Westminster Hall
Thursday 12 November 2009
[Hugh Bayley in the Chair]
Health Inequalities
[Relevant documents: Third Report from the Health Committee, HC 286-I, and the Government response, Cm 7621.]
Motion made, and Question proposed, That the sitting be now adjourned.-(Mr. Watts.)
2.30 pm
Hugh Bayley (in the Chair): We expect the House to prorogue at about 4 o'clock, and the rules state that when the House prorogues, the proceedings in Westminster Hall finish immediately. I see that quite a number of hon. Members will be seeking to catch my eye during the debate, so I ask colleagues to bear in mind the likely time constraint.
Mike Penning (Hemel Hempstead) (Con): On a point of order, Mr. Bayley. Further to your comments, should the House prorogue, obviously no further comment will be allowed here, but the debate is on a very important report and the Government response to it needs a lot of debate. That is why the Government gave three hours for this debate. Should we not get three hours, is there any way in which this business could be brought back, so that the proper debate could take place in this Chamber?
Hugh Bayley (in the Chair): That is not a matter for the Chair. It is, of course, open to the usual channels to discuss future business in the new Session of Parliament. We are lucky to have one and a half hours, so let us make the most of the time available.
2.31 pm
Mr. Kevin Barron (Rother Valley) (Lab): My response to the point of order is that nothing prevents hon. Members, including members of the Select Committee on Health, from applying for time in Westminster Hall for a debate at a later stage if we think the debate has been too truncated this afternoon.
I shall start with a few remarks about the background to the Committee's inquiry. In 2003, the Government established the first ever national public service agreement target for health inequalities: by 2010, they were to reduce inequalities in health outcomes by 10 per cent. as measured by infant mortality and life expectancy at birth. That was perhaps the toughest target adopted by any country in the world. In addition, the Government had introduced a series of policies expected to reduce health inequalities, including health action zones and Sure Start. When we were taking evidence from different parts of Europe and talking about health inequalities, people kept telling us to go back to the UK and ask people there about it because the UK had set the toughest target and had the expertise.
Despite the efforts that I have described, health inequalities continued to increase. That was not because the poor were becoming less healthy, and the fact that they were not is a good thing. The life expectancy of the
poorest quintile of the population was as high as that of the richest quintile 30 years ago. However, richer people were becoming healthier more quickly. Many people thought it unlikely that the Government's 2010 target would be met. My hon. Friend the Minister will probably comment today, if she gets the opportunity, on whether that will be the case.
The Committee's view was that the target was unlikely to be met. On that basis, we launched the inquiry into health inequalities, mainly to see what more the Government could do to improve outcomes. The Committee's focus was on the contribution of not only the national health service and the Department of Health, but other Departments. The Committee's report was published in February this year and the Government response was received in May.
I shall cover only three of the main findings, because of the time constraint. One related to the lack of evidence and poor evaluation of what could loosely be called public health initiatives. We concluded that it was nearly impossible to know what to do, given the scarcity of good evidence and good evaluation of current policy on health inequalities. We regard that as perhaps the most important of all our conclusions in the report. The most damning criticisms of Government policies that we heard in the inquiry were not of the policies themselves, but of the Government's approach to designing and introducing new policies, which made meaningful evaluation practically impossible.
In attempting to deal with inequalities, Governments had rushed in with insufficient thought and a lack of clear objectives, had failed to collect adequate baseline data and had made numerous changes and not allowed time for policies to bed in. Even where evaluation was carried out, it was usually what is termed soft evaluation, amounting to little more than examining processes and asking those involved what they thought about them. Most of us would be fairly happy with a process if we were involved in it. That does not mean to say that the outcomes of the process are being measured.
Professor Sir Michael Marmot's review of health inequalities offered the opportunity for the Government to demonstrate their commitment to rigorous methods of introducing and evaluating new initiatives that are ethically sound and safeguard public funds. I say to the Minister that I understand that Sir Michael's further report will be published next month. We took evidence from him and I am pleased to say that the Government sent some of our recommendations directly to him, although I will not cover all those areas today. The Committee also met him after the event, although that was not in public, to discuss the second phase of his work, so we have kept in touch with what he is doing. He is a world leader in this field and could advise any Government about areas that they need to tackle in relation to health inequalities.
People will not be surprised to know that the Government disagreed with some of our descriptions of their approach and rejected the suggestion that they had wasted learning opportunities. Instead, they insisted that they had sought to build on evidence and learn from their experience in developing and implementing policies and programmes. They did, however, welcome the Committee's practical suggestions to help improve policy design and align it more closely to the best available evidence. They also
committed to referring our recommendations to the scientific reference group, and I am pleased that they have done that.
Specific health inequalities was an area that we covered. The Government had introduced specific policies to tackle health inequalities; two of particular importance were establishing health inequalities targets and establishing Sure Start. In aiming to reduce health inequalities by 10 per cent. in 10 years, the Government introduced a target that was probably the toughest in the world, as I said. Despite the likelihood that it would be missed, we concluded that aspirational targets such as that can prove a useful catalyst to improvement and we recommended that the commitment be reiterated for the next 10 years-obviously, this will be following on next year-so we do not think that anything has been wasted in the process. The difficulty is measuring how good we have been.
Norman Lamb (North Norfolk) (LD): The right hon. Gentleman says that he does not think anything has been wasted. In referring to the ethical imperative of ensuring that things are evidence-based, the report itself points out that when money is spent wantonly on initiatives that have not been properly thought through, that money is not going into other schemes that may well have a real effect. There is potential damage in that respect, and the report highlights that.
Mr. Barron: We are going to get into semantics here. We are not measuring other schemes, either; we said that there is a lack of good evaluation in this whole area. We will not know where money would get a better return if we do not carry out an evaluation. On that basis, although we think that the Government have done some good things, that is difficult to measure.
We commended the Government for taking positive steps on Sure Start. However, Sure Start had still not demonstrated significant improvements in health outcomes or health inequalities for either children or parents. Early years interventions needed to remain focused on the children living in the most deprived circumstances, and the impact of children's centres needed to be rigorously monitored. As I recall, people said that the second look at Sure Start had shown that in three areas there were some improvements; I will not read those out now. Most people would say that early years is a crucial issue in relation to health inequalities. I say to the hon. Member for North Norfolk (Norman Lamb) that things could be measured better-indeed, the Committee came to that conclusion-but I do not dispute that areas such as that are where money should go. I say that not only as Chair of the Health Committee, but as someone who has been a constituency Member of Parliament for many years and seen health inequalities in my own constituency.
The Government agreed that their health inequalities target had helped to focus the national health service, local government and other partners on health inequalities in a way that had not happened previously. Again, from my constituency experience, I agree with that. The Government also welcomed the Committee's recognition of the important focus given to early years and Sure Start in tackling health inequalities. However, they said
that the independent evaluation showed the benefits I mentioned earlier. In their response, the Government said that information-for example, from Head Start in the USA-reveals that such interventions often take time to bed in and do not usually have an immediate and measurable beneficial effect. Research into similar interventions showed benefits in the medium to long term, so we will have to wait. The real question is whether we are measuring things properly.
I turn to the role of the national health service in tackling health inequalities. It would be a fair assumption to make about this wonderful institution, which has served the country for 60 years, to say that it would be better described as a national ill health service, inasmuch as it normally engages with citizens only when they are ill. That is not what health inequalities are about; it is no good waiting for things to happen.
Derek Twigg (Halton) (Lab): Despite the fact that mortality rates have declined, in my constituency they are still above the national average. My right hon. Friend was about to discuss this point, but I want to be clear about it. Does he support the view that we should ensure that primary care trusts, health organisations and the other public bodies in a given area engage with the local population? That would mean that the available resources would all be used, and that the organisations worked together to ensure that things happened. Such engagement is a key factor for the local population in attacking inequalities and improving health.
Mr. Barron: The simple answer is yes. As I said earlier, local agreements with local authorities will be essential to improving health inequalities.
When considering the role of the health service, the Committee found that getting people to adopt a healthy lifestyle was widely acknowledged to be difficult. Evidence suggests that traditional public information campaigns are not successful, especially with lower socio-economic and other hard-to-reach groups.
I do not wish to labour the point, but over the years, and not only recently, the Government have done some wonderful things on lifestyle-for instance, on smoking cessation. They continue to do so in legislation that was agreed in the last few days; they should be commended for their actions. I have had an interest in this subject for public health reasons for many years, and we have now gone there. There are wider issues that impact on health inequalities, but smoking is the biggest issue, and they did guarantee to deal with the smuggling of tobacco into the country. However, we have a long way to go yet.
I shall move away from the report for a moment. Last Friday, I and the two of my parliamentary colleagues who represent Rotherham borough went to the official opening of the Rotherham Institute for Obesity. The organisation was opened by NHS Rotherham, which used to be the primary care trust. The institute is based in the Clifton medical centre, which is not in my constituency but in Rotherham town centre. It will offer many services, including a gym, cooking classes and a resource centre that will provide specialist support for overweight and obese people referred to it by health professionals. The service was commissioned under NHS Rotherham's award-winning and nationally recognised healthy weight commissioning framework, which provides a four-tier intervention programme.
The framework also includes the Carnegie internal camps in Leeds, and summer weight-management camps for children. Rotherham has received national recognition for that. The Carnegie clubs will also run a 12-week weight-management programme for children, and Reshape Rotherham, which is a 12-week community weight-management programme for adults. Two of those programmes will take place in my constituency-ex-mining communities with difficult health profiles.
Professor David Haslam, chairman of the National Obesity Forum, officially opened the institute last week. The opening was also attended by NHS Rotherham weight-management services, including Carnegie weight management, DC Leisure-a private sector organisation that is co-operating with the council in the weight loss programmes-and Reshape Rotherham. The Government have provided resources for areas such as Rotherham borough council; that allows problems to be tackled at source, rather than having to await recommendations from on high that normally take years to roll out.
On the role of the NHS, the Committee concluded that quality and outcome frameworks-QOFs-introduced as part of the new GP contract as a radical way of linking doctors' practice income to the quality of care that they provide, should be considered in relation to improving the health of the population. We also recommended that the role of secondary care in tackling health inequalities should be considered by Sir Michael Marmot's review. We hope next month to hear what it has to say. We also considered that the payment by results framework and "Standards for Better Health" might address large health inequalities. We were repeatedly told that early years offered a crucial opportunity to nip things in the bud; we will also be considering that.
We found that a lack of access to good health services did not appear to be a major cause of inequalities, so the problem is much wider than the centres now being opened can deal with. As well as attending the official opening of the Rotherham obesity centre, I and my colleagues officially opened the new community health walk-in centre, which gives us 13 hours a day of GP services, seven days a week. That will be a major benefit to my constituents.
The Government did reply on the question of QOFs, saying that they would consider introducing a scheme. They also said that the remit of Sir Michael's review was wider than the social determinants of health and their impact on health inequalities. They said that secondary health would be considered separately, as part of a commitment to developing a post-2010 national health inequality strategy.
I hope that the report has done what was intended-to find that there is no silver bullet on health inequalities. It is not there; we would have done something about it years ago if it had been. We hope that a new debate will take place, perhaps over the next decade, on health inequalities and lifestyles. The debate will also be about what society can do. It should not be only the NHS that picks up the failures; society, the Government and others should be involved in reducing health inequalities.
2.47 pm
Dr. Richard Taylor (Wyre Forest) (Ind): I shall be brief. I have questions on four topics-the role of secondary care in prevention; tobacco smuggling; personal, social and health education; and children's services.
Secondary care was mentioned by the right hon. Member for Rother Valley (Mr. Barron), the Committee Chairman. I remember that on one of our visits to the States we met a physician in a hypertension clinic who was bemoaning the fact that he did not have the time to instruct his patients about their smoking and their obesity. We heard from ASH-Action on Smoking and Health-that only half of UK chest specialists have direct access to a stop-smoking counsellor, and we heard that there is a failure to use such services where they exist. We also heard that the chief executive of one PCT, Tower Hamlets, is trying to persuade secondary care services to play their part by providing public health intervention, particularly on stopping smoking and losing weight, and putting it high on everyone's agenda, even at board level.
The last few words of paragraph 152 of the Government's response are:
"Issues around secondary healthcare will be considered separately as part of the commitment to develop a post-2010 national health inequalities strategy."
What can the Minister do to persuade secondary care services to take on a prevention role much more quickly than that?
My second query is about tobacco smuggling. We heard graphic details about the amount of tobacco that is smuggled and the fact that it is the least well-off smokers who use it. We also heard about the proportion of self-rolled cigarettes that contain smuggled tobacco. The issue has to be tackled immediately.
A British Medical Journal report told us that eliminating tobacco smuggling could save between 6,000 and 6,500 lives a year. When that is compared with the only 1,000 deaths a year that result from smuggled illicit drugs, it puts the matter into perspective. It is the least well-off smokers who use such tobacco. Paragraph 232 in the Government's response states:
"The Government will give serious consideration to the Committee's comments on smuggling and the international tobacco control agreements, as part of the development of a new tobacco control strategy during 2009."
As 2009 is very nearly over, I am hoping to hear great things from the Minister about what the Government are doing about tobacco smuggling.
Let me turn now to personal, social, and health education. In our conclusions in the report, we said:
"We are pleased that, five years after we recommended it, Personal Social and Health Education (PSHE) is finally being made a statutory part of the national curriculum."
That has been a recurring theme in a number of our inquiries in the past. We are told in the Government's response that some recommendations require legislation and some can be taken forward immediately. Will the Minister tell us which of the recommendations relating to PSHE can be taken immediately? I do not subscribe to the belief that the nanny state is harmful; there are occasions when it is needed. When young people do not have parents who are doing the nannying, the state has an obligation to step in.
I move on to children's services. Sure Start has been mentioned by our Committee Chairman, and evidence is increasing about the benefits of the scheme. I have visited a Sure Start centre in my constituency; it is based in the heart of a most deprived community, and it is doing absolute marvels. Kids come in looking lost.
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