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The hon. Member for Blackpool, North and Fleetwood (Mrs. Humble) spoke about the meeting with a health professional that a pregnant woman would need to have in order to claim this grant. I share
her vision of how that would work in practice. She talked about an ongoing dialogue involving giving advice to pregnant women about diet and lifestyle choices, for example. However and as I said in an intervention, the Bill, which is vague on detail, does not provide for that. Rather, it refers to a woman receiving
“advice on matters relating to maternal health from a health professional”.
She will have had that, anyway, from her health visitor or GP, so I do not see how we get from the Bill to the idea put forward by the hon. Lady, which I support, of an ongoing interface between the pregnant woman and a medical professional about diet and healthy choices.
I turn to how the scheme will be administered. We know that it will be delivered through Her Majesty’s Revenue and Customs—this huge, sprawling, merged Department that, as we now know, is beset with operational difficulties. If we did not need any other reminders, the events of last week have shown that yet again. However, there is another experience involving HMRC that is relevant here—that of tax credits. We all know from our constituency surgeries the number of people who are having to pay back money that the Treasury is clawing back as a result of overpayments. We know that when many people are given up-front payments, they spend them—that is in the nature of things. Those on low incomes or facing pressing expenditure needs, in particular, will spend them. Where is the evidence to suggest that a pregnant woman will use this one-off cash payment of the health in pregnancy grant in a planned way to meet their ongoing dietary needs and to ensure that they can pay for good-quality fresh fruit and vegetables? Will not human instinct take over if this money is paid in a one-off lump sum? The Secretary of State has talked outside this Chamber about the “broccoli police”, who will not be coming round to check that all the money is being spent on what it is intended for. However, it is worth asking whether this money will just get burned up very quickly and will not be used in the way that Ministers intended.
To conclude on this point, the Government are proposing to spend a significant sum—£120 million—and if one accepts the line from the Royal College of Midwives, that figure will increase significantly in the years to come. In the absence of any effective strategy for well-being during pregnancy or any prioritisation in respect of poorer women or women from areas where there is a higher incidence of diet-related problems, and when the maternity services of many communities are being eroded, could the money be put to better use? To my eyes, this is more part of a political strategy than a health one, and to many people it smacks of the Government trying to create a new tier and category of cash-receiving clients of central Government. There is room for contention and vigorous debate on this measure.
On the national child measurement programme, the hon. Member for Caernarfon (Hywel Williams) knows that I am not the greatest devolutionist in this place, but I support the measures in the Bill to extend powers to Ministers in the National Assembly for Wales to introduce a similar scheme in Wales to the one that has been running in England and to bring it in line with the changes that will be introduced in England for
measuring the height and weight of children with a view to feeding the information into body mass index calculations.
Wales has a significant and growing problem of childhood obesity. It is not a new phenomenon. Ten years ago, groups of general practitioners in Wales were warning that an epidemic of childhood obesity was about to hit Wales. In the past eight years, since the establishment of the National Assembly for Wales, which has responsibility for these issues, precious little substantive action has been taken to tackle childhood obesity in Wales. I welcome this measure in the Bill. If it enables, and provides more tools to, Health Ministers in the Assembly to tackle childhood obesity, it has my support.
I was excited to see the small section on social enterprise in the Bill. Some years before being elected to this place, I was involved in setting up a social enterprise in south London. It was attached to a large mental health charity working with people from the African and Caribbean communities. The idea was to create a social enterprise using some of this charity’s clients in producing high quality frozen African and Caribbean food to sell to national health service primary care trusts, which were demanding such food as they moved towards having more ethnic choice in the meals that they provided. We faced huge hurdles in setting up the social enterprise. Trying to do business with PCTs, get contracts and negotiate all the different hurdles that we had to clear was a time-consuming and expensive process. We benefited from the fact that a PCT supported what we were trying to do, shared the vision of the social enterprise and put its resources behind it.
If, as I understand it, the measures in the Bill will extend such provision, give more direction to it and enable far more social enterprises to crop up in the health and social care field, that can only be a good thing, because this is a rich environment for social enterprises. It would be good to hear from Ministers about their vision for social enterprise and how it can contribute to health and social care.
7.33 pm
Dr. Howard Stoate (Dartford) (Lab): As the House well knows, I still do some general practice for the national health service and I have a particular interest in public health. As we have heard this afternoon, one of the most serious public health issues facing this country is obesity, which is not only growing at an extraordinary and alarming rate, but is one of the most difficult areas to tackle.
The Foresight report, published on 17 October, set out some alarming statistics, and I want to focus on the part of the Bill that deals with the weighing and measuring of children. The report said that in 2004 approximately 10 per cent. of boys and girls aged six to 10 were obese, but the forecasts were rather more alarming. The report pointed out that those figures are likely to increase to 21 per cent. for boys and 14 per cent. for girls by 2025, and to 35 per cent. for boys and 20 per cent. for girls by 2050. Those figures are probably conservative, because they are based on an international standard for measuring obesity that we
do not use in this country and which, if anything, underestimates the prevalence of the problem.
The national child measurement programme records the height and weight of children in reception and in year 6, and at least gives us some information to go on. The national public health service was recently asked by Government to undertake a feasibility study in 2007-08 on the creation of a national surveillance programme of children’s height and weight. Again, that goes some way towards addressing things. The provision in the Bill for weighing and measuring children is buried in the miscellaneous provisions in part 5. I call on the Government to go much further, both from the health point of view and in ensuring much more cross-departmental work in government to try to tackle this issue.
There is no question but that the provision of better information and advice to parents about their children’s health is essential. The majority of parents probably are well aware of the growing incidence of obesity and the need to tackle it, but parents do not always identify problems with their own children. As a general practitioner, I frequently see parents who either are not aware that their children are obese or have little idea how to tackle the situation. It is alarming to note that some parents still say that their children have puppy fat, that they will grow out of it because it is just a phase, that it is because of the hormones or that it will be okay. Unfortunately, that is not the case, and more often than not obese children become obese adults.
Without question better surveillance is needed, but that will take us only so far. Although as individuals we are responsible for our bodies and our health, our freedom to act is often constrained by the nature of our built environment. That is why I want work to be done much more closely with other Departments and across government. Not only our built environment, but our income, our access to transport, the nature of local retail markets and a myriad our social and economic circumstances all come to bear on this issue.
A parent may be fully aware that their child is at risk of becoming obese and they may be fully committed to preventing that from happening or to tackling it, but if they live in a house that is separated from the nearest park by a busy road, or they are reliant on local convenience stores that sell energy-rich food but do not necessarily sell much fresh food, their ability to sort out their child’s obesity problem is limited.
As a consequence, the state, as Lord Krebs made clear in his excellent foreword to the recent Nuffield Council on Bioethics report on public health, has an ethical responsibility to intervene and remove the constraints limiting one’s ability to live a healthy life. In that sense, state intervention should be seen as a means of empowering individuals and of maximising their freedom to live a healthy life rather than, as some critics tend to say, as an unwarranted state interference in people’s lives.
What form of intervention should the state undertake? The Government need to consider a range of supply side issues. Educating children about healthy eating and healthy living in school together with infrastructural measures aimed at enabling people to undertake more physical activity are obvious supply side factors. Other, more contentious interventions, such as a complete ban on the advertising of food and drink products that are high in salt, fat and sugar during TV programmes are
justifiable. A complete ban will give children—the most vulnerable members of society—the freedom to make informed choices for themselves based on information on healthy living that they receive from schools rather than on undue influence from food and drink manufacturers.
Providing people with the opportunity to develop the necessary life skills and the right resources to live healthily is not necessarily enough in itself to deliver a meaningful reduction in overall obesity levels. People often have the necessary motivation to live healthily and possess the necessary skills to do so, but unless they live or work in an environment where there is an established culture of living healthily, there is a good chance that they will never be able to reach their goals. If a community is dominated by people in full-time employment who drive to work each day at 8 am and close their front door when they return home at 6 pm, as happens in many communities, simply providing better sporting facilities and more opportunities will not be enough to change people’s habits. The chances are that if our family, friends, neighbours and peers do not exercise, we will not either.
What can we do about that? In order to achieve a paradigm shift in society, public health policymakers around the world are increasingly experimenting with social marketing strategies aimed first at marginalising antisocial, unhealthy behaviour and secondly at embedding healthy behaviour in the fabric of people’s everyday lives. They would argue that until an activity becomes a normative behaviour and is firmly entrenched in people’s lives, so much so that they do it as a matter of course, we cannot judge a policy intervention to be a success.
Smoking is a prime example of that. Whereas once it was seen as an unremarkable practice, or occasionally even as a socially desirable one, in many public areas smoking is now a marginalised activity—in public spaces it is illegal. We need to take a similar approach on physical activity. That is particularly important at school level where for a child to be seen as fitting in and making sure that they do not miss out on something is of paramount importance to their sense of well-being.
We have to turn that herd instinct to our advantage. Instead of its being socially desirable to be driven to school and socially undesirable or abnormal to walk, we have to try to turn that perception on its head. It is perfectly possible, for instance, to imagine children insisting that they be allowed to join the walking bus to school because that is where all their friends are and where all the social intercourse takes place. Children who are driven to school could feel that they are missing out on an essential part of their upbringing. If we can change the children’s perception in that way, we will see a genuine shift in behaviour. If that becomes a normal way to travel to school, parents will also be less concerned about the obvious potential dangers of walking.
I can see similar examples all over my constituency. People are social beings. We follow the crowd. We ignore empty restaurants and go to full ones. We do not sit down on an empty bench in an empty park because that looks odd, so instead we go to busy parks and sit on benches where other people are sitting. Huge amounts have been spent to create new public spaces in my constituency, but little thought has been given to how they will be used. It is pointless to create them if
they do not deliver. Concerns about security, blind spots, lighting and the possible presence of antisocial users mean that normal people tend to avoid such spaces—except on special occasions when an organised event takes place.
The problem is that when we plan and construct our built environment and leisure spaces, we do not think enough about how—or indeed whether—they will be used by the people they have been created for. Or alternatively, we make assumptions about how they will be used without actually going to the trouble of asking potential users what they want. In many cases, that is because of time and cost issues. A developer will often choose an off-the-peg design because it is the easiest thing to do, and keep stakeholder consultation to a bare minimum, because that can also be difficult. Involving the local planning authority also saves time and avoids expense.
Because bad design is so rarely challenged—and almost never on public health grounds—highly questionable design principles that have never been properly tested become established design conventions that continue to be followed by planners, developers and designers, because that is the way that things have always been done. Consequently, the majority of new developments that are built in this country contain vast areas of unused, unloved, badly planned, dead public space. Only the roads are used regularly. The cumulative cost of those mistakes in social, economic and health terms is colossal. We can and must do something about that.
In many cases it will mean sweeping our established design principles off the table and engaging with users at the very start of the design process, rather than seeing the consultation process as merely a tick-box exercise. Public health professionals also need to be engaged in a meaningful way from the start, rather than simply being invited to comment on established plans. That is blue-sky thinking and it will certainly be more expensive, but if it helps to produce a happier, healthier, more active and socially engaged community in the long term, the savings will more than outweigh the initial costs. I hope that during the Bill’s passage we will be able to envisage, and possible even enshrine in the legislation, how cross-departmental government could deliver some of those aims.
Another issue in which I have an interest, as chair of the all-party parliamentary pharmacy group, is pharmaceutical services. The hon. Member for Romsey (Sandra Gidley) has already laid out some of the concerns of some pharmacists about the change in regulations, and I echo what she said.
Mr. Stephen O'Brien (Eddisbury) (Con): I wish to help the hon. Gentleman out. He rightly declared his interest as a practising medical practitioner at the outset of his speech, but before he addresses the issue of pharmacy, he might wish to remind the House of his entry on the Register of Members’ Interests concerning overseas visits.
Dr. Stoate: I certainly refer anyone who is interested to the register. I have been on pharmacy-funded trips in the past to take part in international debates and they are registered fully.
There are concerns about the global sum being transferred straight to PCT budgets. Although the
Pharmaceutical Services Negotiating Committee has welcomed the creation of a single funding stream as a means of simplifying funding arrangements, many pharmacists and pharmacy organisations have one or two concerns. Those include whether in times of financial difficulty the PCT might be able to move money away from pharmacy services to other services if it felt that that was necessary. That would be regrettable and, with pharmacists doing more and more clinical work—and being asked to engage more in front-line clinical services—there should be some way to ensure that money given to PCTs through the global sum is protected to ensure that it does not happen.
The hon. Lady also mentioned the new regulatory procedures. The Royal Pharmaceutical Society wants confirmation that the transition to a new regulator will be managed properly, will be adequately funded and will utilise the unrivalled experience of many individuals and organisations that play an important role in pharmacy. I ask the Minister to ensure that the process includes full consultation with the profession and all stakeholders in pharmacy.
7.45 pm
Dr. Richard Taylor (Wyre Forest) (Ind): I am pleased to follow the hon. Member for Dartford (Dr. Stoate), who is the only practising member of the medical profession in the House. I congratulate him on his speed of delivery, which means that he gets through a vast amount in a short time, which is very welcome. I cannot promise to go as fast, but I shall not take much longer.
I shall confine my remarks to parts 1 and 5 of the Bill. I shall not touch on the public health issues in part 3, because they are widely welcomed, nor on the regulation of the professions in part 2, because it has been widely covered and some of my concerns raised. Even though I am retired, I am still perhaps a little too close to the profession to avoid being accused of partisanship.
Part 1 relates to regulation of health care organisations and the formation of the care quality commission. I have long been in favour of bringing together health care, social care and mental health care, so that is a welcome move. However, I have several worries. The first is that it is a huge task for one organisation to undertake. I am worried about the financial backing, the personnel and whether the resources will be available to make the body fully efficient. Secondly, the Bill is short on listing the actual duties of the new commission. The Picker Institute has produced a valuable briefing on the Bill, which states:
“The Picker Institute believes the principal duty of the regulator should be to promote the interests of patients, service users and the public with regard to the quality and safety of care services.”
That is vital. The Secretary of State used the words “safety” and “quality of care” in his introduction, and the commission must satisfy those requirements.
I am also concerned about patient and public involvement. The Picker Institute suggests a user panel. The hon. Member for North-West Leicestershire (David Taylor) mentioned a citizens council and the hon. Member
for South Cambridgeshire (Mr. Lansley) was worried about the lack of a formal structure for patient and public involvement. Why is there no mention in the Bill of Local Involvement Networks—LINks—the organisation designed by the Government to take over from the community health councils and the patient forums that they abolished? LINks is the one body made up of ordinary individuals, patients and citizens that can translate their feelings to a regulating body. LINks should be at the heart of assessments of the quality and safety of care. It represents patients, and the NHS belongs to patients, so it is inexplicable that LINks is not mentioned in the Bill—I may have missed it, although I looked carefully.
The Minister of State, Department of Health (Mr. Ben Bradshaw): The simple reason is that LINks is already established under previous legislation. I am happy to talk about it at great length, but it is not required to be covered in the Bill.
Dr. Taylor: I thank the Minister for that intervention, but although we do not need to establish LINks, there should have been some acknowledgement in the Bill of its presence and importance.
LINks is in trouble over TUPE—the Transfer of Undertakings (Protection of Employment) Regulations 1981. It is not yet clear whether TUPE applies to staff in the Commission for Patient and Public Involvement in Health, who badly need to know about that issue before the commission is abolished. A letter to the Department of Health from the CPPIH asks two crucial questions, which I press the Minister to answer; even if he cannot not do so now, he should do so fairly soon, because the matter is urgent. The commission asks the Department to
“Provide its opinion on whether TUPE is likely to apply”
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