GP Referral Procedures (Hansard, 12 June 2002)

§ Jon Trickett

It is his first. I congratulate him on his appointment, and I look forward to him engaging in the debate. I have no doubt that he has a long future as a Minister, and I hope that he can help in the matters that I intend to refer to this afternoon.

The nation is currently preoccupied, largely, by football. If we put that to one side for a moment, the national debate is about the national health service and health in general. Derek Wanless was asked to examine the health of the nation, the state of the health service and its future funding. The debate about the report focused largely on the pressures of expenditure, but is more significant than that. It also deals with supply and demand for the health service.

I want to talk about demand. I am afraid to say that Mr. Wanless described an unhealthy nation. He introduces the appalling concept of premature mortality and PYLL; the potential for years of life lost. We discovered that we live in an extremely unhealthy nation, where people die at a younger age than they should. We compare badly with countries in western Europe and elsewhere in the advanced industrial world. In the UK, women die at a younger age than almost anywhere else in the industrial world, which should trouble us all. The life expectancy for men is 25 per cent. lower in the UK than in Sweden.

Parliament and the nation focused on how we will fund the provision to take us up to the European average. How we can make the nation healthier so that there is less demand on our health service received less consideration. Mr. Wanless's interim report considered a range of issues. Paragraph 3.42 of his final report refers to expected scenarios for the next 20 years and the possibilities of continuing as we are, a mild improvement, or a vision of a much healthier nation. He also refers to the fact that not smoking, nutrition and physical activity can contribute to a healthier nation. He holds out the vision of enhanced life expectancy within 20 years, and of an improvement in the quality of all our lives by being healthier. It is clear in all the work done by specialists and non-specialists working in the health service that a more physically active population is key. Two thirds of our population may be following football as we speak, but they are non-participant observers. We want people to participate in sport and exercise to improve their general health, reducing the demand on the NHS and the taxpayer and generally promoting a much healthier and physically more active nation.

I admit to a genetic predisposition to cardiovascular problems. I come from a family who have had heart problems. I have high cholesterol and other factors that led me to the conclusion that I am in a high risk category. My GP came to that conclusion too, which 300WH worried me rather more. My father had his first heart attack when he was 47. I was in my mid 20s. At that time, I still thought of myself as an athlete but I had become extremely sedentary. I was probably drinking too much and having far too many fry-ups and other unhealthy things.

I decided that I did not want to spend the rest of my life like my father, who has gone in and out of hospital with continuing heart problems for 28 years; he is now 75. First, I wanted a better quality of life and, secondly, I did not want to be a drain on the health service. I wanted to contribute in an economically useful way to the nation. Having said that, I ended up as a Member of Parliament, so I am not sure that I am doing that. I suppose that I am paying taxes and national insurance, which is a small contribution.

I decided to exercise and to change my diet. I have not—touch wood—been affected by the chronic problems facing my father and many others like him. Far too many lives have been wasted and lost through chronic heart disease, strokes and other problems. Also, I have had a wonderful life in terms of my sporting activity. I am proud of my sporting prowess but I will not share it with the House this afternoon. However, I believe that my personal experience can be extended to the nation as a whole.

When I arrived in Hemsworth, the health of my constituents was obviously very poor, compared even with inner-city Leeds where I had come from. I had travelled a few miles but the level of ill-health in the constituency was striking. The Government recently produced various indices of deprivation. We all know that there is a correlation between socio-economic factors, status and health. The differences between the social classes in our country, notwithstanding the fact that we are an unhealthy nation, are clearly shown by the massive propensity to ill-health and to long-term limiting illness in those lower socio-economic groups; what we used to call the working class.

The wilful destruction of the mining industry by a Government who attacked the communities whom I represent, together with the traumatic events surrounding the strike, led to enormous psychological disorder and stress in Hemsworth. In any event, there would have been a link between ill-health and the kind of industry on which my constituency depended; men were not designed to work underground and to breathe coal dust for generation after generation.

The long-term ill-effects of the mining industry—together with the way in which the industry collapsed and the long-term unemployment that, sadly, has continued well into the period of this Government—mean that my constituency has one of the most unhealthy populations anywhere. As I mentioned, the Government produced indices of deprivation, which show a particular cluster of health-related factors. Unsurprisingly, Hemsworth is one of the 25 most unhealthy constituencies. I have three wards where there are massive health problems and they come in the bottom 1 or 2 per cent.

I suppose that because of my personal interest in fitness and health and the characteristics of the community that I represent, I took a particular interest in health centres and health activities, especially the creation of sports and exercise facilities in the area. One 301WH centre is in Hemsworth high school and another is in a small village called Hovercraft—sorry, Havercroft. That will give some fun to the Hansard writers. It is an isolated village with an extremely unhealthy population, some of whom are facing long-term unemployment. We could not fundamentally tackle the problems of deprivation, but we funded a new sports centre there and also exercise equipment in Hemsworth high school.

That was the start, I hoped, of engendering the feeling that promoting healthy lifestyles and activities was important. However, I was slightly disappointed at the take-up by the local population. Both centres are well used, but often not by the unhealthiest people. We should reflect on that problem.

Several barriers impede people from the sort of communities that I represent from frequenting sports centres. Both of the centres to which I referred, incidentally, are located within a single electoral ward; the 100th most unhealthy out of 8,500 wards in the country. Health problems there are both chronic and acute.

It was relatively easy to gain the capital to provide the facilities and equipment, but it was not easy to gain the revenue necessary for supporting the centres. Cultural barriers can be important. If someone feels unfit or obese, they are unlikely to enter the centres, which would reinforce their negative feelings. Another cultural barrier stems from the fact that GPs are often not trained to encourage exercise as a means of tackling ill-health. Other barriers stem from the absence of health and fitness providers in the centres with the requisite skills to deal with unhealthy or obese people who are perhaps at risk of cardiovascular problems. Finally, there are financial barriers, which stem from the pricing policy of some centres. Sadly, my constituency does not contain private sector providers—the money is not there—but even public sector providers have to charge fees, which can deter people from joining and participating in the centres.

My next step was to establish whether a local partnership would allow sports facilities to be opened up to the communities, and that was the context in which I first encountered the subject of this debate; GP referral programmes. I found that someone had already invented the wheel that I was trying to invent. Prompted by the excellent work of the Fitness Industry Association, the Government are taking an interesting step forward. I am grateful to Andree Dean, the FIA chairman, for the advice and information he provided.

Effectively, the scheme allows exercise on prescription. It allows GPs to allocate some NHS funding to local populations for preventive work. Engaging people in the facilities available in their communities and neighbourhoods should enable them gradually to adopt more healthy lifestyles.

It was wonderful to find that someone else had invented a wheel that I was trying to invent in my own community, and I am grateful to the FIA, the Department and everyone else involved. The scheme is at an early stage, but is working well. A register of exercise professionals has been established, and I understand that 13,000 people are already registered, which is an excellent step forward. It started only in January, so we have made great progress, but I must sound a note of caution. We need to ensure that the 302WH register is extended and that the process does not exclude people who are involved in providing sport. Some people feel that this is the professionalising of sport. I think that sport and exercise need to be professional, but the register must operate openly and not be a barrier. I have spoken to the FIA and to the acting registrar, Cliff Collins, and I am confident that the register will operate as I have described; I see my hon. Friend the Under-Secretary agrees.

There has to be a "but" somewhere in this good news story about the good work being done by the Government, and it is this; where is the GP referral programme in my constituency? There is the possibility of creating a coalition of providers that extends from health and primary care providers through the primary care trust to the health and exercise industry and sport in general. We have a wonderful vision of a healthier nation that costs the NHS less and enjoys a better quality of life. Admittedly, we are at an early stage, and I do not want to be critical, but the scheme has not yet been rolled out. Indeed, we do not know—unless the Under-Secretary can enlighten us—exactly where the scheme is working and where it is not working. It is patchy and fragmented.

My experience of public services, which goes back a long time, is that the middle classes tend to know how to manipulate the various programmes that we establish. The lower socio-economic groups are frequently excluded even from good ideas such as the one that we are discussing, but that must not happen. I fear that the exercise referral programme is being captured in middle-class areas, which is a way of putting revenue funding into the equipped provisions that I have described, thereby enabling them to operate. The programme is not reaching into the unhealthiest neighbourhoods. I may be wrong, but I think that we must establish exactly where the programme is working and ensure that it is rolled out as quickly as possible to the rest of the nation.

I shall conclude by talking about how we might profitably move forward. The scheme is excellent, but I would welcome confirmation from the Under-Secretary that the Government accept that there is a clear link between the benefits of exercise and health. It is important that the Government say that clearly, frequently and loudly.

We should perhaps ask the industry to provide us with the information that would allow the Government to ascertain how the scheme is used, how it is rolling out and how we can ensure that it reaches all neighbourhoods. Some form of general audit of provision and of where the lacunae are would be welcome, because we must find out which elements are missing and fill in the gaps.

As I have taken an interest in the issue, the FIA has said that it will help me to try to identify practitioners who will come into my constituency and provide facilities, and we will encourage GPs to be involved. However, that depended purely on the random fact that, as the local MP, I was interested in health and fitness. We should not leave these matters to individuals.

I would like the Government to ensure that PCTs understand the scheme, that money is available and that they facilitate GPs' involvement. That would require a large-scale programme, but an intermediate step may be to consider health action zones. These are located where 303WH there are concentrations of poverty, deprivation and ill health. The first step may be to ensure that at least every health action zone area has a facility to provide the exercise referral programme. The Under-Secretary has powers and can use the national quality framework to ensure that the scheme rolls out. I hope that he will do so.

My final point is that a cultural shift is required to ensure that health and exercise professionals and the general population recognise that health and exercise go together. That can be done by conducting a long-term study that monitors the operation of the referral programme and studies people who are at risk to find out whether their health improves during a certain period. That information could come from the industry and the Government could monitor it, perhaps referring it to the National Institute for Clinical Excellence, which, in turn, could produce a learning report. That itself could be used as a propaganda weapon to encourage people and GPs to get involved.

There is much to say, but I have spoken for 20 minutes. I hope that the Under-Secretary has time to set the general scene as well as to reply to my particular points.

§ The Parliamentary Under-Secretary of State for Health (Mr. David Lammy)

I am grateful to my hon. Friend the Member for Hemsworth (Jon Trickett) for raising this important debate and for giving me the opportunity of my first Adjournment debate in Westminster Hall as a Minister. It is a momentous day on which to have the debate. This morning I visited probably the best football club in London—Tottenham Hotspur—with some local pupils. We were at its learning support centre to watch the England game and were all delighted that, despite the sweltering heat on the other side of the world, England got through to the second round. I was particularly pleased that young people from my constituency were getting such a positive message about sport.

Like many other hon. Members, I am both a barrister and politician. I have only nine minutes to address my hon. Friend's important points, so I hope that he will forgive me if I rattle on.

There is now substantial evidence to support the role of physical activity in promoting good health. Research has shown that physically inactive people have roughly double the risk of coronary heart disease, and it was instructive that my hon. Friend referred to his family experiences of that disease. Physical inactivity is also a risk factor for obesity, colon cancer, type 2 diabetes, hypertension and mental health problems. Those diseases have a significant human and economic cost.

My hon. Friend was right to refer to the Wanless report and its points about health inequalities and the need to move to a fitter society. We have seen a threefold increase in obesity in the past 20 years and, if the trend continues, more than a quarter of adults in England will be obese by 2010. A recent National Audit Office report outlined the significant costs of obesity to the NHS and the economy. In 1998, obesity accounted for 18 million days of sickness absence, 40,000 lost years of working 304WH life and 30,000 deaths, of which 9,000 related to obesity, before state retirement age. In response to my hon. Friend's earlier point, I recognise that there is a problem. Both diet and physical activity play a role in obesity, and we are taking action to address both factors. We already have a comprehensive action programme to improve diet.

Physical activity can help in the prevention and management of obesity and other chronic diseases, but physical activity rates are low across the adult population. About six out of 10 men and seven out of 10 women are not active enough to benefit their health, while among children, four out of 10 boys and five out of 10 girls are not meeting the recommended one hour of exercise a day. My hon. Friend is right to refer to inequalities that exist in our community; these occur in parts of his constituency and in constituencies such as mine. Rates of inactivity are particularly high among older people, some ethnic minority communities and those living in rented council accommodation.

I accept my hon. Friend's point about the middle classes, but he will appreciate that, as the economy grows and people have more leisure time, it is important that that leisure time is used and accessed by everyone. Indeed, one of the second or third things that I said to my diary secretary on taking up my new role was that she had to ensure that I got to my gym early in the morning so that I did not pass out in the Chamber at some future date.

The NHS plan makes a clear commitment to local action to tackle physical inactivity. I hear my hon. Friend's point about GPs being equipped to refer people for exercise. That is in the NHS plan and we must ensure that we roll that out and communicate it to all our medical practitioners. That is also emphasised in the national service framework for coronary heart disease, along with the national service frameworks for older people, mental health, and diabetes.

The national service framework for coronary heart disease, in particular, contains a number of milestones to which physical activity is central. Standard 1 requires all NHS bodies to work closely with local authorities in developing a local programme of effective policies on physical activity, being overweight and obesity. The standards for primary care and cardiac rehabilitation also contain milestones that require action on physical activity.

That is where exercise referral schemes, as my hon. Friend pointed out, play an important role. Research has shown that referral programmes can be effective in behaviour change. The Department of Health funded two reviews by the former Health Education Authority that specifically considered the progress and effectiveness of exercise referral schemes. The research showed that better designed referral schemes could lead to small levels of increased participation in activity, but that practice across the country was highly variable.

To address that, the Department published a national quality assurance framework on exercise referral systems in April 2001 to improve standards of existing schemes and help the development of new ones. The framework focuses primarily on the most common model of exercise referral system, where a GP or practice nurse refers a patient to facilities such as leisure centres 305WH or gyms for a supervised exercise programme, commonly called exercise referral schemes or exercise on prescription.

The document was sent to primary care trusts and leisure services in local authorities, and GPs were notified of the quality assurance framework through the GP bulletin, which is sent to all GPs in England. The guidelines were also promoted at two regional seminars for primary care and leisure professionals held last summer.

I fully recognise the importance of ensuring that fitness instructors have the appropriate training and competence to work with patients in a referral scheme. I therefore support the work of the Fitness Industry Association and the National Training Organisation for Sport, Recreation and Allied Occupations in this area. In particular, the development of the register of exercise professionals, launched last year, played an important role.

My hon. Friend says that he wants the programme to be rolled out across the country, but it is important to emphasise that the national service framework for coronary heart disease requires primary care trusts to develop local programmes and effective policies on physical activity. Referral programmes present only one option for local action to tackle physical inactivity. It is for local primary care trusts to reach their own view about how to promote exercise and make progress on this issue.