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Westminster Hall

Wednesday 12 July 2000

[Mr. Michael Lord in the Chair]

Health Action Zones

Motion made, and Question proposed, That the sitting be now adjourned.--[Mr. McNulty.]

9.30 am

Mr. Jeremy Corbyn (Islington, North): It is nice to start the day in the knowledge that we are adjourning. That always strikes me as odd.

I want to raise the subject of the funding of health action zones and I hope that the Minister will have comfort, if not good news, for them when he replies. I welcome the principle behind health action zones. The Labour Government of 1974 to 1979 recognised that there were serious problems of inequality relating to health and that, in some areas of the country, people lived longer. Similar variations included infant mortality, notifiable diseases and accident rates. The discovery was not new. The relevant work had been going on for a long time. I was fascinated at school by the works of Dudley Stamp on the geography of life and death, in which he demonstrated that people living near steelworks lived for a shorter time than others and that poor housing led to low life expectancy.

The 1974-79 Government saw from the record of the national health service since 1947 that there were serious inequalities in health provision between different parts of the country and commissioned Sir Douglas Black to produce his excellent report on inequalities in health care and the resulting problems affecting life expectancy. The incoming Conservative Government in 1979 promptly banned the publication of the report, because of its implication that much redirection of resources was needed.

I was pleased when the previous Secretary of State for Health, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), not only recognised many of those issues but also agreed, through the publication of the Green Paper, "Our Healthier Nation", and the establishment of health action zones, to examine health inequality in particular areas. That was very welcome. At the heart of what has been said on public policy direction and reducing health inequalities is that

Today is a good time for this debate, because the Government are announcing the reintroduction, after the tragedy of their 20-year lapse, of nutritional standards for school meals. Simple things like the food that is provided for young people in the morning and

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reasonable school lunches have an enormous impact not just on health, but on the ability to study. The Government's strategy of promoting greater health expenditure to deal with health inequalities is important. There are terrifying differences in the levels of serious illness, life expectancy and infant mortality in different parts of the country--for example, in the inner-London ring, by which I mean Lambeth, Lewisham, Tower Hamlets, Newham, Islington, Hackney, Camden, Hammersmith and Southwark. One sees huge inequalities in health in the inner-London ring between those areas and wealthy areas of central London, such as Kensington and Westminster. If one makes a comparison with suburbs further out, such as Golders Green or, even further out, Merton and Kingston, one sees massive inequality. A journey down the Old Kent road from central London to the Surrey suburbs would lead from a place of considerable wealth and high life expectancy through some of the worst cases of public health in Europe. The position changes quickly when one gets a bit further out.

There are many complex reasons why life expectancy is so different, one of which is the conditions under which people work. Building workers, miners, street cleaners, refuse collectors and others in dirty and dangerous occupations are more likely to end up with bronchial-related conditions and more likely to die in accidents at work than people in higher-paid, office-based employment. The Government cannot necessarily solve that problem, but matters can be much improved through rigorous enforcement of health and safety at work legislation.

Inequality in child health often leads to inequality in later life. Children growing up in overcrowded, small flats, where illness is transmitted easily from one child to another, might be unable to do homework properly because there is nowhere quiet to do it. With parents on a low income, they are less likely to eat good-quality, healthy food. They might end up being off school more because they are ill and they might under-achieve at school because they are off so much. They are unlikely to go to college or university or to get jobs for which they might be perfectly capable but for which they could not become qualified.

Those problems cannot all be solved by the Department of Health, but it is important to recognise that much inequality arises from such issues. We must study carefully how the problem is tackled. Merely throwing money at problems does not necessarily solve them. It is a question of approach and how money is spent. I strongly welcome the thrust of what the Government are doing in recognising the causes of health inequalities and in putting together a series of programmes that improve education, access to health care and basic living standards through a minimum wage, although I wish that the wage were much higher.

It is also a question of linking local initiatives, which is where the health action zones come in. Unfortunately, the then Secretary of State did not include the boroughs that I and my hon. Friend the Member for Hampstead and Highgate (Ms Jackson) represent--Camden and Islington--in the initial wave of health action zones, although they were included in the second phase. I can understand the reasons for that--the choices before the Minister were unenviable. He had inherited a terrible situation in the former coalfield communities, where life

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expectancy was low and where there was a high level of industrial illnesses and serious depression because of the loss of the coal industry and the community spirit that went with it. Coalfield communities were rightly in the first round, as was most of the east end of London.

I was pleased when my borough and Camden were included in the second phase of the health action zones because I still find the annual report from the medical officer for the health authority that I represent to be fascinating reading. When reading through it, one sees a pattern of inequality, illness and depression, which is linked to the problems of living in an urban area, of a migrant community and of public services that often fail to meet people's needs, expectations or aspirations. The declaration of a health action zone was an important recognition of the multiplicity of problems.

Our community has, unfortunately, among the highest infant mortality rates in the United Kingdom, one of the highest levels of AIDS, some of the worst housing in the country and a hugely migratory population. In some wards, population turnover approaches 20 per cent. a year, which makes it difficult to build communities or a community spirit. There is a large transient population and the number of homeless people and rough sleepers is high. Public services struggle to make ends meet, to provide services and to survive. Whitehall has to assess the needs of health care services and of local authorities. Although we welcome any support that is given to our public services, it is difficult for Whitehall accurately to calculate the number of people who are sleeping rough or the number of asylum seekers who are passing through, especially if they are in bed-and-breakfast hotels or hostels. Such people, for perfectly understandable reasons, place an enormous demand on local health facilities and services.

The Government did us a service by establishing a health action zone for the area. The broad themes of the health action zone are, first,

The mental health services of inner London are under enormous strain. Although we must deal with people who suffer mental illness in the best way possible, long-stay institutions are not necessarily the right approach. Community care is, in general, a much better option, provided there is sufficient funding, support and

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monitoring. Sadly, some patients were taken out of long-stay institutions and moved into community care institutions where the level of support and back-up became negligible. Many deeply disturbed people who needed significant help ended up wandering around the community and becoming social pariahs in their districts. Although I strongly support the principles of community care, I shall be interested to hear what my hon. Friend the Minister has to say about monitoring it.

On overall funding of our health authority, the Government inherited a situation in which Camden and Islington health authority was in the unenviable position of being the only health authority to receive no increase in the last two years of the previous Government's life. The recent per capita cash increase of nearly £60 a head--a 6.79 per cent. increase--is extremely welcome and recognises the situation that we inherited. However, when the Government announced the creation of health action zones, there was substantial press coverage of associated funding. I am not criticising health action zones, but I hope that my hon. Friend will bear in mind a number of factors. How will the staff and facilities of health action zones integrate with community health authorities and hospital trusts and the health authority as a whole in the long term? Although I welcome specialist initiatives to deal with the particular problem, there is a danger that we will end up with a plethora of experienced, well-paid and well-meaning professionals who spend so much time meeting one another that they have no chance to do anything for the public that they are meant to support.

I am not looking through rose-tinted spectacles at the halcyon days of the late 1970s, but I remind hon. Members that a system in which one health authority had overall responsibility at least ensured clarity, as one knew whom one was meeting and at whom responsibility had to be directed.

When I consider similar issues now, I find myself in conversations with the health authority, the hospital trust, the community health trust, the health action zone and the primary care group--and so it goes on. They tell me that they are all working well together. Indeed, I am sure that they are doing so and that they get on extremely well, but I must say that they spend an awful lot of time getting on well and meeting one another. I hope that the Minister will use his examination of the role of health action zones as a spur to improve co-operation and integration--a suggestion that is made in a constructive, rather than a negative, spirit.

I am always depressed when I hear about the time that hospitals spend in trying to persuade elderly and often psycho-geriatric patients to leave hospital care and to go back into their homes, the community, social services care or wherever else. When co-operation works well, it is fine and there is a seamless transfer, but the result is different when it does not. That can happen when everybody is up against budgetary constraints, when the hospital is desperate to get rid of patients because they are blocking beds and it is expensive to keep them, and when social services can afford no more agency staff and can find nowhere to put people, and are therefore understandably reluctant to take on new patients. As a result, people who should no longer be in hospital are often bored out of their brains for weeks on end, blocking a bed that somebody else could use, whereas they should be in a cheaper facility elsewhere. Such

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issues must be resolved. I know that the Minister is aware of them, but will he reflect on them and suggest ways of dealing with the problems?

I turn now to funding the health and social services needs of a community. The Government have at their disposal a vast array of statistics on issues of poverty, inequality and ill health. Figures on free school meal take-up in primary schools can be used as a broad parameter of poverty. One finds enormous inequalities even within individual areas. My constituency is next to that of my hon. Friend the Member for Hampstead and Highgate. In our area, one can go from schools in which 80 or 90 per cent. of pupils have free school meals to schools with a take-up of 25 or 30 per cent. Such schools are situated within a couple of miles of one another, which is, I suppose, a feature of London life. When the Minister reflects on such statistics and evaluates how circumstances change and improve, will he also consider the efficiency with which the various agencies co-operate?

The Camden and Islington health action zone was expecting an income of £4,075,000. It planned developments accordingly for years two and three. This year, however, the amount was reduced to £3,734,000, which meant that some of the schemes that it proposed could not go ahead. Consequently, it has had to reconfigure its plans. The Government made the cut because they were concerned about underspending. I understand their concern, as it is rightly expected that public money that has been made available for a project should be spent. As I understand it, however, the reason for the underspend was that the health action zone was anxious to ensure that its projects were efficient, well funded and well planned. It was felt that throwing money at its goals in the first year would not necessarily be the best way of achieving them. The zone has shown a degree of caution in its plans, but has been penalised for doing so, which seems slightly unfair. There is concern that the message sent by the Government's attitude to funding is that they no longer give the same priority to health action zones as they gave when the first phase was signalled a couple of years ago--or, in the case of the zone to which I am referring, a year ago--in a welcome announcement.

The health action zone is addressing issues of local health inequality and seeking to integrate with other groups. The improvements in relation to mental health are very important, as are those in relation to coronary heart disease, cancer, accident prevention among older people and drugs action team structures. In the case of the latter, it is easy for us to throw money at drugs action zones or groups and tell them to go away and deal with the problems because we are horrified to find that young people are taking hard drugs and becoming involved in drug dealing. However, it is important for any drugs team to be credible within the local community and to be seen to be effective, but that can take a long time to achieve.

The overall aims of the health action zone are to speed up improvements and integration of local services, tackling the underlying causes of ill health and building local capacity to sustain and improve health; aims that I am sure will be welcomed. I want to give some examples of the "early wins" that have already been delivered by local partnerships:

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Various figures are quoted for the number of people who have given up smoking: 160 people in four weeks, although I have no idea how many of those took up smoking again. I get the feeling that some people are eternal quitters; they receive some sort of prize for quitting and then start smoking again, so that they can quit again, so one must be sceptical about figures for a reduction in smoking. However, health education to prevent young people from taking up smoking is very important.

The "early wins" also include:

More "early wins" are:

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I welcome the establishment of health action zones and the recognition of the link between inequality and ill health. However, I am disappointed that, within a year of our health action zone starting, the planned expenditure had to be reduced by such a considerable sum. I hope that my hon. Friend the Minister recognises that the underspending was the result of caution; people want to be responsible with public money and not throw it at projects in order to gain more money in future years.

The question is how public expenditure should be planned. I look forward to my hon. Friend's response. If he would like to visit our health action zone again, those groups would be pleased to meet him and discuss with him the positive work that has been done to try to give everyone a reasonable chance in life and, as far as possible, equality of access to health care. We must overcome inequalities between the suburbs and inner cities if we are to achieve any sort of harmony within our society.

9.55 am

Ms Glenda Jackson (Hampstead and Highgate): First, Mr. Lord, I congratulate my hon. Friend the Member for Islington, North (Mr. Corbyn) not only on obtaining this debate but on choosing to speak on a subject of such importance. As he said, Mr. Lord--

Mr. Deputy Speaker (Mr. Michael Lord): Order. I remind the hon. Lady that, in this Chamber, the occupant of the Chair is referred to as the Deputy Speaker.

Ms Jackson : Please accept my most humble apologies, Mr. Deputy Speaker, and thank you for enlarging my information pool.

As my hon. Friend the Member for Islington, North was at pains to point out, the Camden and Islington health trust covers several constituencies and boroughs. My constituency of Hampstead and Highgate, which is invariably misrepresented by the popular press as being inhabited exclusively by millionaires who do nothing but sip champagne and chatter, contains areas of grave deprivation. My hon. Friend welcomed the Government's move to create health action zones to try to tackle inequalities in the delivery of health care. Although we were disappointed that we did not achieve a health action zone in the first tranche, we were delighted to be part of the second wave. As my hon. Friend said, the complexities inherent in attempting to tackle inequalities of health provision are themselves a major burden; it takes time, effort and partnership to tackle them.

My hon. Friend the Member for Islington, North mentioned the disappointment felt by the chairman of the Camden and Islington health trust and the director of the health action zone on hearing of the reduction in funding to the HAZ. Richard Sumray, chairman of the Camden and Islington health authority, said that the HAZ leaders conference on 6-7 October 1999 was told that it could assume for planning purposes that it would receive £1,874,000 for the year 2000-01. As we know,

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that amount has now been reduced. Richard Sumray told me in a fax that the allocation for HAZ includes variable funds that are ring-fenced. He went on to say:

I want to speak about the impact of the Government's most recent announcement on those partners that are essential in enabling the HAZ board to achieve genuine equality of health provision in our area. As I said, we were elated by the announcement that Camden and Islington would have a health action zone as part of the second tranche. I believe that that sense of elation was felt by everyone in the boroughs who was involved in delivering health care across a wide range of areas, by the recipients of health care and by those who believed that much better and more integrated work could be done across the boroughs in delivering, improving and targeting health care.

No one was under any illusion that a single agency or organisation could deliver and improve on equality in health care provision. Everyone involved accepted from the very beginning that success would depend on genuine partnerships being put in place. My hon. Friend the Member for Islington, North talked of meetings for meetings' sake. I do not believe that such meetings deliver anything other than, perhaps, the enjoyment of participants of such meetings at seeing each other. Undoubtedly, a great deal of detailed work must be done before partnerships for delivering can be in place. Everyone must be clear about what they are trying to achieve and how to achieve it, and must actively monitor whether they are delivering.

In a fax to me, Gail Findlay, the director of HAZ in Camden and Islington, expressed anxiety that what seems to be a reduction in funding for HAZ programmes might send the wrong message to the partners involved, who are, as I said, central and essential to delivering the desired outcomes. It might be perceived as the Government losing confidence in health action zones, which I and deliverers of health provision in my constituency believe to be innovative and to incorporate in exactly the right way the experience of health professionals, of people who receive the services of health professionals and of people who are active in campaigning organisations. One of those organisations, Age Concern, is holding discussions with a health action zone on a programme to build on the accessibility of exercise for elderly people, to ensure that their health improves.

The partners may regard the development as a lack of conviction on the part of the Government that health action zones will deliver what we all believe that they can. There may be a perceived lack of confidence in the Government in this innovative and exciting venture and a lack of commitment on their part to see the programme through the full seven-year period.

I hope that my hon. Friend the Minister will be able to restore confidence, especially in those in my constituency who are most actively engaged in delivering in the health action zone. Quite apart from tackling, rightly, the scandal of inequality in health provision, as my hon. Friend the Member for Islington, North said, it is not the Government's fault that such inequalities exist. It is a question of time. The root

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causes are many and varied, and there may be a tradition of expectation and aspiration not being encouraged by individuals, families or communities about the level and quality of the health provision that they receive.

We are beginning to tackle those central and essential issues via health action zones and many other innovative programmes that the Government are introducing in health care. On one level, in dealing with health action zones, prevention is better than cure. I have already mentioned encouraging elderly people and making it easier for them to exercise to ensure that they maintain mobility and that their health improves.

At the other end of the age scale, we have the Sure Start initiative's marvellously imaginative approach to children, which will make an amazing difference for far too many children who have been allowed to live in poverty for far too long. That programme will give them a start in life to enable them to discover what is best in them and what can be developed. None of that is possible without constant monitoring to ensure that health provision is in place.

More than 30 schools are taking part in Camden and Islington's programme to tackle health in schools. One of those schools, Beckford school, is operating a befriending scheme whereby 25 nine and 10-year-olds are helping to look after the emotional health of younger pupils by becoming "playground buddies". Although I do not necessarily like the Americanisation--the name "buddies"--the scheme has immense value, not only for the young children who will be assisted to find their feet in the wider environment of a secondary school, but for those who participate because they wish to help younger children. That is not only part and parcel of delivering on a health requirement and outcome, but intrinsic to ensuring that we have healthy communities. It encourages a sense of community in young people from the earliest possible age.

My hon. Friend touched on the issue of targeting by the health action zone in Camden and Islington to encourage smokers to quit. As a smoker who has never had the desire to quit, I should not linger too long on this incentive. Although I would not go so far as to use the phrase "professional quitters", I agree with my hon. Friend that some people seem to quit as part-time entertainment--

Mr. Corbyn : Serial quitters.

Ms Jackson : That is precisely the phrase that I was stumbling to find. Those of us who are still trapped by nicotine know who those people are. They invariably say that they have quit, but then say that they are having difficulties, and ask, "Could I bum a cigarette off you?" I am making light of a serious issue, especially as far as young people are concerned. It is one of the areas in which health action zones can make an enormous difference.

My hon. Friend touched on the special difficulties in our part of inner London. Those difficulties are not exclusive to Camden and Islington, but are shared by all inner London boroughs. They are related to the peripatetic life style of people suffering mental health problems, and perhaps drug and alcohol-related

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problems. In relation to homelessness and rough sleeping, our constituencies include large refugee populations, who have difficulties because English is their second language. That is exacerbated, in many instances, by cultural and traditional approaches not only to the treatment of illness but to access to health professionals. Health action zones can make a major difference because they involve a wider range of partnership in which health delivery professionals had not previously engaged. A wealth of expertise exists, on which health action zones, by virtue of their partnership basis, can deliver. That would be extremely difficult to define on a simple accountancy cost-benefit basis. None the less, the benefits can be enormous and incalculable.

I hope that my hon. Friend the Minister will be able to calm the fears of those who are enthusiastic and committed to the idea of health action zones, and that the work will continue, involving not only the health trust but all those partners who are actively engaged in tackling the kind of issues that we have touched on. I hope that he will give an assurance that the Government are as confident of supporting the schemes for the first seven years as they were when they were introduced. I regret the reduction in funding, for the reasons that I have given, and the timing of the announcement. My hon. Friend the Minister apologised for the delay in his letter to the chairs of the health action zones, which was courteously copied for the relevant Members of Parliament. He said that he was concerned about what he perceived as an underspend in the first year of funding for the zones.

It is time consuming and difficult to set up the partnerships in the first instance. The zone director in my area was adamant that no purpose would have been served by throwing money at the problem and regarded it as a grievous waste of public money to do so. Structures are now set up within their partnership structure that can successfully deliver. I hope that my hon. Friend the Member for Bethnal Green and Bow (Ms King) will make the point to our hon. Friend the Minister that the underspend in the first year was not due to a lack of willingness on the part of the HAZ directors or partners, or a dearth of problems on which to spend the money. The underspend came out of a desire to ensure that public money was well spent and delivered services in not only the short but the long term.

10.11 am

Ms Oona King (Bethnal Green and Bow): I thank my hon. Friend the Member for Islington, North (Mr. Corbyn) for securing the debate.

I commend the Government for focusing on, and rooting out, health inequalities. An impediment to equality has been a compartmental approach to health problems; one of the key aims of the health action zones is to break down that type of compartmentalisation. The best thing about the zones is that, for the first time, British Government thinking embraces a wider definition of ill health and its causes, such as poverty. That can only be a good thing for hon. Members such as myself who represent deprived inner-city areas that are stricken by poverty and inequality of opportunity, manifested perniciously in life-long health inequalities.

The Government's Sure Start programme is another example of that cross-departmental approach. On the Ocean estate in my constituency, 480 children under the

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age of four have been identified as needing help. Throughout Tower Hamlets, £1 million will be spent on trying to improve the early years of some of our most vulnerable children.

That brings me on to one of the main problems with the HAZ programme. The Sure Start programme, which I welcome, exposes the many cracks that HAZ attempts to paper over. One local general practitioner asked me whether I thought it made sense for money to be spent on Sure Start when, in Tower Hamlets, the most basic health services--the ability to get an appointment with one's doctor, or even to be on a doctor's register or to have health visitors--cannot be consistently delivered. My hon. Friend the Member for Hampstead and Highgate (Ms Jackson) said that prevention was better than cure, and one of the fundamental elements of health action zones is that they encapsulate that approach. However, the same GP--the situation is replicated in surgeries around Tower Hamlets--has one health visitor, who is supposed to cover 250 under-fives, but covers 570 young children because resources are so stretched. A young child in Tower Hamlets has half the attention from a health visitor that he or she would receive if registered in a more affluent area, yet has two, three or four times the need.

Another example of a basic service that Tower Hamlets cannot adequately provide is midwifery. In the Evening Standard last week, a distressed pregnant woman in east London wrote:

Most people not living in deprived areas do not have such experiences, and I recognise that the Government set up the health action zones to deal with such problems. However, we need to be careful about mainstream funding, which HAZs are not intended to replicate or substitute for. The methodology behind the HAZ in Tower Hamlets is such that it will focus on young people. It will also target heart disease and mental illness, which are the biggest causes of early death.

I welcome the notification of funding for health programmes from April 2000 to March 2001. As my hon. Friend the Member for Hampstead and Highgate said, we recognise that my hon. Friend the Minister explained some of the delay in a letter, which was courteously copied to relevant Members of Parliament. None the less, there has been great uncertainty among HAZ services. I sincerely regret the reduction in funding that has befallen the East London and City HAZ programme. We have taken into account the allocations made to it, and although we are thrilled to have received an increase of--depending on how it is calculated, and there are many ways to skin a cat--14 per cent., we note that the overall increase for HAZ budgets has been around 36 per cent.

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We are shocked to have received not even half of that in Tower Hamlets, given that we have the highest concentration of poverty in the country. No other area in Britain has more poor people. Health problems are manifest, and I cannot help but be distressed every time I visit my constituents, go round the estates and find families of 12 living in two bedrooms with water dripping from the walls, condensation, all the kids having asthma and none having places to study. As my hon. Friend the Member for Islington, North explained, that inevitably cripples those children's chances for life.

My hon. Friend the Member for Hampstead and Highgate made the point, but I shall make it again. I appreciate that in my hon. Friend the Minister's letter, he said that he was surprised and disappointed at the size of many of the 1999-2000 HAZ underspends. My hon. Friend the Member for Hampstead and Highgate explained some of the reasons for that, but it might be because Tower Hamlets is so full of amazing ready-to-go ideas and has the most incredible need that it has an underspend of 2.04 per cent.--the smallest in the country, I am proud to say. Although many other health action zones may face reduced funding, they will be able to cushion themselves with large carry-forwards. Tower Hamlets is looking at a cut compared with 1999-2000 and will receive £2.37 million as opposed to the previous funding of £3.139 million. That is a great disappointment, especially given the serious health problems in the area. Substantial savings will need to be made in the HAZ budget, leaving a significant shortfall to make up.

East London HAZ is committed to delivering on the Government's national health service priorities, but feels that it is being punished for its success. Will the Minister consider that and the more significant point that, without adequate funding in the NHS, the lessons learnt from HAZ cannot be heeded or acted on? The central fact is that, despite increased resources, the demand for health care in east London outstrips supply. The HAZ cannot bridge that gap, nor should it be responsible for doing so because, although the programme is for seven years, that is a relatively short time.

We are grateful to have been included in the HAZ programme because it has resulted in many initiatives. The emphasis on partnership and the recognition that the local health economy comprises more than the NHS are critical in Tower Hamlets. The multi-agency work to identify and carry through health improvement programmes is also important. GP surgeries have benefited from the funding streams in IT equipment and training. The link between the programme and schools is an important step in the right direction. Nine projects based on the work with the communities fund are up and running, including a Bengali and Somali men's health scheme with 90 participants. All those initiatives contribute to the community. The best HAZ initiatives should be incorporated into mainstream practice and should not just be a bolt-on.

Better communication is needed between the Department of Health and regional health action zones. I hope that HAZs will address people's experiences of the health service and begin to tackle its inequalities. They have expanded provision in health services, but the deprivation uplift of £1.6 million has already been committed for service developments in cancer, coronary

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heart disease and mental health. Tower Hamlets merited the average increase in HAZ funding, as opposed to the 14 per cent. that we received.

We are anxious that expanded provision, which was overseen by the health action zone, will have to be cut back and taken out of mainstream budgets. The best way to prevent that from happening would be to improve the central funding allocation and ensure that the overall formula is fairer. Thus, the work expected of health care professionals in Tower Hamlets, based on the number of people served by Tower Hamlets and the East London and The City health authority, would be founded on fact, not fiction.

I welcome the Government's historical initiative, which, for the first time, recognises that poor health is linked with poverty and enables the more effective delivery of health care services to young children and adults, some of whom have the worst health in the United Kingdom.

10.26 am

Mr. Nick Harvey (North Devon): I congratulate the hon. Member for Islington, North (Mr. Corbyn) on securing this interesting debate. He justified health action zones most convincingly and rightly spoke about the problems that they try to solve.

I represent a rural constituency and I am familiar with pockets of deprivation; rural areas have many problems, such as the cost of running basic services, which are not properly recognised in formulae, but that is a discussion for another day.

Areas such as north Devon do not have to struggle with the extraordinary deprivation that many inner cities have faced for decades. There are no overnight solutions to their problems, but switching additional resources to those areas is justified. The health action zones, which I welcome, will have fewer resources at their disposal in the coming year than they expected. Overall funding to the health action zones, and the total funding at the disposal of individual HAZs has increased. However, not for nothing did the draft letter from the Minister to the health action zones state:

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The hon. Member for Islington, North made a good point about the number of bodies that need to be involved to make HAZs work--it is dangerous to have too many bodies with too many budgets and too many programmes. I enjoyed his point about the need to ensure that everyone gets on, because they must spend an awful lot of their time working together. I am not sure whether I recognise his description of the halcyon days of the late 1970s, but we shall pass over that for the moment.

Mr. Corbyn : I was being perverse.

Mr. Harvey : Yes, I thought so.

The hon. Gentleman made some good points about the dangers inherent in stopping and starting--or boom and bust, as the Prime Minister likes to say--in such services. It was right that HAZs were set up for seven years and told at the outset that they had the right to carry over funds. That encourages sensible phasing and sensible planning.

It should surprise no one that HAZs did not necessarily spend all their funds in the first year of getting up and running from a cold start and that they had reckoned on the basis of being able to carry over those funds. I wish that they could have done so, because they were probably just being responsible and prudent. The Government have changed their view and said that that is not allowed, which is a mistake. If HAZs are no longer allowed to carry forward funds, I hope that the Minister will reassure us that mechanisms will be put in place to spot early the HAZs that will not use all their funds for the year and to redistribute those funds to any other HAZs that could use the funds for programmes on their books during that year.

Many hon. Members will be aware, from experience of the public sector or involvement in it, that problems arise when a budget must be spent in one year. I have sat on the governing bodies of higher education institutions, and the director appears in mid-February and says, "Does anyone have any good ideas how we can blow a couple of million pounds by the end of March? If we don't, the money won't be there next year." It would be regrettable if HAZs were driven in a direction where that perverse logic applied. I urge the Minister seriously to reconsider the matter and recognise that it is not surprising that HAZs have not used up in the first year all the moneys allocated.

The hon. Member for Hampstead and Highgate (Ms Jackson) said that local HAZ leaders were disappointed that they would not receive the funds that they had anticipated. I am not surprised about that. Other organisations were encouraged by the formation of HAZs. The hon. Lady mentioned Age Concern, which was impressed and signed up to the programme, anticipating making a seven-year commitment with the Government. Those organisations believed that the Government were right behind HAZs, but their faith will have been somewhat shaken and they will be wondering how things will work out in the time left for the programme.

I was also struck by the remarks of the hon. Member for Bethnal Green and Bow (Ms King). She is absolutely right to say that programmes such as Sure Start expose in her constituency the problems that HAZs might have

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conspired to paper over. There are real problems on the ground in Tower Hamlets and many other areas. I welcome the new money coming onstream. However, it would be a pity if it were handed down with too many strings attached. When a Government Department makes new funding available it understandably does not want that money to be swallowed up in bureaucracy or used to cover historic debt. Nevertheless, we need to have faith in local people, who understand the priorities for their areas and can therefore sensibly judge how the sums should be used. Too much diktat about how funds should be used is not welcome.

Despite the injection of the funds, serious problems remain to be solved. As the hon. Member for Bethnal Green and Bow said, demand for health services far outstrips supply, and is likely to continue to do so for a long time. It would be a pity if some of the extra funds earmarked for deprivation allocations had to be used quietly to cover up shortcomings.

We must be honest and say that the resources anticipated by health action zones have been reduced. That is regrettable. The programme is a good idea, but the Minister needs to make a fresh commitment to pursuing it fully. He needs to answer some of the questions about the ability of those responsible for implementing the programme to plan ahead and make sensible commitments over seven years. He also needs to set out the future arrangements for carrying over resources. As I said, people should not have to rush around in the last few weeks of the year finding ways to spend money to ensure that they do not lose it in the future.

10.36 am

Mrs. Caroline Spelman (Meriden): I shall endeavour to be brief, because we are running out of time. I should like to hear a full response from the Minister, and there is no need to repeat some points that have already been made well. I congratulate the hon. Member for Islington, North (Mr. Corbyn) on securing the debate. I understand why the three Government Back-Bench Members who spoke have a particular interest in commending the restoration of funding to their areas, which have high levels of deprivation. Those hon. Members made their cases well. I am surprised not to see some other Members of Parliament, whose health action zones are even more adversely affected. The subject is particularly suitable for an Adjournment debate, because it concerns a large number of people.

My constituency contains many contrasts. There is a seven-year difference in life expectancy between people on one large council estate, which has its origins in the Birmingham slum clearance, and people in a more affluent area. Although my constituency does not qualify for health action zone money, I am well aware of the pockets of deprivation that exist in several other constituencies.

The programme budgets of 11 health action zones have been reduced dramatically with effect from this month. My research shows that the biggest casualties are the South Yorkshire coalfields health action zone in Barnsley, whose budget has been slashed by £789,000; Tyne and Wear HAZ, whose budget has been cut by

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£1.2 million to £3.5 million; Manchester, Salford and Trafford HAZ, whose budget has been cut by £1 million; and Lambeth, Southwark and Lewisham HAZ--the "inner-London ring" constituencies to which the hon. Member for Islington, North referred--whose budget has been cut from £3.65 million to £2.713 million. The hon. Member for Bethnal Green and Bow (Ms King) described well the position of the east London health action zone.

Before I came here, I spoke to my hon. Friend the Member for South-West Devon (Mr. Streeter) and the hon. Member for South-East Cornwall (Mr. Breed). They told me that the Plymouth health action zone's budget will be cut from £1.037 million to £771,000. I know that the budgets of many health action zones have been cut by less than that, but Luton, Sandwell, Bradford, Northumbria and North Cumbria HAZs are nevertheless affected. It is important to mention all the affected areas, because one of the purposes of Adjournment debates is to raise wide-ranging issues.

The nub of the debate is whether the money to those areas, which we all agree need additional support, is being cut. The argument has run along the lines--I expect that the Minister will make this point--that the money is not really being cut because the health authorities in those areas will receive other moneys. That does not persuade the local Member of Parliament or those running health action zone projects. We know exactly how public money works. It is parcelled up for particular projects and it is difficult for a project to recover its position if its core funding is cut.

The Liberal Democrat leader made that point rather well at Prime Minister's Question Time. He showed the sequence of internal documentation, which the hon. Member for North Devon (Mr. Harvey) has read out. The Prime Minister replied:

That is the nub of today's debate. We agree that health actions zones are a good idea. They are needed in the areas where, for many complex and diverse reasons, as the hon. Member for Hampstead and Highgate (Ms Jackson) fairly pointed out, there are life expectancy and health inequalities. Those inequalities are complex to tackle and, regrettably, are getting larger. There is hence an understandable political need to target money into the areas concerned. When a seven-year programme has been agreed, it is most disheartening for those who have to deliver the project to have their core funding cut at such an early stage. It sends all the wrong signals to the people on the ground.

I have some straightforward questions for the Minister. Will there be further cuts next year, or will the core funding be restored? I am not persuaded that providing parcels of money to fund other health-related projects in those areas, which is a loose way of describing where the money is going, will restore

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confidence in the health action zones project. Can the Minister assure us that the capacity to carry over from year to year will be restored? A number of hon. Members said that the underspend by their health action zones had resulted in some of that money being taken away. In modern government we are trying to move away from the idea that, unless money is spent on something at the end of the year, it will be taken away or, in this case, cut back. At the outset of the project, there was a commitment to allow health action zones to carry forward their underspend, but it appears to have gone. Can the Minister reassure us that the capacity to carry over from year to year will be restored?

The integrity in the core funding must be maintained if the health action zones are to work and if their seven-year programme is to be completed. I look to the Minister for a clear assurance on that point. It is essential for the confidence of all of those who work in difficult situations. For them, the money never seems enough because the degree of inequality is so large and, regrettably, getting larger.

10.43 am

The Minister of State, Department of Health (Mr. John Denham ): This has been a useful debate and I congratulate my hon. Friend the Member for Islington, North (Mr. Corbyn) on securing it. I welcome the contributions made by my hon. Friends and others. My hon. Friend the Member for Islington, North has a keen interest in health action zones. He has raised a number of points today and he spoke about them recently in an Opposition day debate in the House. This timely debate sets out the position.

In his opening remarks, my hon. Friend welcomed the priority that the Government attach to areas of highest deprivation and to the need to tackle health inequalities and rebuild and modernise the national health service. He also welcomed our practice of launching health action zones. I wish to reassure hon. Members of our continuing support for this programme. I noted what the hon. Member for Meriden (Mrs. Spelman) said. I have to say in passing that there was no such programme during 18 years of Conservative Governments. In the light of the shadow Chancellor's announcement that he is abandoning commitment to any of the spending programmes, I shall probably write to the hon. Lady asking her whether what we heard from her was a spending commitment to the future of health action zones. However, I doubt whether she will be able to reply as I shall reply today. We are committed to health action zones.

Many of the issues raised by my hon. Friends reflected those that Ministers must consider when deciding on the overall allocation of funding for areas covered by HAZ programmes. There is common ground on the importance of areas where some 13 million people suffer particularly harsh deprivation receiving extra money, over and above what they would have received through the usual allocation formula for such areas.

A persistent theme of the debate was that we should ensure that we strike the right balance between the innovative and ground-breaking work of new partnerships that are formed by HAZs and the allocation of mainstream resources for those areas. We have sought to achieve that balance in a series of

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decisions that the Government have taken on funding HAZ programmes and allocating resources. When the total figures are seen, it will be clear that they represent a substantial and increasing commitment to tackling the poverty, inequality and health deprivation that have been described.

We are strongly committed to improving the health of the most deprived communities. The work of HAZs is key, in that much is being done to reduce health inequalities, to modernise services and to tackle social exclusion. The partnerships that have been formed--they have been well described today--between local authorities, local health services and other agencies, including the voluntary sector and local community organisations, play an important part in driving through those changes. That is very different from the fragmentation and lack of partnership in the internal market in the health service under the previous Government.

My hon. Friend the Member for Islington, North essentially asked how we should act to make the co-operation achieved through HAZs a more mainstream feature of operating what I shall call the local health economy. In the past two years, we have instituted health improvement programmes that bring together health authorities, with their strategic leadership role, trusts, primary care groups and trusts and local authorities. We have consulted widely with the voluntary sector and have set out areas' health priorities. As well as the range of services provided by the national health service, those priorities include many of the issues that have been raised this morning. The funding that we give to local health authorities and primary care organisations is intended for locally agreed priorities in the health improvement programme, which of course also reflects national priorities set by Government, such as work on coronary heart disease, mental health and so on.

HAZs can be seen as giving a kick-start to the health improvement programme process, which works across all local health authority resources rather than as a separate, detached element. HIPs have been part of the local planning system for only two years. Hon. Members will have received from their local health authorities copies of the HIP, which is only the second version of the document. The process will evolve over time as the HIP becomes the focus for the sort of co-operation that has been spoken about today. I hope that I can reassure my hon. Friend the Member for Islington, North that we have a clear strategy to develop coherence in health planning and the promotion of good health across the local health economy that goes beyond the partnerships formed through health action zones.

Mr. Corbyn : The Minister will have heard what I said earlier. Can he offer us any comfort with regard to the perverse effects of budget planning in the health service and the local health economy, whereby it becomes a positive incentive not to take patients from a hospital into community care or vice versa because whoever takes them must pay for them and whoever has them is already stuck with the bill? I know that the problem

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sounds minor, but squabbling about who should and who should not have a patient causes an enormous waste of time, energy and resources.

Mr. Denham : That problem is partly addressed through, for example, the local winter planning groups, which were established for the first time last year. They led to much more integrated planning between social services and health services locally and were able to pinpoint places in the system where bed blocking and delayed discharge could occur. We shall build on the experience of last winter for the coming winter. I think that that will become a permanent feature of the system. In many areas, the co-operation has been so productive that the planning process has been extended year round, rather than focusing only on the key winter months for which it was originally developed.

In addition, the Health Act 1999 introduced new legal flexibilities to enable local authorities and health services to pool budgets, to have an integrated provider of health and social care and to have a variety of other means for overcoming problems in developing partnerships locally. Those powers became available only towards the back end of last year, but there is considerable local interest in developing them. We have pointed to the potential role of primary care trusts working with social services departments to use the new powers to avoid individual patients falling down the gaps between the health and social care systems, as we all recognise has happened too often in the past. Although I would not pretend for one moment that all those measures are in place on the ground, the planning mechanisms and the organisational powers are now in the system to enable such problems to be tackled more effectively.

In view of the lack of time, I want to ensure that I deal with the key funding issues that have been raised, although I should like to say more about health action zones. First, however, I will respond to the several hon. Members who asked for signs of our commitment to health action zones.

I have already said that we regard the zones as a key tool in tackling health inequalities locally. We have worked with health action zones in two areas. First, we have rightly impressed on the zones the need, when spending public money, to develop programmes that not only address individual problems but that have clear targets and outcome measures, so that we can evaluate their effectiveness and be sure that the investment is achieving the desired impact. In the first year, we worked closely with health action zones to help them to do that and to encourage them to take the process further.

Secondly, we have worked with health action zones on the mainstreaming of programmes to ensure that their activities, for example, work on coronary heart disease, do not become detached from the mainstream work and the developments of the national service framework on that disease. Real progress is being made on those issues locally, but we shall continue to work with health action zones.

It is important to recognise that the extra funding going into the areas covered by the health action zones this year represents an overall increase of 37 per cent.

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compared with last year. It is true that there have been changes in the balance of streams through which that money goes into the zones, but, by any measure, the resources have substantially increased.

When we launched the health action zone programme, we gave the zones a general indication of the funding that they might expect to receive over the comprehensive spending review period. Everybody recognised that that budget, like any indicative budget, could change in the light of experience and developments. Two significant developments occurred. First, last December we decided to provide through the deprivation allocation an extra £30 million to the health authorities covered by health action zones. That expenditure was not envisaged or predicted this time last year. We had built an initial £30 million of extra funding into the health action zone areas in the previous year, but the new expenditure raised that total to £60 million.

Secondly, it became apparent that there was a substantial underspend of health action zone funding. We had agreed to give some flexibility to allow for slippage and for the development of local partnerships. However, out of the £88 million that was available to health action zones in 1999-2000, about £23 million was unspent and carried forward into this year. Although every zone will give reasons for that slippage, it was much higher than we had anticipated or thought to be justifiable when we agreed to the year-end flexibilities. That is why we have decided not to allow slippage at the end of this year, although we will conduct precisely the sort of exercise that I think was mentioned by my hon. Friend the Member for Bethnal Green and Bow (Ms King) and by the hon. Member for North Devon (Mr. Harvey). We will review progress in about October to ensure that we can take action on any apparent problems. It is clearly important for public money that has been allocated for tackling health inequalities and deprivation to be spent on delivering the services that people want.

Ms Glenda Jackson : As far as my local HAZ is concerned, the Government's attitude is an indication of their desire to push HAZs into the mainstream delivery of NHS services--an approach that ignores local realities on the ground and sends markedly the wrong message to the partners. Early wins can be achieved, but they do not deliver in the long term, which is what most HAZs want to do.

Mr. Denham : My hon. Friend makes a very important point. We must engage the health service more effectively in the wider agenda of tackling health inequalities and ensure that the zones are properly engaged in shaping the mainstream delivery of national health services. I do not see the two matters as juxtaposed. What is important is an effective partnership to tackle the broader issues that are being tackled by the zones and by the national health service.

For this year, health action zone areas will receive a £60 million allocation on top of what would usually have gone to the relevant health authorities. Other resources include £40.5 million in programme funding for joint projects with other agencies; £10 million for smoking cessation, which had already been allocated; £7 million in innovations funding; and £2 million for

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drugs funding. That makes a total of £120 million. It compares with last year's total of £87 million and represents an increase of 37 per cent.

In the Budget, an additional £660 million was allocated to health authorities throughout England. I do not pretend that that point is central to the debate, but it is worth making it clear, especially as health authorities in the health action zones received an additional £215 million of that money. The funds were allocated according to the formula, but there was arguably an increase on last year's investment of more than £200 million in those areas. Although the balance of funding has varied, health action zones received substantially more from both the health action zone project and the wider increase in resources than they would have expected this time last year. They are an important Government initiative and will continue to receive our backing.

Mr. Deputy Speaker (Mr. Frank Cook): Order. The next debate is on the report of the Commissioner for Public Appointments.

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