Poverty and Ill Health

HL Deb 12 February 1997 vol 578 cc246-312

3.5 p.m.

Baroness Jay of Paddington rose to call attention to the impact of poverty on ill health in Britain today and the case for action to raise the standards of health of the nation's poorest families; and to move for Papers.

The noble Baroness said: My Lords, the Motion before the House this afternoon is about social justice—it is about poverty and inequity which is perhaps why it seems to be of little interest to noble Lords on the Benches opposite. Certainly social justice has found no place in the agenda of the present Government.

In your Lordships' House we often debate health policy, usually in the context of the National Health Service. Your Lordships are rightly very concerned about the state of the NHS, about its funding and about its organisation. But good health is about more than the NHS. It is about how we live. It is about the kind of country we are. It is about what priorities we give to things like proper childcare, to worthwhile employment for school-leavers—and, indeed, for everyone of working age—to decent housing, to the environment and to building cohesive communities.

Those are the underlying factors which affect the well-being of the whole population and which determine everyone's health. The tragedy is that we live in an increasingly divided society. The income gap between the rich and the poor is now wider than at any time since 1945, and that divide has grown faster than in any other comparable industrialised country. Sadly, the economic gap is now mirrored by a stark health divide.

Today in Britain in 1997–50 years after the NHS was created—the average life expectancy in the lowest tenth of the income scale is eight years less than those people in the highest tenth. Men and women of working age in the poorest groups in society are more than twice as likely to die prematurely as those in the highest groups. It has been calculated that 30,000 to 40,000 people die before their time every year because of their standard of living. As one commentator observed, if that number of people died unexpectedly in a series of air crashes, floods or in any other catastrophic natural disaster, the public outcry would be overwhelming, but the deadly effects of poverty tend to he ignored. The particularly alarming fact is that as economic inequality has widened in Britain in the past 18 years, so these health inequalities have widened in step.

Death rates at all ages in some of the most disadvantaged areas in our country have not only worsened in relative terms to better-off places but, among some age groups—notably, and very disturbingly, among young men—death rates have actually risen. That is particularly shocking when we remember that death rates overall have been going down since the 1930s. It is shocking but it has little to do with the performance of the National Health Service. As my right honourable friend the Leader of the Opposition in another place said at a recent health service conference: When I meet people who have been unemployed for many years in poor housing with bad health, I know what will transform their lives is not just a better hospital or more regular visits to a doctor: it is a job, good housing and a sense of security. The way to improve the nation's health is to start to build a more inclusive society".

I was vividly reminded of those points last week at a meeting about preventing heart disease. Heart disease is the biggest killer in the United Kingdom and, once again, there is a social divide. You are more than twice as likely to have a fatal heart attack if you are in social class V than in social class I. The medical experts believe that heart disease can be largely prevented. At that meeting they explained that it is about getting the right messages across about healthy lifestyles and about making those clear to people. However, a distinguished cardiologist from Manchester was angrily disputing that view. He said that most of his patients came from the Moss Side area. They were surviving on benefits and could not afford the recommended low fat diet foods and expensive fresh fruit. It was often too dangerous for them to take exercise by walking in their neighbourhoods, and they certainly did not belong to gyms. They were suffering from stress because of the circumstances of their lives and smoking was sometimes their only luxury. Health education would not help them; only a much broader social policy approach to improving their lives would reduce the number of heart attacks of that doctor's patients.

There are now three main causes of death in Britain today. Heart disease is the first and the others are strokes and cancers. All three hit the poorest worst. Social class differences affect health during life, as well as length of life. Overall there is compelling evidence that people who live in disadvantaged circumstances have more illnesses, greater distress, more disability and shorter lives than those who are more affluent.

This is of special concern when we consider the health of our children and the numbers of families living in poverty today. Families with young children are disproportionately represented among the poorest families. They make up 43 per cent. of the total population, but 57 per cent. of them are living on the lowest incomes. One third of our children—over 4 million—are being brought up in poverty, often in single parent households. Not surprisingly, this economic fact is reflected in depressing facts about the children's health. Those facts show that inequalities are built in from birth.

In 1997 we are three generations into the history of our welfare state. In spite of what are on the whole excellent maternity and obstetric services, there are still 50,000 babies born every year who are officially recorded as having low birth weights. Infant mortality in the poorest neighbourhoods is 11 per 1,000 live births. That is more than twice the number in our more affluent communities. A child in social class V who survives infancy is still twice as likely to die before the age of 15 as a child from social class I, and five times more likely to die in an accident. I know that my noble friend Lord Murray of Epping Forest will speak further about the dreadful impact of accidents later this afternoon.

My next point is less catastrophic but it is still serious. There is more and more evidence of poorer children being malnourished or of being more susceptible to respiratory diseases such as asthma because of pollution or damp housing. I know that my noble friends will return to these subjects later in the debate. Last autumn the Health Visitors Association produced a disturbing national survey of children's health and nutrition. Some 61 per cent. of the health visitors surveyed reported seeing iron deficiency and 93 per cent reported gastro-enteritis.

In another report, rather pathetically entitled Children who have no Breakfast, researchers found that in the most deprived inner city schools, 15 out of every 100 primary school children had no breakfast to eat at all before they left home, and nine were not even given a drink. This kind of malnutrition, combined with generally unsuitable and often overcrowded living conditions, is causing the so-called "poverty" diseases to return. In 1997 health visitors across the country now report seeing rickets and TB among families they visit. Recently the British Medical Journal reported that there had been a 35 per cent. increase in TB in the poorest tenth of the population. It is no wonder that the Health Visitors Association report concluded that Britain seems to be returning to the social conditions of 100 years ago. This is an intolerable situation. We cannot passively sit and observe as the great gains in health and welfare which most of us have enjoyed in the 20th century are undermined by the desperate poverty of our most vulnerable families.

The independent health policy institute, the King's Fund, recently issued this challenge: the socio economic causes of health inequality can be amenable to changes in public policy. Such injustice could be prevented but this requires political will". For the past 18 years the political will has been singularly lacking.

I remind your Lordships of the present Government's record on poverty and ill health. In 1977 the Secretary of State for Health in the previous Labour Government—our much missed noble friend the late Lord Ennals—commissioned Sir Douglas Black, the distinguished physician, to investigate the whole subject. Sir Douglas's seminal report was published in 1980. It could have provided the essential base and policy guide to any responsible government wanting to take action in this area. However, by 1980, of course, the Conservatives were in power and the new Secretary of State, the noble Lord, Lord Jenkin of Roding—I am sorry that he does not appear to be present—simply refused to accept the findings of the Black Report. He said he could not endorse what had been written.

Sir Douglas was unlucky to hit the tide of Thatcherism as it began to surge. Social analysis and collective solutions to any problems were unfashionable in a country where the concept of society itself was under threat from the highest level. During the 1980s the Black Report gathered the proverbial political dust somewhere in the recesses of the Department of Health. Fortunately this did not deter the health research community, including my noble friend Lord Rea, whom we shall hear from later. As unemployment rose and economic inequalities widened, researchers have continued to build up an incontrovertible dossier about the links between deprivation and disease and early death. Recently we have had the authoritatively comprehensive overview of the Social Justice Commission which stated: by analysing the different causes of good and poor health we can understand why tackling inequalities in health goes well beyond what is conventionally thought of as health policy". I am delighted that my noble friend Lord Borrie, who chaired the Social Justice Commission, will speak in this debate.

Belatedly even the present Government have come to recognise that there is something in this approach. In 1992 they launched the public health strategy The Health of the Nation. However, this flagship policy failed even to mention social inequality as a factor in health. The need to address poverty on a broad front was simply ignored. Instead over the past few years we have had many ministerial exhortations to change our individual personal behaviour. Noble Lords no doubt recall Mrs Edwina Currie's advice to old people who were threatened by hypothermia because they could not afford heating. She advised them to wear woolly hats and socks in bed. Mrs Bottomley recommended her solution to heart disease; namely, to eat fewer biscuits and to run up and down stairs.

I well remember attending one high level presentation to launch The Health of the Nation where a group of rather exasperated London doctors challenged the then Secretary of State and told Mrs Bottomley that the Chancellor of the Exchequer was far more important to the health of their patients than she was. Latterly there have been some initiatives by the Department of Health to examine what it rather euphemistically calls variations in health and variations in health services across the country. The most recent guidance speaks of, reducing variations by targeting resources where needs are greatest". However, as the House will be only too well aware, this is almost impossible in the fragmented health service we have today where services are devolved to local trusts and there is little capacity for overall strategy, let alone direction of resources. It certainly does not address the broader issues of social policy which go beyond the remit of the health department.

The Department of Health may have simply neglected the problems of inequality in health, or else responded rather belatedly and inadequately. However, the rest of the Government are guilty of actions which have positively damaged the health of poorer people. Apart from the economic decisions which produced record levels of unemployment and a widening income divide, policies about public transport, road traffic, rented housing and homelessness have all contributed to worsening health. Benefits policy has also had a negative input. Importantly, the removal of one parent benefit announced in the previous Budget is bound to make life more difficult for the millions of children already living in poverty. Their health is bound to suffer. All the evidence shows that when poor families become poorer they first economise on food. The children's parents are likely to suffer additional mental stress as well as increased physical deprivation.

Perhaps the single greatest government failure in this area is the failure to tackle the tobacco industry. Smoking related diseases are the greatest cause of premature death and serious ill health in Britain today. And today smoking is predominantly a habit of the poor. Three times as many people in unskilled occupations smoke compared with professional groups. There are particularly high rates among the unemployed and young lone parents; and most smokers start between 13 and 15 years old.

All of that is widely known. It is equally clear that conventional health education will have little impact on disadvantaged people who may see cigarettes as an important prop in difficult lives. The long term approach is of course to improve those lives. But in the short term it is disgraceful that the Government have not taken tougher action to curb smoking, and in particular have resisted demands to ban tobacco advertising. An incoming Labour Government will ban tobacco advertising as a priority in our public health policy. There will be a new Minister of public health to lead public health policy at the national level and to co-ordinate local action as well as to encourage good practice.

We shall review and republish the Health of the Nation in 1998 to coincide with the 50th anniversary of the start of the NHS. The new Health of the Nation will be more likely to follow the Australian national health strategy which calls for action in five areas: the distribution of economic resources; education; living standards; conditions of work; and social support. That approach would reflect the determination on this side of the House to make improved health a central goal of all social policy. We shall aim to reduce poverty and inequality through the commitments to help people move from welfare to work, to end poverty pay by introducing a national minimum wage, and to improve housing conditions by the phased release of local authority capital receipts.

The ambition is to ensure that those measures individually produce improvements in the health of our poorest families and that together they create more equity—a more inclusive society. To achieve an inclusive society where everyone, not just the advantaged and affluent, has the opportunity to achieve their greatest health would indeed be a victory for social justice. I beg to move for Papers.

3.21 p.m.

Baroness Brigstocke

My Lords, we are all most grateful to the noble Baroness, Lady Jay, for initiating this important debate. I have not been a Member of a political party in the past. I am new to debates. I have never taken part in a debate in another place. I am not experienced in debates in this Chamber. However, one thing I know is that noble Lords on the Benches opposite do not have the monopoly on caring for the health of this nation and in particular for those who suffer from poverty. We differ in the ways in which we seek to cope with the problem, but we recognise the problem. I do not have with me at present the report on the variations in health. However, I believe it states that we do not need sudden new developments but a continuation of those already being undertaken.

The trouble with considering improvements in both health and education services is that whatever action is taken it is never enough. While we must keep our eyes firmly on the highest possible standards, it is also important to take regular stock of what has been and is being achieved. I am glad that in a recent report the Chief Medical Officer recognises that, The Department of Health is leading a government-wide strategy to improve the nation's health". The report also urges the department to work actively in alliance with other government departments and other bodies. I can tell noble Lords that the Health Education Authority, of which I am a non-executive director, is already working effectively with the department. I hope that the Minister agrees.

I shall refer to two groups whose health is particularly affected by poverty: children and teenagers, and the elderly. The first group is natural for me because I have been teaching, or trying to teach, all my life. And the health problems of the elderly are becoming increasingly relevant to me personally as the days go by.

We do not need an official report to tell us of the many health hazards which endanger the young today. We already know that teenage mothers are more likely to come from lower socio-economic groups—a phrase which I do not enjoy using, but it seems to be the technical one. In the past there has been and still is much controversy over sex education in schools. I should like to see greater co-operation and liaison between the Department for Education and Employment and the Department of Health, and such excellent voluntary organisations as One Plus One and Relate, in order to provide good sex education classes in schools. However, perhaps I may express a word of caution. It is not reasonable to put the whole weight of sex education, with the essential moral and spiritual considerations, on the shoulders of school-teachers.

I should also like to see more care taken with university students and those in further education. So often at university they are living away from home for the first time in their lives. The Health Education Authority is undertaking work at present—I hope that it will have great support from other bodies—to give more useful information and help through the university student unions.

We do not yet know the full effect of the new alcopops on the susceptible young. But I believe that the lower socio-economic groups of teenagers, and even I hear sub-teenagers, will be most at risk as regards alcoholism.

We have statistics on smoking. I believe that we have had some success. Health promotion is producing a steady drop in adult smoking. We have had national campaigns linked to national smoking helplines which help more and more people to quit smoking. Those campaigns are tailored by the HEA to appeal to people in lower socio-economic groups. There is some evidence that they are succeeding. The noble Baroness, Lady Jay, referred to measures to counter the smoking problem of this country. I was surprised to hear that because several noble Lords on the other side of the House have been rather antagonistic towards what they have called nannying by the Health Education Authority; but perhaps that is a problem they can solve together. One has only to look at groups of young boys and girls near schools, often in school uniform, to see the enormous size of the problem of under-age smoking.

I worry particularly about nutrition and children from poor homes. During term time they qualify for school meals from Monday to Friday, though I should like to see some provision for the holidays. I wish to quote from an excellent publication from the HEA entitled Young People's Health Network. A short article by a reader states: Last year, during the long school holidays £ a local mum from Bates Green, Norwich, became concerned by the fact that so many children were going without proper meals as their parents couldn't manage the extra cost of feeding them during the six-week summer break. So Sharron came up with the idea of providing the children with a healthy meal for less than the price of a bag of chips. Together with a friend, and help from a community health worker, she set up a café in the local community centre. Wholesome pitta breads, jacket potatoes, fruit and yoghurt dominated the menu—a far cry from the fat-filled junk food previously eaten by the children". The article continues: The National Food Alliance £ has details of this project and many more on the Food and Low Income Database, which has been developed jointly with the Health Education Authority". So there are things that are being done.

Finally, I turn to the elderly. One in three of today's pensioners live at or below the poverty line. Evidence shows that older people who have been poor during their life die younger and suffer more ill health and disability. Yet older people now generally have lower levels of disability and fewer chronic disabling conditions than in the past.

The HEA gives high priority to one of those risk factors; namely, physical activity. In 1996 it started a national campaign entitled Active for Life—Stage 1 being to raise general awareness of physical activity for health—

Baroness Miller of Hendon

My Lords, I am terribly sorry to interrupt, but this debate is very tight on time.

Baroness Brigstocke

My Lords, I am so sorry; I thought the instruction said 12 minutes. (I had to borrow some glasses.) It is my fault. I shall sit down.

3.32 p.m.

Earl Russell

My Lords, I apologise to the noble Baroness, Lady Brigstocke, for entering the debate on such a cue. It is the sort of thing that happens all the time.

I also thank the noble Baroness, Lady Jay of Paddington, for introducing the debate. She and I have argued in favour of causes with a considerable degree of overlap since we were undergraduates. I am very glad to continue that process. When I heard the noble Baroness refer to the Black Report, I was reminded of the story of the 16th century Spanish theologian Fray Luis de-León, who in the middle of a lecture was snatched out of his lecture-room by the Inquisition, imprisoned and interrogated. When he was released, 25 years later, he went back into his lecture-room and began with the words, "As we were saying".

I, too, shall go full circle. I return to the public expenditure White Paper of 1980. It drew attention to the marginal propensity of the budgets of both health and education to increase regularly faster than inflation and GNP. When the noble Baroness, Lady Brigstocke, said that there is never enough she was quite right. Any Chancellor of the Exchequer at any time will be concerned by that.

The debate today does not deal with the attempt made to tackle that through the use of market forces. I shall merely say that I think it is agreed in every quarter of the House that it has not brought the problem to an end. In those circumstances, it was very obvious to turn to prevention as the next area to examine.

Listening to undergraduate essays the day before yesterday, I was reminded that the bubonic plague in western Europe was in effect wiped out long before anyone had any idea of treatment or cure, simply by methods of prevention. The same to a rather lesser extent goes for cholera. So there is a lot to be said for prevention.

But obviously there is a limit to what I hope the noble Baroness, Lady Brigstocke, will forgive me for referring to as "puritan" methods of prevention. I assure her that there is no smoke coming out of my ears at the moment. I recognise the justice of the bulk of her remarks. But by itself that is not enough. If we are seriously concerned with prevention, we must end up by looking among other things at poverty.

I do not want to become "hung up" on the definition of poverty. I merely say that, unlike John Moore, it is always with us. When I talk about poverty, I think of going to bed hungry because you cannot afford any more to eat; or, as my noble friend Lady Robson of Kiddington reminded me over lunch, of going to bed with no coal, or no heat, because you cannot afford any more. I am talking about real levels of physical deprivation.

Nor do I want to get hung up on an argument about how great is the extent of poverty. I shall take figures given by the Government and which I think are reasonably quantifiable; namely, numbers of people actually in receipt of social security benefit. According to my last Written Answer, which was not so long ago, those on income support are 13 per cent. of adults of working age and 24 per cent. of children. In addition, the numbers of people over 50 who have not worked for 10 years and who are excused from actively seeking work are 2,594,000. A lot of those ought to be included in the unemployment figures. For the sake of saving time, I hope that if I take that to mean poverty I shall not be thought to be pulling a fast one.

The National Consumer Council recently complained that many consumers living on social security benefits are being denied the opportunity to follow healthy eating guidelines because they do not have enough money to buy healthy food. The National Children's Home, I believe in 1993, studied a sample in which it found that 20 per cent. of those on benefit could not afford an adequate diet. Miss Widdecombe, who was then at the Department of Social Security, said that she did not see the problem because, after all, 80 per cent. could afford it. I am reminded of William Chillingworth's judgment on Thomas Hobbes that, like the elephants of antiquity, he would deal some lusty back-blows at his own side. That, I think, was one such back-blow.

The Rowntree study of January 1995 was particularly concerned with evidence of nutritional deprivation among lone parents. I agree with the remarks of the noble Baroness, Lady Jay, on that subject. She drew attention to the lack of iron intake. It seems that the further they were from benefit collection day, the worse their diet was. Many were going without meals altogether.

We have a series of Chinese Walls in government statistics. The noble Baroness the Minister told me in a Written Answer of just over a year ago that she was attempting to improve government screening in hospitals for malnutrition. I am extremely glad that she is. However, there is no way in which we can discover whether the people whom she finds to be suffering from malnutrition are the same people who are on inadequate benefit or indeed disentitled to benefit altogether. That is a defect in the Government's statistical resources.

It is even more serious for those who fall through the holes in the safety net altogether, usually to justify a small saving in the budget of the Department of Social Security. As noble Lords know, I suspect that on those occasions the Department of Social Security is exporting its costs and that the Minister is their unfortunate recipient.

Let us take the case of student health, which the noble Baroness, Lady Brigstocke, mentioned. I have observed among my pupils—I do not know whether they are a representative sample—that the amount of working time lost by ill health has approximately doubled since the loss of social security benefits in 1990. Among the people I should have been teaching this morning the figure reached 50 per cent., but that is not a statistically significant sample. It was only six people and therefore I put no weight on it.

We have a much clearer body of evidence about the effect on the street homeless. The expectation of life among the street homeless is only 42 years. Fortunately, we have not yet had a repetition of the crisis study of 1995 which found a rate of TB 200 times the national average. I hope we never do. Among the most recent studies we find that the excess mortality ratio for assault was 54.1 and the excess mortality ratio for suicide was 35. Suicide is one of The Health of the Nation targets and it deserves attention.

I hope the Minister has already read the Shelter study Go Home and Rest? It deals with the effects of homelessness on the National Health Service budget: inappropriate use of accident and emergency departments because the homeless have difficulties registering with a GP, difficulties to which the noble Baroness, Lady Masham of Ilton, drew the House's attention well before the Minister was even in the House. So the Government have had plenty of notice of the point.

The problem is the working of the financial targets. If the homeless move on and re-register with another doctor within a quarter of a year, the doctor does not receive a capitation fee. If they have a temporary registration, he gets nothing for vaccination fees or other fees.

All those disentitlements have costs. The House will not expect me to go through the catalogue. I am sure it knows them. They are all introduced in order to produce savings. The question is: are the savings greater than the costs incurred? That seems to me to be a question of considerable interest to us all. The Chinese walls in government statistics mean we do not know the answer. I think we should.

3.42 p.m.

The Lord Bishop of Lichfield

My Lords, I am fortunate to have an ordained colleague working in my diocese with me who happens, as well as being ordained, to be an NHS manager in one of our West Midlands health authorities. The person concerned has recently drawn my attention to a government document entitled NHS Priorities and Planning Guidance 1997–98. In it, one of the main NHS priorities is stated thus: to ensure £ that integrated services are in place to meet the needs for continuing healthcare for elderly, disabled, vulnerable people and children which allow them £ to be supported in the most appropriate available setting". Through my own observation, I see many examples where our regional health authorities are succeeding in some of that. I am told that people in Staffordshire and Shropshire live longer, fewer children die in infancy and many former dangerous illnesses are now treatable. At the moment I have immediate personal contact with an Alzheimer's sufferer and the district nursing services and social services are doing excellent and valuable work under the heading of that NHS priority.

I am grateful to the noble Baroness for this debate because I must go on to say that we also have in the diocese of Lichfield metropolitan boroughs which have the highest proportion of long-term unemployed anywhere in this country. One borough in my diocese ranks as the fourth highest nationally in its proportion of long-term unemployed. That borough moreover contains Pakistani and Bangladeshi communities which have unemployment rates more than three times higher than those of their neighbours.

The close relation between long-term unemployment and various forms of ill health is well known. It was experienced in my family in the 1920s. Research by Moser back in 1987 revealed particularly high mortality rates among unemployed men, caused by such things as lung cancer and coronary heart disease. It revealed equally high mortality rates for their wives.

In particular, in the borough to which I refer, which is not alone in my diocese, unemployment is impacting seriously on people with physical disabilities and mental health problems. That is true in several of the communities where I serve. A recent study of patients with serious mental illness in one borough found that only 7 per cent. of the 400 patients surveyed had any kind of access to paid employment as they improved. In the terms of the noble Baroness's Motion, here surely is a case for action—for the local health authority, in partnership with the social services, firms and economic development partners, to develop new job opportunities of an appropriate kind for families struggling to rehabilitate relatives suffering either physical disability or mental illness. That is a perceived need in the area where I live and work. Those are precisely the kind of vulnerable people to whom the NHS and government document Priorities and Guidance 1997–98 refers.

I now wish to make a general point. I do not hold, nor do I imply, what has sometimes been called in your Lordships' House "a purely sociological explanation" of either ill health or of poverty itself. I have often noticed during debates in your Lordships' House the tension between those who stress the role of social factors in human ills and those who, on the other hand, stress personal responsibility. It is a real tension. Surely it is not a question of "either/or" but of "both and", yet in a complex interrelation. Ill health is caused by a complex mixture of the external social factors over which victims have no control and of personal choices at times by those victims and the groups to which they belong.

In 1992 the government White Paper The Health of the Nation set national targets for improvement in health. They included reducing the number of teenage conceptions, reducing levels of smoking among 11 to 15 year-olds and reducing the incidence of obesity among children and adults. Clearly, success in achieving such targets must lie partly in the region of human choices and the self-responsibilities of families and others. I wish to go further and claim that where I live such self-responsibility can rest successfully with local communities as well as with individuals in several areas of deprivation that I know of.

In one of the most deprived outer housing estates in the Stoke-on-Trent/Newcastle-under-Lyme conurbation, the local community and church have worked up a very successful single regeneration budget that is producing schemes which make a real contribution to raising the standards of health among some of the poorest families. The local people on the estate now have a community house which provides out-of-school clubs five nights a week; a childcare co-operative training scheme for local people to act as registered child minders; courses on family health, run by community dieticians, to offer advice on nutritional meals on low budgets; and so on. I question the secure continuity of such provisions, but I would not want to rub out of the equation the issue of self-responsibility and choices both of communities and individuals.

But the final word must remain with the serious ongoing challenge of the noble Baroness's Motion, both for the present Government and any new Government in the future. In particular, as the noble Earl, Lord Russell, said, we need resources for prevention rather than cure, and that applies to the unemployment link.

I conclude by referring briefly to two or three other areas. First, some of my most experienced priests, who have spent most of their ministries in urban priority areas, bitterly regret the loss of so many of the former statutory youth services which ran football clubs and youth clubs—just the kind of things which are vital contributions positively to the health of young people. Is action not needed there?

Secondly, I am glad to learn, and hope I understand rightly, that the use of bed-and-breakfast accommodation by local authorities is decreasing. But yet—the Children's Society report has proved it—there remain many children at risk in dirty overcrowded bed-and-breakfast accommodation. Parents, usually mothers, often find it impossible to provide an adequate diet and there is no space for the children to play. Homelessness, as well as long-term unemployment, is an enemy of health, and needs long-term solutions.

Thirdly, there is the importance of financially supported maternity leave. The birth of a child is surely a key event in the health story of any family. Yet in this country only a proportion of women receive earnings related to pay during maternity leave and for only six out of the 18 weeks of maternity absence itself. Would not some action there also protect good standards of family health?

Perhaps I may add a short postscript from the Bishops' Bench. For a religious mind—a Christian mind also—health and healing are fundamental to our understanding of the purposes of God. We see that in history in the figure of Jesus of Nazareth. Health is the strength to be fully human. It is, therefore, an issue which embraces not only the body but the conscience, the will and the soul. Therefore, at the centre of health must be faith. That is why the Church in poor areas is committed still to raising, as it did in other ages, the standards of health of the nation's poorest families.

3.53 p.m.

Baroness Symons of Vernham Dean

My Lords, I too thank my noble friend Lady Jay for introducing this important debate today. I offer my apologies to the House. I very much regret that I have to leave before the end of today's debate but I look forward to reading noble Lords' contributions in Hansard.

As the noble Earl, Lord Russell, pointed out, on occasions we can get a little hung up on definitions. But ill health can certainly be measured in death rates and in chronic debilitating illness, which renders individuals unfit to work or to lead a normal life. We all know too that the way in which poverty is defined is a subject of some controversy. We can perhaps all agree that those who are living homeless on our streets are by any definition living in poverty. But there is much poverty behind closed doors in this country, among families with young children and among the elderly.

Put plainly, according to the Department for Social Security's most recently published statistics, 9.9 million people in the United Kingdom—that is 17.4 per cent. of our whole population—relied on income support for all or part of their income in 1994. Again, according to the DSS, one person in four in this country is living on below half the average income after housing costs are taken into account, and of those 4.3 million are children. That figure has increased threefold since 1979, which is a deplorable statistic by any standard.

We all know that in any country poverty is a comparative term. But, according to the Government's own sources, the gap between the rich and the poor in this country has widened enormously in the past 20 years. The real weekly earnings for men in the bottom 10 per cent. of employees increased by 27 per cent. in the years from 1971 to 1993. Over the same period, the increase for those in the top 10 per cent. was 69 per cent.

In 1995, the Rowntree Foundation Report on income and wealth pointed out that incomes rapidly became less equal in the 1980s. It went on to say: Britain needs a far-reaching programme of economic and social reform to avert the damaging consequences of a deepening divide between the rich and the poor". So however we define poverty, the evidence is of a widening gap in earning power; and using the Government's own yardstick, more children are living in comparative poverty than was the case in 1979.

But we must acknowledge that an individual has responsibility for his or her health, as the right reverend Prelate pointed out. Taking enough exercise, eating properly and not smoking—a sensitive point in your Lordships' House—are straightforward enough; but poverty makes some of them more inaccessible. Poor housing means damp and insanitary living conditions. Lack of money means less heating and less nourishing food. It can, and for many old people does, mean a real choice between heating and eating.

Undoubtedly the taxation policy of the current Government has affected the poorest worst in that respect. The theory is that indirect taxation leaves the individual more choice on how to spend his or her income. But we all need to heat our houses in winter; that is not a matter of choice for anyone. It is certainly not a matter of choice for the elderly. It is shocking that in this country, even when the weather is mild, nearly 30,000 more susceptible elderly people die in the six winter months than die in the summer. It does not have to be like that. It does not happen like that in many countries, even those with far more severe winters than ours, such as Canada or Sweden. The elderly need to keep warm but thousands cannot afford to do so. Cold aggravates circulatory and respiratory problems, which in turn lead to bronchitis, pneumonia, heart attacks and strokes. In short, cold kills the elderly and too many of them are cold because they are poor.

Other difficulties may affect families with young children: diets which are low in fresh fruit and vegetables, and even the cost of water, which has risen by 37 per cent. since privatisation—three times the rate of inflation. Is it any wonder that the diseases of squalor, which most of us associate with Victorian Britain, have returned: scurvy, TB and scabies, the incidence of which has doubled in the past five years?

We can acknowledge that since the 1970s health in general has improved in all social classes. But the fact is that the mortality rates of the better-off have reduced faster than those of the less well-off. It is true throughout life. According to the BMA, a baby born to an unskilled manual worker is one-and-a-half times more likely to die before the age of one than a baby born to a manager or a professional.

In adult life we all now expect to live longer, but the widening gap in health remains. Non-manual groups have experienced a much greater decline in the death rates up to the age of 65 than their manual worker counterparts. The mortality rate among those up to the age of 65 is four times higher in the most deprived areas of our country than it is in the most affluent.

Of course, we all have a direct interest in our National Health Service, but perhaps I can make some personal points. Five years ago my husband was diagnosed as suffering from acute myeloid leukaemia. His life expectancy at the age of 38 was two months unless he responded to very aggressive chemotherapy, but even then the chances of his surviving another four or five years were about one in four or five.

He spent six months in hospital. I went to see him three times a day—not only because I wanted to but because I could afford to. I could afford the childcare at home. I could afford the taxi fare to the hospital. I could afford to take in three meals a day with me because the sterile food in the hospital was so unappetising. But so many people cannot afford to look after their family members in hospital in this way. We close our hospitals and, as a result, the families of those in acutely distressing situations simply cannot visit those who need them. Stress and loneliness are added to illness. The hidden cost of ill health bears hardest upon those on low incomes—financially yes, but also in terms of anxiety, stress and who knows, possibly their eventual chances of survival.

Of course, explaining the relationship between economic status and health is the subject of a great deal of research, much of which is still in progress. But that should not prevent an incoming Secretary of State, after the election, using the wealth of evidence we already have. Of course we need to address the reasons why the burden of ill health is associated so clearly with deprivation, but we need to address poverty.

We, on this side of the House, believe in a co-ordinated approach to the growing problems of health inequality. A cross-departmental strategy is needed so that all government departments are co-ordinated, not only on the policy but on the operational requirements to deliver that policy. In that respect the current way in which individual departments operate is too fractured, but primary health care and public health campaigns need to be combined with policy and strategy on education, on urban regeneration, on housing, on the environment and, of course, on job creation.

A new Labour Government will understand the need for frank and targeted public health campaigns, health education in our schools, setting targets to reduce water pollution in our towns and our cities, letting councils build houses which are properly heated and insulated, and introducing policies to get the long-term unemployed into work.

These are positive measures and when put into practice they will substantially improve the health of many in this country: many men, many women and many children.

4.4 p.m.

Lord Birdwood

My Lords, I would like to put down a marker right at the beginning of my short offering today, and that is a measure of my unease, verging on distaste, at the spectacle of a score of able-bodied Lords and Ladies of varying degrees of prosperity pronouncing on the problems of being sick and poor. And I must reinforce the point made by my noble friend Lady Brigstocke. It has always been a signature of the party opposite to claim ownership of compassion, and this Motion is no exception. Only socialist thinkers can empathise with poverty, we are told. It is like the extraordinary assumption of a few years ago that only the Left understood the consequences of nuclear conflict. The word which, again uneasily, comes to mind is "patronising" or perhaps it is "paternalistic". And let us not assume that "Nanny knows best" is the sole property of the Labour Party.

For something like 10 of the past 17 years of government the citizens of the United Kingdom have been fed a stream of hectoring, counselling, persuasion and sweet-voiced bullying from successive Health Secretaries about what to eat and how to take enough exercise. What is it about the British that thinks a government can change behaviour when all the evidence is that behavioural change percolates upwards from individual and collective social influences?

The noble Baroness has focused on a linkage between poverty and ill health. Note I said "a" linkage, not "the" linkage. There is always a problem, is there not, when issues like this are aired of where in the spectrum of intellectual rigour the body of a debate should rest? At one end there are the cold equations of the social statistician, and, as those in this House who have suffered in the past knew, nothing kills discussion more than a procession of numbers flowing from one or other of the Front Benches. As a listener one begs silently for humanity, for feeling, for the reality of being hungry or ill or in despair when force-fed those figures. But just as insidious is the anecdote masquerading as the general, pandering to the eye-blink attention span of the television audience or the newspaper reader who, our media masters believe, can only be captured by another outrage.

One understands the pressures which result in either. A single episode can illuminate a general injustice or blow away complacency. But statistics are not immune, as we all know too well, from political shading. And what I long for and still have never found in these areas is calibration. What is poverty? What is ill health? There are some stark measurable figures, of course, and the noble Baroness opposite has made them with exemplary lucidity. But I still feel a vacuum of forensic analysis of these issues.

To return for a moment to my point about linkage, the true pattern is a triangle surely, in which individual self-esteem or lack of it is the causal initiator. To give the Government their due, it surely cannot be ignorance any more, and you would have to be deaf and blind to escape the deluge of health advice from the media in all its colourings and techniques. Health sells, and don't all of us consumers know it!

I appreciate that previous speakers have not been trapped by the bell-curve fallacy and that we are concentrating on the demography at the end of Maxwell distribution. I cannot say the same of some of the pronouncements which come from other sources, where we are fed the nonsense about relative poverty or that everybody below the median point can be classified as poor.

The triangle I have just proposed of poverty, bad health and low self-esteem feels to me to be a valid model for our deliberations. If lack of material wealth were a cause of sickness, would not ill health be a necessary and sufficient condition always associated with lack of money? Observably, this is not so. So what is the variable? To my intellectual satisfaction I make the case for the lack of self-esteem. What this does is largely de-couple health from material ownership, except in so far as an individual who cares nothing for himself or herself will be more at risk.

What can a government do in this area? America certainly has a lesson for us in recent social policy in its utter rejection of a minimum wage by statute. I believe we can junk this rubbish idea once and for all, because getting into the world of work, in whatever way, at whatever reward, has social benefits. It has human consequences which go far beyond the material.

The American lesson is that all work works. And there is a correlation between American benefit policy and its much lower figure for the long-term unemployed. And now that we cannot put a cigarette paper, if your Lordships will forgive my metaphor in this of all debates, between the two main parties on education, I think that this subject has found its rightful high place in political priorities. Education is a key route to self-esteem and, therefore, in my proposition an essential precursor of the national well-being.

4.9 p.m.

Lord Addington

My Lords, I feel that I have far more in common with many of the ideas, if not the conclusions, of the noble Lord, Lord Birdwood, than I usually have with someone who addresses us from the other side of the House. I agree with his assumption that if we throw around statistics on this subject, as on many others, we shall find ourselves seeing nothing but statistics. I have received a good deal of briefing matter for the debate. I had to read through some of it several times in order to understand how those who produced the analysis actually see poverty.

Previous speakers have said that "poverty" is a relative term. It always has to be so. The links between poverty or lack of income and ill health are irrefutable. There is no dispute about that. The noble Lord, Lord Birdwood, said that much of that is down to low self-esteem or lack of education about health. I received a briefing from a group called the Life Project, working in the Win-al. It is interesting that a group from that part of the world has an input into our debate at the present time. The work carried out by the project shows what the problems are and what can be done to address them.

Primarily it shows that people on low incomes tend to have a bad diet and take little exercise. The food of those on low incomes—I make the assumption that these are people on low incomes and not people completely on the poverty line in the literal sense—tends to be cheaper and easier to prepare. The project also makes an interesting point about lack of exercise. We have an exercise culture for the first time in our society. We have the sense that "thou shalt be fit"; "thou shalt be fit in many different ways";"thou shalt be fit wearing certain items of clothing"; "if it isn't Lycra or doesn't have the right brand name, don't wear it in this place". Indeed, we even have brand names with regard to aerobic exercise. We have brand name step aerobics.

With that kind of pressure it is not that difficult to see why certain types of activity are associated with a level of consumption and economic activity. For the first time we see people taking exercise as a status symbol. That probably applies more to younger groups. In the older groups in society, where high activity or high explosion exercise or training for sporting events become less common, poverty or lack of funding are even more relevant. If you live in an unpleasant inner city you are far less likely to go for a nice, gentle walk. It is not fun to walk around grey, rotting, concrete blocks. Crime—or, more importantly, the fear of crime—may prevent you taking that walk. In addition, other kinds of gentle exercise such as gardening are difficult to carry out when you are dealing with a window box. What are you going to do—put it on your shoulder and walk around your house with it? Other activities such as golf may also be non-starters. Unless you happen to live in a certain part of Scotland and can pick up a half set of second-hand clubs cheaply, you do not have public courses available to you and you cannot afford the equipment.

The Life Project in the Wirral recognised these problems and went out to educate people on how to reduce their levels of ill health, obesity and high blood pressure. Those involved first tried to do this by going around in vans and handing out leaflets asking people to come and see them. Those who already had above average health—they were predominantly female—turned up to get advice on how to become healthier. Often when you are doing this you are preaching to the converted to come and listen to a sermon. That is what happens. Is it not always easier to listen to what we know about? We always turn up to hear it. So the Life Project did something different. It went to pubs at lunchtime with blood pressure testing devices and callipers to test body fat and carried out assessments. This was incredibly well received because those involved were going to people on the right level. They also discovered among people a frightening degree of ignorance about what happens to their bodies. Twenty per cent. of people thought that taking any exercise increased the risk of having a heart attack. One presumes that they were thinking of someone who is grossly overweight trying to run a marathon. In that case they were probably right, but the rest of the time they are not.

The Life Project also started to institute exercise patterns that were relevant to people. It instituted single sex exercise sessions for people who were very overweight and it provided special tuition. If you say to a 40 year-old woman who is four stone overweight that she should look like whoever is the equivalent of Jane Fonda in a modern exercise video, she will laugh at you, wander off and have another packet of crisps. You have to make things relevant. That was done by having the right type of training and by going out and becoming active.

This idea of addressing the problem is something we have to do. Whoever forms the government must address the fact that we have to try to make the message more relevant to people. Certain advertising campaigns—for instance, the heart campaign in which I am told that my heart is a killer—have missed the mark. You have to start talking to people. Unless we address this point and give better education to people in a way they can understand and, more importantly, identify with, all the advice given out by various Ministers and bodies will ultimately fall on deaf ears. We have to talk not at people but to them.

4.18 p.m.

The Earl of Sandwich

My Lords, I have worked for many years with voluntary and Church organisations like Christian Aid whose primary objective is the relief of poverty overseas. We were engaged, in the 1970s, in an international struggle whose motivation was based on the certainty of our own wealth and security in this country. Without going into the whys and wherefores, the situation today is markedly different, partly because of the reluctance of many of the supporters of those organisations to help abroad except in dire emergency, but mainly in the sense of our own ability to relieve poverty and ill health in our own country. I am not denying that in many specialised areas welfare programmes have expanded—infant mortality is well down and the social services have improved day by day—but I do not believe there is the same confidence as there was 20 years ago that the Government are actually on the side of the poorest communities—not the social services on the ground but the government, the national visible government.

In fact, if one visits north-east Coventry, as I was privileged to do when visiting a parish priest and I stayed for a night and met families, one gets a sense of deprivation such as that which exists in the third world and such as I have identified many times overseas, but not in this country. There is an acute sense of deprivation. I am very much in sympathy with what the right reverend Prelate said about long-term deprivation. After all, the social services and the Churches, however well equipped and however good the partnership, cannot deal with the problem instantly. There is also the long-term hardship of the many unemployed car workers and their families.

This sense of deprivation is well summed up in a few phrases contained in a recent report made by the Wildside Trust, which is one of those organisations that helps young people to escape from their urban environment into the countryside. It says: As urbanisation spreads it is important that we recognise that £ lack of social cohesion often leads to destructive life styles and lack of care for the human and natural environment. People feel isolated and unable to make a difference £ Feelings of powerlessness lead to lack of action and increasing neglect". As a measure of their concern and in response to what their supporters are saying, some overseas aid organisations have now built up a substantial anti-poverty programme in the United Kingdom as well. Some are now working closely with local authorities in urban areas, often those with ethnic minority populations where they have special expertise. That was mentioned by the noble Lord, Lord Northbourne, in our education debate together with what is happening very successfully in Tower Hamlets with the Bangladeshi community.

This Government are well aware of the advantages of working with non-government organisations in the health sector and of the necessity to support low-cost and innovative projects, which involve local communities more in their own care. That is a philosophy—almost a tradition in the voluntary movement—which applies universally, whether we are talking about a shanty town in India or in our own cities. But that does not mean that more and more primary healthcare services should be contracted out from the centre to a point where local government, so deprived of central funds, is forced almost out of existence.

I should like to mention some of the excellent projects of a particular charity with which I have worked; namely, Save the Children. Its achievements in the United Kingdom are much less publicised than its successful projects overseas. Those projects are specifically designed to promote positive change and partnership with the local authority and the community.

Perhaps I may give a few examples. Save the Children works with children and their families in the By-Pass Project in Bolton where it has set up a food co-operative to help young people to buy affordable healthy food such as fruit and vegetables. It is a simple project such as that already mentioned by the noble Baroness, Lady Brigstocke, which can make a great deal of difference. There is the Pennywell Neighbourhood Centre in Sunderland where a group of mums and new mothers can discuss concerns with a midwife. It also benefits from a loan scheme for parents on low income. There is also the Blackburn Young Families' Project in Scotland. Local women share their problems; look at ways of coping with stress and are also offered opportunities to take their children out. It is this encouragement of local initiative which is so important. The organisation, Save the Children, is only one of many. There are also health projects with prisoners' families, which include one of the most deprived groups of children in our population. I have mentioned the refugee communities, and, to give an example, the Vietnamese have benefited a great deal from this form of partnership.

In the voluntary sector it is people and not just money, which is the essential resource. Very small amounts of money are needed. Perhaps I may give noble Lords one tiny illustration. The charity called Kids VIP was started a few years ago because one young woman saw children loitering outside Winchester prison and decided to help them. I believe that there are tens of thousands of children in the families of prisoners. Today, that organisation runs crèches in prisons all over the country and it is fully recognised as such by the Prison Service. Perhaps I may give one further illustration. Only a few hundred pounds can mean an enormous amount.

I end with what I believe are our international obligations under the terms of the UN Convention on the Rights of the Child. Many of the charities that I have worked with believe in these articles of faith. Briefly, Article 24 of the UN Convention states, The right of the child to the enjoyment of the highest attainable standards of health". Article 27 states, The right of every child to a standard of living adequate for the child's physical, mental, spiritual, moral and social development". In this short debate I hope that we are able to contribute one iota towards the UN Convention. Perhaps I may beg the indulgence of the House for having to leave for another appointment later in the afternoon.

4.25 p.m.

Baroness Hilton of Eggardon

My Lords, as already apparent from the debate that we have had so far, there are many factors linking poverty and health. The two that I intend to speak about are two environmental aspects of poverty: housing and air pollution. Poor housing has been linked to ill-health since the middle of the 19th century. The Public Health Acts of that century and the production of clean water, sewers, slum clearance and so on, had much more impact on health and life expectancy than medical treatments, which we tend to concentrate on today.

There is no coincidence in that long history of improvement that housing was the responsibility of the Ministry of Health until 1951. In contrast, the Government publication of 1992, The Health of the Nation, made no direct reference to the link between housing and health, although there is a general reference to the importance of healthy surroundings.

The survey of English houses of 1991 found that 7.6 per cent. of housing was unfit for human habitation, but that rose to 20 per cent. for dwellings in the privately rented sector, which are of course those generally inhabited by the poorest families. In addition to those, 20 per cent. of houses had problems associated with damp and 5 per cent. were in need of urgent repairs. I apologise for this use of statistics, but it is essential to drive home the particular point. Twenty per cent. of homes in England have an internal temperature below 12 degrees centigrade when the weather is freezing outside. It is generally agreed that a temperature of at least 17 degrees centigrade is necessary for health. Scandinavians and Americans would expect room temperatures to be very much higher even than that.

The poorest families, one-parent families and the elderly, are most likely to be living in poor, cold and damp accommodation. Studies in several cities—notably in Edinburgh, where climatic conditions are of course worse—have shown a clear association between damp housing and the fungus spores and moulds associated with damp and bronchitic, asthmatic and other illnesses in children. These chronic illness lead to frequent absences from school and all the potential ills of unemployment, crime and drug dependency that are often associated with poor scholastic performance. Illness is an additional factor that can only exacerbate the difficulties of a group of children that is often already educationally vulnerable due to overcrowding and poor living conditions.

Over the past 20 years there has been a decline in public spending on housing. In 1994 the UK was ninth out of 11 European countries for housebuilding completions. The balance of public spending on housing in this country has shifted towards means-tested housing benefit and away from support for capital and current spending by local authorities and housing associations. There has been no provision to improve our existing housing stock.

Moreover, as the building rate falls, less affordable rented housing in particular declines. Market forces—the law of supply and demand—which should be something dear to the heart of the present Government, ensure that rented housing becomes ever more expensive. The consequence is that more and more tenants become dependent on housing benefit, promoting the very dependency culture which the present Government deplore. Unless that trend is reversed, the health of the poorest 8 million to 9 million low-income householders will continue to decline, with an ever-widening gap between families of comfortable means in warm, well insulated houses and those condemned to bring up their children in cold, damp and overcrowded conditions.

An example of further misdirected spending is the announcement only three weeks ago of the award of nearly £7 million to Saatchi & Saatchi for a government-backed campaign directed at social classes A, B and C to persuade them to save energy by installing double-glazing and by insulating their homes. That £7 million targeted through the Home Energy Efficiency Scheme would have insulated 40,000 homes of the poor and vulnerable. The £7 million media campaign, moreover, follows directly on the heels of a £31 million cut in the grant-aid for energy-efficient measures for low-income householders.

The other topic that I wish to address as particularly affecting poor families is air pollution. The current eduction of Social Trends acknowledges that, the increase in the number of people with asthma, particularly young children, may he partly attributable to an increase in vehicle emissions". It is estimated that the health costs of air pollution in our cities may amount to £3.9 billion per year and this is a problem that is rapidly getting worse. Over the past decade there has been a 73 per cent. increase in nitrogen dioxide emissions from motor vehicles, a 43 per cent. increase in carbon monoxide emissions and an 86 per cent. increase in black smoke. Research has shown that life expectancy is shorter for those who live or work near major roads. Poor families are more likely to be living in inner-city areas beside major commuter and commercial routes and are therefore more likely to have their health affected by air pollution, further exacerbating the other factors of damp and cold that I have already described.

If we are to live as one healthy nation, we must do more to improve our housing stock and to reduce air pollution by diverting people and freight from road to rail.

4.32 p.m.

Lord Astor of Hever

My Lords, despite what the noble Baroness, Lady Jay of Paddington, said, this debate is of interest to noble Lords on this side of the House. Seven speakers does not constitute a lack of interest. As president of the Motorsport Industry Association, I was interested to hear her party's commitment to ban tobacco advertising. Clearly, the noble Baroness has thought out the devastating effect that that would have on jobs in the motorsport industry—at this time, a real British success story.

It takes real chutzpah on the part of the Opposition—Labour and Liberal—to lecture us on action to raise the standards of health of the poorest families. So many of the local authorities they control fritter away money on their own wasteful schemes while front line services are cut, and the poor suffer.

I live in Kent, where the county council, a Left-wing old Labour Party, assisted by its weak Liberal allies, has dramatically and irresponsibly overspent its budget. Consequently it has imposed more cuts on services for the needy and vulnerable than any other county in England. However, it refuses to implement efficient savings or embark on a restructuring programme, as it has been advised to do by Price Waterhouse, the auditors. A memorandum sent to Liberal members by their leader states, a large part of the budget pressures are a result of our own policy decisions". As a long-suffering Kent resident commented to me, they are not so much out of their depth as 3 miles from the shore". The result is incompetence, debt, and chaos, and after seeing Labour and Liberal politicians at local level, I can anticipate what they may be like in government. Of course, the Shadow Chancellor has stated that there will be no extra funding, above what this Government have already set out, for the health and social security departments for two years, so clearly he considers that those departments are not underfunded by this Government.

The vast majority of people, spread across all sections of our population, are better off as a result of this Government's policy of promoting economic growth. The UK recovery since 1992 has been the strongest of any of our major European competitors. Britain is a magnet for inward investment and job creation, resulting in a great deal of social mobility and increased prosperity for all—not just top earners. Meanwhile Germany's unemployment figures have increased by half a million. But still New Labour is attracted by the social chapter, the minimum wage and job security deals, not to mention the Tartan tax for the Scots. Social costs are destroying jobs across all sections of the population in Germany. New Labour's fondness for the social market economy could lay waste the livelihood of hundreds of thousands of British families and will particularly hit the poor.

The Opposition are continually running down our social security system, but it does successfully focus resources on vulnerable groups, such as low income families, poorer pensioners, and sick and disabled people on low incomes. Benefits for most groups have increased by significantly more than the rate of inflation since 1979. Compared to 1988, an extra £1.5 billion a year is being provided in income related benefits for families with children. Poorer pensioners now receive an extra £1.2 billion a year. The least well-off pensioner couple is entitled to over £100 a week, as well as having their rent and council tax paid in full. Since 1979, over four times as much is being spent on helping disabled people as was spent by the last Labour Government.

The Department of Social Security is now testing whether in-work benefit assistance is effective in getting single people and those without dependent children, back to work. The Government have launched Project Work, an innovative programme offering job search help and practical work experience to people unemployed for two years or more. A current pilot scheme near me in Medway has so far been very successful. Family credit, which boosts the incomes of those with low or moderate earnings, is now providing help to a record 692,000 families, including nearly 305,000 lone parents, with an average award of over £55 per week. Recent changes have made family credit more accessible to lone parents who may have found it difficult to combine the longer working week with their family responsibilities.

The Labour Party tells us that a healthy diet is not possible on income support. I have discussed this with the Department of Health, which advises me that a wide range of foodstuffs is available at affordable prices within everyone's means. Food is cheaper in this country than most EU countries, particularly as food is subject to VAT in 12 of those countries. May I ask my noble friend the Minister if her department might consider issuing again an information leaflet with suggested cost-effective and healthy recipes? This need not be advice on what should be eaten, but what could be eaten. I know this has been done in the past, unsuccessfully, and that some people prefer an unhealthy diet, but I do feel it would be worth another effort. With imagination, exciting dishes can be made from basic and healthy ingredients.

The Government have just announced the publication of a new guide to community child health services, Child Health in the Community: A guide to good practice. This guide is being sent to health authorities, NHS trusts, community health councils and local authorities with a view to stimulating wide-ranging local reviews of the objectives and provision of community child health services.

The guide brings together policy statements and advice on good practice in child health surveillance, health promotion, school health services and community children's nursing. There has been a steady improvement in the overall health of the nation. Clearly there is always room for improvement.

Action can be carried forward specifically on three fronts: first, the pursuit of even greater economic prosperity; secondly, we must work towards increasing the understanding of variations in health status. To this end the Government are committed to launching a £2.4 million research initiative into variations; and, thirdly, specific initiatives towards particular vulnerable groups. It is a key Government aim to promote equitable distribution of health services throughout the UK and to ensure their availability to all social and ethnic groups. The Health of the Nation White Paper focuses efforts on those groups, and areas where particular effort is needed to achieve the targets set.

I believe that the Government's policies have been good for the people of this country, whatever their circumstances. I also believe the Government are taking effective action to continue the overall improvement in the health of all the nation's families.

4.41 p.m.

Lord Paul

My Lords, our distinguished colleague, my noble friend Lady Jay, deserves congratulations on having initiated this discussion. It is both important and unfortunately often neglected. It is a subject very close to my heart. Your Lordships may be aware of the circumstances which brought me to this country. That experience sensitised me as to how very important, how fundamental, health issues are for society. It is the enduring imprint of these personal concerns which has sustained my long interest in this subject and its larger implications.

I am a new boy here but I am surprised that the noble Lord, Lord Astor of Hever, whose side has been in government for 17 years, wants to palm off the problem and responsibility to the councils, and the Shadow Chancellor.

In an advanced industrial democracy it is sad that we should even have to discuss this issue. The right to good health is surely one of the most basic rights of a citizen. If we can develop sophisticated scientific systems for everything from military weapons to traffic control, should we not be able to provide and administer a system which assures consistent access to improving health care? We can transfer billions of pounds sterling around the globe through marvellous electronic gadgetry, yet we do not seem able to deliver satisfactory health care to working men and women in our neighbourhoods.

In human terms, that is irritating at best and tragic at worst. In economic terms, that has consequences which range from declining morale to declining productivity. Noble Lords who have been associated with various areas of manufacturing know how relevant is the relationship of morale to output.

We too often equate morale with economic incentives and rewards. Morale is also linked closely to physical and emotional health. All of us want to advance the British economy—all of us must then take a broader view of workers' well-being. And to do this we need to begin where action is most needed—at the bottom of the economic scale.

Nineteen centuries ago, the Roman poet-philosopher Juvenal suggested that we must all seek mens sana in corpore sano—a sound mind in a sound body. The same ethic is embraced by the old Indian concept of Yoga. The ancients, in their wisdom, understood how individual performance related to fitness of body and mind. With all the techniques and technologies available to modern society, we seem unable to grasp those truths today.

The conditions of life are now such that individuals have drifted away from those verities. It is surely the duty of the state to mobilise its resources and encourage non-governmental groups to make people aware of that and to take remedial action. Where else do we begin but at the most deprived level of our society—those who are unable to help themselves? Generally, it is the winners who get applause and attention. But if we neglect those less fortunate, if we cannot or will not encourage improvement in their standards of well-being, we risk a deterioration in the entire social fabric. The results will be devastating. Poverty, enduring poverty, is both a human tragedy and the most debilitating sickness which afflicts a nation.

In that context, I need not remind your Lordships of the startling decline in social indicators in several Eastern European countries recently, and the resulting national disintegration. I hope that the nations of Western Europe, including our own, will learn from those situations and not follow in those pathetic footsteps. Perhaps it is more true today than at any other time to say that a physically ailing state is an economically ailing state; and an economically ailing state is always a study in human misery.

We live at a time when it is fashionable to talk of individual enterprise, self-motivation and personal initiative, but all such endeavour is predicated on human energy. We surely cannot expect those who are unable to afford the nutrition and care which begets that vigour to generate it. No longer is this an issue peripheral to society or to the economy. It does concern working people most directly, but it profoundly affects all classes and the future of this country. That is why I hope that it will engage the attention not only of this House but of everyone who wants a better Britain. No price, my Lords, is too much to pay for that.

4.49 p.m.

Baroness Turner of Camden

My Lords, I am grateful to my noble friend Lady Jay for introducing this debate and for the opportunity to participate. There is little doubt that poorer people are more likely to suffer from ill health than the better off. There have been numerous studies which would appear to confirm that. Some of that information has already emerged in the debate. It is useful to look at definitions of poverty. We are often told that we do not have much absolute poverty here, and that may be true if we are comparing with the desperately poor people of third world countries. However, it is useful to look at what Faith in the City says, a publication with which I am sure the right reverend Prelate is familiar. It states: Poverty is not only about shortage of money. It is about rights and relationships; about how people are treated and how they regard themselves; about powerlessness, exclusion and loss of dignity. Yet the lack of an adequate income is at its heart". That final sentence is most important.

There is no denying that inequality has greatly increased in the UK since 1979. Indeed, the UN Human Development Report shows that Britain has the largest and fastest-growing income disparity of any industrialised country. The richest 20 per cent. have 10 times as much income as the poorest 20 per cent. This country has more than any other pursued what the UN calls "ruthless growth", where the already well-off benefit. Between 1979 and 1994–95, the poorest tenth of British households experienced a loss of 14 per cent. in their real income—that is, after housing costs—while the richest 10 per cent. improved their income by about 65 per cent.

That did not happen by accident or because of something now called globalisation, or because of membership of the EU. It happened because of positive policies initiated by the Government during the years of Conservative power. The Government have placed great faith in the "trickle-down" theory; that is, the idea that gains from economic growth for the wealthy will trickle down to the poorest parts of society. So we have had tax changes which benefit the rich at one level and at another the general tightening up of social provision in order to cut down on public spending at the lower level, plus a series of measures designed to weaken the ability of people in employment collectively to secure better terms and conditions.

The most marked effect has been on the lowest paid. Since the Government abolished wages councils, rates in the industries previously regulated by them have been reduced. According to a recent TUC survey, 1.3 million people in Britain earn less than £2.50 an hour. Furthermore, 342,000 people earn less than £1.50 an hour. Every year the taxpayer must find £2.4 billion in benefits for people who simply do not have enough to live on. So for such people, their reality is "poverty pay".

There is no doubt, however, that the major cause of poverty in Britain is unemployment. The Government have made great play of the most recent figures which indicate that unemployment is diminishing. However, as we have said from these Benches on many occasions, while we are always very glad to see improvements, the Government should not be surprised that there is some scepticism about the validity of the figures since they have changed the method of counting them so often. The claimant count is not an entirely reliable record of those without work and wanting it. This gives a figure of unemployed as 6.7 per cent. of the workforce, while the Labour Force Survey, which is another means of counting, puts the figure at 7.9 per cent.

Long-term unemployment, particularly among men in the former areas of heavy industry, remains a problem. Moreover, just over 15 per cent. of unemployed people leaving the claimant count moved on to sickness benefit. Those who do get other jobs are more likely to end up on the claimant register after a relatively short period. The Employment Audit concluded that the job opportunities on offer depend strongly on the length of time a person has been unemployed. The longer people have been unemployed, the less likely they are to enter permanent jobs, whether full-time or part-time.

The Government have frequently cited the decrease in the claimant count as being evidence that unemployment is being effectively dealt with by present policies. However, large numbers of newly created jobs are either part-time or temporary—perhaps better described as casual employment. Much of that is quite appallingly badly paid. There are frequently no non-wage benefits, such as sick or holiday pay. A man made redundant and forced to accept casual work as a rent-a-car driver, recently told the TUC that as a casual he did not receive holiday pay or entitlement to a pension and that his pay was only £2.45 an hour. Another man employed part-time on print finishing was receiving £2 an hour, again with no paid holidays or paid meal-breaks.

The entrepreneurial society, with the lack of any employment regulation at all and the pressure on the unemployed to take any kind of job after a period of unemployment, has certainly created a very happy environment for sweat-shop employers. As I indicated earlier, there is little doubt that poverty created by unemployment or low-paid employment is a prime cause of ill health. Unemployment undoubtedly increases stress and causes depression. We live in a society in which we tend to define ourselves by what we do. Those without work therefore automatically feel excluded. The World Health Organisation concluded after a survey of extensive literature on the subject that: it is almost certain that unemployment damages mental health and probably that it also damages physical health". Tuberculosis, the classic disease of poverty, is making a comeback after declining for most of this century. It is far more likely to spread among people living in overcrowded conditions. The rate of tuberculosis rose 12 per cent. between 1988 and 1992, but the increase was noticeable only among the poorest 30 per cent. of the population. The rate of infection of the poorest 10 per cent. rose by 35 per cent. Furthermore, if you are poor you are more likely to die earlier. The mortality rate for unemployed men who are unskilled is nearly three times that of employed men from the professional classes, a point which has been made today.

Everyone should be concerned about the link between poverty and ill health for the obvious reason that it costs taxpayers more through increased NHS costs. Moreover, as the Victorians discovered in the last century, communicable disease can become established among the poor and then can be passed on throughout the rest of the community, ultimately threatening those who are not poor.

It also makes sense to deal with the problems arising from low pay. Why should the taxpayer subsidise sweat-shop employers through the social security system? Those are reasons why a minimum wage makes sense, despite what noble Lords opposite have said today. Far from reducing the number of jobs available, it could well increase them. It would force low paying employers to pay for the work that they want done. It is not true that the minimum wage is responsible for unemployment in a number of EU countries. Other considerations are involved in their unemployment statistics. Indeed, France has had a minimum wage since 1950, and for long periods during that time unemployment figures were not so high. It is quite wrong to say that if we introduced a system under which very low-paid people received at least a minimum standard there would be less work. I believe that the opposite will be true. We have already seen what has happened since the abolition of wages councils. People are working for appallingly low rates which are being subsidised by the benefits system.

Poverty and ill health resulting from unemployment and low pay actually costs us all far too much. I refer to NHS costs and social benefits and to the threat to the general health of the population. We can and should take steps to deal with these social evils.

4.58 p.m.

Lord Butterfield

My Lords, I hope that your Lordships will forgive me if I take a slightly different tack in the discussion. I am confident that everyone in the Chamber would like to alleviate the problem of some people in this country having poorer prospects as regards sickness. I wish to bring to your Lordships the idea that some—I do not say all—of people's ill health is due to self-inflicted, serious mistakes in judgment about what they are doing to their bodies and their health.

I was most impressed by the opening statement of the noble Baroness, Lady Jay. I am grateful to her for launching the discussion, which is close to my own heart.

I was very impressed by the speech of the right reverend Prelate the Bishop of Lichfield. I could not help but agree with so much of what he said. I believe that I could have spoken earlier in the debate. However, I make a personal point on that. One wonderful thing about coming in late is that one can make remarks to so many of one's colleagues and in that way improve one's friendships and collaboration in the House. Therefore, although I thought that I was to speak earlier, I am very happy to bat at number 13.

Many noble Lords have touched on the evidence as regards the relationship between income groups and illness. In a survey with which I was involved recently, I noticed that references were made to Quick and Wilkinson, who published in the Socialist Health Association Journal; to Whitehead, who published from the Health Education Authority, and Williamson from the Trafford Centre at the University of Sussex. Of course, that centre was set up in memory of a former Minister of Health in this House, although sadly he was Minister for only a very short time. This is not for the record, but he died from smoking. It is dreadful for that to happen to a doctor, but that is the truth.

Something which has been touched upon and appreciated in the debate this evening has been the question of poverty and ill health and the relative poverty in some developing countries. The question about the adverse effects of poverty not being so obvious in, for example, Africa, was rebutted in a way by those two remarkable men who worked in backward parts of the world—Cleave and Burkitt. They brought to us in this country the importance of fibre in the diet. That may perhaps have fended off the need to pay proper attention to the Black Report. I do not know, but I suspect so.

I am intrigued by the fact that policy has been framed on the studies of people who are extremely concerned and link closely with statistics on health. I am thinking about Tom McKeown, professor of social medicine at Birmingham, who underlined the importance of income and housing in relation to health. I am thinking about Sir George Godbar who was a doughty supporter of the poor. We have all heard of Sir Douglas Black today, but his successor, Acheson, and our present Chief Medical Officer, Dr. Cadman, are both very concerned about the relationship between income and health.

As a practising doctor, I was not a statistically-minded man. My approach has come from my experiences of a person-to-person relationship. I noted quite early on when I went to work at Guy's Hospital that I had one or two patients whom I could not convince of the devastating effects of smoking on their lungs. Perhaps the first time that I recorded real failure was when I wrote a prescription for a Mr. Baker who needed antibiotics to ward off infections on his chest when they overwhelmed him rather than waiting at home until he became sick and came to the hospital casualty department.

I remember on another occasion a man of immense wealth, an American with diabetes. Despite all I said to him, he put on a beautiful pair of new shoes, drove in his beautiful new Jaguar motor car to see his son-in-law who was a whisky distiller in Scotland. He was appalled when it was clear that he had early gangrene in his little toe as a result of those tight shoes. Man-to-man, one becomes very worried about health education when that kind of thing goes on, when one is doing one's best for the patient.

Another man whom I knew—and this is an aside but I cannot resist talking about him—was the harbour master at Virginia Beach in Virginia. While playing poker on Christmas Eve, he was infuriated by the chief of police who was cheating. He snatched his gun and shot him in the chest. Of course, he ended up in prison where he was a volunteer for some studies with which I was involved. He was gaoled in America with A1 Capone's safe cracker. His punishment for the rest of his life was to know that he could crack any safe and walk off with the contents at the drop of a hat.

I wish to tell your Lordships that I became involved with the idea that behaviour is very important as regards ill health in the 1970s and the 1980s. I became involved with the Health Promotion Research Council in the late 1980s. I have been sending your Lordships copies of our reports which I expect quickly found their way into waste bins. But those of us who were concerned with that felt that we were doing some quite good work.

We found plenty of evidence that bad judgment and risk-taking have extremely adverse effects on health. We became more and more aware also that there was not quite such a close relationship as my good friend Douglas Black pushed between pay and remuneration and health. We found that those groups of people who had quite marked rises in their salaries—perhaps 30 per cent. or 50 per cent. over 10 or 20 years—very often were rapidly running towards obesity and diabetes. Since I have been interested throughout most of my career in diabetes, I am appalled that people between our first and second survey for the Health Research Trust were putting on between five and seven pounds and over an inch on their girth in just seven years. If that continues, that will lead to a great deal more diabetes which costs the health service something in the order of £0.5 billion per year.

Therefore, I am personally very anxious that we should develop more man-to-man or person-to-person attempts to improve health behaviour. I am sure that that is extremely important. The Moslems make the point that men dig their graves with their teeth. In the case of obesity and diabetes, that is certainly true. It seems to me that as we are all very concerned about this, it must be for someone like me to try to lead to some collaboration between us all. It is extremely important that we should get more help from those who know how to deal with individuals. My profession grew out of the Church. I believe that the Church and the medical profession should spend more time trying to improve health knowledge, education and behaviour.

There must be a big drive to help unemployed people. I do not know how that can be done. I believe that people from the Church can help, as can social workers. The Department of Health should perhaps work with the Home Office in that very important field. In helping criminals' families—a group very much at risk—again, there should be a link between the Department of Health and the Home Office. That might achieve much. We doctors and nurses must realise that the provision of such help must not rest solely on the professions. There needs to be a wide group of people who can provide support and who will work together towards that objective, irrespective of immediate political loyalties.

5.9 p.m.

Lord Ponsonby of Shulbrede

My Lords, I begin by thanking my noble friend Lady Jay for giving us the opportunity to discuss this very important subject. Some noble Lords have apologised for the excessive use of statistics in their speeches. I must warn your Lordships that I too shall use a lot of statistics but I shall not apologise for it. I believe that whoever said that there are lies, damn lies and statistics was quite wrong. When properly interpreted, statistics give a picture of truth that even the most backward-looking of governments or political parties cannot fail to ignore. I wish to talk about the effects of childcare on the family as a whole in relation to their health.

For many families today having children leads to poverty. In 1992–93, 33 per cent. of children were living in families with below 50 per cent. of the average income. In 1979, the figure was 10 per cent. According to that definition of poverty, some 4.3 million children live in poverty today—that is three times higher than in 1979. Moreover, 18 per cent. of children in two-parent families, some 185,000 children, are living on or below the income support level and 78 per cent. of children in one-parent families (some 184,000 children) are living on or below the income support level. One-parent families have a high risk of living in poverty. In 1990–91, 11 per cent. of the poor were one-parent families, whereas 6 per cent. of the population were one-parent families. Therefore, one-parent families are almost twice as likely to be living in poverty.

Poverty has an enormous impact on the lives of families. It affects what they eat, what they wear, their housing conditions and their safety. The Health of the Nation report, about which we have heard this afternoon, stated that life expectancy at birth is around seven years higher in social class I than in social class V. Recent research from the Family Policy Studies Centre has shown that, on current benefit levels, one-parent families who live in the poorest conditions, and who have lived in such conditions for some time, cannot afford to eat a healthy diet.

The DSS commissioned research from the Social Fund which showed that 35 per cent. of single parents on low incomes did not have adequate bedding for all members of their household. It also showed that 31 per cent. lack hot water, that 58 per cent. have inadequate heating and that 38 per cent. have dampness problems in their properties.

In order to support a family, most families need both parents to be in work. Currently six out of ten couples with dependent children have both parents in employment. The majority of mothers are in part-time work, many of them working very short hours. The lack of good quality, affordable childcare is an important factor in determining a mother's position in the labour market. There is only one childcare place for every nine children under eight years of age and there are about 800,000 children under 12 years of age who go home on their own after school every day.

Many women are unable to keep their jobs when they have children and, when they return to work, they return to jobs with much lower rates of pay. Childcare is an important factor in the process. Although there is a system for subsidising childcare for the low paid in the form of the childcare allowance, for those on family credit, few two-parent families benefit from this allowance.

I turn now to statutory paid maternity leave, which is only 18 weeks in this country, and many women do not even qualify for that. There is no statutory paternity leave and that is out of step with standards in the rest of Europe. In addition, there is no right to introduce flexible working hours which would help so many parents. On top of all that, British men—as I know only too well—work the longest hours in Europe. That is no doubt partly to compensate for their wives' low wages. Indeed, I can say with some feeling that long hours do absolutely nothing for family life.

Single parent families face the particular problem of having to combine being a parent and providing an income for the family. I should point out that 90 per cent. of single parents are women and that 75 per cent. of single parents have to rely on income support. Poverty and ill health become a vicious circle. In the recent survey of single parents, one in six were unable to work because of ill health either of themselves or their children.

There are practical measures which can be taken to ease the situation for all parents, especially single parents; for example, enhanced maternity leave, the introduction of paternity leave and the increased availability of flexible working practices. Tackling the quality, the availability and the affordability of childcare would enable more parents, especially those on low wages, to support their families through work while ensuring a good quality of life for their children. These are not necessarily expensive measures but they would make an enormous difference to all parents in this country.

5.15 p.m.

Lord Desai

My Lords, I believe that being 15th on the speakers' list Is a positive advantage, to follow what the noble Lord, Lord Butterfield, said. Perhaps I may start on a very different tack from that outlined by other noble Lords. I should begin by congratulating my noble friend Lady Jay on what has proved to be a most interesting and multi-faceted debate on aspects of poverty and health.

The interesting thing about the Black Report, which came out in about 1981, was that it pointed out to us that the effect of poverty on health persists despite much effort on the part of society to reduce it. I should like to cite one interesting statistic in that respect. My noble friend Lord Ponsonby told us that the difference in life expectancy of those in social class I and social class V is seven years. In America, a comparable difference between the life expectancy of a white male and a black male is 30 years; in other words, the life expectancy of the black urban male in the United States is below that of a man in Bangladesh.

The difference between life expectancies in this country and in America is a great achievement of the NHS. Let us not forget that fact. We cannot say that we have achieved nothing. The Black Report really said that despite making healthcare accessible independent of income—at least as regards medicinal care, while not mentioning other expenses—a national health service can achieve a great deal but it cannot achieve everything. On the other side of the equation is poverty, and a national health service cannot eliminate poverty. Indeed, poverty has to be tackled by other measures. That is a most important point with which to begin.

I turn now to the subject of definitions. Perhaps I may give your Lordships an historical account as regards defining poverty. Interestingly enough, the defining of poverty originated in this country in the 1870s when primary school education became compulsory. The fee for such education was one penny per week for each child. Local school boards had to make a decision and decide whether those children whose parents could not afford to pay should still be allowed to attend school. That is when the first poverty line was defined in this country. So the original concept of poverty concerned not so much the mundane considerations such as food and clothing; it concerned the life chances of children who could not go to school.

As my noble friend Lady Turner of Camden said, that amounts to exclusion. If you cannot send your child to primary school and all the other children in the neighbourhood can attend, your child is effectively excluded. That is why poverty matters. Indeed, it matters very much to me because, if you are born into a poor family or if your family becomes poor, it affects your life chances. Therefore, we must make other arrangements to ensure that the life chances of children are not affected by the poverty of the parents. As much as we have been able to do that in the provision of healthcare, we must also think how we can deal with the problem by way of other measures. That is what will make us a better society.

Many points have been raised by other speakers but perhaps I may just make one or two comments which are relatively complimentary. It is not true to say that demand for healthcare is unlimited; that we cannot afford it; and that, therefore, we must do something drastic to cut government expenditure. I have looked at Social Trends. I promised the noble Baroness who is to reply to the debate that I would not give too many statistics. I shall try to make a spiritual speech, as far as an atheist can make a spiritual speech. Social Trends shows that real government expenditure has decreased over the past 15 years by about £20 billion or 6 per cent., while real disposable income has risen by 50 per cent. Therefore, we are not spending unlimited amounts of money. Government expenditure is not out of control. If there is less government expenditure, yet we allow higher private incomes, while that is good for most people it hurts the poor the most.

If properly directed, government expenditure provides the poor with a cushion. This is where I think poverty and ill heath come together. One simple example of that is overcrowding in housing. Over the past 15 years we have spent only half as much on housing and community facilities as previously. Over the past 15 years the figure has decreased from £20 billion to £10 billion. However, we have had to spend considerably more on social security. Had we spent as much on housing as we used to, we would have had to spend less on social security and there would have been fewer health consequences. If people cannot afford good housing, they go into bad housing. Bad housing is more expensive because, ultimately, it leads to ill health. Of course the National Health Service bears the cost of ill health but that does not mean that society does not bear the cost of ill health. We have to remember to take not a Treasury view of costs and benefits but a more common sense view of costs and benefits. The noble Earl, Lord Russell, has always pointed out that if you make cuts somewhere, costs arise somewhere else; it is just that we do not see those costs arising.

We have tried to make economies in areas such as housing by, as it were, privatising it. That is helpful if one is an owner-occupier. However, it does not help if one does not have the means to buy a property. One has to resort to rented accommodation, which is expensive. Consequently people become homeless, live in hostels or accommodation which is not properly heated, is damp and which causes ill health. That is a cost.

I now wish to mention another hidden cost of ill health. About 4 per cent. of the labour force is absent from work due to sickness. The figure of 4 per cent. may not sound high but even if that 4 per cent. of people contributed 2 per cent. of GDP, that is £15 billion. That is not a small sum of money. Absenteeism is costing us that sum of money, despite having a good health service. We must look again at the issue of poverty. There has been a fall in the number of adult working males who are between the ages of 25 and 55. Jobs for the relatively unskilled have disappeared. Therefore we must systematically consider how we can restore jobs for the relatively unskilled. Sooner or later we shall once again have to grasp the nettle of restoring and increasing real public spending, because that is the best hope for the poor.

5.24 p.m.

Viscount Brentford

My Lords, I too wish to thank the noble Baroness, Lady Jay, for introducing this debate. As the noble Lord, Lord Desai, quite rightly said, it has been a most interesting and varied discussion covering a wide area. I apologise to the House and to my noble friend Lady Cumberlege in that I have a prior engagement this evening and will not be able to stay until the end of the debate.

Income levels are important for the health of families and of individuals right across the board and not only to those living in the most abject poverty. I refer to the two Whitehall studies of the Civil Service. This research has shown that those in the lowest ranks of the Civil Service are three times as likely to die in a given period as those in the senior ranks—the administrators. Similarly, there is a gradient. In each rank people are more likely to die in a given period than those in the rank immediately above. As I understand the research, income levels across the board affect people's health.

Similarly, men and women in the lowest grade of the Civil Service are shown to have six times more sick leave than those in the highest grade. I do not believe that even those in the lowest ranks of the Civil Service are people that we would consider to be living in real poverty. The higher one's income, the better one's health. That is common sense to me but it is something which needs to be pointed out in this debate.

Why is it that the higher one's grade and one's income, the more likely one is to have better health? Many of the reasons for that have already been mentioned. The higher one's grade, the more likely one is not to smoke; the more likely one is to take exercise; the more likely one is to have a healthier diet and the more likely one is to have better resources as regards housing, transport, heating and diet. All those points have been well made and they are obviously relevant to one's health.

There are two other factors which are also relevant to health, one of which is called the psycho-social factor. To put that in English that I understand, I believe it means that an individual has support, affirmation and encouragement both at home and at work. Today I had lunch with a man with whom I discussed the need for the employees in an enterprise with which we are both involved to receive much affirmation and encouragement from those of us who are involved but do not work there. We all need that support and it is relevant to our health. The support I receive from my wife helps and encourages me. I am sure that it is conducive to better health than would be the case if I were without her. As I said, I believe this support is important for health. In this place we can all offer one another that support. We can offer that support to people in employment, to our families, to charities or whatever we are involved in. We can offer support and thereby contribute to the health of the nation.

The second factor I wish to mention—our income levels are relevant to this—is that those in unskilled and repetitive jobs are more liable to stress than those in high pressure, varied jobs. I found that piece of research interesting because it contradicted my own thinking. I had always thought that people who had high powered jobs working at great levels of intellectual capacity and physical pressure were most subject to stress. But it now appears that those in unskilled and repetitive jobs are more subject to pressure. They have less control over what they do; they have less variety in what they do; and less prospects for future development. I believe that all employers need to bear that in mind and endeavour to give everyone variety in what they do. That, again, will contribute to the health of the nation.

I referred to smoking. I am interested to read that people in the lower social groupings in the country are five times more likely to die from lung cancer than those in the top social groupings. That is a message we all need to hear.

Last week in this building, I listened to a talk about drugs. When one bears in mind that someone on drugs may have to pay out something like £500 a week, one can see that there are grounds for poverty let alone ill health in that situation, regardless of criminal tendencies.

Much healthcare in this country is equally available for all whatever their income group. I have recently seen the excellent provision by the NHS for a mother in the course of a birth—the hospital services, the midwives and the health visitors. Those services are available for all whatever their income level. I believe that the NHS does a magnificent job in that regard.

I understand, too, from research that all social groupings visit GPs to a similar extent. However, the indications are that the lower social groupings make less use of available health resources. We have talked about the need for education on using the available resources, and in regard to behaviour patterns, exercise, and so on. Perhaps I may ask my noble friend Lady Cumberlege whether the NHS prioritises inner cities and other areas of deprivation to ensure that those people are encouraged to use the available health resources which the NHS provides.

The average income of the poorest 10 per cent. of the country has risen by nearly 50 per cent. in real terms in the past few years according to the DSS. That is encouraging. I know that the mortality rates among those in the lowest income levels are not good, as some noble Lords have said. That issue needs attention. But I believe that we are on an improving pattern. As the noble Earl said earlier, the poor are always with us. That is not a ground for complacency. Those words of Jesus Christ are a challenge to all of us to keep improving our standards. That is what I believe the Government are doing and what all parties seek.

Lord Rea

My Lords, before the noble Viscount sits down, and as we have a little time in hand, perhaps I may say how grateful I am that he referred to the Whitehall study. However, he implied that the better health of the higher grades was due to the fact that they led a better life style—less smoking, more exercise and so on. But Professor Marmot and colleagues took that factor very much into account. They allowed for all known risk factors that one can think of, and still they accounted for only a 25 per cent. difference in mortality and sickness absence rates. All known risk factors accounted for only 25 per cent. of the gradation.

Viscount Brentford

My Lords, I make no comment on that. I agree with it. I do not think that that affects the main thesis of what I said, but I thank the noble Lord.

5.35 p.m.

Lord Murray of Epping Forest

My Lords, the noble Viscount, Lord Brentford, drew our attention to comparative death rates of people in lower social classes. It is a fact of life, and of death, that children born into social class V, essentially defined by level of income, are 50 per cent. more likely to be stillborn or to die in the first week of life than those born into the top social class. Sixty per cent. are more likely to die in their first year of life than those born into the top social class. The life expectancy of children born to social class V is around seven years less than those born into the top social class. Many factors contribute to that. One factor on which I propose to speak, and to which reference has been made by several noble Lords, is poor housing.

Low income is correlated with poor housing and there is a particularly strong correlation between low income and temporary accommodation, including bed-and-breakfast hotels and short life flats. "Temporary" can be anything from a couple of weeks to several years.

Many studies have highlighted the ways in which the long-term use of temporary accommodation affects the physical health of children, notably through bronchitis, colds, flu, and so on, as well as their mental health and their behaviour.

However, no less significant—it is a point to which I particularly wish to draw your Lordships' attention—is the higher incidence of children who sustain accidents in those substandard living conditions. The Government's report The Health of the Nation recorded that children in social class V are four times more likely to suffer accidental death as those in social class I. I shall address my remarks to the incidence of accidents to children and to the relationship between child accidents and inequality. I very much welcome the observations on this issue made by the right reverend Prelate the Bishop of Lichfield.

Accidents are the single biggest cause of child deaths in the UK, killing more than even childhood cancers such as leukaemia. In 1993, the most recent year for which I have figures, 585 children aged under 15 died in the UK as the result of accidents. The Child Accident Prevention Trust estimates that no fewer than one in five of the population under 15 attends hospital accident and emergency departments each year because of accidents. My noble friend Lord Desai drew our attention to the cost of many factors. It is worth noting that the cost to the NHS alone is estimated at £150 million a year, without taking account of the costs to the police and other emergency services.

The rate of child deaths in the UK through accidents is falling. That in itself is more than welcome, even though the rate of decline is lower than the general fall in child deaths as a result of illness and disease. Unfortunately, there are no comprehensive official statistics for non-fatal child accidents, but estimates by the Child Accident Prevention Trust suggests that there has been little, if any, change in recent years. Does the Minister agree that this is an obstacle to the development of an effective prevention strategy? What is being done to improve the collation of statistics on accidents?

What is beyond doubt is the higher incidence of accidents to children in poor families living in poor accommodation. I refer, to burns, falls from heights, spillages of hot liquids, and so on. Child accident statistics published by the Office of Population Censuses and Surveys shows that children in social class V are nine times more likely to die as a result of a fire than those in social class I. We are always hearing of fires caused in bed-and-breakfast accommodation by the use of substandard gas heaters and overturned paraffin oil heaters.

Until 1988, families on benefit could claim one-off payments for household equipment if they could show that, without it, there would be serious risk to health and safety. That covered household equipment such as efficient heating appliances and fireguards, as well as such items as stairgates. Since the introduction of the Social Fund those payments are no longer available. The only way to get money for a fireguard is through a discretionary loan repayable by deductions from income support—itself set at a level which falls well short of meeting minimum tolerable standards. My noble friend Lady Symons of Vernham Dean drew our attention to the invidious choice imposed on many people between heating and eating. No less invidious is the choice imposed on many mothers between feeding themselves and protecting their children against danger.

Those hazards are increased by the location and quality of accommodation for poor families. Children are particularly at risk from accidents on the higher floors of high-rise flats—notably falls from windows or balconies. Most housing authorities accept that it is inappropriate to house families with children in such conditions; but as the number of homeless families increases, some authorities are forced to compromise their policies in order to reduce the number of families living in B&Bs.

It is also a matter of concern that, according to the Health and Safety Executive, injury rates are rising in our schools. In a 1994 survey, the National Union of Teachers reported that in nearly one school in five a pupil or staff member suffered an injury or illness linked to the condition of the school's fabric. With capital spending on school buildings and maintenance at half the level it was in real terms 20 years ago, that is not surprising. What does surprise me is that I understand that the minimum standards laid down in the 1981 Education (School Premises) Regulations are to be replaced by weaker standards. That will only intensify the risk of accidents in schools.

I fully take the point made so ably by the noble Lord, Lord Butterfield, about the relationship between behaviour and health. I believe it is quite consistent with that to suggest that there is also a relationship between the Government's behaviour and the health of our citizens. I suggest that there are in particular three ways in which the Government might with advantage modify their own behaviour in order to help reduce the number of accidents to children and reduce the inequalities which expose the children of low-income families to greater risk of accident.

First, essential safety equipment should again be made available through grants, not by loans against income support. Secondly, as was emphasised this afternoon, we need much more vigorous action to improve the housing options for low-income homeless families. And, thirdly, local authorities should be firmly directed, and adequately funded, to enforce acceptable safety standards in bed-and-breakfast and other forms of temporary accommodation.

I welcome the assurances of shared concern and protestations of solicitude from so many speakers from the opposite—I almost said, prematurely, Opposition—Benches, notably the noble Baroness, Lady Brigstocke, and the noble Lord, Lord Birdwood. Against that background of support I urge these proposals on the noble Baroness the Minister with yet more confidence.

5.44 p.m.

Lord Prys-Davies

My Lords, in 1980, the Secretary of State for Health of the new Conservative Government dashed many hopes when he promptly rejected the recommendations of the Black Report, claiming that the cost was: quite unrealistic in present or any foreseeable economic circumstances, quite apart from any judgment that may be formed of the effectiveness of such expenditure in dealing with the problems identified". That seems to be as depressing a decision as one can imagine from any government department. The failure since 1980 to implement any of the Black Report recommendations has caused disappointment to many and must have caused a great deal of needless suffering on the part of many of the poorest families.

However, as we heard from many speakers, the Black Report has not gone away. I noted the caveat of the noble Lord, Lord Butterfield, but it seems to me that the basic theme of the Black Report has been re-stated by many subsequent authoritative studies and papers which gave ample warning of a correlation between health and poverty. That is one of the reasons for our concern; namely, that the gap in health status between the social groups has grown since 1980. That point was forcefully made by my noble friend Lady Symons.

To my mind the most striking support for the recommendations of the Black Report comes from the medical profession and is to be found in the 1995 report from the Board of Science and Education of the BMA. After acknowledging that there will always be a need for more research into the correlation between health and poverty, the BMA nevertheless concluded: the currently available evidence is more than sufficient to enable effective policy development". I should be grateful if the Minister will tell the House how the Government respond to that finding of the BMA. We are entitled to know how they view it.

There is also the impressive evidence of Sir Donald Acheson, the department's former Chief Medical Officer. In his 1991 annual report—his final report—he summed up: The clearest links with the excess burden of ill-health are: low income, unhealthy behaviour and poor housing and environmental amenities". I should very much like to hear from the Minister when she replies whether the Government agree that poorer families need more income, better nutrition, improved homes and better access to education, as well as health education and equal access to the best medical services according to their illness needs.

Do the Government still maintain, as they did in The Health of the Nation, that health inequalities are too difficult to understand? Is that their position?

There has been frequent reference during the course of the debate to The Health of the Nation. I should tell the House that we in Wales find ourselves in a dilemma over that document as we are still awaiting a health strategy document from the Welsh Office. The Welsh Office produced a draft health strategy document some two or three years ago, but for reasons that are not well understood it has never seen the light of day. Although the noble Baroness the Minister has no special responsibility for the Welsh Office, can she explain the delay and say whether or not a strategy document will be produced before the general election?

The importance of children is properly included in the Motion. It has been thoroughly examined by many speakers this afternoon and I have nothing to add except to make one brief comment. I believe that the first textbook to be written in the English language on children's diseases was written by a physician practising in rural Wales, Thomas Phaere. In his book, The Boke of Chyldrene, there is the sentence which in modern English reads: Here to do them good that have most need, that is to say children. Those words were written about 400 years ago. They are still true today.

I wish to mention the need to reduce differences in health status between and within regions to which reference has been made by the right reverend Prelate the Bishop of Lichfield. I believe this particular need is relevant to the Motion before the House.

Over the last few months I have been trying to help a small ad hoc group of professional people to develop a scheme which would improve conditions for young mothers and children in the small township of Blaenau Ffestiniog, high up in Snowdonia. It is a clearly defined community with a population of about 5,500. It has a sense of history and belonging, but it has also a sense of deprivation. It has exceptional problems, many jobs have disappeared. There is long-term unemployment as well as youth unemployment. Many young mothers are without work and often without skills. Income is low. Social security dependency is high. There seems no immediate prospect of economic growth and there is much ill health and mental illness. There may be a problem of drug misuse but surprisingly, according to the local office of the clerk of the magistrates, the relevant information on drug abuse is not readily available. So to my mind there are signs of bureaucratic inertia.

However, my hopes are raised because at shopfloor level an ad hoc group of devoted and imaginative local child health professional workers and voluntary workers has not allowed barriers to come between them. They have brought forward a scheme for assisting young families and young people of the area. It seems to me that that is similar to what was described by one speaker this afternoon and it is just the kind of local initiative that requires encouragement. Barnados in Wales has been and remains a considerable source of advice to the group. I hope that the Minister will be able to give us an assurance that the need to support the initiative at Blaenau Ffestiniog and similar initiatives will be brought to the attention of the Secretary of State for Wales.

Looking generally into the future, a new Labour government will, of course, have a huge agenda. Nevertheless, I hope that it will in the first Session of the new Parliament aim towards implementing the Black recommendations, because that would be a move in the right direction, although I have no doubt that there may be snags of which the civil servants will advise.

5.54 p.m.

Lord Colwyn

My Lords, it is always a pleasure to take part in a debate on health initiated by the noble Baroness, Lady Jay. I must apologise to the House for missing some of the earlier speeches, particularly the noble Baroness's opening speech. It is not easy trying to contribute to a debate and having to miss an explanation of what it is all about, but noble Lords will forgive me when I say that my first duty has to be to my patients. Many of them are understanding when appointments are moved to enable me to take part in a debate, but I have to admit that I had not noticed the debate for this afternoon until it was pointed out to me by my noble friend Lord Oxfuird two days ago.

Although we sit on opposite sides of the House, I am well aware of and appreciate the continuing commitment of the noble Baroness to the state of care in the community and this afternoon her crusade on behalf of the less well off. The noble Baroness's debate is very interesting. I believe that successive governments—I mean Labour as well as Conservative administrations—have done all they can to raise standards of health throughout the community, providing ever-escalating funding to improve the quality of the health service.

Our debate this afternoon should be concerned not with the impact of poverty on ill health but with the poverty of knowledge on ill health today. The health service is free at source. Anyone can see a doctor, visit a hospital, have free treatment. What is often lacking is quality advice on the prevention of illness and on the maintenance of good health.

I agree with some of the remarks of the noble Lord, Lord Prys-Davies. The greatest advances in the promotion of health during the last century have been entirely due to the installation of efficient plumbing and drainage systems. Chronic illness is rising. I believe that I am correct in saying that at any one time almost one-third of the adult population has a long-standing illness of some kind.

The NHS has very little to do with health and far too much to do with sickness—with dis-ease. Sadly, instead of the NHS focusing on health, it has concentrated resources on illness. Surely it is a case of waiting for the horse to bolt. Only a dentist could mix a veterinary metaphor into an NHS debate. All that is taking place within the context of a general increase in the use of pharmaceutical drugs. Seventy-five per cent. of all visits to a GP end with the prescription of a synthetic drug. About 20 per cent. of all adults—that is something over 15 million people—are constantly taking some form of prescribed medicine.

I find that fact very disturbing, but it becomes even more menacing when considering the amount of illness which is induced by these very drugs. The assumption that the body can be regarded as a machine whose protection from disease and its effects depends primarily on internal intervention and the idea that illness can be classified into specific named diseases, each of which has a single cause, have led to indifference to and disregard of the external influences and personal behaviour which, without doubt, are the predominant determinants of health.

With our present attitudes to health, it is inconceivable to think that illness should be viewed as a helpful, although often severe, reminder that perhaps there is something at fault with one's lifestyle or attitude. It is precisely because this possibility has been largely ignored that so little attention is being paid to the whole concept of health promotion. Health promotion is about the maintenance of good physical and mental health. It has very little to do with medicine and disease management and everything to do with the ways in which people live and the social and psychological environments in which they do it.

Millions of people, whether they be rich or poor, suffer unnecessarily simply because they are not being directed towards maintenance of health. Merely to increase funding for the health service, to simplify access to doctors and hospitals, without first identifying key factors of health is a recipe for disaster. Many of your Lordships will have seen the recent plethora of articles and programmes on health in the newspapers and on television and the radio. They all have one message in common and I think that the commentators are finally coming round to the idea that health is very much related to environment, nutrition and good sense.

I have to admit that some of us here—and I declare my interest as President of the All-Party Group for Alternative and Complementary Medicine—have been saying for years and years that good health depends on what you eat, where you eat it and the maintenance of a good immune system.

May I quote an article from the Sunday Times of 19th January. It stated: Big increase in infant diabetes blamed on cow's milk feeding £ Doctors have discovered diabetes is increasing at an alarming rate of more than 10 per cent. a year among children under five. Experts believe that using cow's milk to feed infants and exposure to certain viruses at birth may be to blame". How many families do noble Lords know who could have told them 20, 30, 50 or more years ago that mothers' milk is best? The article went on: In New Zealand, researchers have found that large doses of a B vitamin can help prevent diabetes". I am sure that my noble friend will be aware of the recent problems concerned with the Committee on Toxicity's recommendations to the Food Advisory Committee on the toxicity of vitamin B6, which were accepted without any input or advice from the health food manufacturers or professional nutritionists. It is an issue which I hope to take up with my noble friend on another occasion, but it is an example of ignorance affecting health outcomes.

In the Sunday Times last weekend I read of a startling new discovery by Professor Phillip Lamey at the Royal Victoria Hospital in Belfast claiming to have worked out how to treat long-term migraine by adjusting the way teeth bite together, using small plastic splints to avoid the production of neuropeptide chemicals which trigger violent headaches. Is that a new discovery? A major breakthrough, indeed. My Lords, my dental colleagues and I have been treating such headaches for 20 years and the treatment has been dismissed by the majority of the medical fraternity as inconsequential.

So the answer to the noble Baroness, Lady Jay—and I hope the answer that she will elicit from my noble friend—is that the maintenance of health is dependent—as well as on housing and full employment—on water supplies, sewage disposal, elimination of atmospheric pollution and provision of a diet containing high proportions of unprocessed food and raw vegetables. Then, and only then, when we deliver a true health service to all should we be able to eat our words concerning the present concept of a health service based on sickness.

6.2 p.m.

Lord Borrie

My Lords, the debate initiated by my noble friend Lady Jay of Paddington has already been worth while and there are more speakers to come. The debate has attracted a large number of speakers.

Two years ago this month, the Joseph Rowntree Foundation published its authoritative report—some noble Lords referred to it this afternoon—on the subject of income and wealth. Among its key findings were that income inequality in the UK rose rapidly between 1979 and 1990 and that the pace at which inequality had increased in the UK was faster than in any other country of the world except New Zealand.

One of the members of the Rowntree team was Mr. Howard Davies, then Director General of the CBI and now Deputy Governor of the Bank of England. In a newspaper article on the day of the Rowntree Report's publication, he wrote that, when growing numbers of people become detached from the market economy, it represents a significant waste of resources and increases other social costs, in the health service and in the criminal justice system, as well as the social security budget.

Who can doubt, especially at this point in the debate this afternoon in your Lordships' House, that poverty and ill health are closely linked? The BMA paper of 1995 on inequalities in health, to which my noble friend Lord Prys-Davies referred a moment ago, confirmed the view of the Joseph Rowntree Foundation that inequalities in living standards had indeed increased in the UK since 1980 and that severely unequal societies—not just societies with high rates of poverty—had worse health and worse economic growth than less unequal societies. In 1987 the Health Education Council said that: all the major killer diseases affected the poor more than the rich". I shall not give your Lordships a number of statistics, partly because of the objections of my noble friend Lord Birdwood and partly because an adequacy of perfectly good statistics has already been given. Nor shall I refer to the particular problems relating to children's health because many of your Lordships have referred to children. I simply want to emphasise the importance also of the need to raise the standards of health and care of those at the other end of the age spectrum—the elderly. I do so because poverty among the elderly is widespread. It has a serious adverse effect on the health of the elderly. I am grateful to the noble Baroness, Lady Brigstocke, who said earlier that one-third of our elderly are at or below the poverty line—I repeat, one-third of the elderly are at or below the poverty line.

Fifty years ago almost all the elderly were poor. We know that that is no longer the case, at least for some elderly people—an increasing proportion of the elderly. A number of people enjoy the fruits of occupational and other private pensions and adequate care, if needed, either at home or in residential facilities. But there is tremendous and increasing inequality among the elderly. Apart from the group that I mentioned, there are those who are dependent on the state pension, topped up by various means-tested benefits, if they are understood and applied for, including income support. The very worst off are often those who are entitled to income support or other benefits but are put off from claiming through the difficulties involved, the stigma attached or otherwise in some way.

The elderly are living longer, which is partly due to the benefits of the health service and the rest, but inevitably as the years go by they become more prone to physical and mental ill health. If they are poor, they are likely to have a less healthy diet, poorer housing conditions, inadequate heating and less opportunity for and access to exercise facilities. All those factors will exacerbate the risk of ill health. The impact of such expenses as those for eye tests, which are essential to check on the possible advent of eye disease, may cause them to neglect or postpone taking desirable precautions, which better-off elderly people would take. It will be interesting to hear the Government's response to the Starred Question of my noble friend Lord Molloy, which deals with that matter, in two weeks' time.

Sadly, while it is generally understood that babies and very young children are extremely vulnerable and dependent, it is not always recognised and understood that there is at least a possible vulnerability, possible dependency and possible disability among the elderly. They are often overlooked. Some noble Lords may have noticed newspaper accounts last week of a report by the Association of Community Health Councils, backed up by over 200 complaints from families of hospital patients, which showed that in some hospital wards food for elderly patients is placed beyond their reach and no attempt is made to see whether they are strong enough to feed themselves. The eminent medical correspondent of The Times, Dr. Tom Stuttaford, formerly a Conservative Member of the other place, recounted in his column a personal experience of visiting in hospital an octogenarian relative, who was too debilitated to feed herself. Yet her meals were just put on her bedside table. Half an hour later, the food was gathered up again, with the jolly quip, "No appetite yet, I see".

Where, one might ask, is the old-fashioned nursing that would have coaxed the frail into taking the nourishment essential for their recovery and well-being? I am concerned that someone of Dr. Stuttaford's experience and eminence should comment—I use his words—that there is a "creeping tendency" in the National Health Service to regard the very old as expendable and undeserving of the expense of high quality care which ought to ensure their survival.

If I might draw a conclusion from the particular and, one hopes and believes, exceptional circumstances that I have just quoted about the possible position of the frail elderly in hospital, it is that here and more generally we need an approach that is holistic. Responsibility for the care of the elderly is surely not something which can be neatly divided up between, let us say, the dispensing of antibiotics, on the one hand, and the provision of food and cups of tea, on the other hand, with the availability perhaps of occupational therapy. Such divisions of responsibility may mean that really no one has responsibility for the patient as a whole person.

Similarly, as the BMA has put it, a "total approach", rather than just a service-oriented approach, is needed if inequalities in health are to be addressed in general for the whole population. People's health can be influenced by many different aspects of public policy ranging from dealing with the squalor of poor housing conditions to the adequacy of income in old age, from improved working conditions to the banning of advertisements for tobacco. As my noble friend Baroness Symons said, there is a need for a co-ordinated approach across a number of different government departments. This debate is as much about fiscal and welfare policies, public policy generally, as it is about the state of the National Health Service. It is surely a debate which is welcomed from all parts of the House.

6.11 p.m.

Lord Haskel

My Lords, that poverty leads to disease and early death is beyond dispute. That is why poverty is a matter of morality and not just a matter of economics. This debate is precisely about that—to draw attention to the moral issue of poverty and inequality causing ill health—and I congratulate my noble friend Lady Jay on her rather angry introduction, a justifiable anger if I may say so, shared by many of us.

On these Benches we have always been anxious to attack poverty and the causes of poverty because we see it as a moral issue. The noble Lord, Lord Birdwood, and the noble Baroness, Lady Brigstocke, implied that this view is shared by the Government. That is not so. The Government's view on poverty was clearly stated by the right honourable Mr. Peter Lilley, who, on 13th June, 1996, in a speech on welfare reform and Christian values in Southwark Cathedral, stated: Conservatives believe that eliminating poverty and pursuing equality are not merely different, they are ultimately incompatible. In other words, a trickle down view. Trickle down is a fantasy. All it does is lead to greater inequality and more poverty. My noble friend Lady Turner told us that, the Government know that, and I think even Mr. Lilley knows that because in November 1994 he said, The single most significant social change affecting the United Kingdom is not the ageing of the population, nor the breakdown of the family, nor the increasing proportion of women at work. Rather, it is a phenomenon which is still largely unrecognised—a growing dispersion of earnings". And he is right.

Many noble Lords have told us how income inequality has grown further and faster in Britain than in any major industrialised country except New Zealand, as my noble friend Lord Borne reminded us. My noble friends Lady Turner and Lady Symons gave us the figures. If we define poverty as net income at less than half the average earnings, poverty was 7 per cent. in 1979 and today it is 24 per cent.—nearly one in five of the working population. The noble Lord, Viscount Brentford, told us that the poorest 50 per cent. are better off. If this is the case they must have carried the bottom 10 per cent. of the population because they are considerably worse off in absolute terms. The richest 10 per cent. are much better off and this is what Mr. Lilley meant by the "growing dispersion of earnings".

My noble friend Lord Borne spoke of the elderly. The composition of the poor today is much more weighted towards the workless than the retired. The percentage of pensioners in the poorest decile has halved since 1979, while the percentage of unemployed has doubled. My noble friend Lady Turner reminded us that in Autumn 1996, 4.3 million people in Britain were without paid employment and wanting a job—more than twice the number of officially unemployed. This is why the Bank of England—and may I assure the noble Lord, Lord Astor, that they are no apologists for the Labour Party—in their quarterly inflation Report in July 1996 concluded: Almost the entire net improvement in unemployment performance in the 1990s, compared with the 1980s, was accounted for by the rise in inactivity". So the root cause of this inequality is not the tax and benefit changes since 1979, but the increased worklessness and widening income distribution. This was clearly brought out by the Rowntree Report and the report on social justice chaired by my noble friend Lord Borrie. And many noble Lords who have spoken have told us that poverty is caused by an absence of education, an absence of skills and an absence of opportunity.

But there are the poor who are in work caused by this widening income distribution. Among male workers, the gap between the highest paid and the lowest paid is now at its greatest this century. New evidence has shown that the growth in wage inequality is driven by skills.

Nor has just raising benefit been shown to be the answer to poverty. Welfare used to be a stop gap for short spells of unemployment. Now, welfare has become a way of life. What is worse, if you do get back into work, you are more likely to become unemployed again. Those who leave poverty have a tendency to fall back into it and the poverty trap has deepened in the modern labour market.

Paul Gregg's recent book Job, Wages and Poverty, shows why there has been a massive increase in workless households because of the poverty trap, and how the poverty trap has deepened with a cycle of low pay and no pay.

And so we have a picture of poverty: a large group of people who stand little chance of leaving poverty and unemployment behind because they lack the skills, the education and the opportunity; the unemployed, the economically inactive, and those on low pay subsidised by welfare. In total, one household in five has no breadwinner.

After almost two decades of Conservative Government, little has been done about this. Their failure to educate our workforce is legendary. And their legendary policy of a flexible labour market has left us with even greater poverty. The right reverend Prelate the Bishop of Lichfield said that prevention is better than cure. He is absolutely right. That is why the best way to attack poverty is by getting people into good jobs. And that is why Labour's anti-poverty strategy concentrates on raising education and skills level in the workforce and introducing welfare to work measures rather than just raising benefits. That will create a flexible workforce; not a flexible labour market to easily hire and fire but a workforce flexible in skills and abilities which can adapt to the changing demands of the economy.

That is why we will use the windfall tax to train 250,000 youngsters. That is why we will use the money from the assisted places scheme to reduce class sizes, and that is why we will seek to reduce the starting rate of tax instead of eliminating capital gains tax and inheritance tax. We will help the many to move out of poverty rather than help the privileged few. That is why we will also have a national childcare strategy.

The Minister will say that the Government are now intending to follow the same policy. They steal our clothes. Indeed, Mr. Lilley made announcements last week about training schemes designed to get people off welfare. I can only say that it is too little and too late, and point to the years of missed opportunity. And what a missed opportunity! Since 1979, there has been an unparalleled opportunity available for this Government to invest in Britain's people and to eliminate poverty. Let me explain. In today's money, the Government's income from the North Sea and from privatisation is equivalent to £35 million every single day for the past 16 years. Many would argue that this income comes from assets which belong to us all. To save the Minister time, I can tell her that this is equivalent to £6 per person per day.

My noble friend Lord Desai spoke about the effect of misdirected public expenditure on poverty. Would you not think that with an extra £6 per person per day, a reasonably competent government would have been able to reduce poverty and inequality? Instead of reducing poverty, this Government have managed to treble it. What an indictment of the Government's mismanagement! What an indictment of their priorities! What a missed opportunity to reduce poverty and inequality! What a missed opportunity to improve the nation's health!

6.21 p.m.

Lord Luke

My Lords, I should first like to thank the noble Baroness, Lady Jay, for introducing this important debate. There have been some excellent speeches. I have not agreed with everything that has been said and particularly not with what the noble Lord, Lord Haskel, has just said, but I shall try very hard not to be repetitive.

My interest in this subject stems from my family's involvement with health matters over four generations. Bovril was my old family company. We made a product called Virol, which was based on malt extract, and was widely known as a valuable food supplement for children and adults to help prevent rickets and other diseases derived from chronic malnutrition. So noble Lords can imagine that I was a little worried when I heard the noble Baroness, Lady Jay, say that the incidence of rickets had increased recently.

I have carried out a little research. I find that a recent survey by the Health Visitors' Association claimed that 4 per cent. of the health visitors asked had encountered a child with rickets. Whether or not that is true, I do not know. However, the Committee on Medical Aspects of Food and Nutrition Policy is inquiring via an expert sub-group into bone health in the United Kingdom population.

I belong to the Court of the Sons of the Clergy, a 350 year-old charity devoted to the relief of clergymen and women and their families. It does not, thank God, have to deal with extreme poverty, or penury, but frequently with the results of relatively low pay coupled with less than adequate management of limited resources. I mention this because it shows how difficult it is to define the word "poverty". Here I rather dangerously cross swords with the noble Earl, Lord Russell. I think it is important to define the word "poverty". In the Oxford English Dictionary it is inter alia, the condition of being without adequate food, money, etc.". I prefer to use the words "relative poverty", "inequality", "penury" or "extreme poverty", as "poverty" by itself conjures up in the minds of those who have not been attending this debate harrowing photos of starving children in Africa and other third world countries.

I believe there is no valid reason to find malnutrition through shortage of funds in this country. Available benefits, concentrated by this Government where they are most needed, have increased in value by more than inflation since 1979. They undoubtedly provide enough resource for living; not plush, luxurious living, but sufficient to get by on, and with good and sensible management of funds, a little more. This may not be ideal, but I believe that everything possible should be done to encourage independence and a move away from reliance on the state. However, many Labour politicians talk a great deal about poverty—we have heard a great deal of it today—high poverty levels and indeed increasing poverty levels. But really, my Lords, how many of those earning below the national average income do not have a freezer, central heating, often a car and sometimes a microwave, and, of course, that most important staple of all, a television set?

If the level of "poverty" is based by Labour on a percentage of the national average income, rather than as an absolute standard of living, then the goal posts continually move, and however rapidly the standard of living rises in this country there will always be relative poverty. Poverty itself—that extremely emotive word—can be used to show that the wicked Conservatives are condemning millions of fellow citizens to "poverty", implying a lack of resource to buy food—hence malnutrition of children. It is a poor argument.

The quality of food, and whether it will or will not keep people healthy, is a highly complex matter. I agree with the noble Lord, Lord Addington, that it is probably true that many teenagers and young adults do not receive in an acceptable and understandable way good advice and training on the nutritional value of different foods; for instance, the simple fact that fresh food should, by and large, be more healthy and does not often cost more.

In carrying out some research for this speech I have taken some information from a report from the Family Policy Studies Centre entitled Diet, Choice and Poverty 1994. Some rather interesting facts emerge from its survey of 48 of the poorest families in a deprived area of the Midlands. Junk food is often superficially more attractive to children and their parents too often take the line of least resistance. I can remember being in awful trouble through not wanting to eat my cabbage. I was made to, my Lords, and much the better I am for it. The report also shows that when a family is very poor pride has much to do with the priorities in terms of how it spends its money. If money is short, it appears that extra emphasis is put into keeping up appearances—street cred. That is very interesting. It also seems that there is a strong tendency to buy only food that it is known the children like, to avoid the possibility of waste, because there is no inclination to say, "Eat it, there isn't anything else". That does not seem to be right.

I have been concerned in the past with the Order of St. John. For a long time it has been trying to widen first-aid teaching in schools. I believe that first aid should be a compulsory part of the national curriculum in all schools. That would do more to save life and injury than anything else.

I shall finish with a brief quotation from Izaak Walton: Look to your health; and if you have it, praise God and value it next to a good conscience; for health is the second blessing that we mortals are capable of; a blessing that money cannot buy".

6.28 p.m.

Baroness Farrington of Ribbleton

My Lords, when I first became a Member of your Lordships' House, one of the best pieces of advice I was given was never to speak in anger, so I shall seek to abide by that. I speak with some trepidation in this debate. The noble Lord, Lord Butterfield, who is not in his place, referred to those of us who dangerously increase our risk factor by putting an inch on our girth as we get older. I am disqualified to speak. I am a self-admitted smoker but I support the Labour Party's ban on tobacco advertising.

In this debate I wish to speak about the effect of homelessness on the health of young people. Homelessness is generally devastating for young people and it impacts very severely on their physical and mental well-being. An NCH Action for Children survey of vulnerable young people, the majority of whom were in temporary accommodation or homeless, found that one-third had had only one or no meal within the past 24 hours; nearly all were following unhealthy diets—good, home-cooked broth is very difficult to make on the streets of Victoria at night. A disproportionately high number have been recently physically ill and the overwhelming majority were depressed and nervous. Unsurprisingly, these problems are most acute among those whom we shall pass tonight on our way home from your Lordships' House.

The 1995 Mental Health Foundation survey found a disturbingly high level of psychiatric disorder among homeless young people. A quarter had attempted suicide in the past year; more than half had been the victims of parental abuse or neglect; they had twice the likelihood of psychiatric disorder as other young people in that age group and only 15 per cent. were receiving treatment.

These are among the factors highlighted last week at the NCH Action for Children's Youth Homelessness Initiative, House Our Youth 2000. It calls for changes in housing and social services to develop a partnership approach; to develop policies and to respond to the need in particular for mediation when the young person first becomes homeless and seek to return him or her to the family; to devise strategies to improve access to, and the quality of, private rented accommodation and a more effective benefits safety net.

To those very sound objectives I would add the points raised by my noble friend Lord Haskel in his contribution to this debate. In particular, I single out investment in a satisfactory supply of high quality, well-insulated housing for people in need in this country. It is a scandal—I speak with sadness, if not in anger at this stage—that billions of pounds have been wasted, as the noble Lord, Lord Haskel, said, tied up in local authority budgets. I say to the noble Lord, Lord Astor, that the real tragedy lies in money which is tied up. The housing need is there, but local authorities are prevented from spending that money to meet the need.

It is a vicious circle. Many of the homeless young people come from poor quality, overcrowded accommodation which has put intolerable pressure on families. The grinding poverty that many have experienced in their families has contributed to the inability of the family to cope with a growing young person. I would not dare to go to those living in overcrowding and poverty—I declare an interest in local government as a councillor in Lancashire—and tell any young Lancashire woman that if only she borrowed my cookery book she could cook a meal for a family for 40p. on the day of the week before her benefit is due.

While there are examples of people who despair and give in and who lack the proper skills to be able to feed their families properly, most of them look at good quality food. I refer to those who have the confidence to look at the issues and organically produced food. They look at the price tags and go for the cheapest offer of processed food with which to fill their children. It is a vicious circle. It is the young people in communities with poor housing who are most likely to suffer unemployment themselves. We waste so much money in this country on the cost of unemployment instead of putting those young people to work.

We had this matter explained at Question Time. If it is right to tax the banks with a windfall tax, how much more worth while is it to tax the privatised utilities and their high level of resources in order to get these young people back to work. We have family pressure and poverty wages. I believe that the figure was 250,000 over-50s who have been excluded from the unemployment list. They are excused from being considered available for work. If this Government stay in office, those over-50s, single grandfathers, will be told that they may no longer seek help from social security in order to stay in their homes. They too will put pressure on family accommodation as they seek to get away from cheap rooming houses and try to move in with their married sons and daughters, creating greater pressure.

All these factors contribute to homelessness. I do not believe it is possible to look at what has happened in society and say that all the faults are those of the Government and their policies. That would be unreasonable. There is a cycle of factors which has occurred to create this very vulnerable group of young people. What has happened as that problem has grown? More and more young people sleep on our streets, first in the poorest areas of London, Glasgow and Edinburgh and then in the large cities like Manchester and Liverpool and now in some of our smallest market towns. It is possible to find homeless young people in those places. Health breakdown is one of the factors.

We on these Benches share all the concerns of the Government about law and order. But the most likely victim of violent crime is a young man. Statistically, a young man is most at risk. We walk past those young people whose health and housing needs are not being met, and who are not a worthwhile investment for those whose interest is making money out of housing. Their housing needs cannot be met by market forces. They are also the most likely victims of crime in the streets of our towns and cities tonight.

I said at the beginning that I had been advised not to speak in anger. I would speak in despair, were it not for one fact. I cannot stop because, like noble Lords, I am a parent and I cannot avoid seeing those young people on the streets. I do not come here in a paternalistic spirit. Despair will not solve their problems. I have been fortunate in my life. The young people to whom I have referred could have been my children in different circumstances. Any one of us can have a child on the streets if we are unfortunate. We all have a duty to work together to get them off the streets.

6.38 p.m.

Lord Rea

My Lords, when the noble Lord, Lord Butterfield, spoke as the 13th speaker, he considered himself lucky because of all the friends that he had gathered through listening to the previous speeches. However, by the time one reaches the 24th speaker just before the gap in the list of speakers, it is almost un embarras de richesse of friends that one has to think about. The other problem is that almost everything that one was going to say has already been said. Therefore, perhaps I may crave your Lordships' indulgence because I have had to do some mental cutting and pasting with my speech.

The noble Lord, Lord Luke, spoke about different kinds of poverty. He said that he preferred to speak about relative poverty. That is a reasonable aspect of the matter to look at. So let us think about the relevance of relative poverty rather than the people at the very bottom of the scale.

The importance of that has been demonstrated by Dr. Richard Wilkinson, who was introduced to us by the noble Lord, Lord Butterfield. He has stated that the greater the proportion of wealth going to the lowest 70 per cent. of the population—that is, to the majority of our people—or the more equal the distribution, the higher the life expectancy or, conversely, the lower the mortality rate. That is the case over quite a range of incomes per head in the developed world. Indeed, Dr. Wilkinson showed that that applied when 25 developed countries were compared. It has also been shown to be true when the individual states of the USA are compared. The more unequal the income distribution, the higher the mortality rate.

It was the same Richard Wilkinson who, when a post-graduate student, wrote an open letter which was published in the Guardian in 1977, to Lord Ennals (who was mentioned by my noble friend) when he was plain David Ennals, the Secretary of State, pointing out some worrying statistics that were beginning to appear which suggested that the mortality rates of the different social classes were again beginning to diverge after nearly two decades—the 1940s and 1950s—when the gap had started to narrow. Those were the decades of the 1939–45 war, of the first Labour Government and of the early years of "Butskellism".

Unlike the present government, David Ennals took immediate steps and within three months had set up the working group on inequalities under Sir Ronald Black, about which so much has been said. Although the Government rejected the Black Report, it was taken seriously by the research community, the World Health Organisation and by a number of other countries which began to look into their own health inequalities with considerable concern, even countries with Conservative health ministers such as the Netherlands.

Although the causes of the inequalities could not be fully disentangled by the Black working group, it concluded, there is £ much which cannot be understood in terms of the impact of so specific factors, but only in terms of the more diffuse consequences of the class structure: poverty, working conditions, and deprivation in its various forms". In other words, the health inequalities related to patterns of living over which the National Health Service is relatively powerless.

Practically all of the 37 recommendations of the Black Report are highly relevant today and although starting a decade late, the Government have partially implemented some of them. I refer, for instance, to the Health of the Nation strategy. That comes close to one of the recommendations, as does the setting up of a Cabinet committee, under Tony Newton, to monitor the progress of those Health of the Nation programmes. However, neither of those initiatives directly addresses the problems of social inequalities, as Black suggested they should. It would be interesting if the Minister could tell us how many times that high-level Cabinet committee on the Health of the Nation has met and something about its deliberations.

In much strengthened form, such a Cabinet-level, cross-departmental committee should be able to make a serious impact on many of the factors affecting health which lie outside the remit or capabilities of the Department of Health itself, such as poverty, housing, nutrition, working conditions, education and transport. Transport is particularly important in terms of the nutrition of people with lower incomes. If you live on a housing estate, you often cannot get to where the food is cheapest because the public transport system is not very good, particularly since the privatisation of bus services. There are also those much more subtle areas such as community support and stability, to which noble Lords on all sides of the House have referred. It has been calculated that living and working conditions are responsible for about 80 per cent. of the premature mortality and worse health of the less privileged part of the population. Factors which medical care can influence account for only about 20 per cent. of the total.

One of the Black Report's recommendations which has been vigorously followed (although not by the Government until recently) has been to increase research into health inequalities. Since 1980 there have been literally thousands of well conducted studies confirming and amplifying Professor Black's findings. My noble friend Lady Jay mentioned that I have recently carried out some research that is relevant to today's debate. I was going to keep that quiet, but as my noble friend has invited me to describe it, I shall do so briefly.

The study was carried out in a north London inner-city group practice. It is entitled Counting the Cost of Social Disadvantage in Primary Care. Its findings were based on a retrospective analysis of five years of patients' records. The methods used are described in our paper—here comes a plug, my Lords—which appeared in the British Medical Journal on 5th January. The main findings were that the cost per head of providing primary care, including medication, for patients in social classes I and II worked out at very nearly £100 per annum while the cost for those in social classes III and IV was £250 per head, or two-and-a-half times as great. That difference was rather greater than we had expected. We think that it is an inner-city effect. We found, for instance, that those in the lowest two social groups had 4.3 times as many episodes of serious illness as those in the professional group. The cost aspect of the study is a stark reminder of the other costs which poverty inflicts on the National Health Service—that is, if the care is equitably applied according to patient need (and there is evidence that it is not quite so equitably applied as we should like).

That is just one small piece of research. As I have said, there have been thousands of other well conducted studies. The most recent compendium of such studies is to be found in Health and Social Organisation: Towards a Health Policy for the 21st Century which was published by the Centre for Health and Society, which has just been established at UCL. One wonders what the noble Baroness, Lady Thatcher, our previous Prime Minister, would have thought of a centre with such a title. If studied, that volume could well serve as a basis for the health policy of the next government. I recommend it.

Our most important public health issue is the one that we have discussed today. With our new Minister for Public Health, we on these Benches will start to address the problem effectively as soon as possible from 2nd May.

6.50 p.m.

Baroness Robson of Kiddington

My Lords, I join other noble Lords in thanking the noble Baroness, Lady Jay, for introducing this debate. We have had a long and interesting debate with 25 speakers. No one who has listened to the debate can be in any doubt about the influence that social and environmental factors have on the health of the nation. It would be churlish not to admit that the health of the nation has improved over the years since 1970. That improvement has happened in all classes of society, but the difference is that the improvement has been greatest among the middle classes. That has inevitably resulted in the gap between the health status of the affluent parts of society and those in the poorer areas having widened during those years; in other words, it has become worse than it was when we all suffered poorer health.

One must therefore draw the conclusion that poverty, poor housing, environmental conditions and poor diet have a profound effect on the health of that part of the population in social classes IV and V. The evidence for that statement is overwhelmingly presented by the body of people who are most involved in providing healthcare in the community, such as the BMA, the RCN and the Health Visitors Association.

The BMA calls for the Government to consider, above all, their policies in the field of housing, unemployment, transport and the environment, and to relate them to their policies on health. It calls upon the Government also to look more closely at their cost-saving exercises in the NHS, such as the abolition of free eye examinations and its implications for the long-term health of people, particularly people over 65.

Of all tests, eye tests are probably one of the most powerful tools for diagnosing early signs of potentially dangerous conditions, such as diabetes, cataracts, glaucoma, detached retinas and even brain tumours. Those are conditions which, if detected in their early stages, can be treated effectively at a relatively low cost. The RNIB confirmed that people are becoming ill and suffering incurable eye disease because of the withdrawal of free eye tests. The Government claim that it would cost £120 million a year to reinstate free eye tests. I should like to ask whether, against that so-called saving, they have made any assessment of the inevitable future increased cost to the NHS of not treating people with more advanced illnesses at the right time because of the lack of an early diagnosis.

My noble friend Lord Russell asked the Government always to ensure that the savings are greater than the costs of the increased care that will have to be provided in the future. Eye tests are a good example of preventive medicine which we on these Benches would wish to reinstate.

The RCN is concerned especially about the impact of poverty on children in our society. Many noble Lords have spoken about that. They have said that there are today 4.3 million children living in households whose income is less than half the national average. In 1979, the figure was 1.4 million. There has been a three times increase since then. Despite that, the RCN is concerned that there is no mechanism for weighting community and district nurses and health visitors' care on the basis of need. Inner cities are areas of worst deprivation but they receive no higher priority for the supply of those community nurses and health visitors than other areas which do not have the same need.

Health services should target and focus always on those most in need, in particular people living in poverty. Probably the most disturbing report that I read when preparing for the debate is the one from the Health Visitors Association published in November last year. I do not believe that it is scaremongering. It goes as far as to say that Britain would seem to be returning to the social conditions of 100 years ago. According to its survey, 29 per cent. of health visitors encounter TB every year; 93 per cent. gastroenteritis; and 4 per cent. rickets. One of the most upsetting things that it found was that 83 per cent. of health visitors encountered failure to thrive among children, which, together with rickets, is a sign of severe malnutrition.

My noble friend Lord Russell suggested that there should be hospital tests to detect malnutrition. Malnutrition and an unhealthy infant diet have long-term implications for the future. We are looking to build up problems for ourselves in the future by neglecting what is happening in society, because malnutrition and a bad diet are likely to increase the incidence of heart disease in later years. It is a tragedy that the many improvements in health and welfare now possible are being undermined by extreme poverty.

Another problem which has been mentioned is the increase in asthma. It is a disease that is growing alarmingly. Sufferers from the most deprived areas are almost twice as likely to be admitted to hospital than others. On average, 155 children with asthma are admitted to hospital each day of the year in this country. There again, there seems to be no doubt that poverty has an enormous impact on the incidence. Damp and mouldy housing, together with high levels of pollution in urban areas, are largely responsible for the difference in incidence between social classes.

At the end of the debate there seems to be no doubt that poverty, poor housing and environmental conditions are responsible for the widening gap in health between social classes I and II and social classes IV and V. Genuine progress towards closing that gap will take place only with the involvement in the NHS of other government departments and local authorities. Too often actions are taken by other government departments, perhaps in a cost saving exercise, which have an enormous impact on the health of the nation and the cost to the National Health Service. Close co-operation between the NHS social services and social security and the departments responsible for the environment and housing are a prerequisite for any improvement in the status of health, in particular that of the poorest in our community. I charge the Government—whether the present Government or that coming in on 2nd May—to make sure that the departments which have an influence on the health of the nation work together and not against each other.

7 p.m.

Baroness Hayman

My Lords, I believe that the whole House will wish to thank my noble friend Lady Jay for her masterly, lucid and comprehensive speech and for giving so many Members the chance to speak on such an important subject. She has provoked a debate which has inspired many speeches of a high quality. They have not all been speeches of anger, but they have certainly been speeches of passion which has been rightly provoked.

The speech of my noble friend Lady Farrington was the better for being angry. It was a fine contribution and it reminded us that there are issues in our society about which we should be angry. Only with that passion will we tackle them. I say to the noble Lord, Lord Luke, that it is true that money cannot guarantee good health. However, a lack of money can certainly guarantee that one's chances of good health will be reduced.

The figures relating to children have been mentioned many times today. We know that a baby whose father is an unskilled manual worker is one and a half times more likely to die before the age of one than the baby of a manager or professional worker. We know that the poorest children are twice as likely to suffer from respiratory disease, four times more likely to be killed in a traffic accident and six times more likely to die in a house fire than are their counterparts in Social Class I. We should take those figures into great account and be angry about them. My noble friend Lord Desai said that there are issues at work which are not merely about the workings of the health service; they are issues which relate to overall social conditions in our country and issues which we must attack comprehensively.

There has been much debate about whether there is any real, absolute poverty in Britain today. My noble friend Lady Symons of Vernham Dean spoke about the people who in winter choose between heating and eating. My noble friend Lord Murray of Epping Forest spoke about the mothers who choose between feeding their children and protecting them from the risk of accident. They were expressions of real poverty in our society. Many of us read in the myriad of material available for the debate the stories from individual families about the choices that they must make. We are most reluctant to start hectoring about good housekeeping and feeding families well for a week on the kind of money that we can spend without thinking in one evening on a meal for four.

We should be concerned not only with absolute poverty but also with relative poverty because of its effect on illness and the cost of that to society and its effect on economic growth. That point was made by my noble friends Lord Paul and Lord Haskel. The work of Wilkinson was referred to by my noble friend Lord Rea and it has been shown that very unequal societies, not only those with high rates of poverty, have worse health and economic growth than less equal societies. Winston Churchill knew about that in 1943. He then stated that there was no better investment for a nation than to put milk into babies. He said that healthy citizens are the greatest asset that any nation can have.

If we are to perform economically well in the future we must perform well in terms of the health of our population. As regard concerns about child nutrition, when one compares countries, say, in the Pacific Rim, Malaysia and Singapore it is fascinating to note that they are looking at ways of feeding their children properly as part of producing an effective, well educated workforce for national success in the future.

In some ways, it has been a very depressing debate. We have heard a repetition of depressing statistics and depressing tales of how income poverty is compounded by the deprivation which comes with bad housing and living in a polluted atmosphere. My noble friend Lady Hilton spoke clearly of the effects of bad housing and pollution. The noble Lord, Lord Addington, spoke of the impossibility of having a healthy lifestyle when one lives in an area in which one's chances of dying prematurely are four times greater than in an affluent area.

I thought of the poem by Larkin when contemplating the terrible inter-relationship between housing, poverty, deprivation and a poor environment. Everyone remembers the first line of the poem, but that is not the one I shall quote. The final stanza begins: Man hands misery to man, It deepens like a costal shelf, Get out as quickly as you can, And don't have any kids yourself'. That is a terrible philosophy, but looking at some of the poverty and deprivation that we heap on individuals today one understands that despair.

Much has been said about the importance of looking at both costs and benefits when considering prevention as regards healthcare. The noble Earl, Lord Russell, has spoken of that on previous occasions. However, we must be careful before we throw up our hands, as did the noble Lord, Lord Jenkin of Roding, when the Black Report was published, and say, "It's all very difficult. It's not certain that they were the causes, anyway. It's not certain that if we carried out those measures they would have any effect and, anyhow, it is too expensive". It is very easy to say that it is too expensive and to ignore the transfer of costs to other departments.

One sees that everyday with the health service. We are always willing to pay the cost of the repeated hospital admissions of the child with respiratory disease, but we are not willing to pay the cost of providing an adequately heated and insulated home for that child. We are willing to pay the plastic surgeon to repair the damage caused to children by the fires in which they are injured, but we are not willing to pay for fireguards and smoke alarms. We have a very narrow definition of cost and benefit, which gets us into terrible difficulties.

I believe that reference was made by my noble friend Lord Borrie to the Rowntree Report and the comment on it by Mr. Howard Davies, who said: Too much of our public spending is devoted to compensating for the effects of failure rather than investing in the ingredients of success". It is the short-termism which deals with those consequences of failure but does not deal with investment which I believe is so damaging to us as a nation.

It is the acceptance of the inevitability—that quote that we have had from across the Floor—that the poor will always be with us; the inevitability that things will get worse; and the catalogue of neglect which has seen the nutritional standards of school meals go down, the withdrawal of the EU subsidy for school milk and the water privatisation programme which has allowed families in this country to be disconnected from clean water. There is that terrible acceptance that those things will always be there and nothing can be done.

But other countries do not accept that. Japan is a very interesting example in terms of economic growth and stopping inequalities. There are very low differentials in income levels in Japan. The height of its citizens has increased, as has the life expectancy of its citizens. Moreover, it has increased the healthy life expectancy of its citizens which Social Trends showed us this month that we have failed to do. Japan has the highest number of centenarians of anywhere in the world and they are healthy centenarians.

After the war, in Finland, a much poorer country than this one, raised infant mortality rates to much better than those in this country and they still are because of the focus on child and maternal health. Sweden has actually abolished the differentials in perinatal mortality between social classes. In America, 6.3 million children receive a free school breakfast every day. They have milk and a proper hot meal—not a bag with a sandwich, a biscuit and a coloured drink which is what the nutritional standards in this country allow. That is done not because it is some great Scandinavian liberal democracy which believes in socialised medicine but because it has worked out that every dollar invested in child nutrition in school saves three dollars in medicare.

Therefore, there are proper cost-effective reasons for taking action. There has been much talk about what is private and public responsibility in relation to health. I have worked for most of my working life in voluntary organisations and I do not challenge the scope that there is for community action. That is very important. But it is also important that we should not leave national issues like the health and nutrition of our children to charitable endeavour. It is a matter of concern for the whole country.

I listened to the right reverend Prelate describing that scheme in his own diocese. He described how a community can become involved and do a great deal to help itself. While listening to him, I was reminded of that haunting and powerful saying that it takes a whole village to raise a child and it takes a whole nation to raise a generation: to invest in that generation's health, education and development, to ensure that both individuals and the community to which they belong thrive.

It will take something else in this country. It will take a change of focus and direction of government policies after the sorry record of the past 18 years. We need a change in government so that there will be the leadership needed to create a more inclusive, less divided society. On these Benches, we are eager to embark on the task of creating that healthier society.

7.15 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)

My Lords, first, I start by congratulating the noble Baroness, Lady Jay, on initiating what has been a fascinating debate, the subject of which is poverty and its link with health. I cannot vouch for the state of your Lordships' health. When listening to my noble friend Lord Brentford, who told us how we should support each other in your Lordships' House to give up smoking and to encourage healthy lifestyles, I was thinking of your Lordships' Guest Room. I was feeling somewhat unequal to the task. Perhaps I shall just issue visitors with a government health warning.

This evening, a number of theories have been postulated; statements have been made; and conclusions have been reached, many of which have been surrounded in controversy. However, I believe that there is a consensus that the causes of poverty are the most complex of all social issues and their link with health is deeply difficult. There is even disagreement as to definitions, a theme which was explained most ably by my noble friend Lord Luke. I thought that the noble Earl, Lord Russell, was going to sidestep that whole issue but if I understood him correctly, he was defining poverty as it relates to income support.

There is a problem with that definition because the more people there are on income support, and the more we help the less well off, the more poverty is created. Of course that is misleading. Likewise, using a fraction of national average income can be misleading as that ignores the rise in average income itself—about 37 per cent. in the UK since 1979. It ignores the fact that everyone is better off, including those who have least income.

I do not wish to delve into semantics but I state the obvious in saying that no ideology can solve the problems and no party has the monopoly of compassion. But this Government have demonstrated, through their actions, that they have been neither complacent nor uncaring. We are not burdened with the doctrine that everyone should be treated the same. Free of that constraint, we have targeted resources towards those who really are poor, in line, with the urging of the noble Lord, Lord Prys-Davies.

That money has paid dividends. Independent research by the Institute of Fiscal Studies shows that there is very significant movement in and out of the 10 per cent. of those on the lowest incomes, a point made by the noble Lord, Lord Haskel. But surely the noble Lord is pleased that, of those who are in the bottom decile, up to half have moved up one year later.

I understand the great interest which the right reverend Prelate the Bishop of Lichfield has, especially regarding the influence of unemployment on a community, on families and on individuals' health. That is one reason that this Government have been so concerned with the economy. Our economic policies have cut unemployment by almost 1.1 million since its peak in 1992 and a further fall of 67,000 for the last month was announced today, the eleventh consecutive month of falling unemployment figures. That contrasts sharply with the experience of other European Union countries, in particular Germany, which has sustained an increase of 0.5 million in one month.

Time and again, poor people do not ask for social security payments; they ask for jobs. They want to earn their way out of poverty. They seek the self-esteem referred to so powerfully by my noble friend Lord Birdwood. That is why we oppose the job-destroying minimum wage. We are not ashamed of spending money to attract inward investment. It is what it says: investment for the future as well as now. As my noble friend Lord Astor said, overall economic policy has a profound effect on poverty and health.

I am sorry that the noble Earl, Lord Sandwich, feels that the Government are not on the side of the poor. Perhaps he has not related our policies to the results that we have achieved. During our tenure, average incomes have increased not only for those in work but also for those seeking work. The vast majority of people today are better off. Average incomes have risen by more than one-third, and those rises are not confined to a few top earners. Average income is up for all types of family, including lone parents. The least well off—those in the bottom 10 per cent. of income—have seen a rise in the consumer goods they own, and I rejoice in the fact that everyone is now better off.

During the past 18 years this country has been through a dramatic period of perestroika. From the chaos of 1979 we have come to realise that we have to compete in a world market. In parallel with that change there has been a revolution in health services. The ethic of the NHS has been nurtured but the delivery has been revolutionised. In 1979 inefficiency was commonplace—in fact it was never measured—and we had "never never" waiting lists. Today the average waiting time for an operation is four months. We are treating more people, for more conditions, with more staff and with a range of drugs and high-tech equipment—for example, laser beam technology—undreamt of 15 years ago.

The noble Baroness, Lady Jay, implied that the NHS was not that relevant to improving health. I would disagree with that view; indeed, so would the 9 million people treated last year. Moreover, I believe that her noble friend Lord Desai, in a fascinating—and, yes, largely spiritual—speech, made that point well. I must say that it is very interesting to listen to an economist who remains untouched by the Treasury. It is most refreshing.

The noble Baroness, Lady Jay, and the noble Lord, Lord Prys-Davies, were dismissive of our Health of the Nation policy. Perhaps they are aware that it is applauded by the World Health Organisation and lauded by it as a model for other countries to follow. The WHO recognises it as a world leader and a world beater. It is not a woolly series of political statements, as I suspect the Labour Party's sequel will be; it is a highly focused action plan, consisting of five key areas with 27 targets. Of those 27 targets, there are only two areas in which we are not making progress—obesity and teenage smoking. Deaths from coronary heart disease and from cancers are coming down in all parts of the country and length of life has been extended.

I would not claim that the Health of the Nation policy should take all the credit. But, as my noble friend Lady Brigstocke said, the public today are better informed, lifestyles are changing, teenage pregnancies are reducing and the number of people smoking is going down. I believe that great credit should go to the Health Education Authority for its work.

The noble Lord, Lord Addington, mentioned the "Life Project" in the Wirral. Although I accept some of the noble Lord's humorous comments, I do think that the way that that project has influenced the local community is quite simply inspiring—likewise, many of the other health alliances which involve all sections of an area. I shall perhaps bore your Lordships on another day with details of a scheme that I visited in St. Helens and Moseley entitled "Hairdressers for Health". However, I shall not do so today.

I turn now to what is happening in the country and I look especially at our children today. Our children are growing taller and heavier than ever before and that is in all socio-economic groups. Infant deaths, deaths of babies under a year—an international indicator of general health—are at their lowest rate ever. Among social classes IV and V, infant death rates have fallen by more than half in the past 15 years. So, today, infant death rates in social class V are better than those in social class I just 15 years ago. That is real progress. Overall, the trend is one of steadily improving health.

Of course, to celebrate that achievement is not to deny that there remain stubbornly persistent differences in rates of illness and death between different social groups. Indeed, that issue was raised by many speakers this afternoon, especially the noble Lords, Lord Murray and Lord Borrie, and the noble Baroness, Lady Robson. But those disparities are not new; they did not suddenly appear in 1979 or, indeed, in 1992. Nor should we mislead ourselves into thinking that such variations are somehow unique to British society. I was amazed to hear the noble Baroness, Lady Hayman, mention Finland. Finland has far greater disparities between its various social groups than we have when it comes to health.

Baroness Hayman

My Lords, I was in fact talking about Sweden in terms of differentials in infant mortality and about Finland's performance since the end of the war, when it was low down in international comparisons overall as regards perinatal mortality. It has now moved right up the scale.

Baroness Cumberlege

My Lords, if we look at all the health indicators in Finland, it will be seen that they do far worse than this country, as does France. That makes the point that this is not particularly pertinent to Britain; it is across developed countries.

While it is the case that our excellent national statistics have shown an association between health and social status for more than a hundred years, the same pattern is also seen in other developed countries. Some commentators argue, using particular measures of health, that some of the differences in Britain have become wider since the war. But, as I said, this needs to be seen against the tremendous overall gains in health and life expectancy which have benefited every social class. Simplistic arguments tend to imply the possibility of simple solutions and do not do justice to the complexity of these issues.

Both poverty and health are influenced by a huge range of factors. In the NHS jargon, it is impossible to ring fence them. Housing, employment, behaviour, genetic endowment, education, family relationships, lifestyles, geography and access to health services, all play a part.

It is certainly true that there is a link between deprivation and illness—not least mental illness. I use the word "deprivation" advisedly, because loss of employment, loss of a marriage or a family breakdown are causes of both illness and poverty. Only recently we debated "the family" in your Lordships' House without being able to formulate "the answer". Again, I believe that H.L. Mencken was most apt when he said: For every difficult and complicated question, there is an answer which is simple, easily understood and wrong". My noble friend Lord Colwyn very succinctly described the complexities: there really is no quick fix. Therefore, the Government have addressed the problem systematically. Through the Child Support Agency we have sought to introduce a system where, particularly mothers with children, get financial support. I am sure that the noble Baroness, Lady Turner of Camden, will acknowledge that family credit has helped 700,000 people to get back to work. We have just launched the "Parent Plus" initiative to help lone parents get back to work. The long term unemployed now make up 37 per cent. of claimants compared with 43 per cent. 10 years ago.

Our voucher scheme is being introduced to increase the number of good quality nursery places for four year-olds, which will not only benefit the working parent but will also help the child reach its educational potential and will therefore provide a spin-off to health. I share the view expressed by the noble Lord, Lord Ponsonby, that childcare is a crucial issue. I am sure that the noble Lord will be pleased to hear that we have doubled the number of nursery places in the past 10 years.

The noble Baroness, Lady Hilton, is of course correct to say that bad housing and unhappy communities cause illness. While it is part of the national character to dwell on failure, the extension of home ownership has been the greatest single factor in improving the quality of housing; and, indeed, we should celebrate the lowest mortgage rates for 30 years.

Over five years, public investment has built or refurbished around a quarter of a million homes for social renting or shared home ownership. The problems of cold, damp and mould are being tackled by renovation and regeneration polices. Nearly 2 million homes have benefited from grants for basic insulation and draught proofing under the Home Energy Efficiency Scheme.

The noble Baroness referred to the 1991 English House Conditions survey. She will realise that it pointed to a falling number of unfit homes over the previous year. I can assure the noble Earl, Lord Russell, and the noble Baroness, Lady Farrington, that the Government are committed to ensuring that there is no necessity to sleep rough. The Rough Sleepers Initiative and the Homeless Mentally-ill Initiative are helping get people off the streets and into secure accommodation. Indeed, 35 projects funded by my department are helping homeless people to make contact with primary care services and to integrate them into mainstream services.

We share the views of the right reverend Prelate and those of the—

Earl Russell

My Lords, I am sorry to interrupt the Minister. I do not wish to dispute anything that she is saying, but I would be grateful if the noble Baroness could give me an assurance that she will look at the points that I raised about the difficulty of the homeless in registering with a GP.

Baroness Cumberlege

My Lords, I shall certainly do so. However, as I said, we have schemes at present which are geared towards that. Nevertheless, I quite appreciate that the noble Earl wants a fuller response and I shall endeavour to write to him in that respect.

As I was saying, we share the view of the right reverend Prelate and those of the noble Lord, Lord Paul, about the problems of inner cities. We are committing almost £4 billion over three years to economic and social regeneration through the single regeneration budget. We can expect regeneration to pay health dividends through helping to create better homes and environments for families and communities, and improved prosperity. The active involvement of local people which is such an important feature of schemes such as City Challenge, increases pride and self-confidence and brings communities together. The results have been startling. Desolate, miserable, crime ridden inner-city areas have been transformed into thriving communities. Places where people were unwilling to go, let alone live and work, have been transformed and are now desired. As a Sponsor Minister I can confirm the transformation that I have witnessed.

I wish to refer briefly to education, as I know the Chief Medical Officer believes that education is one of the main keys to improved health. It is encouraging to see that educational standards are improving, with more young people obtaining good school-leaving qualifications. Today one in three are in higher education, compared with one in eight only 18 years ago. I was concerned to hear the noble Earl, Lord Russell, say that some of these students are ill. I expect that is a complex matter which also concerns lecturers, quality of education and other factors.

My noble friend Lord Birdwood is quite right; it is not for governments to tell people how to live their lives. That is arrogant and patronising. What is more, we know that it does not work. We should give them the information and then it is up to individuals to make their choices, not least in the area of food. The noble Baroness, Lady Jay, my noble friend Lady Brigstocke and the right reverend Prelate referred to diet and nutrition. I hope they will be reassured that a survey of the diets of over 3,000 children aged between 10 and 14 carried out in 1982 showed the intakes of all nutrients were above recommended levels. Government surveys over the past 20 years have consistently shown that there is no evidence of malnutrition in British children. I understand the points that were raised about the health visitors' survey. We find that quite an unsatisfactory survey, in that we are experiencing difficulties in obtaining the evidence and also as regards the methodology that was used.

Baroness Farrington of Ribbleton

My Lords, can the Minister confirm that her former honourable friend, Mr. Matthew Parris was unable to live for, I believe, two weeks and feed himself while living on an income equivalent to income support, which at that time was higher in real terms than it is now? He has since ceased to be her honourable friend and has taken to writing about her noble friends instead. My recollection is that he could not feed himself, let alone feed a family.

Baroness Cumberlege

My Lords, we recognise that some people on low incomes have particular difficulty in eating a healthy and varied diet. That is absolutely true. But often where they live the right food is not available and they do not have storage and cooking facilities. We have done much work with the supermarkets on different baskets of food and we know that a healthy diet is composed of all sorts of foods. We are encouraging people to eat more bread, potatoes, pulses, seasonal vegetables and fruit. Those are not expensive items. We believe there is no such thing as a bad food or a good food. What we seek is a balanced diet.

When one is dealing with people on low incomes, one of the factors is energy. They do not have the energy to cook often if they are poor. There is also the question of accessibility to food. There is a range of issues here. What I am trying to put over to your Lordships this evening is that there is no quick fix. These issues are extremely complex. I become quite concerned when noble Lords on the Benches opposite think that one can snap one's fingers and the problem will be solved. We know that that is not so.

Noble Lords

Oh!

Baroness Cumberlege

My Lords, that was the impression I had. It is interesting to hear the Shadow Chancellor say that for the next two years he will keep to the same public expenditure levels as our Chancellor has indicated. The Labour Party thinks that it will solve these problems without any increase in resources. I interpreted what many noble Lords opposite were saying this evening as a plea for better housing and other such provision. However, that would require more resources. This Government have promised more money for the National Health Service for five years, unlike the party opposite. We know that health services also have an influence on the health of our nation. I am running out of time because of the interventions.

Earl Russell

My Lords, I apologise to the noble Baroness but I ask her to withdraw the phrase "the party opposite" because there is one party opposite that has matched and even topped that offer.

Baroness Cumberlege

My Lords, I stand corrected. I wish to say a few words about tuberculosis, which was mentioned by a number of noble Lords tonight, including the noble Baroness, Lady Turner. The UK has an excellent record of controlling TB. We are determined that this should continue. TB notifications in England and Wales have reached the low level of under 6,000 cases a year, compared with around 50,000 cases in 1950. That success has been achieved against a worldwide resurgence in TB which is having a small but important impact on trends in the UK. One has to see it in that context.

My noble friend Lord Butterfield, in a scholarly and also practical dissertation, mentioned in particular the issue of smoking. My noble friend is right; the level of smoking in the poorest sections of our community is far higher than the national average. Our research shows that social disadvantage greatly increases smoking while in turn the expense of smoking increases hardship. Even though they have the most to gain from quitting, the traditional anti-smoking messages are resisted by some vulnerable groups, especially young people and low income groups. With this in mind, we are trying new approaches to reach these groups with the collaboration of voluntary bodies, social workers and role models. Indeed the "towering inferno" which I visited in Birmingham is one such classic case where real progress has been made in a tower block of council flats.

The noble Lord, Lord Murray, mentioned childhood accidents. He acknowledged that childhood accidents are declining across all social classes. We have a good record compared with the rest of Europe as regards adult accidents, but we accept that we need to address childhood accidents more vigorously. As well as the initiatives at the Department of Transport to reduce pedestrian deaths and car speeds, we fund a number of organisations and initiatives working to tackle childhood accidents. The noble Lord mentioned the work of the Child Accident Prevention Trust, and I refer also to RoSPA.

A number of noble Lords mentioned the Black Report. It was not so much the analysis of the Black Report that was disagreed with but its strong prescription. One of the recommendations of the report was that we should have a strategy for health. We have accepted that. As your Lordships will know, we have taken up a vigorous policy which I have mentioned, The Health of the Nation. Many of the strategies within that document relate to the Black Report. There is a lot of synergy between the two. I heard the noble Lord, Lord Rea, say that we had taken up the Black Report, albeit rather late. Certainly The Health of the Nation policy is bearing fruit.

The noble Lord, Lord Rea, also asked about the Cabinet sub-committee that oversees the whole of The Health of the Nation strategy. It meets about three times a year. Secretaries of State from nearly every department sit on that sub-committee. The most recent issue that it has addressed is the environment. The noble Lord will be aware of the consultation paper that has been produced which considers the environment in the context of Health of the Nation.

The noble Lord, Lord Haskel, mentioned the widening dispersion of earnings, in relation to the quote by my right honourable friend Mr. Lilley in Southwark Cathedral. I believe that that should be seen as a whole. My right honourable friend was saying that this is a global problem; and that the widening dispersion of earnings power was because the unskilled were lagging behind the skilled. He firmly rejected the notion that the Opposition's solution of making the rich poorer to make the poor richer had any basis, logic or practical application.

The noble Baroness, Lady Robson, raised a number of points. If the noble Baroness will forgive me, I shall write to her. However, as regards the health services and the evidence that the RCN submitted in briefing for the debate, I think that it has misunderstood the funding formula in the National Health Service which takes into account deprivation and is very much targeted towards those areas that need most healthcare.

I am aware that I am overrunning my time. I conclude by saying that I believe the majority of your Lordships care passionately about the health and well-being of the people of this country. I reiterate that I do not think that anyone has the answer. But I think we all agree that it is a thriving economy. There is full employment, regeneration of city centres, and better education, housing and health services, and a dynamic health of the nation policy which will lead to a fitter country. In all those areas this Government have a very proud record; and indeed overall we have a healthier nation.

7.41 p.m.

Baroness Jay of Paddington

My Lords, I thank the Minister for her reply. At this stage of the evening it would be clearly inappropriate to respond in detail to many of the rather controversial points that the noble Baroness made. I believe that I speak for both Benches on this side of the House in saying that we strenuously reject the idea that any noble Lord on this side had offered quick fixes or simple solutions to what we all recognise to be extremely complex problems. I should be grateful if the noble Baroness would write to me if she can identify in the remarks I made any additional public expenditure commitments beyond those already undertaken by the shadow Chancellor and his colleagues.

We welcome the consensus which seems to have emerged about the link between poverty and ill health. I remind the House that that has not been true for the whole of this Government's term. We also welcome the Minister's acknowledgment that we on these Benches—I think that I speak now specifically for the Labour Party—will have the opportunity to reorganise the health of the nation policy. We look forward to doing so at an early opportunity.

I thank all noble Lords who have taken part in the debate. It has been extraordinarily interesting. I thank my noble friends who have brought a wide range of personal knowledge and expertise to this multi-faceted debate. The terms of the Motion were deliberately widely drawn. I am grateful to noble Lords for their contributions. I believe that we have focused attention on a wide range of issues: economic policy, the environment, housing and homelessness, and the many problems of children living in very poor families.

In particular I thank my noble friend Lady Hayman for her excellent and comprehensive concluding speech. It left me with the necessity to say very little. I simply agree with her that this afternoon's debate has been depressing. The picture of life in Britain today for our poorest families has been saddening. My noble friend Lord Haskel said that I sounded rather angry. At the risk of transgressing the advice given to my noble friend Lady Farrington of Ribbleton, I am prepared to acknowledge that I am rather angry about the state of poverty and ill health in our country. I have been made angrier by some of the extraordinary situations and experiences about which we have heard today.

I said at the beginning that the debate was about social justice. I repeat that. It is also about the state of our sadly divided country. We shall hear more about that in the weeks leading up to the general election. But in the meantime, I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.