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I congratulate the right hon. Member for Rother Valley (Mr. Barron) on his introduction to the debate and on the work that he and his Committee have done on this incredibly important report, which highlights a number of crucial issues. Let me start by addressing the
scale of issue that we face. This country has gross health inequalities. The report highlights the fact that the life expectancy of a girl born in Kensington and Chelsea is 10 years longer than that of someone born in the city of Glasgow. Sometimes, in the same city, the difference in life expectancy can be as much as 14 years, and we can see such gross inequalities in northern cities such as Sheffield. The really disturbing aspect is that these inequalities are getting worse. Over the past 10 years, the gap has increased by 4 per cent. among men and 11 per cent. among women. That should concern us all.
The hon. Member for Wellingborough (Mr. Bone) rightly said that these things are relative and that the whole nation's health is getting better, but that should not satisfy us and we should not be comfortable with a society in which there is such a significant gap between rich and poor. Just because someone is born into a deprived community, they should not be condemned to a shorter life than someone who is born in the wealthier suburbs. Something is wrong somewhere.
Hon. Members may be aware of the important study that Richard Wilkinson published earlier this year. In a nutshell, his case is that inequalities in health and inequalities in outcome in areas such as education and crime are closely related to the extent to which a society is unequal. The more unequal the society, the worse the outcomes and the more inevitable the inequalities in mental and physical health, education and so on.
Potentially, that is a bit of a counsel of despair because it suggests that if we are stuck with an unequal society that has gross health inequalities, there will be little that we can do to change things unless we make that society more equal. I will come back to that. There is an overwhelmingly compelling case for us to address inequality in society and to look at the symptoms of that inequality. The Government have had a golden opportunity to tackle the extent to which society is grossly unequal, but the measurements are getting worse, not better. Furthermore-this is about political choices-can anyone really believe that the Conservative party, if elected, would have as an imperative the creation of a more equal society? I really think not.
Norman Lamb: Hon. Members say from a sedentary position that I am wrong, but when the Conservative party's one key tax proposal is to give millionaires a massive tax break on their estates, that does not suggest a commitment to a more equal society.
Irrespective of the extent to which we can tackle the inequality in our society, we have a duty to do what we can to address health inequalities in the existing system. At a time of austerity, when the Government's focus is on reducing the budget deficit, there is a real danger that the wrong decisions will be taken and that the cause of public health and reducing health inequalities will be damaged. In the aftermath of the 2005 general election, health budgets were squeezed and times were tough for the finances of the NHS.
As the Committee's report pointed out, cuts were made to mental health, public health programmes, staff training and so forth. This time, we must not allow constraints on public expenditure to result in crazy decisions that damage our chance of reducing health
inequalities. The report notes that we have a seen a reduction in the number of public health specialists working in the NHS in recent years, while the number of administrators and other health professionals has increased. Why is that happening? When the importance of public health practitioners is as great as ever, why are we cutting their numbers?
The report makes a powerful case for the importance of evaluation and evidence, and it is pretty critical of the Government's record in that regard. It describes the failure to evaluate and the failure to base policy making on evidence as the
"most damning criticisms of Government policies".
"The latest initiative on Healthy Towns has all the failings of previous policies, indicating that the Government has learnt nothing from past mistakes."
I intervened earlier on the right hon. Member for Rother Valley about the case for an ethical imperative to base policy on evidence. Paragraph 4 of the conclusions to the Select Committee report states:
"All the reforms we have discussed are experiments on the public and can be as damaging (in terms of unintended effects and opportunity cost) as unevaluated new drugs or surgical procedures. Such wanton large-scale experimentation is unethical"-
"and needs to be superseded by a more rigorous culture of piloting, evaluating and using the results to inform policy."
The report also refers, in paragraph 8 of the conclusions, to the NICE process, which we all like to think of as objective and evidence-based-something by which we approve drugs and procedures on the basis of evidence. However, the report makes the critical point that we do not evaluate what is lost when new drugs, for example, are introduced as a result of a NICE approval. The conclusion states that
"more needs to be known about the relative cost effectiveness of treatments and services that are displaced to fund the new treatments recommended by NICE."
I think that the hon. Member for Wellingborough made the point, on the funding of primary care trusts, that the Government absolutely correctly introduced a new system, to base funding on need. No one could object to that. Yet they failed to implement it. They had the opportunity to begin to reduce the difference between historical funding and funding based on need, but they took no step in that direction. So there is still just as great a disparity, and year by year the cumulative effect of underfunding, in many communities, gets greater. Why, having introduced a system for basing funding on need, do the Government not implement it? That is another damning criticism.
The report refers also to the fact that funding that goes to primary care trusts and is intended for good public health initiatives to improve health and well-being often ends up being spent on acute care. That, I am afraid, comes down to the financial incentives in the
NHS, and the failures of payment by results. There is now widespread recognition, including from senior people in the Department of Health, that there is an urgent need to reform payment by results. It is sucking funding into acute trusts and away from proactive programmes to improve health and well-being locally. It is essential that we seek urgently to reform that process.
We should also consider the work of Chris Ham and others, from Birmingham university. He puts forward the case for capitated budgets and integrated care organisations bringing GPs to work alongside other professionals in health and social care, so that they have responsibility for the whole budget for the care of patients and an incentive to keep their patients in better health and, particularly, to manage those with chronic conditions better. The funding of those organisations would reflect the level of deprivation and the health needs in the relevant communities.
We must also look much more smartly at the potential role of incentives in driving a change of behaviour, to ensure that the finances are used to address the problem more effectively than in the past. Julian Le Grand, who was an adviser to the former Prime Minister, Tony Blair, put forward the case, in a recent report, for incentivising commissioners to engage with this issue, and to work with local authorities across organisations to produce health and well-being programmes. That might include introducing cycle lanes, or all sorts of imaginative local things, but critically it would involve working with housing, community regeneration and education services, to achieve better outcomes. I visited the Norfolk's primary care trust website last week, to see what it offered for health and well-being, and how it was engaging the community, and I could find nothing. At the moment, the commissioners of health care are failing to grapple with the imperative of addressing the need for health and well-being, particularly in our most deprived communities.
Reference has also been made to incentives for professionals, and the qualities and outcomes framework system, which has made a difference. It has started to change behaviour, but we must surely ensure that QOF incentivises GPs on the basis of outcomes, not procedure. At the moment, payments are made when processes are gone through, not when outcomes are achieved.
Dr. Stoate: I must take issue with the hon. Gentleman on that; most of the QOF measures are evidence-based. They are evaluated by NICE, which is now responsible for negotiating QOF on an annual basis. Most of them are to do with outcomes, such as lowering cholesterol. The number of people whose blood pressure is controlled, and the number whose diabetes is controlled in the long term is not a matter of process. The focus is now very much on outcome.
Norman Lamb: I did start my point by saying that QOF had made a difference and had begun to change behaviour, but in areas such as obesity, which involves the measurement of the patient's weight, payment is not on the basis of reducing weight. Smoking is another example; telling a patient to set a date for giving up smoking, and going through certain processes, brings the payment. It is not given for getting the patient to give up smoking.
We must ensure that in all respects QOF is strictly related to outcomes, and that it plays a part in dealing with health inequalities. We also need to examine evidence from other countries, and perhaps insurance systems, to find out the potential value of incentives to change individuals' behaviour. Such initiatives are starting in parts of this country. Again, the use of incentives in deprived communities may begin to affect behaviour. We should be open to those opportunities. The report says that there is no assessment of how much we spend on tackling health inequalities, and the Government need to address that fact.
Finally, I want to mention early years. The report expresses concerns about the impact of Sure Start and children's centres so far. I am a strong supporter of Sure Start, which is an important initiative. I should be extremely concerned about any termination of that programme. However, according to the report there is limited evidence of impact. It expresses concern about the shift towards children's centres. If the programme is to be spread across all communities, will the focus on the most deprived communities be weakened?
The hon. Member for Wellingborough appropriately made the point that the focus needs to be on reaching the households that are hardest to reach. We are not doing so effectively enough. The Worldwide Alternatives to Violence Trust has done fascinating work on the absolute importance of early intervention, and the changes that can be made to life chances by making a difference in the first three years of life. We are not yet doing enough to make that a reality.
Does the hon. Gentleman agree-and he will know about this because his constituency mirrors mine-that one of the problems with early-years work is that children in deprived circumstances in very rural areas often lose out, and that we need to be smarter about the way Sure Start and children's centres reach out to them?
Norman Lamb: I am grateful for that intervention, because it is an incredibly important point. Measures of deprivation inevitably end up focusing attention on the entrenched areas of deprivation in our inner cities, but they risk missing hidden deprivation in rural areas, which can often be exacerbated by inaccessible services, lack of public transport and so forth. We must be much more sophisticated in analysing where deprivation is, to ensure that people in rural areas do not lose out.
In conclusion, I reinforce the point that I want us to be honest in this debate. There are limits to what we can achieve in this country while we continue to maintain one of the most unequal societies in the developed world. The United States and Portugal are more unequal, but we are up there among the worst, and that has a significant bearing on health inequalities. Unless we address that, we will not tackle a critical problem discussed in the report that I find unacceptable in a civilised society.
Mike Penning (Hemel Hempstead) (Con):
This is an important debate. I congratulate the Select Committee on Health, of which I have had the privilege of being a
member for many years. When I first came to the House in 2005 and was asked what Committee I wanted to be on, there was only one answer: health. It took me a couple of months to convince the Whips, but I convinced them and joined the Committee. It is enormously important and considers the evidence very well, and it is exceptionally well chaired by the right hon. Member for Rother Valley (Mr. Barron). I pay tribute to the Committee.
Interestingly enough, the report, when it first came out, drew on a lot of previous reports by the Committee, particularly its excellent report done at the time of the smoking debate. Without the Committee and its proposed amendments, the present legislation would not be on the statute book. I know that whenever the right hon. Gentleman speaks, he always likes to bring up smoking and how we can encourage more people to stop. It is an important issue that I know is close to his heart. Other reports include work on deficits and the funding formula. We looked at inequalities not just in socially and economically deprived parts of the country but in other parts of the national health service, to which I will return in a minute.
The issue of inequalities is nothing new. Beveridge was discussing health inequalities long before I was born, and the House has been discussing it for many years. Increasing progress has been made, but sadly, over the past few years, even according to the Government's own statistics, the situation has been falling back.
As we have heard today, the Government have had a golden opportunity, with more than £100 billion-there will be a debate about just how much, but it looks to be about £110 billion by the time the election comes-of taxpayers' money being spent on the NHS. The report highlights criticisms that have been around for some time, not just from political parties but from experts in the field, about how that money has been spent and why so little of it seems to get to the front line. The evidence in the report shows clearly that one reason is that it is really not known whether the money is being spent efficiently or is working.
The contributions that we have heard today have been eminently sensible. They show that the House really cares about the issue. It is not party political, although we have had a bit of banter. I was disappointed with the hon. Member for North Norfolk (Norman Lamb)-I will call him my friend from the Liberal Democrats-who did a bit of pre-electioneering for a few moments, but he is better than that and he knows it, so I will not bother to comment on the silly remarks that he made.
Mike Penning: Absolutely, which is why my party, should we be lucky enough to be elected, will change the Department of Health to the Department of Public Health so that we can start locking other agencies into a better working environment. The report criticises the lack of joined-up government on such an important subject, so it agrees in many ways with me that we need to come together as a Government. Different Departments need to work together. The hon. Gentleman is absolutely right: no one Department can solve the problem, but Government can start to get there.
One of my concerns about the report is that although it is crucial that we consider social and economic deprivation, it is not just about deprivation in big cities; there are small pockets of deprivation in the most affluent parts of this great country of ours. We stand in the Palace of Westminster, while not far from here-probably literally within a couple of hundred yards-there is deprivation on the streets of this great city that we are not touching. We heard earlier, when hon. Members were discussing Sure Start, that there are people whom we are not getting to. Sure Start catches all, but it is not targeted at the families who desperately need it. That is one thing we need to look at.
Inequality is not just about social and economic deprivation. There are other kinds of inequality in the health service as well. Older people, for example, face inequalities that younger people do not face. As people get older-although, thank goodness, they are living longer-they start to suffer more problems. Are those problems being addressed in the right way? Is funding going directly to the patient? Is rationing of any description occurring? The accusation has been made in the press for many years that as people get older, the money does not necessarily follow them.
Sadly, ethnic minorities also suffer health inequalities. I accept fully that some ethnic minority groups live in the most socially deprived areas of this country, but others do not. There are issues involving language and how people are helped. At the Conservative party conference in Manchester this year, there was an interesting debate on how to reach groups of people in this country who not only do not speak English as their first language but do not speak it at all. Fantastic work on health inequalities is being done with the Bengali community around Brick lane, particularly with ladies who do not speak any English at all, on how to reach them to get them to come in for breast scanning, cervical smear tests and so on.
That sort of innovation in our communities is the way forward, rather than the Government knowing everything. I agree that the Government have a role, but it involves commissioning rather than, as in most cases, providing. The work done on Brick lane, interestingly enough, used a speaking card that was sent directly to the people whom the hospital thought were at risk. When the card was opened, the message in Bengali was, "You may be at risk; you need to come forward." Such things need to be considered for our GPs' surgeries and so on.
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