ethnic groups and between ethnic groups and whites could not be explained by the disadvantage that was experienced in the country of birth; those who were born in Britain or migrated at early age were, if anything, likely to have less good health.

The report also emphasised the significant variations within specific ethnic groups, and said that a key factor appeared to be socio-economic status. Nevertheless, it said that it was unlikely that that was the only cause; if it were, it would be hard to explain why ill health in one group was demonstrated through increased risk of hypertension, whereas in another group it manifested itself in heart disease. The report also suggested that biology and culture, with other factors such as the knowledge and experience of racism, might also be relevant.

I make those points not to muddy the waters; I want to clarify the arguments. The link exists, but it is more complicated than has been suggested. People may be poor because they are in ill health, and there are a range of other factors, including environmental and genetic.

We should also consider life styles. We now know that smoking wreaks devastation on the population's health. No one—whether rich, middling or poor—much above the age of 10 does not realise that smoking is harmful.

Mr. Gareth R. Thomas

The example of smoking is particularly apposite. Does the hon. Gentleman recognise that the incidence of smoking is greater among low-income families than among high-income families? Does not that demonstrate the need to tackle inequalities of income as well as the other inequalities to which he has referred?

Mr. Nicholls

The hon. Gentleman is mistaken; one cannot say that poverty drives people to smoke. We have to accept that, ultimately, people are responsible for their health. Some people use poverty as an excuse and ignore what is in their best interests. One cannot say that people who are poor or on low incomes are entitled to turn away their faces from the damage caused by smoking.

Smoking, whether one has a high, middle or low income, is devastating. I give the Government full credit for the fact that they have made that abundantly clear, and done a great deal to publicise the damage that smoking does. I believe that a forthcoming White Paper will make the same point.

Whatever we may have had to say in the past—it may be relevant to say it again in the future—about the fact that sometimes, even in taking forward a good policy, one can unexpectedly strike an uncertain note, the fact is that the Government have made it clear where they stand on smoking, and that is a jolly good thing.

I want to leave sufficient time for the Minister for Public Health to respond, but first I shall comment on a note that I detected, more in the speech by the hon. Member for Harrow, West than in that by the hon. Member for Stoke-on-Trent, North—perhaps because, like me, the hon. Lady has been in the House long enough for a certain cynicism to sink in—to the effect that, somehow, everything will now be sweetness and light.

I do not necessarily see that. Yes, some things in the Green Paper on public health were worth while, but the targets were cut from more than 20 to four. So far as one can compare them—that is not easy, and it probably was not intended to be—the four targets are less exacting than those in "The Health of the Nation".

The Minister will correct me if she thinks that I have it wrong, but I see nothing in the Green Paper that deals with inequalities in health in particular. Obviously, that is the dimension of the national health service that we are talking about today.

I am not the only one who says that. Let us look at the reception that the left-of-centre press gave the Green Paper. We now have four targets, none of which seems to address health inequalities specifically. That aspect has been criticised by both health groups and journalists.

The Financial Times said: ministers have dropped plans for targets to cut the health gap between the social classes. Karen Caines, director of the Institute of Health Service Management said: 'on this most crucial issue of health inequality they have bottled out. Without measurable targets, even over a long time-scale, there will be less pressure for change and less scope to hold them to account.' There was a leader in The Guardian, too. On the whole, Guardian leaders do not give comfort to Conservative spokesmen—[Interruption.] I suspect that that intervention was good enough to put on the record, but I did not hear it.

Mr. David Jamieson (Plymouth, Devonport)

We have not found them helpful, either.

Mr. Nicholls

It is always nice to enable a Whip to record something for posterity. Let me assure the hon. Gentleman that he will not find what I am about to read helpful, either, but he may find it true.

The Guardian leader said: The Government is wrong to shrink the number of targets from 27 to four … Most serious of all is the absence of targets for reducing health inequalities. Anti poverty campaigners must insist on their inclusion. There must be a specific commitment to close the gap". There is more from the Health Service Journal in the same vein: King's Fund chief executive Julia Neuberger said, '… we do have to measure progress in reducing inequalities, otherwise there is a danger that no one will take responsibility and be held to account'". I could read out more of the same sort of thing.

I must say in passing that the wholesale closure of hospital facilities in London, although the Labour party said a little while before the election that it had no plans—[Interruption.] I shall go through it all if hon. Members want. There is the closure of the accident and emergency department at Guy's and of the Greenwich district general hospital; there is the transfer of facilities from Queen Charlotte's hospital to Hammersmith hospital, and many other similar developments throughout London. It is all about hospital closures and the reduction of facilities in areas of high social deprivation.

It is not only Conservatives who are entitled to raise doubts about the idea that nothing was done under the previous Government and nothing like enough was spent, yet that, under the present Government, everything will be different. The left-wing press is expressing the same doubts.

The argument is not as easy as it may seem. Inequalities in health must be addressed, but as for the idea that simply by a change in Government one can produce a brave new dawn in which complex problems become simple, I do not believe it. But I shall wait and see what the Minister has to say.

10.43 am

The Minister for Public Health (Ms Tessa Jowell)

I begin by adding to the congratulations offered to my hon. Friend the Member for Stoke-on-Trent, North (Ms Walley) on prompting the debate and providing an opportunity for one of the best debates on the issue that we have had for some time. We are grateful to my hon. Friend for that, and for the way in which she has raised issues of such direct concern to her constituents.

I shall deal first with some of the general issues arising from the Green Paper on public health and the response to it. It has two broad aims. One is to increase the length of healthy life, and the second is to close the health gap. For the first time in 18 years, there is the recognition that inequalities in health linked to social class have got worse.

For example, if, between 1991 and 1993, all men had had the same death rate as those in social classes I and II, there would have been more than 17,000 fewer deaths each year. Children born today into social class V are five times more likely to be killed in an accident before they are 15 than children born into social class I. The litany of evidence in support of the existence of health inequality goes on.

We should not take a simplistic view of health inequality, but we must start by recognising that it exists. The poorer people are, the more likely they are to be ill. For example, people in social class IV or V are more likely to face every illness—except, I think, melanoma—than people in social class I or II.

The case for the existence of health inequality—the link between poverty and ill health—is clear, but the story is not as simple as that. That is why the Green Paper does not take a simple deterministic view of ill health and poverty, but recognises the important role of confronting poverty as a way of improving health.

We also draw attention to the inequalities between different ethnic groups and between regions. The rate of heart disease is three times lower for men in Oxfordshire than for men in Manchester. We need to take such regional inequalities as seriously as other manifestations of inequality, including inequalities between men and women.

When we talk about tackling health inequality, we are talking about tackling the reasons that divide us as individuals in our enjoyment of good health, and about recognising the many factors that are brought to bear. Some of those are determined early in our lives and others later, and they result in a differential expectation of good health between men and women, and between people from different social classes and ethnic backgrounds. The expectation even varies according to where people live.

The inheritance is complicated, and things were not helped by the previous Government's refusal to recognise the link between poverty and ill health, and to confront the complex nature of inequality. The targets that we have set to meet our two overriding aims of improving healthy life expectancy and tackling the health gap aim to yield two results.

The first is a reduction in avoidable deaths. More than half the people who die under the age of 65 die from cancers or from circulatory disease, including heart disease or stroke. If we are to make an impact in reducing preventable death, we have to concentrate our efforts on those areas which represent the greatest risk.

It is important to recognise the need to establish a proper balance between nationally determined targets and those that measure specific problems in relation to particular local needs. It is not true to say that we have refused to set inequality targets. The better informed commentators—the leader in the British Medical Journal, Professor Julian Le Grande and others—have made that absolutely clear. They have endorsed the Government's approach in reducing the number of targets, and linking targets to a clear strategy for action.

Setting national targets for inequality is a complex and inexact science, which is why the Government have commissioned Sir Donald Acheson to review the evidence relating to inequality and to provide guidance on the areas of Government policy where action to reduce health inequality which impacts on other aspects of policy is likely to be most productive. In that respect, as in all other aspects of our health policy, we are pursuing a common approach, which is to apply what works, based on the best available evidence. Through consultation, and in the light of Sir Donald's conclusions, we shall reach a judgment as to whether or not to set national inequality targets; but we shall urge local health authorities to set inequality targets in the context of health improvement programmes.

We are determined to deliver a strategy, and it is one of the toughest challenges facing the Government. As my hon. Friends the Members for Harrow, West (Mr. Thomas) and for Stoke-on-Trent, North made abundantly clear, delivering improvements in health, especially to the poorest, will rely on successful Government policy across a range of issues, including getting people off benefit and into work, improving educational standards and tackling environmental problems such as air pollution and congestion. Those are all vital ways of improving health and reducing avoidable death, as well as being policies for economic renewal and regeneration.

Cross-Government working and partnerships at local level will also be key, but we need to recognise that success in delivering the strategy will rely on effort in three broad areas. First, the Government must take the action that only the Government can take. Secondly, through health action zones, the single regeneration budget, education action zones and the range of regeneration initiatives and health improvement programmes, we must ensure a local fit to local circumstances when addressing local priorities.

Thirdly, we must all recognise that we bear a responsibility to ourselves and to our families for improving and safeguarding our health. Only if we secure properly balanced action in those three areas—Government action, local intervention and action and personal responsibility—will we begin to see progress in those areas where progress has been elusive thus far. That is the essential national contract for better health which sits at the heart of the Government's approach.

I shall now deal quickly with some of the important points made by my hon. Friend the Member for Stoke-on-Trent, North. With other hon. Members, she pointed out the extent of inequality whereby areas of poverty and poorer health can exist alongside areas of relative affluence. Her own constituency clearly illustrates that point.

The national average mortality from heart disease is 42 per 100,000 people, whereas it is 53 per 100,000 in North Staffordshire, and that picture is repeated when we look at other causes of premature death: death rates from stroke are worse than average, as are those from lung cancer; infant mortality is worse; and schizophrenia and suicide are more common. Those are only averages, which conceal pockets of deprivation and poor health in wards that suffer problems equal to the worst in the country.

I should also underline the evidence of great enthusiasm and resilience shown by voluntary organisations, the local authority and the local health authority in the face of that deprivation in my hon. Friend's constituency. I have read with great interest their recent bid for health action zone status and of their bid to the single regeneration budget, and their work with the World Health Organisation on the healthy cities initiative. All those initiatives, to which so much effort has been devoted, show that there is real spark and a commitment to get to grips with the problems facing her constituents.

I am sure that my hon. Friend will forgive me if, having given her every assurance about the careful consideration being given to the health action zone bids from her constituency and that of my hon. Friend the Member for Harrow, West, I do not make any announcements today about successful applicants. However, whether or not their bids are successful, all the 41 authorities that have bid for health action zone status should use the effort and partnerships developed for the bid as the foundation for continued progress in tackling health inequality.

I reiterate the concerns expressed by my hon. Friend the Member for Stoke-on-Trent, North about fertility services in North Staffordshire. I note that the health authority has been taking positive action to compare its expenditure on fertility services with that of other health authorities.

Although I am conscious that all health authorities need to balance local spending with local need, I would encourage my hon. Friend's local health authority to ensure that provision is in keeping with the level of service available elsewhere in the country. In passing, I pay tribute to the Staffordshire ambulance service: it is a beacon to other services, and another example of successful local endeavour.

Let me now deal with some of the other aspects of the broader relationship between the Government's approach to public health and the regeneration of the national health service. The Government view the White Paper "The new NHS: Modern—Dependable" and the Green Paper "Our Healthier Nation" as components in the plan to improve the health of the people of this country.

Let me restate the guiding framework, which was set out in our election manifesto and repeated in the NHS White Paper and within which treatment—whether for cancer or for any other condition—will be delivered to the people of this country: If you are ill or injured there will be a national health service there to help; and access to it will be based on need and need alone—not on your ability to pay, or on who your GP happens to be, or on where you live. We are deeply concerned about inequalities in access to treatment, which is why the fair access dimension is one of the key performance measures for the new NHS. We are also concerned that areas whose residents are in greatest need of health care may not be getting their fair share of health care resources. We are determined to make every possible effort to ensure fairness in access and in treatment.

Mr. Sayeed

Will the Minister give way?

Ms Jowell

I hope that the hon. Gentleman will forgive me if I do not. We have almost run out of time, so I shall not take his intervention, other than to say that I accept his analysis that the cancer care framework set out in the Calman-Hine report provides a model for the development and delivery of health care services in other areas. The Government have made it clear through the development of service frameworks that we intend to build on that approach to provide an integration of prevention, health promotion, community care, primary care and acute care, available where it is needed and on the basis of need alone.

Let me finish by recalling the words of William Farr, the first Registrar-General, who said 150 years ago: Good health is as dear to the rich as it is to the poor. We are determined to remove the many obstacles which stand in the way of the poor enjoying the good health to which they are entitled.