House of Commons Hansard Debates for 25 Feb 1998 (pt 4)

Mr. Gareth R. Thomas: The example of smoking is particularly apposite. Does the hon. Gentleman recognise that the incidence of smoking is greater among low-income families than among high-income families? Does not that demonstrate the need to tackle inequalities of income as well as the other inequalities to which he has referred?

Mr. Nicholls: The hon. Gentleman is mistaken; one cannot say that poverty drives people to smoke. We have

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to accept that, ultimately, people are responsible for their health. Some people use poverty as an excuse and ignore what is in their best interests. One cannot say that people who are poor or on low incomes are entitled to turn away their faces from the damage caused by smoking.

Smoking, whether one has a high, middle or low income, is devastating. I give the Government full credit for the fact that they have made that abundantly clear, and done a great deal to publicise the damage that smoking does. I believe that a forthcoming White Paper will make the same point.

Whatever we may have had to say in the past--it may be relevant to say it again in the future--about the fact that sometimes, even in taking forward a good policy, one can unexpectedly strike an uncertain note, the fact is that the Government have made it clear where they stand on smoking, and that is a jolly good thing.

I want to leave sufficient time for the Minister for Public Health to respond, but first I shall comment on a note that I detected, more in the speech by the hon. Member for Harrow, West than in that by the hon. Member for Stoke-on-Trent, North--perhaps because, like me, the hon. Lady has been in the House long enough for a certain cynicism to sink in--to the effect that, somehow, everything will now be sweetness and light.

I do not necessarily see that. Yes, some things in the Green Paper on public health were worth while, but the targets were cut from more than 20 to four. So far as one can compare them--that is not easy, and it probably was not intended to be--the four targets are less exacting than those in "The Health of the Nation".

The Minister will correct me if she thinks that I have it wrong, but I see nothing in the Green Paper that deals with inequalities in health in particular. Obviously, that is the dimension of the national health service that we are talking about today.

I am not the only one who says that. Let us look at the reception that the left-of-centre press gave the Green Paper. We now have four targets, none of which seems to address health inequalities specifically. That aspect has been criticised by both health groups and journalists.

The Financial Times said:

"ministers have dropped plans for targets to cut the health gap between the social classes. Karen Caines, director of the Institute of Health Service Management said: 'on this most crucial issue of health inequality they have bottled out. Without measurable targets, even over a long time-scale, there will be less pressure for change and less scope to hold them to account.'"

There was a leader in The Guardian, too. On the whole, Guardian leaders do not give comfort to Conservative spokesmen--[Interruption.] I suspect that that intervention was good enough to put on the record, but I did not hear it.

Mr. David Jamieson (Plymouth, Devonport): We have not found them helpful, either.

Mr. Nicholls: It is always nice to enable a Whip to record something for posterity. Let me assure the hon. Gentleman that he will not find what I am about to read helpful, either, but he may find it true.

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The Guardian leader said:

"The Government is wrong to shrink the number of targets from 27 to four . . . Most serious of all is the absence of targets for reducing health inequalities. Anti poverty campaigners must insist on their inclusion. There must be a specific commitment to close the gap".

"King's Fund chief executive Julia Neuberger said, ' . . . we do have to measure progress in reducing inequalities, otherwise there is a danger that no one will take responsibility and be held to account'".

I could read out more of the same sort of thing.

I must say in passing that the wholesale closure of hospital facilities in London, although the Labour party said a little while before the election that it had no plans--[Interruption.] I shall go through it all if hon. Members want. There is the closure of the accident and emergency department at Guy's and of the Greenwich district general hospital; there is the transfer of facilities from Queen Charlotte's hospital to Hammersmith hospital, and many other similar developments throughout London. It is all about hospital closures and the reduction of facilities in areas of high social deprivation.

It is not only Conservatives who are entitled to raise doubts about the idea that nothing was done under the previous Government and nothing like enough was spent, yet that, under the present Government, everything will be different. The left-wing press is expressing the same doubts.

The argument is not as easy as it may seem. Inequalities in health must be addressed, but as for the idea that simply by a change in Government one can produce a brave new dawn in which complex problems become simple, I do not believe it. But I shall wait and see what the Minister has to say.

10.43 am

The Minister for Public Health (Ms Tessa Jowell): I begin by adding to the congratulations offered to my hon. Friend the Member for Stoke-on-Trent, North (Ms Walley) on prompting the debate and providing an opportunity for one of the best debates on the issue that we have had for some time. We are grateful to my hon. Friend for that, and for the way in which she has raised issues of such direct concern to her constituents.

I shall deal first with some of the general issues arising from the Green Paper on public health and the response to it. It has two broad aims. One is to increase the length of healthy life, and the second is to close the health gap. For the first time in 18 years, there is the recognition that inequalities in health linked to social class have got worse.

For example, if, between 1991 and 1993, all men had had the same death rate as those in social classes I and II, there would have been more than 17,000 fewer deaths each year. Children born today into social class V are five times more likely to be killed in an accident before they are 15 than children born into social class I. The litany of evidence in support of the existence of health inequality goes on.

We should not take a simplistic view of health inequality, but we must start by recognising that it exists. The poorer people are, the more likely they are to be ill. For example, people in social class IV or V are more likely to face every illness--except, I think, melanoma--than people in social class I or II.

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The case for the existence of health inequality--the link between poverty and ill health--is clear, but the story is not as simple as that. That is why the Green Paper does not take a simple deterministic view of ill health and poverty, but recognises the important role of confronting poverty as a way of improving health.

We also draw attention to the inequalities between different ethnic groups and between regions. The rate of heart disease is three times lower for men in Oxfordshire than for men in Manchester. We need to take such regional inequalities as seriously as other manifestations of inequality, including inequalities between men and women.

When we talk about tackling health inequality, we are talking about tackling the reasons that divide us as individuals in our enjoyment of good health, and about recognising the many factors that are brought to bear. Some of those are determined early in our lives and others later, and they result in a differential expectation of good health between men and women, and between people from different social classes and ethnic backgrounds. The expectation even varies according to where people live.

The inheritance is complicated, and things were not helped by the previous Government's refusal to recognise the link between poverty and ill health, and to confront the complex nature of inequality. The targets that we have set to meet our two overriding aims of improving healthy life expectancy and tackling the health gap aim to yield two results.

The first is a reduction in avoidable deaths. More than half the people who die under the age of 65 die from cancers or from circulatory disease, including heart disease or stroke. If we are to make an impact in reducing preventable death, we have to concentrate our efforts on those areas which represent the greatest risk.

It is important to recognise the need to establish a proper balance between nationally determined targets and those that measure specific problems in relation to particular local needs. It is not true to say that we have refused to set inequality targets. The better informed commentators--the leader in the British Medical Journal, Professor Julian Le Grande and others--have made that absolutely clear. They have endorsed the Government's approach in reducing the number of targets, and linking targets to a clear strategy for action.

Setting national targets for inequality is a complex and inexact science, which is why the Government have commissioned Sir Donald Acheson to review the evidence relating to inequality and to provide guidance on the areas of Government policy where action to reduce health inequality which impacts on other aspects of policy is likely to be most productive. In that respect, as in all other aspects of our health policy, we are pursuing a common approach, which is to apply what works, based on the best available evidence. Through consultation, and in the light of Sir Donald's conclusions, we shall reach a judgment as to whether or not to set national inequality targets; but we shall urge local health authorities to set inequality targets in the context of health improvement programmes.

We are determined to deliver a strategy, and it is one of the toughest challenges facing the Government. As my hon. Friends the Members for Harrow, West (Mr. Thomas) and for Stoke-on-Trent, North made abundantly clear, delivering improvements in health, especially to the poorest, will rely on successful