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10.22 am
Dr. Peter Brand (Isle of Wight): I congratulate the hon. Member for Stoke-on-Trent, North (Ms Walley) on her wide-ranging and comprehensive introduction to this important debate. She clearly showed that there is inequality in health, and I think that every hon. Member could have made a similar speech, perhaps using different examples.
The problem is that we have no longer a national health service but a fragmented one. What one can expect depends not on one's clinical need but on where one lives--it is a lottery by postcode. We need the Government to declare what they will deliver to users of the health service and what people's core entitlements are. If we cannot deliver a comprehensive entitlement, let us be honest about it. It is wrong to leave it to clinicians to cover up for politicians who are not prepared either to raise the money or to suppress the expectations of the people who rely on the health service.
Mention has been made of the allocation of resources. We can make wonderful speeches about what we are trying to achieve, but without resources we cannot do anything. We need to look again at how resources are allocated. RAWP, the resource allocation working party, went a long way, but it was very insensitive. We must have a system that considers not only patients' profiles--including age, incidence of illness and social and economic deprivation, which are important factors in determining the input of resources to a particular area--but the cost of delivering care.
It is more expensive to deliver comprehensive core services in an isolated area. I know that the Government are examining rurality as one aspect of this problem, but I make a special plea for those who experience a unique aspect of isolation--those who live in island communities in England. Such communities in Scotland are recognised as having a greater need, and I hope that there will be a similar recognition south of the border.
The hon. Member for Stoke-on-Trent, North made a very good case for partnership and the encouragement of partnership. I welcome the health action zones that the Government have introduced as pilot projects. I hope that they will be bold and choose a wide range of pilots. It is sad that they are restricting themselves to 10 to 12, and I hope that they will have a rethink.
Mr. Patrick Nicholls (Teignbridge):
I too congratulate the hon. Member for Stoke-on-Trent, North (Ms Walley), not only on securing the debate, but on introducing it in the way she did. As is clear even from this debate, we might have different views and different suggestions as to how to tackle the problems, but there is no doubt that there are inequalities in health provision.
The hon. Lady drew on her constituency experience as a starting point, but the figures for her constituency also tell a wider tale. She referred us to the public health common data and the standardised mortality ratios. They show that Stoke is below the national average only in cerebro-vascular disease. That is bad news: I am not saying that Stoke is a terrible place to live, any more than she did, but it clearly concerns her.
However, the picture is mixed, because the same figures show that Stoke is below the national average when it comes to infant mortality rates, with about 5.5 deaths per 1,000 live births compared to 6.1 per 1,000 in England as a whole. That brings us to the "gap" about which we have heard so much today.
In 1995, the age-standardised death rate per 100,000 of the population in Stoke-on-Trent was 860, compared with 1,056 in 1985. Both those figures for Stoke were higher than the averages for England in those years, which were 748 and 894 respectively. Interestingly, if one compares the average rates in 1985-87 with those for 1993-94, one finds that, in percentage terms, the reduction has been greater in Stoke than nationally. One could ask, "Is my glass half full or half empty?" I accept that one could say that there was more room for improvement in Stoke, so the decline would be greater. That is a perfectly fair point, which needs to be made.
If the health gaps between social classes widened in the 1980s, that must be seen in the context of a declining mortality rate for all classes. For men aged
35 to 64, age-standardised death rates fell by 32 per cent. for classes one and two between 1976-81 and 1986-92. The highest fall--44 per cent.--was experienced by socio-economic group three, whereas there was a 21 per cent. fall for groups four and five.
The hon. Member for Stoke-on-Trent, North reminded us that we all use statistics to back our particular cases, but I mention those figures because they show how careful one must be in using the gap as a measure of success or failure. I suspected that the hon. Lady--I hope that she will take this as a compliment--was going to make more of the gap, as the hon. Member for Harrow, West (Mr. Thomas) did, but she was right not to.
The gap is a relevant fact and indicator, but what matters more is the absolute standard of treatment that the poorest and most disadvantaged members of society receive. We could, for example, imagine a situation in which the gap had narrowed even though the absolute position of the poor had worsened. No one would regard that as a measure of success. It is too simplistic to argue--as people often do--that the continuing gap between the rich and poor must mean that the situation is worsening. I compliment the hon. Member for Stoke-on-Trent, North on not overplaying that argument.
In the debate, there has been more than a hint of the great cry,
Ms Walley:
I made it clear that the setting up of the health action areas has made a significant difference. I want us to address the current situation.
Mr. Nicholls:
I am sure that the hon. Lady is absolutely right in that, but it is not the case that, when the new Government took office, they found that the previous Government had applied manifestly inadequate resources. I shall not blind the House with statistics, but the previous Government spent some £80,000 every minute on the national health service. One can always cry, "Even more should have been spent," but that was a substantial sum.
The third progress report on the "Health of the Nation" project, which was published in July 1996, showed that progress had been made on 18 of the 21 targets. The death rate from coronary heart disease for those under 65 had fallen by 19.2 per cent. and by 12.5 per cent. for those between 65 and 74. The death rate from breast cancer in women aged 50 to 69 had fallen by 9.6 per cent. The death rate from strokes among those aged between 65 and 74 had fallen by 14.3 per cent., and the death rate from lung cancer among men aged under 75 had fallen by 13.9 per cent.
We are debating this subject against a background of substantial improvement in the nation's health. As the hon. Member for Stoke-on-Trent, North said, we do no good by saying that the position is worse than it is.
Numerous studies have made the connection between poverty and ill health. The hon. Member for Harrow, West seemed to take the view that the wicked old Tories had always said that there was no such link. I am not trying to avoid a good argument--I am always in favour of one if necessary--but the hon. Gentleman is wrong. People sometimes advance the view that the cause of ill health is poverty, and that ill health will disappear at a stroke if poverty is abolished. That is an attractive view, but numerous studies show that it is not so.
The Minister may mention--or we may hear about them in the continuing debate--the various reports that are cited as evidence that poverty causes ill health. Sir Douglas Black's report is the most famous; it is often cited as showing the linkage beyond doubt. However, the Black report said that the argument is much more subtle and complicated. For example, it found that health inequalities related not so much to poverty as to the way in which different parts of the population used health services. It suggested that the lower occupational classes made greater use of general practitioner services, but that their use of preventive health care was markedly lower than that of higher occupational classes. That argument was confirmed in a study by the King's Fund in 1995.
There are other factors that are not directly related to poverty. The Policy Studies Institute report on aspects of health inequality, which received some publicity, argued that the differences between ethnic groups and between ethnic groups and whites could not be explained by the disadvantage that was experienced in the country of birth; those who were born in Britain or migrated at early age were, if anything, likely to have less good health.
The report also emphasised the significant variations within specific ethnic groups, and said that a key factor appeared to be socio-economic status. Nevertheless, it said that it was unlikely that that was the only cause; if it were, it would be hard to explain why ill health in one group was demonstrated through increased risk of hypertension, whereas in another group it manifested itself in heart disease. The report also suggested that biology and culture, with other factors such as the knowledge and experience of racism, might also be relevant.
"Four legs good, two legs bad".
It was suggested that everything that happened under the previous Administration was bad, whereas everything that will happen under this Administration will be good, and that the previous Government allocated insufficient resources, whereas things will be much better now. I do not think that the figures substantiate that argument.
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