Public Health in England

HL Deb 27 April 1988 vol 496 cc211-45

2.59 p.m.

Lord Hunter of Newington rose to call attention to the government publication Public Health in England (Cmnd. 289); and to move for Papers.

The noble Lord said: My Lords, I rise to move the Motion standing in my name on the Order Paper. I cannot find a better introduction to this debate than to quote from the foreword of the report: Although it is over a hundred years since the last major review of the public health function and in the interim there have been major changes in the spectrum of prevalent illness, the proposition … is as relevant today as it was in 1871. Today as then, a great burden of premature disability and death occurs which is preventable and for which the consequent suffering and expense are unnecessary. Today as then, all sectors of society, the individual and a number of professions as well as the state have their roles to play.

It is true that the resources which can be devoted to health care are limited. It is also true that because of new methods and new technology and public awareness the demands on the treatment side of medicine will continue unabated and will probably become more and more expensive. The problem is: how can resources be found for the new public health in the face of these insistent demands?

Thinking of the old public health dominated as it was by the medical officer of health and concerned with food, housing, nutrition and inoculations, and comparing this with the developments of recent years, we find that a whole host of things have happened that will become a permanent feature of the new public health.

As the report says, it is ironic that the year 1948 which is usually viewed as being the date on which a new era dawned for the health of the nation was the year which in fact separated much of the public health function from the rest of the National Health Service thus sowing the seeds of a confusion of roles between local authorities and health authorities. Between 1948 and 1974 the more farsighted medical officers of health performed valuable and creative work, striving for functional unity of the administratively tripartite National Health Service. They developed a substantial range of community health services.

A further and unforeseen consequence with the National Health Service which was deleterious was the neglect of preventive services which seemed to be administratively separate functionally and in terms of policy from the hospital service. This has been increased by the more recent separation of general practice services from the hospital activities and the placing of family practitioner committees directly under the Department of Health and the Secretary of State.

Perhaps one could give a few examples of the deteriorating situation and of the present confusions. In the United States of America children are required by law to be inoculated against measles before they attend school. In the United Kingdom measles epidemics continue causing permanent damage to some children. We have only achieved a 70 per cent. inoculation rate and it requires a 90 per cent. rate to stop epidemics of this highly infectious disease. Should we legislate?

The uptake of cervical cytology screening in one Manchester practice has been 14 per cent. That is very low, in spite of the family practitioner committee introducing a call and recall system. Investigation of this system showed that more than half of the cases of non-attendance were directly attributable to administrative errors which resulted in appointments being sent to the wrong addresses or to inappropriate people. This is not an isolated situation. Confidential inquiries in districts with high mortality rates from cancer of the cervix in women showed that the possible reasons varied. In one district none of the women who died had ever been screened. In another district with a high mortality rate all the women who died of cancer of the cervix had previously been screened at varying intervals. Although more than half of those women had shown some abnormalities on the original screening, they had had no re-examination six months later. That was possibly because of a failure of communication between the laboratory, the general practitioner and the woman concerned. The mortality rates for specific conditions such as cancer of the cervix can serve as indicators of matters to be rectified in the delivery of preventive health services.

Under the old public health system, X-ray of the chest was accepted without question to eliminate tuberculosis. Should all patients entering hospital now have an AIDS test? The desirability or otherwise of this and other possible legal requirements needs the application of the skills and knowledge of the law and politics. This necessity becomes more acute as the epidemic spreads and becomes heterosexual in transmission.

The public must have a view about the new public health system. What are the responsibilities of society against the background of the rapidly escalating costs of running the treatment side of the NHS about which we have heard so much recently? What part should be played by individual decisions? Should smokers who develop carcinoma of the lungs be required to meet part of the cost of the treatment according to their means?

In recent years there have been remarkable changes in the contributions made to the public health by other government departments than the National Health Service or the Department of Health and Social Security. The Department of the Environment and the Ministry of Agriculture, Fisheries and Food are very substantially involved as is the Home Office in relation to narcotics. The Department of Education and Science is concerned with health education, and the Treasury is also involved in relation to taxes on tobacco and alcohol. I quote the words of the report: we wish to draw attention to the fact that at present the policies of almost every Government Department can have implications for health and that consequently there is a need for effective co-ordination of such policies if health is to be improved".

This view is also the opinion of the Select Committee on Science and Technology in its examination of priorities in medical research. Saving money on health and for health could be a government-wide exercise.

Much publicity recently has been directed at disturbing difficulties which have arisen over the deficiency of medical treatment, almost entirely in specialised hospital units. The hospital service as we know still remains central in the thoughts of the people of this country. But with regard to the hospital service and specialised treatments one is forced to ask how many of the procedures have been the subject of study by careful analysis of need, and by close collaboration between administrators and clinicians. How many have been the subject of controlled clinical trials and in how many situations such as the Birmingham Children's Hospital have the additional costs been assessed and properly budgeted for?

When we debated the National Health Service last month under the skilled guidance of the noble Lord, Lord Ennals, the focus was mainly on the hospital service but there was mention in that debate of the tripartite nature of the NHS and of the public health and also of the contribution of the voluntary services in assisting in a skilled and positive way people with disabilities, helping them to be as independent as possible.

Much is, and will continue to be, the responsibility of local government as Sir Roy Griffiths has said in his recent report, Community Care: Agenda for Action. Sir Roy Griffiths also pointed out in the report with reference to the National Health Service: There is little measurement of health output: clinical evaluation of particular practices is by no means common and economic evaluation of these practices extremely rare. Nor can the NHS display a ready assessment of the effectiveness with which it is meeting the needs and expectations of the people it serves".

It was clear from the evidence given to the Acheson Committee that there was a lack of co-ordinated information on which to base policy decisions about the health of the population at national and local levels and particularly at local levels between health authorities, local authorities and general practitioner committees. That was a function carried out in the 1960s by medical officers of health. The present situation has led to widespread confusion about the role and responsibilities of public health doctors. Very importantly, there has been confusion about the responsibility for communicable diseases, as was recently evident in the epidemic of salmonella poisoning which occurred in Birmingham. In that case, collaboration did not occur. The Sir Donald Acheson inquiry showed a wide support for a well-trained and medically qualified public health specialist as a key figure. If such a figure had been present and active during the Birmingham outbreak, the consequences might have been very different.

The report suggests that there should be a new director of public health within the health authorities concerned. Moreover, it suggests that there should be established within the DHSS a central unit to facilitate and improve the monitoring of the nation's health. Although the phrasing is different, that seems to refer to the need for R&D as a basis for determining policy, which was a central recommendation by the Select Committee of this House which looked at priorities in medical research with particular reference to the needs of the NHS.

A recent debate in your Lordships' House on Investing in the Future: Child Health 10 years after the Court Report illustrated the growing importance of community paediatricians who could be valuable in building bridges between general practices and the schools. If such doctors are members of a large practice, they can keep the whole question of children and their welfare constantly in view. Another important aspect of the changing scene is mentioned in the Government's White Paper, Promoting Better Health. It proposed considering amendments to doctors' terms of service to clarify their role in health promotion and the prevention of ill-health. Perhaps the Minister will feel able to tell us more about that.

As an illustration of one of the most urgent questions facing public health and primary care, one cannot do better than to consider how the general practitioner is tackling the whole question of AIDS infection. The evidence so far seems to suggest that the GP does not consider that talking to his patients about that problem is very important. If advice about the infection was given to every patient, it might substantially reduce the spread of the disease. However, raising the subject during routine consultations about other matters is difficult.

Another difficulty in testing for AIDS has received little attention. However, it is exceedingly important. Although all tests for antibodies are sensitive and specific, false positive results occur. The ratio of false positive to true positive results is always high when the prevalence of an infection is low in the population, as it is in this case. In the case of AIDS, false positive results are at least five times more prevalent than true positive results. That is yet another difficulty in this desperate problem. That is an illustration of an infection which is closely linked to personal behaviour, for which there is a diagnostic method which may be delayed for many months before it becomes positive and for which there is presently no treatment available which will cure the condition. It adds a new dimension to the importance of personal public health measures; it can only be controlled by personal behaviour.

A different illustration of the importance of public health measures concerns the condition hepatitis B, for which there is a diagnostic test. The condition is spreading in this country. There is a treatment and all that is required is the provision of sufficient resources to eliminate or substanially control it within a matter of years.

Ministers have to make decisions between the demands for resources for those health measures and demands for the resources for development of new cardiology transplant units, modern high technology in radiology departments, intensive care units and the purchase of medicines. The task is difficult and time-consuming. When one considers what has happened in recent months with the crisis in the NHS over funding in hospitals and the further crisis in social security, one begins to realise the almost impossible task facing the Secretary of State. The Health Department should be able to argue its case for the NHS directly with those responsible for an overview of public expenditure. The social services should be able to do the same. Surely there should be a Minister of Health in the Cabinet.

I believe that this important matter should be looked at by the top review body which is considering the future of the National Health Service. As the Acheson Report makes clear, many governmental departments are concerned with public health. I beg to move for Papers.

3.15 p.m.

Lord Trafford

My Lords, we are told that the National Health Service is undergoing a review at the present time. However, I have not seen any rumours reported in the media or elsewhere of the place of public health in that review. Therefore, it is very pertinent that the noble Lord, Lord Hunter of Newington, should raise the subject for debate. I am sure that we are all grateful to him.

I hope that the fact that we have not heard much about public health in the review does not mean that the reviewers have forgotten it. Amid all the hints dropped in the press and the media about more competition in primary care, more competition in hospitals, the involvement and competition from the private sector and even the American-style hospital maintenance organisations or the DRG systems in hospitals, we should remember that the domain of public health is not suited to that sort of approach.

The great advances in the health in this and indeed all nations were accomplished by public health measures until relatively recently, when the discovery of drugs such as insulin, penicillin and a host of other agents began a treatment revolution. It was people like Snow who took the handle off the pump as a means of controlling the waterborne infection, cholera; Jenner who used cowpox to vaccinate for smallpox; and Chadwick who was not a doctor but who was an administrator concerned with sewers and drains in London in the middle of the last century who saved more lives and gave a better quality of life to the people of this country than all the pedlars of modern therapies, myself included. I suspect from what the noble Lord, Lord Hunter, has just said that he would include himself with me in that category.

That trend is being continued and it should not be forgotten. We have seen in our own time the development of the Salk and the Sabin vaccine for polio and its massive significance for the eradication of that disease. Incidentally, Fleming, who discovered penicillin, was not working on anything related to it at the time, as it was unknown. He was working on the natural protection of the body to infection from lyzozymes, a secretion of the tear ducts of the eye. He accidentally discovered penicillin. Nonetheless, he started a massive revolution which has led to all the subsequent antibiotic therapies and developments in treatment and therapy for sick patients. However, it is in the prevention of those diseases that the significant advances in health have been made.

We tend to take the advantages of a proper public health service largely for granted. It is only when we visit less fortunate lands that we see the grave consequences of its deficiency. I well remember my horror on receiving at my unit two charming gentlemen who were doctors from another country. The purpose of their visit was to purchase on behalf of their government the most suitable kidney dialysis machines for theircountry. I was horrified because the last things they needed were kidney machines and high technology.

What they really needed was a basic practice of medicine, work on the health programme and work on the prevention of polio, which was and still is endemic in that country. They needed to work on sewers, drains and the water supply and they needed to work on an immunisation programme. I was shocked to think that any government—and that was only 15 years ago—could waste money in that way when so much more was needed of that which is basic to the continuing health of a nation.

We have had a number of reports on public health over the years, including the very famous Royal Sanitary Commission, all the way through to the Todd Report of 1968 and the report of the noble Lord, Lord Hunter, of 1972. We have had a number—probably too many—of NHS reorganisations, and a large number of statutes with which your Lordships are only too familiar. Now we have another report. One might well ask why. Why in 1988? What is special?

I think there is a simple answer. It is because a once unitary system is in danger of confusion, fragmentation and ultimately collapse. When the NHS started 40 years ago the old medical officer of health remained with the local authority. His duties continued to cover much the same ground although he was supposed to be limited to non-interference, so to speak, with those GP and hospital medical services. That separation created some problems. The solution in 1974—which was to restore the tripartite basis of all medical activity—may have looked good in theory but in practice did not work out. It left only environmental health with the local authorities. Of course they were allowed to look to the medical officer of environmental health who was employed by the late but not lamented area health authority.

Just before that we heard of and had developed the new specialty of so-called community medicine. In 1972 the noble Lord, Lord Hunter, recommended that once again those roles should be combined, including the medical staff in the academic departments of public health. Had that happened I think that it would have gone some way to solving some of the problems. It did not, partly because community physicians were treated and appointed quite differently from other physicians and partly because their involvement in planning, manpower, medical personnel and consensus management teams led them in many other directions. It was also partly because there was no longer the respected career progression and training in some basic public health disciplines such as epidemiology, communicable diseases, control of infection and, above all, the research into disease patterns and preventive health, which in a way is part of epidemiology. The noble Lord, Lord Hunter, referrred to this in his speech, and I could not agree with him more.

One of the most important deficiencies in all that we hear about the health service is the question of outcome statistics. I do not mean by that output statistics. It is no good saying that a million patients went through the hospital or that 750,000 people were seen by their general practitioner on an average working weekday. What matters is to know whether it was all worth while, what happened to those patients and what was the result.

I once saw a doctor (who fortunately did not practise in this country, nor was he trained here) who had been carrying out a large number of oesophageal operations—gullet operations. He had been removing gullets at a great rate of knots for carcinoma of the gullet—without I might add many facilities where he was operating. I asked him, "What are your results?" "Well", he said, "some live a week". I said to him, "Why don't you stop?" I did not get a very satisfactory answer. He was appointed as a gullet surgeon and so he continued to operate on the gullet.

That is the sort of thing that we need to know. Fortunately there are not such exaggerated examples in this country. However, as the noble Lord, Lord Hunter, has just said, we need to know the true outcome of, say, coronary bypass operations. Are we really talking about a 2 per cent. or 3 per cent. marginal difference in effect compared with medical and surgical therapy? Are we talking about survival? Are we talking about relief of symptoms? All this makes a fundamental difference to the decision or the allocation of resources. If it does not work, shut it down; if it works, give it support.

Unfortunately, as a practising clinician I have to agree with considerable reluctance with the noble Lord, Lord Hunter, that we frequently carry out practices the results of which, the true outcome of which, we do not actually know. He used the example—and I think it is a splendid one—of preventive health as regards carcinoma of the cervix in women. We know from the results that have been published over 25 years in Vancouver in Canada that, although one cannot eliminate the consequences of that disease one can minimise them, not by operations, not by radiotherapy and not by heroic measures but simply by screening at the right time and place. To do that one needs to obtain a sufficient proportion of the population.

One of the great problems that has always bedevilled screening programmes is that when one sets up a screening programme everybody who is already fairly intelligent and initiated into such matters rushes along to be screened. They are the last people who need to be screened because they would be the first to notice anything or complain and get action. The people one wants to get at are the people who do not come, the groups one cannot easily reach. That is one of the difficulties of the methodology.

Another problem is that one gets five doctors burning with enthusiasm to rush into some particular piece of preventive medicine. I remember very well one study on the contraceptive pill conducted at the University of Aberdeen 14 years ago. The results were splendid. The number of participants was about 96 per cent., which is something one never gets from the general population in ordinary circumstances. When the results were extrapolated to other districts and other places, the number of people who attended and who were reached dropped steadily until when it became routine it was something of the order of 53 per cent. or 55 per cent.

A really significant, well directed effort is needed to achieve results. A really well directed effort is needed to assess and evaluate the consequences of what we do and then to decide whether more effort or less should be put behind those services.

For some time now we have seen tragically a failure of communication between those who work for the local authorities and those who work for the district health authorities in this field. That has also led sometimes to a lack of interest and certainly to a failure of training of some of the current community physicians and those concerned, for example, with infection and communicable disease. I shall not go over the points made by the noble Lord, Lord Hunter. I am in total agreement with him and the example of the salmonella outbreak to which he referred; there is also Legionnaires' disease.

Perhaps I may now turn to the report. I found it difficult to read, verbose, repetitive and definitely lacking in clarity. Having been so rude about it, I must also say that I agree with its central points that public health needs revitalisation, that its role needs definition and that a new career structure with proper training, continuing education and association with academic faculties of public health certainly needs development.

I note that some recommendations seem to suggest the recreation of the old medical officer of health. Back comes the annual report, and it is to be discussed in public. Back comes also the role in the field of communicable disease; and back comes the wider role of advising on health care development. Indeed, the role suggested by paragraph 5.3 of the report is very wide-ranging indeed. There are some amusing points. For example, I could not understand quite why the subject of communicable diseases was sandwiched between training and shortage of manpower. Nonetheless all points were taken.

In all of this the two most important statements to which I have already drawn attention were nearly lost: first, that the evaluation of disease patterns, the measurement of outcome and the resultant planning resources are critical; secondly, research in these fields could and should properly be a duty of the medical officer of health. I should therefore welcome the establishment of a proper public health science and service. I welcome also the idea of building on the current role of the London School of Tropical Medicine and Hygiene to provide pivotal leadership in this field. I hope that the medical officer will cease to be the repository of unwanted medical chores.

I have one final plea. Why can we not bring back the Diploma of Public Health, which everybody understood, once more call these people medical officers of health and let them walk tall in an old but honoured role?

3.30 p.m.

Lord Pitt of Hampstead

My Lords, I, too, wish to thank the noble Lord, Lord Hunter, for initiating this debate. I owe him an apology for not being present at the beginning of his speech, but I shall catch up with it in Hansard.

I agree with him about having an independent Minister of Health who has a seat in the Cabinet. I have no doubt that the health service suffers from the fact that the Minister who represents it in the Cabinet has other serious financial considerations to lay before his colleagues at the same time. He probably has to decide within the department beforehand how resources should be allocated between social services and health. What is required is that the health service should have its own Minister to argue its case in Cabinet. I am only too pleased to endorse what the noble Lord, Lord Hunter, said.

I was very interested in the speech of the noble Lord, Lord Trafford, and I am very glad to be able to follow it. I, too, found the report difficult to read, but I thought that it had some very good recommendations which I should like to endorse. However, I was a little disturbed when I read the chapter on the shortcomings in the availability of future public health physicians, as community physicians will now be called. If they are to play the important role that the report suggests, we shall need to do a great deal of recruiting and training fairly quickly.

However, I want to talk about the role of general practice in public health. I read the report and then looked at the government White Paper, in which the Government suggest additional roles for GPs in the field of preventive medicine, which I strongly support. I could not see that suggestion reflected at all in this report. I know that there will be discussions on this matter. I do not know whether they have taken place yet. When the Minister replies, I should like him to tell me whether his mind is running along the same lines as mine. The general practitioner is the only person who sees the individual from birth to death, and often before birth. I often see men and women in the Caribbean and also in this country whom I knew before they were born because I provided antenatal treatment for their mothers. Sometimes I delivered them myself but, even when they were delivered in hospital, I provided most of the antenatal care.

Although we have community paediatricians, it is the GP and the health visitor who look after the pre-school child. It is a very important role. Although we have a school medical service, again it is the GP who will be consulted by the parents when anything happens to the child. Therefore, the GP's role in preventive medicine is as important—perhaps even more important—as his role in curative medicine. For example, the GP carries out the immunisations, and it is only he and the health visitor who can monitor them. The GP's role in preventing these children from later developing serious illnesses is of the utmost importance.

It is the GP who has the opportunity of influencing the life-style of his patients. Today that is most important when health education enables people to understand which rules are safe and which are unsafe—the GP should not necessarily make the decision for them as to which rules they follow but he should make quite sure that they understand them.

I was glad to hear the noble Lord, Lord Hunter, refer to the GP's part in dealing with the problem of AIDS which now confronts us. I agree with him that GPs should discuss with their patients the whole question of the dangers of HIV infection and explain to them in as much detail as necessary what is involved, how they can become infected and how they can avoid being infected.

Although neither the noble Lord, Lord Hunter, nor the report touched on the serious problem of drug addiction, which I have raised in this House several times, I have always felt, and still feel, that here the GP has an extremely important role to play. Now that there is AIDS, which is a concomitant, because addicts pass the infection from one to another through their needles, it is even more important as a preventive measure that GPs should play their part.

I agree very strongly with what the noble Lord, Lord Hunter, said about hepatitis. It seems incredible, since we know how to control hepatitis, that we have not devoted the resources to it. I do not believe that the resources required are so alarmingly high that they cannot be provided. It is surprising that we have not devoted the necessary resources to dealing with hepatitis, as we should have done.

I hope that my contribution will bring into focus the importance of the general practitioner in public health and that the Minister will take that fact back to his discussions. Whatever decisions may be made about the implementation of the report and about the importance of the GP's role in preventive medicine in the new arrangements proposed by the Government, I hope that there will be a coalescing of those two factors.

If the report is implemented, I do not understand who will monitor the GP's activities in this field. As in every other activity in the field of public health, the contribution of the general practitioner needs to be monitored. Therefore, in planning the structure—because obviously some structure is being planned—I hope that the Government will recognise the importance of the general practitioner in this field and will make sure that his role is properly monitored.

3.40 p.m.

Lord Winstanley

My Lords, not for the first time I find myself in some difficulty in one of your Lordships' debates. I was delighted when I learned that the noble Lord, Lord Hunter of Newington, was to introduce this debate. It is indeed a subject of immense importance. It is one in which I have a very deep interest and in which I have had some professional involvement throughout my professional life. Indeed, there are those who may remember that over 12 years ago I made my maiden speech in your Lordships' House on a related subject: it was on water supplies, hygiene and sanitation. At that time I said, and I repeat now, that plumbers and sanitary engineers together have done more for the public health than all the doctors put together. I adhere to that statement. It will therefore be clear that I attach very great importance indeed to the work of those in the field of public health.

I looked forward therefore to speaking in the debate, but it is apparent that in order to speak I had to read the report. Frankly, I have not found that the most enjoyable of experiences. I had to read it twice before I could begin to understand it. That is no criticism of the chairman of the committee of inquiry, Sir Donald Acheson, and certainly not of his command of the English language. I recently wrote an article in one of the medical journals paying tribute to Sir Donald's work and to his English in two admirable publications for doctors and patients. One was about AIDS and the other was to patients and parents about meningitis in the area of Stroud. I complimented him on his extremely lucid and totally clear English. When my wife read the article she said, "You seem to want something from Sir Donald Acheson". If I had been going to receive it perhaps I shall now forfeit it! However this report does not add to the nation's wealth of literature. Some reports have done so. For example, we have had the Annan Report, with beautiful prose. I can name many reports.

Although it is no criticism, it is interesting to note this fact. Some noble Lords will remember the truly delightful speech of my noble friend Lord McNair on the Second Reading of the Education Reform Bill in which he made a plea for further instruction in Latin as an important means of improving the use of the English language. Perhaps it is not altogether without relevance that Latin is no longer required by medical students for entry into medical schools. The fact that the use of English by doctors has declined since that time may not be unrelated to the point that my noble friend Lord McNair was trying to make.

Perhaps I may put in another plea. One of the difficulties I found in reading the report is that it is littered with acronyms or with alphabetical abbreviations. I open the report at the recommendations. That is the point at which everyone always opens a report. They are what we read first before we decide whether we wish to read the rest. I turn to one recommendation purely at random. It is Recommendation 30: We recommend that DHSS, the GMC, the NHSTA, RHAs, the medical schools, the UKCC and other training bodies/institutes should review their education"— and so on. If I go across the page I see that it recommends that it should be the responsibility: of each RHA to ensure the provision of specialist support services in consultation with DHAs, LAs, PHLS and the relevant academic departments"— and so on. By the time one has read the report about four times one begins to understand, what those initials mean. I make a plea to those compiling reports of this kind who find it necessary to use acronyms or alphabetical abbreviations. Will they please put a glossary of those terms at the end of the report so that, if one has forgotten what they mean, one can find out without having to thumb back through 30 pages of the report to find when the body was last referred to. I found it a little difficult.

Lord Donaldson of Kingsbridge

My Lords, before the noble Lord leaves the report, perhaps I may ask a rather important question. He seemed to suggest that one can have a bad report and a good chairman. I should have thought that that was a contradiction in terms. I should have thought that the chairman was responsible for every single word of the report and that if it is not good it is his fault.

Lord Winstanley

My Lords, I am quite sure that the chairman of this committee of inquiry will accept that any criticisms of his report are criticisms for which he must take some responsibility. However, the chairman of this committee of inquiry must accept some of the credit for the very wise advice that is also given in the report. I am sure that Sir Donald will not quarrel with what we have said about the use of English in this report. Perhaps it is the nature of the subject which, from the point of view of language, tends to make it less interesting than other reports.

Among other things, in the main the report seeks to clarify the administrative structure whereby public health is delivered to the nation as a whole. That is an immensely important task. I agreed with everything that the noble Lord, Lord Trafford, said in his speech about the importance of the public health function. Indeed, had we had any doubts, we should look again at that excellent report of Sir Douglas Black on inequalities in health which showed utterly clearly the importance of housing, sanitation and all such matters with regard to the health of the individuals in our society. Those functions were, in part, under the control of the old medical officer of health, and are now under the control of people who work in the public health field.

There has been difficulty with the emergence of people with new names, such as the environmental health officer, the community physician, and so on. We now have community paediatricians. I should like to make a plea that the existence of the community paediatrician should be more widely known and understood. The community paediatrician, in those areas that have one, can do a great deal to integrate services for children between the general practitioner and the school medical service, and so on. That is an important function but it is right that the general structure should be integrated and simplified. I also think that the line of command should be more clearly defined. It is defined in this report, as noble Lords will find if they take the trouble to study it.

The noble Lord, Lord Hunter, mentioned this point in his opening speech. We also have before us a report from Sir Roy Griffiths on the question of community care. Community care has a very important impact on the public health function. In many ways the two reports have to be considered in conjunction. I note that Sir Roy recommends that some of the functions of community care should now be transferred back to the social services departments of local authorities. In a sense, that is putting the clock back because that is where they once were. That might be wise, although I hasten to say that I am not in favour of returning to the old tripartite structure of the health service whereby the public health service, the hospital service and the domiciliary service were three totally separate services. I am not in favour of returning to that position, but if we are to transfer some control over community care to local authority social services departments, there would clearly be a need to restore the role of the medical officer of health. He was a very senior officer in the local authority. As a senior local authority officer he was listened to not only by the general public and patients but by doctors as well. I found the role of the MOH invaluable. I sought his advice on many occasions about infectious diseases and matters of that kind. That advice was always forthcoming.

In the later days when I was still in general practice we had no medical officer of health. I found it difficult to know to whom to turn. I know that there were people; this report spells it out. I did not always know how to find them. I agree that it is necessary that these services become better harmonised and better integrated. There has to be a much clearer line of command.

I come to another point which has been referred to by the noble Lord, Lord Hunter, and by the noble Lord, Lord Pitt. It is: who is in command at the top? Morale in the National Health Service at the moment is low for many reasons. I take the view—I have said this in your Lordships' House before—that it will not be fully restored until such time as we have a single Minister responsible for health and nothing else; a Minister of Cabinet rank. That was so in days gone by.

Noble Lords will remember that when Mr. Enoch Powell was Minister of Health he used to send out a personal message to all National Health Service employees every year. I venture to suggest that if the present Secretary of State sent out a personal message to every National Health Service employee, he might receive some fairly rude answers. But I also suggest that some of those would arise not so much from his functions in relation to the health service but from his involvement in social security matters. They are very different.

It seems to me that if, in the fullness of time, we were to move to some kind of unity of taxation and social security, with a negative income tax scheme, it would be essential that matters such as national insurance, pensions and social security come much more under a Ministry such as the Treasury and not under the Ministry of Health. I hope that sooner or later we shall have a single Minister of Cabinet rank responsible for health and for nothing else. That will improve morale, and will be good for the health service and for the whole British public.

The situation has been difficult and has gone on for many years. My recollection is that it was Richard Crossman who originated this huge conglomerate and subsequent Secretaries of State quite liked it, even though they may have voiced some suspicions of it. I remember that the noble Lord, Lord Ennals, was not all that happy about this mass multiple ministry until he himself became Secretary of State—

Lord Ennals

No, my Lords.

Lord Winstanley

My Lords, I rather think he stopped asking for it to be broken up, but I should be delighted to hear that he is now asking for it to be broken up because I think that would—

Lord Ennals

Wrong on both points, my Lords.

Lord Winstanley

My Lords, I do not know which points I am wrong on. The noble Lord will be speaking later and I hope that he may say that he would regard it as an advantage for this Ministry to be broken up and for the functions of social security, pensions and national insurance to be taken away into a separate department, as they used to be.

I have gone on long enough. I know that I have not taken up all my time, but it is not yet compulsory for speakers to fill all the time allotted by the rules. I take the view that, when people talk about having time-limited speeches, it is not how long a speech actually is but how long it seems to be. Sometimes it seems to be too long if people have gone on after they have finished saying whatever it is they have to say. I have said what I have to say on this report and I shall now sit down.

3.53 p.m.

Baroness Masham of Ilton

My Lords, I should like to thank my noble friend Lord Hunter of Newington for selecting this very important subject for debate. He is a great expert in medicine and is mentioned in the report. I was brought up to understand the importance of public health, for at one time one of my grandfathers was a doctor working in public health in Glasgow. We have advanced a long way since those days, but the dangers and difficulties of many infectious diseases are still with us. With the speed and ease of travel nowadays the world seems smaller, and with the resistance of some diseases to antibiotic treatment the need for vigilance is paramount.

Only this Sunday I heard about the case of a student at one of the Northern universities who had reported at his health centre that he had a serious headache. Fellow students later had to break down his door. He was found dead from meningitis. I should be interested to know how many cases of meningitis there have been in the past year, as this seems to be an increasingly serious problem. Acute meningitis is a notifiable disease.

I welcome the report. It states: we have made recommendations which simplify the current system and will introduce clear and unambiguous lines of accountability for surveillance, prevention and control and above all improve the capacity to react quickly". I hope that these recommendations will be speedily implemented.

The Committee of Inquiry into the Future Development of the Public Health Function was set up in response to two major outbreaks of communicable disease: salmonella food poisoning at Stanley Royd Hospital in Wakefield in August 1984 and Legionnaires' disease at Stafford in April 1985. As a member of the Yorkshire regional health authority at the time, I asked at the RHA meeting what was being done at regional level about the outbreak. I was smartly told that the Wakefield district was dealing with it. Now with a different chairman and team of officers the response would be different.

I welcome paragraph 4.32 on page 21 of the report, which states that regional health authorities should monitor strategic and operational planning and performance of district health authorities. It recommends that the Secretary of State should consider issuing guidance clarifying and emphasising the public health responsibilities of health authorities and that there should be reports.

I particularly welcome paragraph 4.27.5, which states that district health authorities should, give advice to and seek co-operation with other agencies and organisations in their locality to promote health". When I chaired the Committee on Alcohol and Young People, that was also one of our recommendations. When dealing with the health of the nation, whatever the category may be, people should not work in isolation.

Paragraph 3.2 of the report states: We strongly support the emphasis given by World Health Organisation to the role of individuals in preserving their own health". To do this the general public needs education. I recommend your Lordships to read what the report says in paragraph 4.21.3 about schools. It suggests, supporting curriculum development of health education projects suitable for use by children of different age groups". I hope that all noble Lords taking part in the debate will support the proposed amendment in my name to the Education Reform Bill that life skills, including health education, be part of the core subject of science in the national curriculum.

The Government know better than anyone what bad health costs the nation and the advantages of good health. It is vital to project good health wherever possible. It is widely recognised that smoking, wrong diet, lack of exercise, alcohol abuse, dangerous drugs, unwise sexual relationships and too much stress are all dangerous. Young people should grow up recognising that a healthy well-balanced lifestyle will help to promote good health. This advice should be given to them as early as possible before they are sucked into bad habits.

I was very interested to see the excellent educational material on exhibition last week by the Open University. It included advice on looking after oneself, drug abuse and many other subjects. This year we had as a Winston Churchill Memorial Fellowship category infectious diseases, treatment and care. I was one of the selection panellists. The applicants were of very high calibre and the dedication and enthusiasm in the fields of microbiology and infectious disease control, both medical and nursing, were most encouraging. One university graduate was given a fellowship to study the setting up of health education programmes. He told us that the United States of America and Japan are far more advanced than Britain in computer programs of this kind. He was keen to bring back this expertise and help to provide better systems here.

Many of the candidates told the panel that they had to work in isolation and many were working at patient level. A young Scottish dental nurse who worked with patients who had AIDS and hepatitis B said that she did not have a chance of gaining the much-needed expertise she felt she needed. After interviewing so many excellent people I was interested to read on page 12 of the report that the committee advocated the development of a school or schools of public health where stress would be placed on the multi-disciplinary nature of the subject.

The report also stresses that there is often confusion as regards what public health embraces, confusion between community medicine and environmental health and confusion about the many different government departments involved. There is also often confusion among the many different names and abbreviations being used, as has already been said by the noble Lord, Lord Winstanley.

The report emphasises that health policy involves the whole of government. I hope that if the Government accept the recommendation for the establishment of a small unit within the DHSS, bringing together relevant disciplines and skills to monitor the health of the public, it will include the problems of road traffic accidents and all other accidents which can have long term effects of brain injury and spinal damage.

I believe that the general public often think of health in terms of either the public or private sectors of hospitals or going to the general practitioner. The immense work carried out in providing the science and art of preventing disease, prolonging life and promoting health through organised efforts is not wholly recognised. For example, I am told that Birmingham City Council Environmental Services Division has 1,800 employees and a budget of £100 million per year. Some of the people with whom I work on the regional health promotion group would have liked to see the report's terms of reference set wider than they were.

A leaflet published by the Danish Government on their health service states that health care has been based on good housing, wholesome food, good working conditions, pollution control and an adequate social network. I should like to quote to your Lordships the public health alliance charter: Public health means more than being free from illness and disease. It means having the resources to keep ourselves fit, secure and happy in a society which provides an environment free from unnecessary stresses, hazards and risks. Despite all the social and medical progress this century we are still faced with as many avoidable hazards to health as ever before". With the growing problem of the AIDS virus in our midst it is stated in this week's Sunday Times that there are 20 new patients a week in Britain. There are 1,429 cases of fully fledged AIDS and 8,500 people have been identified as carrying the virus. It is thought that as many as 100,000 people may be infected. We cannot be complacent. We are fortunate to have as our Chief Medical Officer of Health Sir Donald Acheson, who has an interest in infectious diseases. Even though the report has been criticised for the way in which it is written, I hope that it will project the need for better public health in Britain.

4.3 p.m.

Lord Aylestone

My Lords, I am extremely grateful to the noble Lord, Lord Hunter of Newington, for introducing the debate. I have read the report and I confess at once that I understood only a part of it. I do not feel too distressed about that because it has been the admission of most noble Lords in the medical profession who have spoken before me. However, we are grateful to the noble Lord, Lord Hunter, because we can raise any subject connected with public health.

I am particularly interested in the situation which exists between the family doctor and the patient. The point has already been raised by the noble Lord, Lord Pitt, who unfortunately has now left the House. His great interest was that the work of the GP requires monitoring by some organisation. From my understanding of the situation, doing precisely that are the family practitioner committees. They are known as FPCs. They must solve many difficulties and problems, not least those which to many individuals are major problems but which, overall, can be settled easily. I believe that in addition to solving problems and difficulties there are other areas in which the FPCs could assess and assist the working of the National Health Service. The FPCs are an autonomous body composed of both lay members and professional people from the field of medicine. I believe that they perform their duties extremely well.

One should realise that the general practitioners see approximately 500,000 people on every day of every week. It would be somewhat surprising if complaints did not arise from one side or the other when such numbers are involved. The FPCs have a system whereby diagnostic complaints, or complaints of treatment, are dealt with by specialist sections known as services committees. If a complaint is made about the service being given by a doctor, or his actual treatment of an illness, the services committees of the FPCs deal with that. There are also other complaints such as the manner of GP; his apparent lack of interest; his reception of the patient; or of care. All those complaints fall within the purview of the FPCs.

I should like to give your Lordships an example. I have heard of a case of a lady patient who arrived at a doctor's surgery feeling very frightened and unwell. She was probably fearful of the unknown. Without any physical examination she was met joyfully by the GP who told her that she had the 'flu virus, and that there was a great deal of it about. He reached for his prescription pad at the same time and I suppose that she was prescribed the usual dose of antibiotics. That is not a hypothetical case. The GP must see a certain number of patients within the hour. However, he does not have to decide to see 12 or 10 patients within the hour; he must spend the amount of time required for each one. In the case that I have quoted, where the GP saw a lady who perhaps felt that she was unwell, he should have given more attention. In some cases only a few minutes spent with each patient may be all right; but in other cases it is not.

On the other side of the coin, we must accept that some patients are particularly difficult; and on occasions the doctor finds it awkward to deal with them. There may be patients suffering from hypochondria or who have a psychosomatic illness. The doctor—he or she—is at his wits end to know precisely what to do. It may be necessary for the FPC to be called in to deal with the problem. Here again, not hypothetically, I understand they do just that, and make arrangements whereby the FPCs think they satisfy the patient by transferring that patient to another GP, and they certainly satisfy the GP in that case.

I am sure that complaints of this kind, either from patients or GPs, are few and far between. Undoubtedly the work and activities of the family practitioner committees in this country vary considerably. If one looks at the overall picture—and I cannot pretend to have reviewed it completely—they seem to vary in an area both in quantity and in quality. They are related, or should be related, to the population of the area, but that is not always the case. I would certainly urge that if there is a national body—and I do not know whether one exists—serving the family practitioner committees themselves, it should endeavour to have some sort of standardisation in the work of the FPCs.

At this stage I think one could ask the question quite fairly, "What else could they do"? First, they would need an increase in funding which would probably mean more full-time members, which would enable them to carry out regular inspections of doctors' surgeries. Those of us who visit surgeries know that many are excellent; but in depressed and deprived areas they are anything but that. In South London I have seen what were obviously derelict shops with the windows painted over being used as doctors' surgeries. Heaven only knows what they are like inside! They may be all right; one does not know. However, one is put off by that sort of thing. We really must ask ourselves why these are necessary. Are the FPCs doing their job and visiting doctors' surgeries frequently?

It may not only be in deprived areas where surgeries are below standard. In some picturesque country villages it is only necessary for a doctor to visit the village two or three times a week. He has to use temporary accommodation which is the best he can find for the purpose; that could be a converted garage of some description. Surgeries are not always what they should be. I know of one example—and again this is not hypothetical—where there is no regular supply of hot water in that particular surgery, which is used only temporarily.

Another area in which the FPCs could take an interest is the post of doctors' receptionist. Are we satisfied that doctors have the number of receptionists which they require? Are there too many or too few? Is this not a matter that the FPCs can look at? Maybe they do. Can they not engage in some sort of training for doctors' receptionists? Receptionists vary as do all of us in whichever sphere we work. Some receptionists are kindness itself and are absolutely involved in the work they do to the extent that the patients regard them as someone to talk to as well as the doctor. On the other hand, there are receptionists who scare the living daylights out of the patient who is waiting to see the doctor.

We are told that some FPCs have modern computer details not only of doctors but of patients. That would be extremely helpful if generally used for the call and recall of patients for their periodic examinations and tests.

We can think of a number of other things which the FPCs could be doing. In some parts of the country doctors particularly will be aware of what are known as Well Women Clinics whereby once each year the lady patient—although feeling quite well—goes to such a clinic attended by a doctor and nurses to reassure herself that all is well in the area where one is usually concerned about what are known as women's complaints. This is a function which the FPC could take under their wing and insist that more are formed. There are a number of clinics and they do very well.

These are just a few thoughts of how the NHS and the Government can be used by the FPCs, and I hope that they will take on board these few suggestions.

4.16 p.m.

Baroness Faithfull

My Lords, I am grateful to the noble Lord, Lord Hunter, for providing this opportunity to bring before your Lordships' House the report Public Health in England. The term "public health" is defined in the report as, the science and art of preventing disease, prolonging life and promoting health through organised efforts of society". To this end on page 11, the report states: The discharge of the public health function in England today involves not only the activities of many different Government and non-Government agencies but a large number of different professional disciplines". Bearing in mind the definitions and aspirations contained in the report, perhaps I may deal first with the recommended structure for the future of public health. That has been referred to by my noble friend Lord Trafford and by the noble Lord, Lord Winstanley.

I have to confess that I look back with nostalgia to the days when, as a chief officer—a director of social services—I worked in the city of Oxford which was a unitary authority; that is, all services were within the orbit of the local authority. The chief officers under the chairmanship of the chief executive, met regularly. They included an absolutely outstanding medical officer of health who also worked in one of the hospitals and was therefore in close personal touch not only with the doctors, nurses and health visitors in the city but also with the education department, the housing department, the planning department and the social services department. Indeed, the medical officer of health planned the seven health centres in the city which has a population of 110,000. I can assure the noble Lord who has just spoken that the health centres, beautifully built—five of them purpose built—provide general practitioners with good conditions in which to work. The medical officer of health sent me the health centre plans for my comments.

By law the medical officer of health produced an annual report each year which was submitted to the local authority councillors and to the Department of Health. All departments of the local authority received a copy; they were outstanding reports. I often think that each department of the local authority should produce such a report. The medical officer's reports gave an awareness of the work and the public health needs of the city. It would be interesting to see the annual reports of a social services department alongside those of public health, particularly now that we have the Griffiths report.

With the reorganisation of local government and the health service, the role of the medical officer of health has disappeared. And, as often happens with reorganisations, there is left a gap. Every time I travel on the Underground and I hear a fearful voice saying, "Mind the gap", I think of the gap in various areas of our changed legislation.

No longer is there a co-ordinator, a promoter of education, in our public health service. The report offers as a remedy the appointment of a unit at central government level bringing together the relevant disciplines to monitor public health and suggests at local level the appointment of a regional director of public health whose duties are laid out on page 34. This would go some way towards alleviating the gap left by the abolition of the medical officer of health. But an appointment at regional level will not provide the close personal touch that existed with the medical officer of health.

As president of the National Children's Bureau and believing that children are the seed corn of the nation, I can point out some serious areas of concern in public health. There is serious lack of co-operation both at Ministry and at local authority levels affecting the health, lives and development of children. I shall quote various examples of social policies which are adversely affecting the lives of children. The points I propose to make have been brought before your Lordships' House on more than one occasion. Reports have been made and research work has been done: but still the problems continue. It is for that reason that I bring them forward yet again to your Lordships' House hoping that perhaps the recommendation in this report might go some way to alleviating them.

First, I would mention the appalling situation with regard to bed and breakfast housing accommodation. A scandalous state of affairs exists which is very expensive of public money. Not only is it not cost-effective; it is positively dangerous. In your Lordships' House there was a most notable doctor, the late Lord Stone. His son is a doctor working with families in bed and breakfast accommodation in Bayswater. As a doctor he is doing his best to alleviate the appalling conditions there. He has brought to the notice of local authorities and government departments the conditions in bed and breakfast accommodation—I cannot go over them as there is insufficient time—and has written a splendid booklet on the matter.

Also, there has been research done and a report made to the governors of the Thomas Coram Foundation for Children called A Survey of Families in Bed and Breakfast Hotels. That report lists the same complaints that are made by Dr. Stone. Health visitors and doctors say—it is a terrible thing but they have to say it—that, in effect, visiting those families from a medical point of view is a waste of time because it is not the health of the children which is at fault but the conditions under which those children live.

I make an appeal to the Government that someone should at last do something. I hope my noble friend the Minister will forgive me. I hope he does not say that it is not the department's business but the local authority's business. If that is so, the local authority must be helped. That is one social policy which the doctors and the nurses are up against.

Secondly, the education Bill is going through Parliament. I echo the point made by my noble friend Lady Masham that the curriculum for teaching home economics should include child development and health in the community. I learnt today that she intends to move an amendment; I have put down almost the same amendment. People should be responsible for their own health in their own communities in their own families. But if they have not been instructed and trained, they will not do so. That is a terrible gap in our services.

Thirdly, I would ask the Minister if any research has been done into the nutritional state of children following the abolition of school meals for a number of children. I wish that some of your Lordships could see children at lunchtime eating from bags of chips or peanuts. They are, I believe, getting good nutritional value, but it does not seem to be enough. Those children are not sitting down having a social life around a table. Surely that must have affected the health of many of our children.

I am the governor of two schools for maladjusted, emotionally disturbed children, and I have to say from personal experience that the disturbance of those children is increasing. It is more serious now than ever before. Why is that? Surely, there should be an investigation and some research made into that situation. It is very worrying that a number of social workers in child guidance clinics are being withdrawn. I hope that my noble friend the Minister will be able to comment.

There is a very serious situation with regard to school children working. It is the duty of the local education department to register any child who works and to ensure that the child has a medical examination. That is not happening. Many children in London schools are working long hours; they are unable to attend to their classes in schools; they are overtired.

An extremely good review has been undertaken in one school by Mrs. Elizabeth Clark, a trained nurse at the school who has a health education certificate from Croydon College. I am unable to go into the details of the report but I suggest that, from the public health point of view, there should be a study as to how many children are suffering as a result of working long hours in unsatisfactory conditions and for poor pay. The poor pay situation has been investigated by the Low Pay Unit.

It will be remembered that on 28th October there was a debate in your Lordships' House on Investing in the Future: Child Health 10 years after the Court Report, a report by the National Children's Bureau. There is no time for me to quote from that report but the noble Lord, Lord Lovell-Davis, said there was good evidence that children's needs had been given a lower priority over the last 10 years than previously. I do not think that that is something of which we can be proud. There were also some very interesting speeches about how children were losing out in the public health area.

Finally, I come to the Acheson Report. I have to say that where children are concerned it is most disappointing that very little mention is made of community care of children by paediatricians. That is not new. In December 1986, the Minister in another place, Mr. Newton, reported that the Committee on Public Health in England was being looked into by Sir Donald Acheson. In January 1987 the Social Services Committee in the House of Commons called on the Government to re-examine their proposals for child surveillance. Then, in 1987, the White Paper Promoting Better Health made Recommendations for keeping under surveillance children who have special needs and the relationships between doctors, health visitors, school nurses, education departments and the social services. Sadly, however, at page 68 of the recommendations in the Acheson Report, there is no mention of surveillance of children. It recommends making, arrangements for the surveillance, prevention, treatment and control of communicable disease", but says nothing about children. If we do not look after our children, we cannot expect a healthy nation.

My final point—I have taken just 14 minutes—concerns the chapter on the education and training of the proposed directors of public health. In Oxford, in a social services department, we reckoned to have doctors working there for at least a week so that they knew what went on in social services departments. If the Griffiths Report is to be successful and if we are to have good surveillance in the community of our children I suggest that these new people, whoever they may be—directors of public health at government or local authority level—must be trained in the social services and the social policies of the country. They must have a wider view than just that of medicine, important though that may be.

4.30 p.m.

Lord Auckland

My Lords, I join in the tributes that have already been paid to the noble Lord, Lord Hunter of Newington, who, by no means for the first time, has enabled your Lordships to debate an extremely important matter. Reports on the National Health Service as such—there have been many—are much less complicated, at least to my brain, than this report from a committee which was chaired by Sir Donald Acheson. Nevertheless, I think we should all pay tribute to him for enabling the first report on public health for many years to be available. According to my researches there is certainly no shortage of evidence; indeed, there are 10 pages devoted to distinguished bodies and individuals who have given evidence to the committee. Some 39 recommendations were made, which no doubt the Government will consider seriously.

Public health is basic. I wonder whether we in this country pay sufficient attention to the basic needs of hygiene. I believe every doctor's surgery should display a prominent notice about hygiene; for example, washing one's hands where necessary, and such matters. The most disturbing events at the Stanley Royd Hospital in Wakefield were mentioned by my noble friend Lady Masham: the report read like a horror story. One wonders whether enough attention is yet paid to hygiene in kitchens, not only in hospitals and other institutions but also in restaurants and hotels as a whole. Surely that is a basic priority. If there is a large outbreak of salmonella poisoning or a similar disease, the public health authority and its director of public health services have an enormous burden on their shoulders.

Moreover, I ask whether enough publicity is given to the need for innoculations (after all, they do not have to be given subcutaneously) to children and others against the dreaded diseases—they still are dreaded—of measles and whooping cough? One hears, or has heard, of the occasional tragedy due to the after-effects of those innoculations, but measles and whooping cough are still far too prevalent. I believe that if more children had those vaccinations there would be fewer conditions which lead to hearing and, indeed, sight defects.

The report itself is a complicated one. Conversely, it is well set out and has an attractive cover, which is more than some reports do; but I agree with the noble Lord, Lord Winstanley, about the number of hieroglyphics. Perhaps they are necessary but they do make the report difficult to follow. As I have already mentioned, public health is a much more complicated issue than the ordinary broad basics of the National Health Service.

Perhaps Members of your Lordships' House and, indeed, Members of the other place need a seminar or some sort of conference with visual aids to convince us of the great importance of public health and of this report. I believe that seminars, especially with visual aids, teach one far more than just an ordinary document. This is an aspect which my noble friend the Minister might perhaps bear in mind and pass on to the relevant department. Of course, one of the troubles with the present amount of parliamentary business is to find the time for such a seminar. However, I seriously believe that it would be valuable.

I make only one other point, because there are the winding-up speeches still to come. I refer to the value of international exchange. Recently there was a most valuable international seminar on the subject of AIDS. I know that some Members of your Lordships' House and also Members of the other place, met some of the delegates—health Ministers from 120 countries. It may well be that public health authorities should send their head of public health, or whatever title they may have, to a similar seminar. There is much to learn on the issue of public health, especially with the amount of international travel these days, from an exchange of views with various countries. That aspect is perhaps not completely germane, but such a report does lead people to put forward suggestions which may not be in the report itself.

We all have the year 1992 in mind, which will see the advent of complete absorption into the EC, and medicine and health services will play their part. That thought should perhaps be borne in mind in view of the amount of travel which takes place today. It is to be hoped that the Government will study the report carefully and that at least some of the 39 recommendations will come into force in the not too distant future.

4.38 p.m.

Lord Ennals

My Lords, first, I owe the House a small apology in that I missed part of the speeches of two noble Lords. However, that was only because of a small private illness rather than public health. Therefore, having made that small apology, I move on to the subject of public health.

We are all extremely grateful to the noble Lord, Lord Hunter, for choosing public health and the Acheson Report for what I believe will turn out to have been an important debate—indeed, it has already turned out to be important. The noble Lord always speaks with great authority and we expect of him the reasoned careful presentation that we had today. I agree with many of the points made about the report. I agree very much with the noble Lord, Lord Trafford, on the importance of public health and the danger of a degree of fragmentation. I agree with the noble Lord, Lord Winstanley, that the report is not the most exciting read. If I were to give it a book review, it would not be a very good one.

As to the contents, if one sets aside the irritations of constant repetition of initials, the fact that it lacks humanity and, as the noble Baroness, Lady Faithfull, said, that it does not deal in any way with community care, and considers rather the recommendations, they are of great importance.

I want to start with the statement that, although there may have been many great advances in the treatment of particular diseases and in surgery, which have wrought miracles for patients in the National Health Service, in fact we are socially a very sick society. The noble Baroness hinted at some of the sicknesses, and I want to look at a few others.

The Government—I shall be somewhat critical of them in this, but perhaps that would be expected of me—not only have refused properly to fund the National Health Service but have ignored growing evidence of health inequalities and have failed to attack the causes of ill-health. I agree very much with the noble Lord, Lord Winstanley, that when the Black Report was published shortly after I ceased to be Secretary of State, having established the committee that made the report, it was rubbished by my successor, now the noble Lord, Lord Jenkin of Roding, and it was thought that it could be put into the wastepaper basket because there were only 162 copies to put away. At a later stage, it was realised that this was an historic document. It has been part of the agenda for social and political debate in the 10 years since it was published.

A report published in June by the Royal College of Physicians says that Britain now has one of the worst health records among developed countries after having been a leader a generation ago. It says that Britain has the highest death rate from heart disease in the world. Expectation of life at age 45 is one of the worst in any developed country, with Scotland markedly worse. A man in Scotland aged 45 can expect to live 26.5 years compared with 28 years in England, 29 in France and 32 in Greece. A woman aged 42 can expect to live 32 more years in Scotland, 34 in England and 35 in France and Greece. There is no good reason for these statistics to prevail.

Perhaps more disturbing is the fact that infant mortality has fallen less in the United Kingdom than it has in most other European countries. Measles, which was referred to by the noble Lord, Lord Hunter of Newington, congenital rubella and whooping cough have been virtually wiped out elsewhere but not in Britain. The noble Lord is right to ask whether consideration should be given to legislation in this respect. The cervical cancer death rate has hardly changed in 15 years but has halved elsewhere in Europe.

Women get a particularly poor deal. Breast cancer claims 13,000 lives each year and 2,000 die from cervical cancer, yet 3,000 and 1,000 respectively could be saved by effective screening and treatment. Only 13 out of the 201 England and Wales health authorities operate computerised call and recall cervical schemes. That is simply not satisfactory. These facts have been researched and are known by the Secretary of State, yet little has been done about it.

Reference was made to diet. The United Kingdom leads the world table in coronary heart disease deaths with 180,000 deaths a year. Many of course are related to a poor diet. The diet of poor families in particular lacks adequate nutrients and fibre and has too much sugar, salt and saturated fats. Cuts in free school meals and the ending of nutritional standards are undermining children's nutrition. The Social Security Bill will take a further 500,000 free meals away from children. I find that deeply disturbing for the future health of the coming generation.

Bad housing means bad health, both physically and mentally. Badly insulated housing means fuel poverty and ill health in Britain. One and quarter million homes are unfit for human habitation. As to safety at work, some 750 workers die and 300,000 sustain serious injury as a result of occupational accidents. The cost to Britain's economy of accidents and occupational ill-health runs to £2,000 million a year.

I deal next with smoking. Tobacco kills almost 100,000 a year. Although adult smoking is on the decline, it is running at a high level among the young. I find that deeply disturbing. Eleven to 16-year-olds purchase over £70 million worth of cigarettes every year. We know that the people who are most likely to be regular smokers in adulthood are those who start as children. We know that those who start as children are more likely to come from families where parents smoke. Thirty per cent. of fifth-formers smoke regularly, on average 50 cigarettes a week. I arrived in Beijing about three weeks ago on the first world international non-smoking day. Knowing how heavily the Chinese smoke, I was fascinated to note that the place was virtually plastered with posters and neon signs urging people to stop smoking. I very much hope that our Government, who are so much against smoking, will encourage the World Health Organisation to proceed with a regular year-by-year international non-smoking day.

I turn to alcohol. We spend £35 million a day on alcohol; most is spent on moderate social drinking, but alcohol abuse is growing. Over 1,000 people a year are killed as a result of drunken driving. One can go on giving statistics about the dangers of alcohol. Professor Alwyn Smith, president of the faculty of community medicine at the Royal College of Physicians said recently: Britain was the leader in public health a generation ago. It has now lost that pre-eminence and the result is that we are falling behind our neighbours in … child health and immunisation, health promotion and prevention". I think that that is a wise and correct statement.

There is a responsibility upon the state. The Secretary of State, in Section 1(1) of the National Health Service Act 1977, is charged with a duty: to continue the promotion in England and Wales of a comprehensive health service designed to secure improvement—

1. (a) in the physical and mental health of the people of those countries, and
2. (b) in the prevention, diagnosis and treatment of illness".

Section 3(1), delegates to regional health authorities and, through them, district health authorities, and imposes a duty: to provide throughout England and Wales, to such extent as he considers necessary to meet all reasonable requirements … such facilities for the prevention of illness, the care of persons suffering from illness and the after-care of persons who have suffered from illness as he considers are appropriate as part of the health service". Although the Act does not use the term "public health", it is explicitly stated that the duty imposed upon the Secretary of State in Sections 1 and 3 of the Act includes responsibility for, among other things, the improvement of the physical and mental health of people by the prevention of illness. This carries the implication that the state of health of the population should be assessed and progressively monitored. There is therefore a major responsibility upon the Secretary of State. He is not just responsible for the National Health Service. He is directly responsible for the whole of public health.

I may be unpopular with some for saying this but there is at the present time a serious lack of leadership from the centre on precisely the issues we are talking about today. It may be that, in responding to the many recommendations made by Sir Donald Acheson, the Minister will move us forward into a more positive sense of leadership on the issues that have been raised here. Time will tell. However, I fear that on many issues we are awaiting some formal leadership from Her Majesty's Government.

Perhaps we should look at some of the reports that have been received. On the Wagner Report there has been no response from the Government. On the Firth Report there has been no response from the Government. There is also the Griffiths Report. I do not know how long we shall have to wait for a response to that, but there will be a debate in your Lordships' House on mental health on 18th May. Perhaps that will give the Government an opportunity to give a considered response. It is unsatisfactory that recommendations should be made while the Government sit silently and watch so many things getting worse. We are a sick society. Once we move down the track of sickness it is difficult to start building up again.

There was an interesting article in the Health Service Journal last week which dealt precisely with the problem of inadequate leadership. It stated: Although it is generally acknowledged that not everything can be done with available resources, ministers and civil servants have not taken it on themselves to offer clear and consistent guidance to health authorities on priorities for service development … Since Priorities for health and personal social services in England was published in I 976"— I pause to say that I was Secretary of State in 1976; I devoted an enormous amount of my time to the preparation of Priorities for health and personal social services in England, a document that attempted to give some leadership to health authorities and other bodies— there has been a progressive move away from identifying specific and achievable objectives for the NHS. This has resulted in health authorities being expected to pursue a wide range of policies regardless of whether they have the financial or managerial resources to do so. The clear impression has been created that there is no coherent vision or plan for the NHS at a national level". I would say for the health of the nation and not just for the NHS. Often from these Benches we have asked the Minister about this, that or the other, and the answer almost always has been, "Priorities are a matter for district or regional health authorities", as if the Secretary of State himself did not have a direct responsibility. He was just shuffling it off on to health authorities. That is not good enough. We are entitled to ask for some leadership.

The fundamental of this failure of leadership has been the Government's refusal to accept the principal conclusions of the Black Report—not just its recommendations but the principal philosophy on which it is based—that health is closely linked with poverty and with all those social conditions to which I referred at the beginning of my speech.

The review team chaired by Sir Donald Acheson considered that the public health responsibilities of district health authorities are so important that they require the identification of a single person to be responsible and accountable for the function on behalf of the DHA and the district general manager. I believe that this recommendation—that there should be appointed a director of public health—is an extremely important one. We would expect him to receive advice from the Secretary of State and, taking account of that advice, to be able to co-ordinate the policies that are carried out not only, as the report later says, by health authorities but by local authorities as well. It is important to bring together the roles in public health of health authorities and social services departments. I look forward to hearing what the Minister has to say in responding to that point.

In conclusion, I should like to congratulate the noble Lord, Lord Hunter, on introducing the debate and at the same time congratulate the chief medical officer on this important series of recommendations. Thirty-nine recommendations were made of which many have already been underlined. The report says that 31 can be implemented with no delay and 29 can be implemented at low or minimal cost. Therefore if in reply the Minister says, "If only there were resources the Government would be able to do this", I say to him that there are hardly any resource implications in the recommendations. I hope that we shall hear a positive response to them from the Minister.

4.56 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Skelmersdale)

My Lords, I too should like to congratulate the noble Lord, Lord Hunter of Newington, on initiating the debate and thank him on behalf of the Government for providing the House with an opportunity to debate this interesting report. Who better to introduce the debate than the noble Lord. Indeed, much of the committee's findings must have a familiar ring to him. He chaired a working party in the early 1970s which looked closely at community medicine in the reorganised health service. Reading his report I was struck by how similar its conclusions are to Public Health in England.

It is arguable that if health authorities had fully implemented the recommendations of that earlier report we would not be facing the problems regarding the specialty of community medicine that Public Health in England has highlighted. That is as may be. But times have changed. We must ensure that any proposals we adopt to solve the only too familiar problems are suitably adapted for the NHS in the late 1980s and beyond.

As the report makes clear, it is the first general review of the public health function since the Royal Sanitary Commission of 1871. Sir Donald Acheson's remit was so wide, and the weight of evidence so great, that it proved to be impossible for the committee to report within the timescale originally proposed. I am sure that the House will agree that the time taken has been fully justified. I should like to thank Sir Donald and his colleagues for the care and energy they have devoted to a most constructive and thought-provoking report. Seldom have I ended up with a list of so many questions in a short debate. From those questions it is clear that the report has generated wide interest among your Lordships. I am sure that it will influence developments in the vital field of public health services for a considerable period of time. Today's debate gives us a most welcome opportunity to hear the views of noble Lords and for them to be taken fully into account in the Government's consideration of the report.

If the noble Lord, Lord Ennals, thinks that I am going to go through the 30 or so recommendations of the report this evening, accepting this one, not accepting that one and accepting the other in part, I am afraid that he will be disappointed. The report was presented to the Government in January 1988. I have to come clean at the beginning and say that the Government have not yet made up their mind on the recommendations. The noble Lord shakes his head. Whether he expects me to be able to announce the Government's findings or decisions on the report I do not know. He gave me the impression in his speech just now that he does.

Lord Ennals

My Lords, I am most grateful to the Minister for giving way. Yes, I expected such an announcement. Although many of the issues were admittedly not put into the report (which was not seen by Ministers until four months ago) they are ones that have been discussed in the department for a number of years. Sir Donald Acheson did not start from scratch, so of course I expected in a debate about the report given to Ministers four months ago that we would have replies to the principal recommendations. I shall be disappointed if we do not.

Lord Skelmersdale

My Lords, in that case, the noble Lord will have to contain his soul in disappointment.

As I said, in 1972 the noble Lord, Lord Hunter, studied many of the matters discussed in the report. To that extent I accept the proposition of the noble Lord, Lord Ennals, that some of the matters contained in the report are not new. The noble Lord, Lord Hunter, did not however include communicable disease, and the Acheson Committee's report is a careful and detailed analysis of the extensive evidence which was presented to it across the whole field of public health. Well over 300 individuals and organisations submitted written or oral evidence to the inquiry.

My noble friend Lord Trafford and many other noble Lords pointed to the relationship which exists between public health and other government departments, whichever of them is responsible for the public health function at any period. I accept that the Acheson Report is only the latest in a long line of reports which have drawn attention to the interdependence of health and other services; for example, housing, education, social services and environmental services and of course the responsibility | which each one of us has for our own health. Again I agree with the noble Lord, Lord Ennals, that there is an interrelationship; but decisions on the composition of the Cabinet and the restructuring of the government machine are not for me. However, I shall pass on the many comments that have been made by your Lordships this afternoon.

With regard to that interrelationship, an example was produced by my noble friend Lady Faithful!, who raised the issue of children in bed and breakfast accommodation, which she sees as a public health responsibility, and especially a child health responsibility—and one which is neglected at that. I am most grateful to her for sending me the two reports about families in such accommodation. I shall read them with great care. As I understand it, they illustrate vividly the complex and varied problems of homeless families in inner London and the importance of a co-ordinated approach to resolve these problems. Of particular relevance to the debate is the way that they highlight the many agencies which have a role—local authority housing and social services departments, general practitioners and so on.

The importance of local authority public health responsibilities was emphasised in the report, as was the need for effective collaboration among the many agencies concerned. The report Public Health in England also drew specific attention to the director of public health's responsibility for assessing and advising on the comprehensive provision of preventive and surveillance services for children, which is especially relevant to some of the problems discussed in the reports on homelessness.

The department has also funded a four-district project looking at the organisation and management of child health services. It includes Riverside, where the problems of providing health services for a highly mobile population are well recognised.

One of the committee's first tasks was to agree a working definition which fully recognised the wide range of influences on public health. Its definition accepted the importance of lifestyle as well as those aspects of public health, such as sanitary hygiene and epidemic disease control, with which it is more commonly associated.

The committee fully recognised that the task of minimising, and where possible removing, injurious environmental, social and behavioural influences of all kinds is fundamental to public health and that this task is the shared responsibility of a wide variety of government departments. However, it also recognised that to investigate such an all-embracing concept would go far beyond its collective capacity or the time available for its work. So it concentrated on reviewing the relevant aspects of the work of those statutory agencies with major responsibilities for securing the health of the public; that is, it interpreted its remit as being concerned principally with arrangements within the current institutional framework to do three things: to improve the surveillance of the health of the population centrally and locally; to encourage policies which promote and maintain health; and to ensure the means are available to evaluate existing health services.

A number of points emerged in the evidence given to the committee. The most important of these was a lack of co-ordinated information on which to base policy decisions about the health of the population at national and local levels. In its view this has led to: a lack of emphasis on the promotion of health and healthy living and the prevention of disease; widespread confusion about the role and responsibilities of public health doctors both within the NHS itself and among the public, to which I referred earlier; confusion about responsibility for the control of communicable disease and poor communication between the agencies involved, in particular widespread dissatisfaction with the position of the medical officer of environmental health, to which the noble Lord, Lord Hunter, drew attention; weakness in the capacity of health authorities to evaluate the outcome of their activities and therefore to make informed choices between competing priorities; and, lastly, wide support for the need for a well trained, medically qualified public health specialist as a key figure in the health service.

"Bring back the medical officer of health", says my noble friend Lord Trafford. We shall have to consider whether, and, if so to what extent, it is possible to turn back the clock and resurrect a post set up to co-ordinate public health functions in the last century. I should remind my noble friend that local authorities were much more involved in the health scene at that time than they are now. The committee has recommended however that the function of the medical officer of health is: To inform himself as far as practicable respecting all matters affecting or likely to affect public health", to quote from an Act of the last century, and to advise his employing authority by preparing an annual report which should be incorporated into the responsibilities of the individual that the committee calls the director of public health, who would also take on a number of other public health functions more suited to the health service in the late 20th century.

The committee adopted a number of key principles which underpinned the recommendations it made. These include: clarifying the nature of the public health responsibilities of health authorities and making named individuals accountable for the discharge of these functions within the framework of general managements; improving the means whereby objectives and targets for health are set; and stressing the need for collaboration for health among central and local government, the voluntary sector, industry, the media, the private sector and the individual, but particularly among the triumvirate of agencies at local level—health authorities, local authorities and family practitioner committees.

In his inimitable way, the noble Lord, Lord Winstanley, put his finger on a major problem, which is how to find who is responsible for public health. We acknowledge that problem. One of the main principles behind the report's recommendations was that health authorities should identify named individuals who would be personally accountable for performing carefully defined functions.

The question of the evaluation and measurement of the outcome of the public health function, or indeed any health function, is exercised sometimes directly and sometimes indirectly—I can tell the noble Lord, Lord Ennals—by the Secretary of State of the day, and is a situation incidentally which has not changed in the period between the noble Lord's distinguished tenure of that office and that of my noble friend today. The emphasis given by my noble friend Lord Trafford and the noble Baroness Lady Masham to the importance of a scientific base for the input of the public health medicine, the development of health indicators and the growing importance of health targets are of course of great interest to this Government at the moment. I rather wonder why nobody else has had the idea of my right honourable friend the Secretary of State to set up a health index so that we can identify where there are gaps or a lower quality of service delivered in various areas of the country. I should have thought that this was essential.

I agree with both my noble friend and the noble Baroness that there is a desperate need to quantify health in this country. I anticipate such a unit as the report suggests, namely a central unit within the department, to facilitate and improve the monitoring of the nation's health. I see that unit doing just such a job.

The recommendations are designed to secure the better discharge of public health functions mainly but not exclusively by health authorities, local authorities and by family practitioner committees. To crystallise this higher level of functioning the report recommends a change in the style of community medicine to public health medicine. There are early indications that this change is going to be taken up by the professions. The report recommends that both regions and district health authorities appoint directors of public health and I gather in some places this recommendation is already being put into effect. The director of public health would, as I understand it, become a source of medical advice not just to health authorities but also to local authorities and family practitioner committees.

Another key recommendation is that authorities should publish an annual report in which the director of public health would report on the health of their population. This would be drawn up after consultation with family practitioner committees and other relevant local bodies. The report's training and manpower recommendations follow on from these main recommendations affecting the way in which the public health function is discharged. Those which deal with the control of communicable diseases are important to pursue because of the need to ensure that everything is done to deal quickly and effectively with outbreaks when they occur and the need to prevent them taking place wherever possible.

In a speech which I found most interesting and very wide-ranging, the noble Lord, Lord Hunter, asked me a vast array of questions. I should like to take up straight away the point about smoking. The risks associated with smoking in pregnancy were once again highlighted in the recent fourth report of the Independent Scientific Committee on Smoking and Health. We are considering the recommendations it made. It is clearly important that pregnant women should be aware of the risks. Indeed cigarette packets have carried the specific warning since 1986: Smoking when pregnant can injure your baby and cause premature birth". The House will know however that it has never been a principle of the National Health Service that people should be assessed and charged according to the extent to which they contribute to their own ill-health. There are many illnesses, not just smoking-related ones, which are connected at least in part with people's lifestyles. Our aim must be to try to prevent ill-health by making people aware of habits which they should avoid and the positive actions that they can take such as having a better diet. This emphasis on prevention is the key to the Government's approach.

There are three major causes of ill-health. In heart disease the number one cause is diet, followed by smoking and lack of exercise. As far as cancer is concerned, the order is reversed somewhat, and the No. 1 evil is smoking followed by inappropriate diet, followed, as the noble Baroness, Lady Masham, will know well, by excessive consumption of alcohol. I find it particularly interesting and not a little disturbing that the amount that the public is prepared to spend on alcohol almost exactly equals the amount that the country currently spends on the National Health Service as a whole.

Several noble Lords mentioned family practitioner committees. The noble Lord, Lord Hunter, asked whether they should be re-amalgamated with district health authorities. In our White Paper on the Government's programme for improving primary care, which all noble Lords from their speeches have clearly read, we responded to the recommendation made last year by the Select Committee on Social Services in Primary Care that family practitioner committees should be re-amalgamated with district health authorities. We concluded that this was not the time for further major organisational change.

The separation has given the family practitioner services a stronger voice in the National Health Service overall and the FPCs are taking an increasingly active part in the planning and development of services in their areas. Our hope now is to build on that and to extend their management role as a means of securing improvements in primary care services.

I can tell the noble Lord, Lord Aylestone, that part of the trouble is that FPCs rather hide their light under a bushel. I can advise him that they systematically inspect doctors' surgeries. The department has recently issued guidelines on general practitioner premises. Furthermore, paragraph 3.5, I think it is, of the White Paper on Primary Health Care says that the Government will also review minimum standards. FPCs will continue to be responsible for the inspection of premises and will be required to apply sanctions more stringently than before in respect of inadequate premises.

As regards the remarks of the noble Lord, Lord Aylestone, I suggest that a friendly and effective receptionist is an important member of the practice team. Very often the receptionist is in the first line for complaints rather than the GP or the dentist. The Government's review of the complaints procedure will make it easier for patients to make complaints where that is appropriate. I am sure that the whole House would agree with that as a point of view.

This brings me very neatly to the role of general practitioners. The Government's White Paper on Primary Health Care again contains proposals on important changes in the GP's contract which would have the aim of increasing their role in prevention. Clearly this is an area of great potential for preventing disease and promoting good health.

The noble Lord, Lord Pitt, pointed out that it is only the general practitioner who sees people from life to death. That is not always so. I was told recently by a family practitioner committee that a doctor had not seen a particular patient for over 20 years. I should therefore say that with computerisation the general practitioner is the only person who is in with a chance. Therefore, computers and computer-aided general practitioners are the essential first link in what will be a very long chain if the report's major recommendations are accepted.

However, the noble Lord is quite right. In spite of the rude remarks which many of your Lordships have made about it, the Acheson Report leaves us in no doubt about the need to acknowledge the role of the general practitioner. It envisages the work of a director of public health as drawing on information provided by family practitioner committees. Clearly general practitioners, as both the White Paper and the report say, have a major role in prevention.

The report concentrates its attention on how health authority responsibilities for public health could be emphasised and clarified, but repeatedly emphasises the role of the many other agencies and individuals who make important contributions to public health, not least general practitioners. For this reason, it also stresses the importance of collaboration between health authorities and family practitioner committees on public health issues.

Should general practitioners do more AIDS counselling? With the development of care in the community it is clear that general practitioners will play an increasingly important role in the care and treatment of people with AIDS and HIV infection, not only in providing the necessary treatment during periods of symptomatic illness and liaising with other professionals and groups involved but also in providing counselling and support. We have recognised the importance of GPs by funding counselling training courses, a course in the clinical management of people with AIDS and part-time training services for general practitioners to work under the supervision of hospital specialists.

The noble Lord, Lord Hunter of Newington, is of course quite right. At the moment only a change in personal behaviour will reduce the spread of this incurable disease and certainly there is opportunity for general practitioners to influence personal behaviour. Gaining accurate information on the extent and the speed of spread of HIV infection is clearly also very important. An expert group under the Director of the Public Health Laboratory Service has been reviewing the current surveillance arrangements. The group's report will be published shortly.

I was very pleased that my noble friend Lord Auckland felt able to comment favourably on the Government's international activities in the field of AIDS. The House will be interested to know that my right honourable friend the Secretary of State will be continuing this theme in Geneva next week.

Many noble Lords spoke about immunisation. The House will know that in 1985 we asked health authorities to set progressive uptake targets for all major childhood immunisations and to designate one person to be accountable for performance in this field within the health authority system. These people are called immunisation co-ordinators. So important is this subject seen to be in district health authorities that at a recent meeting in London that I addressed over 80 per cent. of a possible 191 designated officers attended. I was told that this was extremely unusual in such a meeting where it would be good going to get 60 per cent. of representatives from district health authorities countrywide to attend.

We have no plans to introduce compulsory immunisation in this country or to make it a condition of school entry. Indeed there is some evidence now emerging from the United States that compulsion of this kind does not necessarily lead to a universally high uptake. Health authorities in this country are already aware that no opportunity should be missed to immunise a child against infectious diseases. But equally we do not yet believe in compulsory immunisation. It has never been compulsory in the United Kingdom except for a very brief period for smallpox in 1949 and there is no present intention to change this.

I think that it would be right to move on very rapidly to meningitis and to the question of the noble Baroness, Lady Masham of Ilton. I confirm that there has been an upsurge since 1984 similar to the one in the 1970s. In 1987 notifications in England and Wales reached 1,090. I could go on but I think that it might perhaps be appropriate if I wrote to the noble Baroness.

I mentioned earlier the interest of my noble friend Lady Faithfull in children. Again I think that I should write to her on this matter, but I wish to comment on the overall effects of the new social security arrangements, which are clearly still misunderstood. Before 11th April about 210,000 children in families receiving family income support actually took free meals and a further 340,000 took them under local education authority discretionary schemes. The Government estimate that cash help in the form of family credit will reach around 650,000 children of school age so the new arrangements will benefit around 100,000 more children. It is too early to say how these arrangements are affecting children's diet, but of course as with the other forms of social security we shall be watching this.

In considering the report's recommendations our aim must be to ensure that any changes we implement and any new mechanisms we set up are appropriate and workable. We should not wish to make matters worse by making quick decisions recommending solutions that will not work in practice. We are considering the report with the urgency noted by my right honourable friend the Secretary of State in announcing publication in January. Our intention remains to make a statement on implementation in the near future.

I know that that will disappoint some of your Lordships. The noble Lord, Lord Ennals, has made it quite clear that it disappoints him, but as I said it is only four months since we received the report. There is much more in it than in the previous reports, and we shall need to look at its reaction on other proposals that we shall be bringing forward for the health service as a whole.

5.25 p.m.

Lord Hunter of Newington

My Lords, we have had a good debate. I wish to thank all noble Lords who have taken part in it. I beg leave to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.