HL Deb 08 July 1992 vol 538 cc1183-98

6.8 p.m.

Baroness Cumberlege

My Lords, with the leave of the House, I shall now repeat a Statement which is being made in another place by my right honourable friend the Secretary of State for Health on The Health of the Nation. The Statement is as follows: "With permission, Madam Speaker, I should like to make a Statement about better health.

"I am publishing today a White Paper The Health of the Nation. Copies have been placed in the Vote Office. Last June my right honourable friend, now the Chancellor of the Duchy of Lancaster, published a Green Paper on the same subject. Since then we have consulted extensively.

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

"The Government are committed to improving the health of the nation. The White Paper is the latest—but not the last —step in our strategy.

"The response to the Green Paper was impressive. More than 2,100 individuals and organisations responded directly. There has been a wide and productive debate—at specially organised conferences and workshops, in newspapers and journals, and on television and radio.

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

"We wish to build on this healthy trend. No responsible government can be a disinterested observer of an unhealthy nation. There is an enormous cost to both the National Health Service and to our economy of avoidable illness. The cost includes working days lost and expensive treatment given. We should prevent illness wherever we can. Prevention is better than cure. We will be able to target health resources where they are really needed.

"We are spending record amounts on the National Health Service. We must use these resources to improve health as well as health care. We are seeking to improve the quality of life—and of individuals' lives—in the most cost-effective way.

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

"At the heart of the White Paper is the setting of targets in key areas. We have selected five areas.

They are coronary heart disease and stroke, cancers, mental illness, HIV/AIDS and sexual health, and accidents.

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

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

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

"In other areas more development and research will be needed before national targets can be set. What we are proposing are not short-term measures. The strategy will grow and develop. To provide the knowledge and methodology for that to happen the research and development strategy launched by my department in April 1991 will play a crucial role.

"The White Paper identifies other possible target areas for the future. That underlines the fact that it represents a beginning, not an end.

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

"We need targets for three reasons. They give us something real at which to aim. They provide a common focus for action. They allow us to measure progress.

"To be respected, targets have to be tough. To be credible they have to be realistic. It would be folly to set a target so far out of reach that we will never get there, or one which is simply the extrapolation of existing trends.

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

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

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

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

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

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

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

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

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

My Lords, that concludes the Statement.

6.18 p.m.

Lord Carter

My Lords, I should like to begin my remarks by thanking the Minister for repeating the Statement which was made earlier in another place. Obviously we all welcome anything which improves the health of the nation. I should like to say at once that the setting of targets is an excellent idea and we welcome the clear focus in the White Paper on preventable diseases, reproductive health, mental health and accidents.

Perhaps I may first deal with the targets. Can the Minister say how the targets were arrived at? Was it on the basis of a clinical analysis, medical forecasts or estimates of acceptable cost? As for coronary heart disease, the aim of the "Look After Your Heart" programme strategy produced in 1990 by the Department of Health and the Health Education Authority was a 25 per cent. reduction in premature deaths from coronary heart disease by the year 2000. The Green Paper published last June suggested a target of a 30 per cent. reduction and the White Paper now has a target of a 40 per cent. reduction.

We welcome that increase in the target which presumably resulted from the consultation process. The strategy document for "Look After Your Heart" estimated that cigarette smoking accounts for at least one-fifth of deaths from heart disease and that 80 per cent. of heart attacks in men under 45 years of age are thought to be due to smoking. The cigarette smoker faces two to three times the risk of having a heart attack than a non-smoker. The BMA points out that 450 of our children start to smoke each day. Despite all that—and this is the great disappointment of the White Paper—the Government still refuse to introduce a ban on tobacco advertising. The Minister said that 2,100 individuals and organisations were consulted. How many of them supported the Government's views on tobacco advertising? I am sure that it is no more than an unfortunate coincidence that a major tobacco company made 2,000 of its poster sites available to the Conservative Party in the general election. If further evidence is produced—if, indeed, any more is needed—to show that a ban on tobacco advertising would reduce smoking, will the Government introduce such a ban?

The biggest omission in the Statement and the White Paper is the reluctance to recognise and admit the crucial link between health and social conditions.

We all know that poverty, bad housing and low incomes are major factors contributing to the poor health of large sections of the population. Do the Government accept that there is a link between those factors and the health of individuals? The Minister will find the statistical evidence for such a link in Appendix F paragraph 16 of the White Paper.

I turn now to AIDS and sexual health. We all of course welcome any initiative which will improve sexual health. The Minister mentioned in the Statement the importance of research. It is a truism that no one dies of AIDS but that death comes as the result of a variety of infections to which the AIDS sufferer succumbs. Vast sums of money have gone and are going into finding a cure for AIDS but there is little research into the treatment and the management of the conditions which may cause the death of those with AIDS. Will the Minister comment upon that disparity in the research?

There is a conflict throughout the White Paper between diagnosis and prescription. Paragraph 23 of the Statement states: The White Paper demonstrates the Government's commitment by … setting out a range of actions to improve health which only government can take". That of course is correct. The White paper contains a proper emphasis on a healthier diet. Will the Government now reintroduce nutritional standards for school meals, which they scrapped? Paragraph 15 of the Statement states: Our task was to choose areas of greatest concern: where there is the most serious avoidable loss of life". The White Paper refers also to targets for the reduction of alcohol consumption. Does that mean that the Government now accept the case for random breath testing? Paragraph 8 of the Statement states: We should prevent illness wherever we can. Prevention is better than cure". We obviously all agree that people should be encouraged to keep a check on their health. Will the Government now scrap charges for eye tests? The rise in teenage pregnancies is obviously worrying. Will the Government now restore the cuts in funding which have led one health authority in four to cut their family planning sessions in the past six years, some by as much as half?

As I have said, the diagnosis contained in the White Paper is good. We can all welcome the setting of targets, the proposal for a powerful Cabinet Committee and the emphasis placed on healthier living throughout the White Paper; but, as I have said, I fear that in many areas the prescription is in direct conflict with many government decisions affecting health which have been taken in recent years. We all hope that the White Paper demonstrates a change of heart by the Government. It sets out some clear objectives. We all hope that those objectives will be achieved.

Lord Winstanley

My Lords, on behalf of my noble friends on these Benches, I must hasten to join the noble Lord, Lord Carter, in thanking the Minister for repeating the important and interesting Statement. Perhaps I may also thank her for giving us so much homework. Even the summary runs to 34 pages, and therefore we are provided with enough interesting reading material to keep us all busy until the long Recess is over. I look forward to studying it with the care that it clearly deserves.

Let me say at once that I agree with every word of the Statement. Having said that, I must also say that that is not saying much because most of what it says has been well known in the medical profession and outside it for many years. The White Paper inevitably consists of many platitudes and truisms, but what is helpful is that it collects in one place all the evidence which shows clearly how true the truisms are so that it is readily available to us all. That is of help to those of us involved in health education should we need to argue and discuss these matters with people who are not as ready to accept them as we are.

As I say, most of these things are known. Some years ago I had the honour to be invited by what was then the Health Education Council to edit a book on its behalf. Noble Lords will be aware that when one is invited to edit a book, that really means that one has been invited to write the book. One consults a great many people who help but one finishes up writing it. The book was called A Guide to Better Health. If I were to look back at it I should find that many of the things it said are now repeated in the White Paper. There is nothing wrong with that. The White Paper provides all sorts of evidence. The book was circulated widely but, frankly, I doubt whether it had much effect. Everyone agreed with it. Everyone already knew what was necessary. The problem then was—it still is—how to persuade people to heed the advice which everyone knows is wise.

What do we learn from experience? It was Bernard Shaw who said that the only thing we learnt from experience was that we never learnt anything from experience. During my lifetime there has been one period during which there has been a remarkable improvement in public health. That was during the latter years of the Second World War when everyone led a healthy life. No one could eat too much of the wrong food because they could not obtain it. They could eat enough of the right food because they could obtain it: we had rationing. We took plenty of exercise because we had no petrol. No one but a lunatic would recommend a third world war as a remedy for the present state of public health, but that underlines a real problem: how do we persuade people to heed the advice?

I join with the noble Lord, Lord Carter, in saying how right the Government are to set targets and to have specific aims —aims which are capable of fulfilment. In many ways your Lordships' House shows the way ahead. The fact that so many noble Lords appear to live for ever is not due to the fact that they have healthy lifestyles. I would say that the reverse is true. What is true is that noble Lords had healthy lifestyles when they were children. They had good diets; they lived in good housing; and they took plenty of exercise. One was made to take plenty of exercise. I am all for that, but the most important part of targeting is that the Government should as far as possible focus their efforts on youth. That is the time when people can develop sensible, healthy eating habits and take exercise.

By the time people reach our age it is too late. The one way to get rid of smoking—I am all for banning advertisements—is to ensure that people never start. Once one is faced with nicotine addicts, which is what such people are, it is difficult to get rid of the habit. We get rid of them because they pass away in the fullness of time. But the fact remains that it would be infinitely better if people never started smoking. We are not having much success in preventing children from starting to smoke, which is what we must do. I hope that these commendable efforts will as far as possible be directed at youth, because that is where the hope lies. We must persuade young people to take plenty of exercise, to eat plenty of the right food and not too much of the wrong food, and so on. If they follow all those simple rules which are set out in the White Paper, the battle will be half won.

There are many aspects to this subject. I do not want to comment upon them in detail. AIDS was mentioned, and that issue was taken up by the noble Lord, Lord Carter. The White Paper, which summarises much information, refers to the way in which we have conquered pulmonary tuberculosis. At the start of this century pulmonary tuberculosis was the main cause of death; it was known as the "captain of the army of death". Now it has virtually disappeared. What caused that? Two things: first, a vast improvement in housing, sanitation and such things; secondly, the development of chemotherapy. Once cases were under treatment, they ceased to be infective.

I have supported everything that the present Government have done so far on AIDS. They have taken the right steps. But the real hope lies in the discovery of a therapeutic agent which, once the patient is on it, renders that patient non-infective to other people. That is where results will come.

Epidemiology is not an exact science. We constantly hear of exceptions and I can remember an old man who reached the age of 100. He was asked, in an interview on television, to what he attributed his age and he replied, "I've no idea". Looking back, the only thing he could think of was that he could not remember ever having taken any exercise.

We cannot argue from the particular to the general. Noble Lords will remember Lord Shinwell who reached the age of 100. After his presentation, during Question Time in your Lordships' House which dealt with the sponsorship of tobacco, he said, "I have been a regular smoker since 1894". We cannot argue from the particular to the general; we must take the kind of evidence which is well summarised in the White Paper and learn the lessons which we have all known for a long time. Somehow we must get people to follow the advice which we all know is right.

I am glad that at long last the Government have recognised that it is not just a matter for the National Health Service or the Department of Health, but for every government department. Accepting that, and accepting the importance of housing and other matters, it seems to me that the Government have at last learnt all the lessons so carefully underlined in the Black Report on health and the disadvantaged. At long last, it is clearly accepted in the White Paper that, unless we do something to improve people's living standards in all kinds of ways, we shall not be able to answer all these questions.

The noble Lord, Lord Carter, mentioned school meals. They are important. At the moment far too many children suffer from malnutrition of one kind or another. I regret the disappearance of universal school meals; I did not awfully enjoy them, but in many ways we received the nutrition we needed. I risk the wrath of some of my professional colleagues by saying that I regret that school milk disappeared. I know that many doctors are suspicious of milk; they think that every bottle should carry a government health warning. However, I believe that for young children milk is an important and useful source of nutrition, calcium, vitamins and other nutrients. The cost of restoring school milk to state primary schools is small. I put down a Question on this and the Answer showed that it was minuscule. I believe that the results would be helpful. One matter which we must tackle is youth.

I am so glad that the Government have finally agreed that the subject of health covers all government departments, including local government. The targets that the Government have set are wise. Some of us may last long enough to see whether they will be reached because they continue until the year 2010. Some of us will still be around then. The setting of these targets gives us all an opportunity to monitor progress and to see whether we are succeeding. We have succeeded in meeting many targets in the past, as the White Paper illustrates, and we can succeed in meeting these targets in the future if people will speak for themselves—not just doctors and health departments, but the public as a whole. We must get them to follow the excellent advice set out in the White Paper.

6.36 p.m.

Baroness Cumberlege

My Lords, first, I warmly thank the noble Lords, Lord Carter and Lord Winstanley, for the support which the strategy has received. It has received a welcome throughout the country, from within the National Health Service and, as I said in the Statement, from within the World Health Organisation which cites this strategy as an example for other countries to follow.

The noble Lord, Lord Carter, asked why we should have these particular targets. Three criteria were set out in the Green Paper, The Health of the Nation. The first was that the area should be a major cause of premature death or avoidable ill health; where there was major concern, that area was included. The second was where we knew we could have effective interventions, offering significant scope for improvement in health. The third was where it was possible to set objectives and targets, and monitor progress towards them.

During the consultation period, we received a great deal of advice and help, and much research took place. As a result, not only were some of the targets stiffened, but also mental illness, which had previously not been included in the Green Paper, was included. I know that many people and organisations in the country and those involved in the mental health field will be pleased about that.

The noble Lord, Lord Carter, cited how targets had been increased for coronary heart disease, starting with the target of 25 per cent. for the year 2000, progressing towards the 40 per cent. target in the White Paper. It is a challenging target. The 30 per cent. in the Green Paper did not prove to be challenging enough for those in the field. They felt that as a nation we could do better than that. That is why the target has been increased.

The noble Lord raised the issue of smoking and I know that a body of opinion in this country feels that the advertising of tobacco should be banned. Clearly that is something which the Government have considered, but they believe strongly that the decision to stop smoking is a matter for individual choice. The Government's role is to ensure that that choice is exercised on an informed basis, knowing the risks.

Many tools can be used in order to reduce the consumption of tobacco. The price of products is a powerful tool. We know that the real price of tobacco has risen by 43 per cent. over the past 12 years, whereas it increased by only 1 per cent. under the Labour Government. Today a packet of cigarettes costs more in the UK than in any other EC country except Denmark. We know that this policy is effective. We have markedly reduced the consumption of tobacco, which has fallen by one-third over the past 16 years. Our target is to reduce that further by one-third by the year 2000, again a challenging target which we shall set out not only to meet but to beat.

The noble Lord also went on to ask about the links between poverty, housing and health. There can be no doubt that these issues have an effect on health. But the Government have done much in recent years to ensure that the resources available to low income families are increased.

These targets are not aimed purely at areas of deprivation; they go across the board, and we believe that to be right. We know that in inner city areas general practitioners are meeting the targets which have been set for them and which were included in the GP contract. We believe that, with the new management systems we have introduced and that have come through the reforms, we are now much better able to target our resources to ensure that inner city areas become as healthy as other areas.

On the subject of school meals, the strategy ensures that in the future we work closely with other organisations. We do not see this purely as a National Health Service issue. We shall want to work with local authorities in their efforts to ensure that school meals are more nutritious, and that the children eat them. The noble Lord, Lord Winstanley, made the pertinent remark that he did not awfully enjoy them. We know that in the past many school meals were not eaten. But today, with a different style of catering in schools, the cafeteria style where children can choose, the food is eaten.

The charges for eye tests and for some of the national health services that are provided produce a considerable income for the NHS. Free eye tests for the country would cost us another £100 million a year. It seems to me correct that those who can afford these charges should pay them, but of course we know that as many as 40 per cent. are exempt from the charges.

The sum of £206 million accrues to the National Health Service from charging for prescriptions. That equates to 9,000 community nurses for a year or 228,000 surgical operations. However, 80 per cent. of all NHS items are exempt from charges. Again, it seems appropriate to me that those who can afford to pay should contribute to the National Health Service.

Finally, I know that there has been concern about the number of family planning clinics that have been reorganised during the past few years. The figure of £100 million is spent on family planning services, and in 1991–92 the Government gave £750,000 to voluntary organisations such as the Family Planning Association. Regional health authorities are reviewing these services and we have made it a priority for the current year that the whole shape of family planning should change. We know now that two out of three women go to a GP for family planning advice. We would want to keep clinics, as they offer a comprehensive service. However, it is important to give choice to women either to use the GP services which we have built up over the years or to use family planning services.

I should like now to take up a few of the points which were made by the noble Lord, Lord Winstanley. I agree that this is not a revolutionary document but it is the first time that we have had a comprehensive strategy with defined targets. It is the first time that the Government have made a commitment across all departments. It is the first time that we have had a Cabinet sub-committee in order to ensure that these targets are monitored and met. It is the first time that we have had a structure and a system that we know can deliver these targets. Therefore from that point of view this is revolutionary.

The noble Lord referred to lifestyles and I certainly would not want to comment on the lifestyles of noble Peers, but I do take the point about the emphasis being laid on youth. Of course in the past, and again at the present time, we are putting more effort into vaccination and immunisation to ensure that we have healthy children who will grow into healthy adults.

We have also targeted specifically in this strategy teenage pregnancies and we have set a target to reduce smoking among the 11–15 year-olds by at least 33 per cent. by 1994. We have set very challenging targets —targets that we expect not only to meet but also to beat.

6.45 p.m.

Lord Boyd-Carpenter

My Lords, first may I thank my noble friend for repeating this very important and far-reaching Statement, to which I think the whole House has listened with the very greatest of interest. May I add that it seemed to do a very effective demolition job on the propaganda which, until recently, used to emerge from certain quarters to the effect that the Government were not interested in questions of health and were indeed damaging the National Health Service. The Statement makes very clear the importance that the Government attach to the National Health Service and to questions of national health. Therefore it was very valuable from that point of view.

The effectiveness of the policy seems to be borne out by the figures given by my noble friend for the improved expectation of life. I was very interested to see that the increase in expectation of life has been more for men than for women, but I take it that that is against the background that a woman's expectation of life has been, and still is, rather longer than a man's. Therefore all it amounted to was a reduction in the difference between the two rather than in any victory for the male. Perhaps she could confirm that.

On smoking, I personally very much agreed with the noble Lord opposite when he said that it would be right to ban the advertising of smoking. My noble friend said that people should be left to make up their own minds. Of course that is true, but the making up of one's mind is often very much affected by the advertisements that one reads. Therefore it seems a pity that a practice which does so much injury, and such increasing injury, to health should be able to be advertised, often in most seductive terms, all over the place. I hope that the Government will give some further thought to this, as the view expressed by the noble Lord opposite is very widely shared. At the same time I hope that the Government will consider the suggestion I made a little while ago, that one of the ways of checking the growth of smoking is by a very substantial increase in the tax. Higher taxation, which would make tobacco more expensive, must work in the right direction.

Finally, perhaps I may ask my noble friend one further question. Can she add to what she said about the policy in the White Paper of dealing with AIDS?

Lord Houghton of Sowerby

My Lords, is there not a Standing Order about the length of debates following a Statement? Who is going to protect the next Business? Some of us are waiting for the next debate to start.

Baroness Trumpington

My Lords, I think that my noble friend should continue.

Baroness Cumberlege

My Lords, I should like to thank my noble friend Lord Boyd-Carpenter very much for those comments. He is correct in his assumption that the expectation of life is greater for women than for men, but this is not perhaps a victory for men but rather a victory for both genders, in that both are now living longer.

With regard to reviewing the advertising ban on cigarette smoking, I should like to say that we have proved to be successful in this. Without a ban, our success is the greatest in Europe, except for the Netherlands. We know that our present policy works and is achieving results. But, having said that, a review is going on in regard to the question of advertising, especially with regard to children and smoking.

Lord Stoddart of Swindon

My Lords, I was wondering whether the professionals wished to say something—

Baroness Trumpington

My Lords, would the noble Lord kindly be as quick as he can? We have spent some time on this already.

Lord Stoddart of Swindon

My Lords, we do have 20 minutes for Back-Bench contributions under the Standing Orders, so that we have 16 minutes left. I appreciate that people want to get on with the next business, but at the moment we are on this business. I wish to make a contribution and I am going to make that contribution.

In regard to the Statement, of course everybody believes in prevention, and indeed I do myself. However, we must be extremely careful that obsession with health itself does not lead to a national neurosis. We are coming to a situation where we see in one newspaper that something is bad for you; yet a few days later we see that it has been agreed that the same thing is good for you. Therefore, it is necessary to ensure that people have the right information and are not bombarded with statistics which are sometimes contradictory.

For example, I have read statistics about cholesterol. I am told in one article by a renowned medical person that cholesterol is good for you. On the other hand, another eminent physician tells me that cholesterol is bad for you. One day we are told that butter is good for you and the next we are told it is bad for you.

No, I shall not stand heckling from my noble friend, Lord Cocks. I shall make my points and ask my question. The sooner he behaves himself, the better I shall be able to get on with what I have to say.

I turn to the banning of tobacco advertising. The noble Baroness who read the Statement will be aware that there are several opinions on the subject. Some people, indeed some authorities, believe that banning tobacco advertising increases the rate of smoking. If we ban tobacco advertising in this country we also ban the health warnings which appear on the tobacco advertising. Tobacco advertising is so sophisticated these days that almost all one sees is the message that smoking kills, smoking causes heart disease or smoking causes cancer. There are two points of view and the Government are right to give proper consideration to the matter before introducing a ban on tobacco advertising.

Finally, I want to refer to HIV and AIDS. While I appreciate that the Government must inform the general public about the dangers of AIDS and HIV, believe that they are not doing their duty in that they do not target high risk groups. I sincerely hope that they will do just that and ensure that the public are properly informed about that dread disease.

Baroness Cumberlege

My Lords, perhaps I may deal first with the point made by the noble Lord, Lord Stoddart of Swindon, concerning conflicting advice. I agree that where there is conflicting advice it causes a great deal of unhappiness and distress and people do not know where they stand. We are placing more emphasis on research and development. We think it essential that we get more accurate and better information.

Due to the efforts of noble Lords in this House a Director of Research and Development was appointed for the National Health Service. The National Health Service has agreed a commitment of 1.5 per cent. of revenue for research and development over the next five years. We need better information, accurate information and the means to put it across to the public.

I very much welcome the noble Lord's support for the Government on the subject of advertising and tobacco. We are reviewing the matter and I am sure that we shall have a debate on the subject in the future.

Perhaps I may say a word about HIV and AIDS. I apologise to the noble Lord, Lord Carter, for not mentioning this before. The Government recognise that it is the most serious public health risk that we face. We have a five-part strategy in relation to AIDS which includes prevention, public education, monitoring, surveillance, research, treatment, care and support, addressing social, legal and ethical issues and also working with our colleagues across the world in international co-operation. As I have said, regional health authorities are reviewing family planning services because we see HIV and AIDS in the context of sexual health. We have set targets in relation to gonorrhoea, which we know is an indicator of what is happening concerning HIV and AIDS. The issue is a crucial one. This is the greatest public health risk we face and we shall ensure that we continue to put substantial amounts of investment into combating this serious disease.

Viscount Caldecote

My Lords, is it in order to make a short point?

Lord Stoddart of Swindon

My Lords, we have 10 minutes! Viscount Caldecote: My Lords, my noble friend referred to the importance of sexual health. Can she assure the House that moral aspects will not be lost sight of and that the value of self-discipline and self-control will be fully emphasised?

Baroness Cumberlege

My Lords, I agree with my noble friend. It is crucial that AIDS and HIV are set in a moral, family and social context.

Lord Walton of Detchant

My Lords, there are some of us in the medical profession who would have welcomed an opportunity to say rather more on the Statement. Perhaps I may just say that I look forward with great interest to reading the White Paper. I am sure that the members of the medical profession will welcome the objectives and the targets that have been set and which have been so clearly enunciated.

Coronary artery disease and stroke are two of the greatest scourges of the modern world. The incidence of those diseases is far higher in the United Kingdom than in many other developed countries. Curiously, it is much higher in Scotland than it is in England and Wales, for reasons which are not at all clear. The message that an aspirin a day helps to keep the stroke or coronary away has not been promulgated as effectively as it might in preventive medicine. Nevertheless, preventive medicine in screening for breast and cervical cancer has been a great success story. The transformation wrought in the treatment of mental disease by neuropharmacology and developments through our pharmaceutical industry—truly the jewel in Britain's industrial crown—have been remarkable. However, there are many points still to be looked at in relation to the community care of those who have been discharged from mental hospitals, despite the fact that their symptoms are well controlled.

We still succeed in providing under the National Health Service what I believe is the best emergency care of any in the world. However, there are anxieties over the role of the medical profession, and not only in preventive medicine and cure, because of the fact that we have the lowest incidence of consultants per unit of population in most specialties in any western country. Those are issues to which I very much hope the Government will turn their attention, bearing in mind their pledge to increase the consultant establishment and at the same time to reduce the intolerably long working hours of junior doctors.

Given those objectives, I believe that the White Paper is admirable. I hope that we can manage to achieve exactly what is set out. The evidence is very clear that in other countries the abolition of advertising of tobacco has reduced smoking by the young.

Finally, I commend to your Lordships' House the report published last week by the Royal College of Physicians on smoking and the young, which contains many important lessons.

Baroness Cumberlege

My Lords, I am grateful to the noble Lord for those valuable remarks. I agree that community care is a huge agenda for the future. I take his point on medical manpower. The noble Lord will be aware that a review is taking place by the Medical Manpower Standing Advisory Committee, which will be reporting later in the year.

Lord Mackay of Ardbrecknish

My Lords, is my noble friend aware that one particular part of her Statement brings me particular pleasure—namely, her report that the immunisation rate has now reached its 90 per cent. target? There is no doubt that the improvement in the immunisation of children has come about because targets were set and, dare I say, because doctors were given financial inducements in their contracts to improve the rate of immunisation.

Therefore, targets are an excellent concept. However, I hope that my noble friend takes on board that one must also identify the target group. In the case of immunisation, for example, there was not much point in targeting your Lordships; it was important to target young mothers. Therefore, as the noble Lord, Lord Winstanley, said, it is important in some aspects to target young people. I hope that my noble friend will do that. I hope that she can assure me that in certain subjects, such as smoking and diet, the Government will target young people in particular. In the case of sexually transmitted diseases such as AIDS, that is the target group, not the general population. I hope that my noble friend will ensure that all the advertising and propaganda will be aimed at the target groups who are most at risk.

Baroness Cumberlege

My Lords, I am indebted to my noble friend for that advice. He has my assurance that we shall target the correct groups.

Lord Butterfield

My Lords, I wish to intervene very briefly with two points. First, we must all welcome the White Paper and wish it well. Is there any chance that the very important development of a Cabinet committee concerned with health can be diffused down into other departments and indeed into industry generally? I believe that a wonderful fruit of the White Paper would be a general concern for health among administrators and those concerned with the management of people throughout the country. I hope that they might encourage their workpeople to take more exercise and to be more careful about their canteen food.

My other question is this: can the Minister give me an assurance that those of us who have been interested in independent health promotion research may look forward to a continued interest in the work we do? We would be very anxious to support Professor Peckham in any way we can but we should be most unhappy if there seemed to be a centralisation of attitudes which would prevent research into questions such as "Is cholesterol good or bad?" by people of independent turn of mind.

Baroness Cumberlege

My Lords, the whole essence of this strategy is that we shall be building healthy alliances with all sorts of people across the whole spectrum: healthy workplaces, schools, environment —right across the spectrum. The noble Lord is absolutely right. It is not a health service matter. It is beyond that. With regard to his question on research, I shall take up the matter he raises with the Director of Research and Development.

Lord Cocks of Hartcliffe

My Lords, given the appalling toll of alcohol-related diseases, does the Minister agree that there seems to be some discrepancy in the attitude of those who call for a ban on tobacco advertising but do not couple it with a call for a ban on alcohol advertising?

Baroness Cumberlege

My Lords, I suspect that many of us subscribe to the premise: a little of what you fancy does you good.

Baroness Carnegy of Lour

My Lords, some very important points have been raised about the content of school meals. Can my noble friend assure me that there is no question of the Government returning to the old system whereby schools provided a compulsory menu which the children who most needed the food refused to eat? The children who did not need it were subsidised by those who did and very often the children who needed it most went unfed.

Baroness Cumberlege

My Lords, I agree with my noble friend's views on school meals. There is no suggestion that there should be compulsory menus dictated from the centre.