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Midspan Project

12.30 pm

Ann McKechin (Glasgow, North) (Lab): I am grateful for the opportunity to speak about the Midspan studies, which are centred in my constituency at the university of Glasgow's division of community based sciences, which has just celebrated 30 years of follow-up studies.

Since the creation of the Scottish Parliament, it is a bit unusual for a Scottish MP to speak here about health issues, but not every aspect of health is devolved. There is significant cross-border interest regulation in the medical professions, terms and pay rates for NHS staff and medical research.

The Midspan studies are as worthy of analysis by politicians in this place as they are in Holyrood, not least in the debates over the next few weeks as the Health Bill passes through its legislative programme. As I will explain today, I have more than a passing constituency interest in those studies.

The Midspan studies based in Renfrew, Paisley and workplaces in the west of Scotland are the largest long-term health studies ever carried out in predominantly working-class areas and they were, importantly, the first such studies to include women. It is amazing to think that major research into cardiac problems and lung cancer routinely did not include women until this study commenced in the 1970s.

The driving force behind the studies was Dr. Victor Hawthorne, who entered medicine immediately after world war two and still takes an active role in the studies in his present position as emeritus Professor at the University of Ann Arbor in Michigan. He arrived in Glasgow in the 1950s and recalls that parts of the city reminded him of the deprivation he observed when serving as an artillery officer in India. His future career was to be marked by his work in tackling the persistent pockets of tuberculosis that remained in Glasgow in the late 1950s and taking part in the TB campaign from 1957 to 1959, which involved a large number of volunteers, one of whom was my mother.

By the late 1950s, the service had identified those populations at high risk and its success in effectively tackling the problem encouraged Professor Hawthorne and his colleagues to extend their gaze to a wider range of chronic diseases and examine a whole population. Based on a small study on the island of Tiree in the Western Isles, and in collaboration with the team behind the famous Whitehall study, Professor Hawthorne's team developed the methodology that would subsequently be used in Midspan, particularly the use of community involvement. Community involvement was key to the success of the studies and the team chose an ideal location in the towns of Paisley and Renfrew, which are a short distance from the university. I am pleased that my hon. Friend the Member for Paisley and Renfrewshire, North (Jim Sheridan) is here today.

A total of 23,000 local people have been involved over the history of the studies, which is a wonderful example of civic public spirit and community involvement in an age when it is often assumed to be dead and buried. Both those towns and the Midspan team deserve credit for their efforts. Paisley, my home town, is Scotland's fifth largest centre of population, but it is often said with
 
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justification that it is also Scotland's largest village. That is one reason why it was not difficult to get everyone in the town talking about this study. As a young child, I remember the launch of the Midspan project as a huge event in the town, where local people from all backgrounds—but particularly from the working-class areas—were keen to volunteer for a study that they believed would hold real benefit for future generations. The council, the local newspaper, community groups, Churches, as well as local doctors, were all engaged in promoting the scheme.

My parents, who fell within the 45–64 age bracket being examined, were among the 15,400 men and women who participated at that time. They had their height, weight, respiratory function, blood pressure and cholesterol measured, had an ECT, chest x-ray and tuberculin tine test, and answered questions on smoking habits, social background and medical history.

Jim Sheridan (Paisley and Renfrewshire, North) (Lab): I congratulate my hon. Friend on securing this worthwhile debate. Currently, I am the Member of Parliament for Paisley and Renfrewshire, North, but at the time of the survey I was at primary school.

On Saturday, I had the pleasure of visiting the Midspan reunion and it was heart-warming to watch the people who took part in the study some 30 years ago meeting again. I pay tribute to the people of Paisley and Renfrewshire, North for doing that, particularly my hon. Friend's family, who are well respected in Paisley.

Can I ask how the survey identified the dangers of passive smoking?

Ann McKechin : I thank my hon. Friend, and I will come to the issue of passive smoking later.

Of the original participants, more than 8,000 were women, and there were more than 4,000 married couples involved, making the study unique in providing a general UK population sample of women, and long-term follow up. Although coronary heart disease killed a quarter of the women in the study, women tended not to feature when people talked about their understanding of the disease.

All the participants were invited for a further visit between 1977 and 1979, in which the same round of tests was used. More than 50 per cent. of the original participants took part—again, a significant tribute to the dedication of the local community. Computer linkage was established for data on Scottish hospital discharge and cancer incidence, and follow-up on mortality figures was established with the General Register Office for Scotland.

In recent years, some survivors involved in the original survey have been recontacted and asked to take part in studies on healthy ageing and cognitive functioning. We have become much more aware, as medical science has developed, of the generational links to health problems. The Midspan studies had the good sense to include women and, in particular, couples, and that allowed the Midspan team to enlarge its work by looking at the health of the children of the original participants. In 1996, the team, now led by Professor Graham Watt, conducted a similar round of tests involving 1,040 sons and 1,298 daughters aged between
 
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30 and 59 from 1,477 families. I can disclose that I was one of those later participants. Although trying to get blood from me is a real struggle, and although—like most—I am not too keen on the idea of testing, I knew that many could benefit from the study.

I am impressed that, over such a long time, the Midspan team has been able to achieve such a high response rate. That, in turn, means that their findings are reasonably representative of populations living and working in areas characterised by high rates of socio-economic deprivation and early mortality. For many years, our policy makers lived under the delusion that there was no clear link between ill health and poverty; in fact, I remember well that the Tory Administration refused point blank to admit the correlation and the consequent need to prioritise health spending accordingly. The study conclusively proves that link and it continues to assist us in our understanding of how to tackle the most entrenched health problems affecting our society.

Of the 150-plus research papers in a wide variety of journals that directly use the data, the majority have been produced in the last seven years. I shall give just one example of how the Midspan data show up the failings of standard risk assessment criteria still in use. Research by Dr. Peter Brindle, working with the Wellcome foundation at Bristol university, published just this month in the British Journal of General Practice, shows that people from deprived areas are less likely to receive medical treatment to prevent heart disease. That is because the method used to assess an individual's risk of getting heart disease underestimates the true level of coronary heart disease risk associated with elevated risk factor levels in some social groups.

The recommended way of preventing heart disease involves using the Framingham risk score to identify high-risk patients, but the relevance of the score to the British population is uncertain. That is partly because the US data on which it is based are more than 20 years old, and partly because the original study did not include areas with high socio-economic deprivation. The original Midspan survey involved 12,304 men and women who were free from cardiovascular disease at the time of testing. During the next 10 years, 696 died from cardiovascular disease; the Framingham score predicted only 406 deaths.

Although cardiovascular disease mortality was underestimated across the study population as a whole, for people in manual occupations the risk was underestimated by a significant 48 per cent., compared to by 31 per cent. for people in non-manual work. The same effect was observed when people living in affluent areas were compared to those in deprived areas. Crucially, the Midspan data show that in addition to scoring systems based on cholesterol, blood pressure and smoking, there is another measurement that predicts how long people will live, namely, how hard they can blow—that is, their lung function. That last test was shown by Midspan to be the strongest predictor of long life.

In the light of the report, can my hon. Friend confirm whether her Department will consider adjusting national agreed clinical guidelines to take account of those higher risks? If that is done, what additional
 
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resources will be provided to general practices to treat, monitor and review the additional patients to ensure that they receive the benefit of life-saving treatments?

My hon. Friend the Member for Paisley and Renfrewshire, North mentioned smoking. The Midspan results show that lung function was decreased by smoking, air pollution and poor childhood circumstances. I am sure that, in the light of current debate, the Minister will be interested to know that Midspan was one of the first studies to demonstrate the harmful effects of passive smoking by examining the health of non-smokers living with a smoker. Passive smoking cast a long shadow, not only in terms of increased coughing, chest pain, lung cancer and heart disease deaths in non-smokers, but through reduced lung function of the non-smoking offspring of parents who smoked, which is a prediction of reduced lifespan spreading down generations. Perhaps in her response my hon. Friend. can give some indication of how her Department intends to tackle the problem of the home environment in relation to passive smoking, which is likely to be the main indoor location for smokers after changes in legislation, both here and in Scotland. In particular, what efforts can her Department make to highlight the effect on children's health of passive smoking in the home?

As for generational changes in health, the good news is that the Midspan offspring had greater social mobility, smoked less and were taller, which is another predictor of longer life. The bad news is they had twice the rate of asthma and obesity, with the horrific statistic that obesity affected one in five adult sons and daughters.

I am delighted to highlight the excellent work of the Midspan study at Glasgow university and thank Professor Watt for his assistance in providing me with information about the research results. However, the history that I have outlined shows the importance of funding long-term research to ensure that our health priorities are based on reliable, relevant and up-to-date statistics. The data take time to bear fruit; most of the information coming out of this particular study has been of use only in recent years. Sustained investment and engagement with our communities is required.

I urge the Government to commit themselves to tackle the deep-seated causes of socio-economic deprivation by continuing to fund such work and ensuring that its conclusions are put into action in as we deliver a health service fit for the 21st century.

12.43 pm

The Parliamentary Under-Secretary of State for Health (Caroline Flint) : I congratulate my hon. Friend the Member for Glasgow, North (Ann McKechin) on securing this debate. I welcome the presence of my hon. Friend the Member for Paisley and Renfrewshire, North (Jim Sheridan), and thank him for his contribution.

I thank the Midspan project for the work that it has done over a considerable length of time, but I also give thanks—as my hon. Friend the Member for Paisley and Renfrewshire, North (Jim Sheridan) mentioned—to the people who took part in that project. I imagine that it would be daunting to be part of such an experiment,
 
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particularly when one is asked to come back for monitoring at various periods of one's life. It must be especially daunting for mums and dads to be asked whether their children will form part of the project. That is a sensitive and difficult area, and the stark reality of the link between poverty and ill-health is hard for families to cope with—knowing that one is in poverty and finding out that that links to the health of oneself and one's family. I am sure that my hon. Friends and you, Mr. Cummings, agree, that a Labour Government understand this issue more than any other. The driving force of all the pioneers of the 19th century who tackled issues of public health and working conditions led to the formation of the Labour party.

Jim Sheridan : On the question of working conditions, my hon. Friend will be aware that, in many working-class communities, the participants in Midspan were involved in using products such as asbestos. Even today, they and their families are suffering the consequences. On that basis—and on behalf of my right hon. Friend the Member for Paisley and Renfrewshire, South (Mr. Alexander)—I invite the Minister to meet some of the participants in the Midspan project so that she can see for herself what has been happening.

Caroline Flint : I am interested in that because there are some lessons to be learned across the United Kingdom from the work that is being carried out. I hope that my hon. Friends, the people who took part in the project and the people running it are reassured that the Government are keen to tackle health inequalities. My constituency, Don Valley, is a former coal-mining constituency. I see all the people who come forward with their coal-mining health claims for vibration white finger and respiratory disease. There is no doubt about   it—the consequences are generational. The consequences of unemployment are also a problem for health. However, we are learning more and more about those links. In addition to the Midspan project, we have what we learned from the Black report in 1981 and the Acheson inquiry in 1998, which we set up to look at the links involved in health inequalities. That has shaped our thinking in England and in Scotland, as well.

As my hon. Friend the Member for Glasgow, North indicated in her speech, there was a time, not long ago, when we could not even discuss the idea of health inequalities in public. The approved phrase was "variations in health". I am glad to say that since 1997 we have been able to face up to the realities of health inequalities across the United Kingdom—partly because of the research evidence generated by this and other projects.

As my hon. Friends have said, the Midspan project has had an interest in systematic, long-term studies, including of the health of middle-aged people in deprived areas. Alongside other work, it has highlighted the necessity for policy to be underpinned by sound evidence. I am afraid that that is even more necessary in Scotland than in England. The health consequences of deprivation are stark in terms of the impact on life and lifestyle, and on life expectancy. The latest figures show that average life expectancy at birth is almost three years longer for men in England than in Scotland and almost
 
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two years longer for women in England than in Scotland. Eight out of 10 areas in the UK with the shortest male life expectancy are in Scotland.

We need to share the research and learn about the key issues across the UK and elsewhere that provide important lessons for us when it comes to delivering policy. In identifying the policy, we need to think about what sort of practical delivery should be happening on the ground. A lot of work has been done in Glasgow, for example. Record levels of resources have been put into the Greater Glasgow NHS board. We are talking about more than £1 billion this year. The Glasgow Centre for Population Health has been established. It will help to consider action to improve health and to tackle health inequalities in Glasgow and the rest of Scotland. As in England, the information and the studies are being used to try to provide practical, long-term solutions to improve the situation.

We have tried to reflect that work in the health inequalities themes of our EU presidency. All the home countries have worked together to promote the issue, most notably at the presidency summit last month. We hope that we will continue to inform ourselves on good practice and on the work that is being done across the UK and the European Union, and we will share that information so that we can have a discussion that lasts beyond our presidency.

In England, we have been trying to develop a cross-Government approach to improving health and tackling health inequalities. We hope that a national health inequalities target for 2010 on life expectancy and infant mortality has helped us to galvanise action in that area. A national health inequalities strategy, the programme for action, has engaged partners on the health inequalities agenda across Government and elsewhere. Scotland has the prevention 2010 initiative, in which the issues will be considered in a more serious and concerted way.

There are three key lessons to be derived from the work. There is the need to lay bare the evidence. That is the first step in challenging the assumptions that exist in many communities about ill health and chronic disease and about their being the norm for people in early middle age. There is also a need to revise expectations about what constitutes a healthy life. I hope that that will encourage changes in the way in which health and other services are delivered and used. In England in particular, we are considering the link between health services and local government in tackling health inequalities.

Jim Sheridan : Does my hon. Friend agree that it would be wrong for anyone to underestimate the role that the Labour Government have played in the past by protecting people's health and safety in their workplaces? We have to remember the role played by the Health and Safety Executive, particularly in the Midspan project, in helping people to understand the dangers of working life.

Caroline Flint : I agree with my hon. Friend. I am thankful for the past eight years that we have had in government. When we look back over the past 100 years, it is undoubtedly the case—I know I am partisan in saying this—that Labour Governments have been the
 
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most progressive and thought-provoking in the legislation they have introduced concerning education and health and safety in the workplace. We should be very proud of that.

As times change, we have to adjust to the changes in people's lifestyles and the way in which they work and live. As the Minister with responsibility for public health, I am concerned with the issue of diet. In some respects, our diet in the 1940s was better than the diets today of some in our poorest communities.

Ann McKechin : I am sure that my hon. Friend will welcome the initiative of Glasgow city council—unfortunately it has the worst health statistics in Scotland—to give free fruit to primary school children and set up breakfast clubs in primary schools in an effort to tackle diet and its links with ill health in children. Poor diet is also a major cause of ill health in later adult life.

Caroline Flint : I certainly do welcome that initiative. In parallel, there is a scheme in England that supplies fruit and vegetables to children in schools. I am pleased to say that just this week in Devon and Cornwall we have launched a reform of the welfare food scheme, which will for the first time give parents from lower-income families vouchers to exchange not just for milk or infant formula but for fruit and vegetables. Importantly, in order to be part of the scheme many families will have to discuss nutrition and food with their health visitor or midwife. We are taking the earliest opportunity to address the health of pregnant mothers and their children, which leads to the work we are doing in schools with free fruit and vegetables, breakfast clubs, after-school clubs and that important meal in the middle of the day. We have an opportunity to get that right in the next few years, I hope.

We have recognised that we can target intervention on some of our poorest communities. In England, we have the spearhead group of 70 local authority areas with the worst health and deprivation indicators. They are leading our work in this sphere by testing out different ways in which we can reach communities. Earlier, the identification by GPs of patients' health problems was referred to. We are looking at better ways of reaching those who are not coming forward to GPs in communities, as well as considering the way in which people are treated when they visit GPs and the sort of things GPs should be looking out for. A point was made about clinical guidelines, and England has separate ones from Scotland, but I shall write to my hon. Friend the Member for Glasgow, North on that issue from an English perspective.

In the spearhead areas, we are focusing on deprived and vulnerable groups and examining the health needs of the over-50s in particular. That group is crucial if we in England—it is probably the same in Scotland—are to meet our 2010 target because of the differences in the health and life expectancy of men and women of this age in spearhead areas and in the rest of the country. I am pleased to say that we have seen some startlingly good work in some spearhead areas that has already had an impact. Services and how they are received have been considered and they are getting better in providing a health service that is fit for purpose.
 
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We shall need extra effort in the spearhead areas, such as the new health training scheme announced in the "Choosing Health" White Paper, to support local people by improving health and preventing diseases such as cancer and coronary heart disease, and by providing support for the management of people's health when they have had treatment in one of those areas. That is an important part of the process as well. Identifying the post-treatment support that will enable people to take advantage of diet and exercise, which will make treatment sustainable and allow it to work for longer, is also an element of the process. There is the matter of prevention, but people can change their lives even if they have had a heart attack or cancer.

My hon. Friend referred to clinical guidelines. We try to consider the best available evidence of clinical effectiveness and cost-effectiveness. I have heard what she has said, and I shall make some inquiries. In Scotland, clinical advice is provided by NHS Quality Improvement Scotland.

We have announced extra support for primary care for many of the spearhead areas. In relation to obesity, we are discussing guidance and support for GP practices and health professionals to engage with people about what can be a sensitive issue. We are also getting better data about obesity levels among children in schools. We are working through that, and there will be more information on it in the months ahead. In Scotland as well, schools and weight management in schools are being considered.

Ann McKechin : May I add to that equation the issue of alcohol, which is also included in the Midspan data? The relative cost of alcohol has made it much more available throughout our society, but it has had a detrimental effect on health. I am sure that that is the same in England.

Caroline Flint : Returning to our founding fathers, one of Kier Hardie's five ambitions was to ban the sale of alcohol. I think that we covered four of his ambitions, but not quite that one. However, my hon. Friend makes an important point. Children learn from parents. Alcohol is one aspect; smoking is another. From some of our evidence, we know that the likelihood of children smoking is greatly increased if their parents smoke. With alcohol, we need to send out messages that explain how it contributes to one's long-term health.

I have watched a couple of episodes of a programme called "Honey We're Killing the Kids", which gets in a couple of parents and, using computer technology, analyses their children's health profile to show the parents—not the children—what their children could look like aged 40, if eating, exercise and learning issues are not tackled. The programme is quite thought-provoking for parents. I am pleased to say that it gives some simple steps that any parent can take to improve things. We preach, but too often we set goals that are difficult for families to deal with in one go. They need some simple steps to take.

We are concerned about smoking throughout the UK. Smoking is the biggest cause of avoidable death, and we have run adverts—the campaign about children has been particularly effective—about smoking in the home and in the car. I am afraid to say that even if
 
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people pull down the window in the car, they are not thinking about what is happening to baby in the car seat in the back. We are trying to do some more work on that. In England, we are launching a major quitting education campaign to extend the work of smoking cessation services, particularly in deprived areas.

I saw an article describing how some young mothers felt that if they smoked, their baby would have a low birth weight and the birth would be less painful. We must find out how people think about such matters and what they are prepared to do. We can do that only if people are responding to the health service. We must investigate the reasons why some people act on health advice and others do not. That needs some radical thinking.

I am pleased that we have had the opportunity to discuss the matter. There is more work to be done. I have no doubt that smoking proposals throughout the United Kingdom will have an impact during the next few years. Importantly, within our deprived communities, services must be fit for purpose, meet needs and not only provide information about what constitutes better health; if we are to make real inroads, we must go beyond that. We shall make more advances in the 21st century only if we base our work on the major advances that we made in the 20th century.

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