HL Deb 06 July 1999 vol 603 cc745-59

4.31 p.m.

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

My Lords, with the leave of the House, I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:

"Madam Speaker, the new White Paper which I am presenting to the House today is called Saving Lives: Our Healthier Nation; and that is exactly what it is about. It spells out how we want to save lives by stopping people getting ill in the first place.

"We are aiming to save 300,000 lives between now and the year 2010, by reducing the death rate from cancer in people under 75 by at least one-fifth; by reducing the death rate from coronary heart disease and stroke in people under 75 by at least two-fifths; by reducing the death rate from accidents by one-fifth; and by reducing the death rate from suicide by one-fifth.

"Those are ambitious targets which should mean that we become a healthier nation. They are bigger reductions than we suggested in the Green Paper; and unlike the Green Paper, these tough targets now apply not to people aged under 65 but to people under 75.

"They are targets backed by action: on cancer—action against smoking, action to improve diet, action to improve screening uptake and quality, action to modernise cancer scanners and equipment, and action to improve treatment; on heart disease and strokes—action on smoking, diet, blood pressure, and exercise, action to cut heart attacks, and action to improve rehabilitation.

"But that is only part of the story. We are not only setting tougher targets than the last government; we are explicitly aiming to do something quite different. Poor people are ill more often and die sooner. So we are going to tackle the inequalities in health which grew under the last government. Our policies are designed to improve most of all the health of the least healthy. The National Health Service has a big part to play, but our strategy requires a three-way partnership between the whole government, local communities, and families and individuals. None can succeed without the others. We reject the idea that individuals are powerless victims of their fate. But we also reject the Tory idea that individuals are entirely to blame for their own poor health.

"We need to use all the means at our disposal to make it possible for everyone to lead healthier lives. Unemployment, low wages, poor housing, crime and disorder, lack of education and environmental pollution all make people ill. The Government are taking action to tackle them all. The windfall levy, opposed by both Tories and Liberals, is providing jobs and training for young people; and 400,000 more people are now in work. Low pay is a health hazard—so we will improve the health of over 2 million people and their families by our introduction of the national minimum wage. This autumn those families and many others will be helped further by the working families' tax credit. Many thousands more will benefit from having a decent home to live in as a result of our increased investment in new and better homes for people who are badly housed. And improved educational standards are providing economic opportunity and pathways out of social exclusion.

"So the Government will play their part, but so too must communities. In some areas whole neighbourhoods are made unhealthy by poverty, pollution, crime and disorder. So we must target effort on those neighbourhoods. The most deprived areas are being helped by the extra effort and extra funding that flow from regeneration schemes, from health action zones and education action zones, from lottery funds going into healthy living centres, from the replacement of sub-standard GP premises, from the Sure Start programme for children, from the Healthy Schools project and from our £96 million Public Health Development Fund.

"We want to work with community organisations, local councils and health bodies to make sure these programmes are delivered on the ground. Every health authority will have to draw up and implement a health improvement programme which identifies and meets the particular health and healthcare needs of its area.

"That is because priorities differ in different parts of the country, with different individuals and groups having different problems; for example, respiratory disease in areas of heavy industry or the higher incidence of heart disease or cancer in certain ethnic groups. Local councils, businesses and voluntary organisations will all be involved in developing and implementing these plans.

"Fluoridation illustrates the new approach. The White Paper makes it clear that we will conduct an independent expert review of the safety and benefits of fluoridation. If it shows that fluoridation is beneficial, local authorities will be given new powers to require water companies to fluoridate where there is local support for doing so.

"We also propose to strengthen the public health profession and to develop extended roles for health visitors, community and school nurses and midwives.

"The new primary care groups will also enable GPs and practice nurses to draw upon their unique relationships with patients to help to promote better health. That is what many are doing already.

"So we want action by government and action by communities. But that cannot be the end of the story. Individuals and families must also play their part. Smoking is the biggest single cause of avoidable death and the biggest single cause of inequalities in health. We have a twin-track strategy to stop the tobacco companies recruiting new smokers, and to help existing smokers to give up the habit. Unlike the Tories, we accept the overwhelming evidence that tobacco advertising helps to get children addicted—so the Government intend to play their part by banning advertising from December. But we also accept that individuals need help giving up. That is why we are making nicotine replacement therapy available free to poor smokers who want to give up.

"This is a recognition of the fact that up to now most health promotion strategies have actually widened the health gap, because the better off have taken more notice than the worst off. We need to develop strategies which have most impact on the least healthy, and that is one reason why the White Paper announces our decision to replace the Health Education Authority with a new hard-hitting health development agency, with a much bigger role in working out and delivering those approaches that will work best.

"Individuals and families can help one another. That is why we are launching a health skills programme that will give young people first aid skills and health information. It is why we are launching our expert patients programme to help people with chronic diseases like asthma and diabetes to manage their conditions better.

"This will be good for the NHS and good for patients, as fewer complications mean better health and less demand on GPs and hospitals, with resources used to tackle the highest priorities.

"This White Paper sets out long-term plans for improving the health of the nation and reducing inequalities in health; and these really are long-term plans. Their full benefits will only show up in a decade or more. That is the time-scale involved, but that is no reason for delay. It is all the more reason for getting on with it: 300,000 lives saved—300,000 reasons for action.

"Fifty-one years ago this week the National Health Service, which Nye Bevan founded, came into operation. We all benefit from the far-sightedness of that Labour government. They cut inequalities in access to healthcare but, by themselves, they could not reduce inequalities in health, but common justice requires that we do.

"Members opposite representing areas where people are comfortably off and pretty healthy should recognise that ours is a simple but difficult aim. We want to help to make sure that the standard of health of the people they represent in Surrey or Sutton Coldfield is shared by the people we represent in Barnsley or Bethnal Green. That is what we mean when we say we want to end the divisions which mar our society—a genuine "one nation". I believe that that is what all decent people want to see, wherever they live and whatever their own state of health. That is why I commend this White Paper to the House".

My Lords, that concludes the Statement.

4.39 p.m.

Earl Howe

My Lords, I thank the Minister for repeating the Statement which I welcome, as I do the evident seriousness of purpose with which the Government are addressing those important issues.

I should say at the outset that I believe the Government are right to regard poor health as something which originates from a range of social and socio-economic factors such as housing as well as from causes which are more directly health related, such as smoking. Any credible plan to tackle public health must look across government as a whole and must involve society at every level.

In the short time that I have had to study the White Paper, it is rather difficult for me to comment on the detail of it. However, I should like to pick up on one or two points arising from what the noble Baroness said.

The Green Paper issued in February last year laid some considerable emphasis on the role of government, local government and individual responsibility. I was rather sorry that the Statement sought to portray the policy of the last government as focusing exclusively on the third of those matters. Incidentally, I do not know whether I am alone in finding the presence of barbed party political comments in the Government's Statement to be somewhat out of place. But we seem to be seeing rather a lot of those, in particular from the Department of Health.

It is surely right for government to promote better health and to require health authorities to set appropriate targets in health improvement programmes. That very much follows the path set by the last government in The Health of the Nation White Paper of 1992. Nevertheless, without a recognition on the part of individuals that it is their choice of lifestyle which will have a major bearing on their own state of health, the whole exercise will inevitably falter.

The Green Paper spoke in terms of a national contract for better health. I wonder whether the Minister will enlarge on that concept today. In particular, what does the White Paper say about some of the major underlying causes of better health, such as good diet, food safety, exercise, moderate alcohol intake, sexual hygiene and so on?

The executive summary is critical of what it describes as the scattergun approach of the last government. But it was surely absolutely right for that government to lay emphasis, as they did, on the key causes of better health. I am unclear as to the extent to which the present Government's approach will permit that emphasis to be renewed. The fact is that the last government set themselves targets in 21 areas. Today's White Paper reduces that number to four.

The Government are to be commended on targeting their efforts most strongly on less affluent areas of the country. However, will the Minister say what that implies for the transfer of resources from what is termed middle England to poorer urban areas? How much money is to be retargeted from one to the other?

Again, in passing, I cannot help regretting the assumption in the Statement that Conservative Members of Parliament only represent healthier and wealthier areas of the country and are therefore, by implication, ignorant of the difficulties that tend to characterise poorer areas. Conservative MPs are aware of and sensitive to those issues, as are MPs of any party. Conservative MPs represent many deprived areas and, on this side of the House, we have every wish to see the nation as a whole benefiting from those initiatives. However, I believe that we are entitled to ask what the Government's policies will mean in practice in terms of the redistribution of the Department of Health's budget.

In taking through the recent Health Bill, now the Health Act, Ministers laid considerable stress on the need to iron out health inequalities, a theme which the Statement picks up. In answer to that point, on this side, we are all in favour of such an ironing out, as I said before, so long as it involves a levelling up.

It is somewhat ironic that as a result of devolution, we are likely to see three different standards of health implemented in the three countries of the Union outside Northern Ireland. Does the Minister recognise that one of the measures most conducive to the process of levelling out would be a government commitment to ensure that the availability of certain key groups of medicines is not prejudiced by unnecessary barriers? I am thinking in particular of statins, which is a class of drugs which has a proven value in reducing the risk of heart attack, atypical antipsychotics for the treatment of schizophrenia and cytotoxic drugs. For all of those, there is a marked disparity around the country in terms of the funding made available for them by health authorities.

The Secretary of State expressed the ambition in May to make our cancer services the best in the world and he added: We know this will cost money". I applaud those sentiments but the inescapable fact is that the level of spending per head in the USA on cytotoxic drugs is about five times that in the UK. In Germany, it is over twice as much; and in France, nearly three times as much as in this country. The equivalent comparison for statins is equally stark. Will the Minister tell the House what more the Government propose to do to ensure that patients receive the drugs they need when they need them?

Osteoporosis is another important area of concern. The UK has the lowest number of bone density scanners in the European Union, a situation described by the National Osteoporosis Society as vastly inadequate. Will the Minister comment on that and say what action the Government propose to take?

Will she comment also on the targets for mental health? In particular, will she correct me if I am wrong in interpreting the targets set out in the White Paper as implicitly equating the state of mental health in this country with the incidence of suicides and that suicides and what are termed "undetermined injuries" are the only worthwhile measures in that area? I find that proposition instinctively difficult to accept. Finally, will the noble Baroness say what further primary legislation is implied by this White Paper?

I am supportive of the Government in the ambitions that they have articulated in the White Paper and wish them success in achieving the targets that they have set. I have no doubt that noble Lords will wish to hold the Government to account as the months and years pass and we see the fruits of the Government's efforts.

4.47 p.m.

Lord Clement-Jones

My Lords, I join the noble Earl in saying that I too have a great deal more reading to do of the White Paper and the attendant response to Sir Donald Acheson. But I also thank the Minister for repeating the Statement made in another place. Although the White Paper is making a belated appearance, nevertheless it is making an extremely welcome appearance. In particular on these Benches we welcome the fact that public health is now being treated as core to the health department. We welcome too some of the imaginative initiatives set out in the White Paper.

The Secretary of State said recently that promoting better health is not just a matter for the NHS or for social services; this is a job for the whole Government. The White Paper re-emphasises that, saying that it requires a three-way partnership between government, local communities and families and individuals. We welcome that partnership.

We also welcome the fact that there is indeed a new landscape. I believe that the treatment of public health issues is different under this Government. They link public health with social conditions. That was not done explicitly by the previous government. Therefore, I give this Government credit for that.

Health inequalities have widened over the past 20 years. However, the test is the implementation of the Acheson report and its 39 recommendations. Obviously, at a glance there is a great deal of response in the White Paper to the Acheson report's recommendations. But will the Minister be explicit as to which of the 39 recommendations have been accepted by the Government? They cover a wide range of areas; for example, tackling poverty, education, employment and transport. That is a wide variety of tasks which the Government are setting themselves.

In his report Sir Donald wanted the Government, above all, to put women and children first. Last week the BMA published a report which showed that the United Kingdom ranked 18th for deaths in early childhood. It is quite clear that public health policies should concentrate in particular on the first five years of life. There are correlations between low birthweight babies, future poverty, under-achievement and crime. Those are serious links.

Despite talk of joined-up government, however, the key question is whether the Treasury and the DHS will buy into the Acheson agenda. Is the Welfare Reform and Pensions Bill really working to improve public health? How did the withdrawal of benefit from lone parents contribute to improvement in public health?

We welcome the extension of some of the targets such as those for cancer and the other three areas. But why are there no national targets in other areas despite the responses to the Green Paper and the key issues raised by Sir Donald Acheson, such as the reduction of income inequality? If there is no target for a particular aspect of public health policy do we not risk being unable to measure progress? Therefore, does not the Acheson report risk the fate of the original Black report? Do we not need targets to understand what kind of vision the Government have in all areas?

As regards existing targets, what are the financial implications, particularly concerning cancer? It was recently estimated by CERT that in order to put the original targets in place a minimum of an extra £170 million was needed. The same is true for other targets such as coronary heart disease, mental illness and accidents.

We particularly welcome the development of health action zones and health improvement plans, which we discussed as the Health Bill went through this House. That means that we shall not be repeating some of the mistakes of The Health of the Nation which, despite many good intentions at government level, did not really reach down to grassroots level. I believe that the health action zones and the health improvement plans will do a great deal to make sure that the targets, limited though they may be, will reach the levels required. Those targets need to be locally owned. There are some signs that the voluntary sector is not becoming involved in the health action zones as they should be. I believe that East London and Hackney health action zones are a particular case. Will the Minister comment on that?

We welcome the health development agency, as far as it goes. But does it mean that it is effectively a public health commission? For instance, will it have relationships with Scotland, Wales and Northern Ireland in the public health area? Will it be charged not just with overseeing best practice in England, but also best practice across the country? Who will now carry out health promotion campaigns? Will the agency also spread best practice between health action zones, which is so important in order to make sure that resources are used in the most effective way?

The White Paper mentions primary care groups. But will public health doctors be involved in the formulation of policy and its implementation in those primary care groups? We welcome the introduction of health impact assessments. But will they operate right across the board for all national government policies, and who will carry them out? I wonder what that will show if we subject it to the Welfare Reform and Pensions Bill and a public health assessment.

We welcome the fact that the Government have expanded their policy on children's safety. Although widely trailed, sports medicine is not contained in the White Paper. Can the Minister comment as to whether a sports strategy will be provided later in the year? One of the key areas for accidents is those caused during sporting activities.

A key aspect of public health is risk management and the communication of risk. We need to have a communications policy in place. That also was trailed, but I can see no sign of it in the White Paper. Can the Minister comment on whether the department will be taking on board the work done by the previous Chief Medical Officer as regards the language of risk? That would help enormously in terms of avoiding future problems such as BSE, E.coli and GM foods.

Finally, in common with the noble Earl, I suggest that a number of elements require legislation. What undertakings can the Minister give as regards early legislation? I thank her in advance for her reply. I realise that I have raised a number of questions. I would not like the Minister to believe that we do not welcome many aspects of the White Paper. We have started down a road which is quite a long one. The results may not be evident for some years, but it is very important that we set off in the right way with a very clear understanding of what the Government are trying to achieve.

Baroness Hayman

My Lords, I am grateful for the contributions of the noble Earl and the noble Lord and, perhaps most of all, for the recognition by the noble Lord, Lord Clement-Jones, that he raised a wide range of questions. I shall do my best to answer the broad issues raised by both speakers.

As regards his remarks about inequality, that ties in with the issue that the noble Earl, Lord Howe, raised about there being real differences in approach to those matters. We cannot avoid recognising those differences. They are reflected in the attitude of previous Conservative governments to the Black report and of this Government to the Acheson report.

The noble Lord, Lord Clement-Jones, asked about work to take forward the health inequalities agenda together with the White Paper, which makes it quite clear that we have dual aims for a public health strategy. One is improving the health of the whole population and the other is improving the health of those who are worst off and most deprived so that we narrow the gap that has been widening in previous years.

Together with the White Paper we have published another action report on reducing health inequalities. It recognises in particular the range of government activity necessary if we are to make a real impact on poor health as well as on health services. That means work to tackle poverty and deprivation, poor housing, lack of facilities, and providing access to fresh food at reasonable prices and decent public transport. In those areas people suffer from multiple deprivation which is reflected in ill health. That is why we have a separate and parallel publication on the action that we are taking.

For example, the social exclusion unit concerned with teenage pregnancies recognises the need to tie up issues concerned with social security, financial support, access to work as well as access to information and services. For example, investment in education can have an enormous effect on the health of individuals.

The noble Lord, Lord Clement-Jones, asked whether it was a matter of women and children first. Women are certainly key determinants as regards the health of families. There is much international evidence that investment in the education of women results in the improvement of health of children and populations. That is something that we have to recognise. The Sure Start programme reflects that recognition. It is recognised in the targeting of work within health action zones and in the funding for smoking cessation services. There we find the answers to the questions of the noble Earl, Lord Howe, about targeting resources to the areas where there is most need. I agree with him that we are here seeking to level up rather than level down.

The noble Lord also asked about equality of access to effective medicines. We are taking action, for example, on psychotropic drugs in terms of reference to the National Institute for Clinical Excellence to make sure that the same evidence base is used by health authorities. On the issue of statins, we have the National Service Framework for Coronary Heart Disease. Looking at the National Service Framework for Mental Health, we see that we recognise the need to focus on a whole range of services to improve mental health.

The noble Lord made the point that reducing suicides is a rather crude measure of improvement in mental health services. The National Service Framework for Mental Health will address the unacceptable variations in service across the country. However, we recognise that health services alone cannot prevent suicides.

This is a clear, focused document on saving lives. The interim report of the national confidential inquiry into suicide and homicide by people with mental illness, directed by Professor Louis Appleby, found that there is scope for improvement in providing services which are integrated and which do not leave people suffering from mental illness unsupported at times when they are most vulnerable. Having a suicide reduction target will require a concerted effort towards primary prevention, secondary prevention and treatment which I believe will have an effect throughout the provision of care for those suffering from mental illness.

On the issue of whether there are too few targets at national level, it is our belief that four national targets, focusing on the four major causes of premature death and avoidable ill health, will be tougher for the Government but that it is right to focus on delivering on those. If we are to deliver on clear targets, it is necessary to work across a whole range of activities.

I recognise that the White Paper is a big document which people have not had a long time to study, but it clearly shows, in the partnership that we are seeking, how the allocation of responsibility between the individual, the local community effort and national government will be tied together. However, there is scope in local health improvement programmes to set targets that address the specific local health issues that arise.

The noble Lord, Lord Clement-Jones, asked whether there would be a sports strategy. The Department for Culture, Media and Sport is developing a sports strategy, to be published later this year, to promote greater scope for participation in sport and physical activity for all. I believe that the noble Lord was approaching the problem from a different viewpoint. I was looking at the issue of exercise as an important determinant of good health; he was looking at the risks in exercise and sport in terms of causing injury.

That leads to another element in the strategy which is the improvement in the first aid skills of the population as a whole, which can be as applicable on the sports field as at home or in school. Out-of-hospital care delivered by people who know the basics, at least, of first aid will be a tremendous help in a variety of situations.

As the noble Lord suggests, risk is a difficult area. It is included in the White Paper. Currently, the department is developing principles for producing policy and is using risk analysis to interpret information. Earlier the noble Lord mentioned the extremely important initiative to try to ensure that departments across Whitehall—including the Department of Health—and individuals can base their personal decisions, as well as government decisions, on well evidenced information. I believe that the communication of risk is one of the biggest challenges for our scientific and political communities. At the moment, that is not carried out in a consistent manner.

As regards the issue of legislation, the White Paper will be followed by secondary legislation to convert the Health Education Authority into a new health development agency. It is not our belief that other legislation is necessary to implement the White Paper. A great deal of other actions by a wide range of people are required in order to do that, but they do not depend on legislation.

5.06 p.m.

Baroness Gardner of Parkes

My Lords, the issue of fluoridation is mentioned on page four of the Statement. At a time when 2.5 million fewer people have National Health Service dentistry than when the Government came into power, at a time when the most under-privileged children have deplorable dental health and suffer unnecessary pain from decaying teeth, why are the Government suggesting an independent expert review; yet another review? Can the Minister tell us what form that review will take and whether it will include any pilot studies? How long will that delay the introduction of fluoridation? Will the matter be settled before the next general election? How can the Minister say, Fluoridation illustrates the new approach"? Is the new approach to avoid decision-making, to delay again and to review again and again? When shall we see such legislation and help for the desperately unhappy children suffering dental pain?

Baroness Hayman

My Lords, I respect the commitment of the noble Baroness to this area. I believe that she knows that I personally share her views on the benefits of fluoridation. However, we should deceive ourselves if we thought that our views were shared by everybody. We want to tackle dental health inequalities and we want to end the current legislative impasse. It is no good pretending that everything has been working satisfactorily up to now.

Since 1985, 55 requests from health authorities have been turned down and nothing more has happened. We want to overcome that. There is a view that the evidence on the safety of fluoride is based on studies conducted some time ago. That is why we have asked Professor Jos Kleinen at the NHS Centre for Reviews and Dissemination at the University of York to lead the review. The report is due early next year. Once we have that report, and if there is no doubt about the safely of fluoridation, we can take the kind of action that we believe would be effective.

At an optimum level of one part per million fluoride, dental decay in children is reduced by between one-third and one-half. We want a targeted programme to tackle dental health inequalities. Some 25 local authority areas now fluoridate their water. If another 25 local authorities fluoridated their water—say, in the North-West, East London, East Midlands, Southampton and Bristol—we would make an enormous impact on the problem. No other oral health promotion measure is anywhere near capable of reducing the rates of tooth decay in deprived areas to the levels in affluent areas. That is why we believe that we have to find a way of negotiating ourselves out of what has been an impasse for many years and take effective action. If the matter takes a few more months but produces more legitimacy for the policies of the future, I believe that will be worth while.

Baroness Pitkeathley

My Lords—

Baroness Carnegy of Lour

My Lords—

Earl Russell

My Lords, it is the turn of the other side.

Lord Hunt of Kings Heath

My Lords, there are another 17 minutes. I believe it is the turn of this side.

Baroness Carnegy of Lour

My Lords, I want to speak on fluoridation. Are noble Lords in agreement? The Government say that they will give local authorities power to force independent water companies to fluoridate water if the local community agrees. I agree with my noble friend and with the Minister that that is highly desirable, but as the Minister says, opinions differ. Does that mean that local authorities will be able to conduct surveys on the matter? If at present a water company fluoridates water, but the local community does not want its water fluoridated, will local government be able to force that company to stop fluoridating the water?

Baroness Hayman

My Lords, I may have preferred the question from this side!

It is important that we understand the different levels of consultation that will have to be gone through. First, we shall have to undertake a review and make sure that the evidence exists. Then we must make sure that local authorities rather than health authorities—they have not so far been a successful mechanism in this regard—have the powers to take forward fluoridation. Also, because the water company and local authority boundaries are not the same, we must discuss with the national body which represents water undertakers the technical implications of taking forward this policy in areas where, for example, the majority are opposed to it.

We need to break the deadlock that presently exists. Also, when we transfer from health to local authorities, the form of public consultation on fluoridating the local water supply will have to be decided. We intend to introduce a legal obligation on water companies to fluoridate where strong local support exists for doing so.

Baroness Pitkeathley

My Lords, does my noble friend agree that one of the most welcome aspects of this far-reaching and welcome White Paper is the extension of the age range that it covers to those who are under 75? Does she agree also that old people can benefit just as much from health education, from fitness programmes and better nutrition as younger people, but too often are ignored and expected to deal with their ailments as a consequence of old age? In her response, can the Minister also assure me that the provision of better health for older people will include their mental health as depression, leading to self-neglect and even suicide, is more common in older people than is currently acknowledged?

Baroness Hayman

My Lords, my noble friend is right to point out that we have extended the age range in terms of targets. We must recognise that there is not a sudden point in terms of age after which people can no longer benefit, either from health education—there are many important ways in which people can be given the information to enable them to improve their health—or from a range of services. Again, the extent of the importance of exercise and access to it in maintaining good health may differ in nature and scale depending on one's age, but exercise can be an important component for the elderly as well as for schoolchildren. My noble friend is also right to point out the mental health aspects that can affect older people. Targeting policies to reduce suicides covers all age groups.

Earl Russell

My Lords, the Statement was surely correct that low pay is a health hazard. Will the Government therefore consider the hypothesis that no pay is a greater health hazard? To that end, when they conduct their health impact assessment, will they collect information on the health of those disentitled to social security benefits?

Baroness Hayman

My Lords, the Acheson inquiry into inequalities in health showed that poor health is associated with low income; that is, low income whether from benefit or in terms of a low wage.

Earl Russell

My Lords, I said "disentitled" to social security benefit, not "on benefit".

Baroness Hayman

My Lords, I apologise to the noble Earl. That takes us into the area of looking at entitlement to benefit as a potential health hazard.

We have said that the health impact assessment programme will be carried out across the board, assessing major policies for their impact on health and health inequalities. We are already applying that assessment to policies assessing fuel poverty and the New Deal for 18 to 24 year-olds. I shall ensure that disentitlement to benefit and its potential impact on health assessment is taken into account by my colleagues in the Department of Social Security.

Lord Jenkin of Roding

My Lords, is the Minister aware that I share the distaste expressed by my noble friend on the Front Bench for the unpleasant "barbs" which the Secretary of State saw fit to include in his Statement, which was otherwise positive and forward-looking? Can the noble Baroness point to any other Statement by any former Secretary of State for Health in which it was argued that health inequalities were the fault of the poor? That is a monstrous accusation to address to anybody.

Is the noble Baroness also aware that I regard the Acheson report as a great improvement on the rather unfortunate Black report which I had to receive a good many years ago? Its research was sadly flawed and its remedies, I was advised, appeared to involve the spending of billions of pounds on abolishing the class system. Is the Minister aware that I regard the detailed proposals in the White Paper as a great deal more practical than the Black report and that I hope that they will succeed? If the Minister is right in arguing that it will take many years, I am sure that is wise. In the mean time, can she describe to the House what measures the Government will put in place to monitor the targets she announced?

Baroness Hayman

My Lords, we need to monitor progress. We are setting ourselves interim targets and every health improvement area will contain specific targets. There were targets in the tobacco White Paper for reducing the number of people in this country who smoke. We shall be evaluating progress at a regional and local level in regard to the different targets.

I do not want to enter into a spat across the Dispatch Box in relation to the relative commitment of individuals to good health. We made explicit our commitment not only to improve the health of individuals across the board, but also to reduce the existing inequalities—not a phrase that was popular or acceptable in the Department of Health for many years. Those inequalities have increased rather than reduced over the past 18 years.

Lord Bruce of Donnington

My Lords, the Government are to be congratulated on reasserting the undoubted experience of society as a whole. The health of the individual, while depending in part on the efforts to maintain good health made by the individuals themselves, is fundamentally dependent on society as a whole; and society as a whole is fundamentally involved in the health of the individual. At last, after many years of experiments—no doubt conducted in good faith—into the way in which the health service should be organised, we have an examination of the fundamental causes which reside in society. Aneurin Bevan himself pointed that out in much detail in that very great work of his, In Place of Fear, which was published in 1952.

We now have the opportunity to reassert the priorities in the nation as a whole as regards maintaining good health. Plans to relieve poverty and the fundamental causes of poverty and ill health are now matters for our consideration. I am very proud to be on the same Benches as a government who are now going to make this effort to emphasise the real priorities and give people some purpose in living again; indeed, to give them a fundamental sense of security in place of fear.

There will have to be a reassertion of priorities. One will not have to pay too much regard to private interests which are inevitably involved in the provision of, for example, pharmaceuticals or even ordinary diets. All these things will have to be reassessed. I am very glad that we have reasserted this. I am also very glad, as I am sure we all will be in due course, that perhaps some purpose in life has been restored.

Baroness Hayman

My Lords, I do not think that I need answer the specifics of my noble friend's contribution. However, I believe that the whole House recognises that he has perhaps a longer time-frame and perspective on the National Health Service through personal experience; and, indeed, as I remember, through being in Parliament with Aneurin Bevan when the original legislation to establish the National Health Service was introduced. We are now 51 years on from that time, but it has transformed the social landscape of this country in many ways. It has transformed the way in which we think of ourselves as a society.

The challenge that this White Paper and the inequalities that still exist give to this Government goes beyond the provision of service to the question of access to good health for all our citizens. It is an enormous challenge and one which demands action covering a wide range of people from the individual, through local communities, to government. But there are enormous prizes to be won because there is much deprivation to be fought.

Baroness Thomas of Walliswood

My Lords, I was most interested in what the Minister said about international examples in respect of the benefit to be obtained by educating women. I have had some experience of that myself in one of the most deprived countries in the world. Does the noble Baroness agree that one way to ensure that individual women get the messages that they need to receive for the improvement of the health of their families is to work at the lowest level, on an absolutely face-to-face basis, with individuals? Can the Minister tell us what aspects of the Government's programme would respond to that need; in other words, to what I would call the "outreach element" of such measures?

Baroness Hayman

My Lords, a range of activities in the White Paper would respond to that particular need. Some of them relate to the development of healthy living centres, not as buildings and bricks and mortar but as regards inter-community access to health information. It is fascinating to see the uptake of NHS Direct from women, including from women with young children; indeed, an enormously high proportion of callers are looking for information and advice.

Most of all, I would answer the noble Baroness by focusing on the role of community nurses, health visitors, school nurses and midwives. They gain great respect from the people with whom they deal. They have tremendous opportunities, often at very crucial times in people's lives, for making interventions which have real impact. A whole range of areas is important in this respect, although not especially mentioned in the White Paper. I refer, for example, to the provision of prison health services, especially those for women in prison. There is the opportunity to make a difference there. That is also the case in schools, where children can be introduced to the concept of cooking healthily, or to the concept of taking responsibility for their own health—be it sexual health or health in relation to drugs and alcohol—or the health of others by knowing the fundamentals of first aid. Those are very individual people-oriented activities, which can make an enormous difference.