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3.21 p.m.

Baroness Brigstocke: My Lords, we are all most grateful to the noble Baroness, Lady Jay, for initiating this important debate. I have not been a Member of a political party in the past. I am new to debates. I have never taken part in a debate in another place. I am not experienced in debates in this Chamber. However, one thing I know is that noble Lords on the Benches opposite do not have the monopoly on caring for the health of this nation and in particular for those who suffer from poverty. We differ in the ways in which we seek to cope with the problem, but we recognise the problem. I do not have with me at present the report on the variations in health. However, I believe it states that we do not need sudden new developments but a continuation of those already being undertaken.

The trouble with considering improvements in both health and education services is that whatever action is taken it is never enough. While we must keep our eyes firmly on the highest possible standards, it is also important to take regular stock of what has been and is being achieved. I am glad that in a recent report the Chief Medical Officer recognises that,

The report also urges the department to work actively in alliance with other government departments and other bodies. I can tell noble Lords that the Health Education Authority, of which I am a non-executive director, is already working effectively with the department. I hope that the Minister agrees.

I shall refer to two groups whose health is particularly affected by poverty: children and teenagers, and the elderly. The first group is natural for me because I have been teaching, or trying to teach, all my life. And the health problems of the elderly are becoming increasingly relevant to me personally as the days go by.

We do not need an official report to tell us of the many health hazards which endanger the young today. We already know that teenage mothers are more likely to come from lower socio-economic groups--a phrase which I do not enjoy using, but it seems to be the technical one. In the past there has been and still is much controversy over sex education in schools. I should like to see greater co-operation and liaison between the Department for Education and Employment and the Department of Health, and such excellent voluntary organisations as One Plus One and Relate, in order to provide good sex education classes in schools. However, perhaps I may express a word of caution. It is not reasonable to put the whole weight of sex education, with the essential moral and spiritual considerations, on the shoulders of school-teachers.

I should also like to see more care taken with university students and those in further education. So often at university they are living away from home for the first time in their lives. The Health Education Authority is undertaking work at present--I hope that it will have great support from other bodies--to give more useful information and help through the university student unions.

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We do not yet know the full effect of the new alcopops on the susceptible young. But I believe that the lower socio-economic groups of teenagers, and even I hear sub-teenagers, will be most at risk as regards alcoholism.

We have statistics on smoking. I believe that we have had some success. Health promotion is producing a steady drop in adult smoking. We have had national campaigns linked to national smoking helplines which help more and more people to quit smoking. Those campaigns are tailored by the HEA to appeal to people in lower socio-economic groups. There is some evidence that they are succeeding. The noble Baroness, Lady Jay, referred to measures to counter the smoking problem of this country. I was surprised to hear that because several noble Lords on the other side of the House have been rather antagonistic towards what they have called nannying by the Health Education Authority; but perhaps that is a problem they can solve together. One has only to look at groups of young boys and girls near schools, often in school uniform, to see the enormous size of the problem of under-age smoking.

I worry particularly about nutrition and children from poor homes. During term time they qualify for school meals from Monday to Friday, though I should like to see some provision for the holidays. I wish to quote from an excellent publication from the HEA entitled Young People's Health Network. A short article by a reader states:

    "Last year, during the long school holidays ... a local mum from Bates Green, Norwich, became concerned by the fact that so many children were going without proper meals as their parents couldn't manage the extra cost of feeding them during the six-week summer break.

    "So Sharron came up with the idea of providing the children with a healthy meal for less than the price of a bag of chips. Together with a friend, and help from a community health worker, she set up a cafe in the local community centre. Wholesome pitta breads, jacket potatoes, fruit and yoghurt dominated the menu--a far cry from the fat-filled junk food previously eaten by the children".

The article continues:

    "The National Food Alliance ... has details of this project and many more on the Food and Low Income Database, which has been developed jointly with the Health Education Authority".

So there are things that are being done.

Finally, I turn to the elderly. One in three of today's pensioners live at or below the poverty line. Evidence shows that older people who have been poor during their life die younger and suffer more ill health and disability. Yet older people now generally have lower levels of disability and fewer chronic disabling conditions than in the past.

The HEA gives high priority to one of those risk factors; namely, physical activity. In 1996 it started a national campaign entitled Active for Life--Stage 1 being to raise general awareness of physical activity for health--

Baroness Miller of Hendon: My Lords, I am terribly sorry to interrupt, but this debate is very tight on time.

Baroness Brigstocke: My Lords, I am so sorry; I thought the instruction said 12 minutes. (I had to borrow some glasses.) It is my fault. I shall sit down.

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3.32 p.m.

Earl Russell: My Lords, I apologise to the noble Baroness, Lady Brigstocke, for entering the debate on such a cue. It is the sort of thing that happens all the time.

I also thank the noble Baroness, Lady Jay of Paddington, for introducing the debate. She and I have argued in favour of causes with a considerable degree of overlap since we were undergraduates. I am very glad to continue that process. When I heard the noble Baroness refer to the Black Report, I was reminded of the story of the 16th century Spanish theologian Fray Luis de-Leon, who in the middle of a lecture was snatched out of his lecture-room by the Inquisition, imprisoned and interrogated. When he was released, 25 years later, he went back into his lecture-room and began with the words, "As we were saying".

I, too, shall go full circle. I return to the public expenditure White Paper of 1980. It drew attention to the marginal propensity of the budgets of both health and education to increase regularly faster than inflation and GNP. When the noble Baroness, Lady Brigstocke, said that there is never enough she was quite right. Any Chancellor of the Exchequer at any time will be concerned by that.

The debate today does not deal with the attempt made to tackle that through the use of market forces. I shall merely say that I think it is agreed in every quarter of the House that it has not brought the problem to an end. In those circumstances, it was very obvious to turn to prevention as the next area to examine.

Listening to undergraduate essays the day before yesterday, I was reminded that the bubonic plague in western Europe was in effect wiped out long before anyone had any idea of treatment or cure, simply by methods of prevention. The same to a rather lesser extent goes for cholera. So there is a lot to be said for prevention.

But obviously there is a limit to what I hope the noble Baroness, Lady Brigstocke, will forgive me for referring to as "puritan" methods of prevention. I assure her that there is no smoke coming out of my ears at the moment. I recognise the justice of the bulk of her remarks. But by itself that is not enough. If we are seriously concerned with prevention, we must end up by looking among other things at poverty.

I do not want to become "hung up" on the definition of poverty. I merely say that, unlike John Moore, it is always with us. When I talk about poverty, I think of going to bed hungry because you cannot afford any more to eat; or, as my noble friend Lady Robson of Kiddington reminded me over lunch, of going to bed with no coal, or no heat, because you cannot afford any more. I am talking about real levels of physical deprivation.

Nor do I want to get hung up on an argument about how great is the extent of poverty. I shall take figures given by the Government and which I think are reasonably quantifiable; namely, numbers of people actually in receipt of social security benefit. According to my last Written Answer, which was not so long ago, those on income support are 13 per cent. of adults of

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working age and 24 per cent. of children. In addition, the numbers of people over 50 who have not worked for 10 years and who are excused from actively seeking work are 2,594,000. A lot of those ought to be included in the unemployment figures. For the sake of saving time, I hope that if I take that to mean poverty I shall not be thought to be pulling a fast one.

The National Consumer Council recently complained that many consumers living on social security benefits are being denied the opportunity to follow healthy eating guidelines because they do not have enough money to buy healthy food. The National Children's Home, I believe in 1993, studied a sample in which it found that 20 per cent. of those on benefit could not afford an adequate diet. Miss Widdecombe, who was then at the Department of Social Security, said that she did not see the problem because, after all, 80 per cent. could afford it. I am reminded of William Chillingworth's judgment on Thomas Hobbes that, like the elephants of antiquity, he would deal some lusty back-blows at his own side. That, I think, was one such back-blow.

The Rowntree study of January 1995 was particularly concerned with evidence of nutritional deprivation among lone parents. I agree with the remarks of the noble Baroness, Lady Jay, on that subject. She drew attention to the lack of iron intake. It seems that the further they were from benefit collection day, the worse their diet was. Many were going without meals altogether.

We have a series of Chinese Walls in government statistics. The noble Baroness the Minister told me in a Written Answer of just over a year ago that she was attempting to improve government screening in hospitals for malnutrition. I am extremely glad that she is. However, there is no way in which we can discover whether the people whom she finds to be suffering from malnutrition are the same people who are on inadequate benefit or indeed disentitled to benefit altogether. That is a defect in the Government's statistical resources.

It is even more serious for those who fall through the holes in the safety net altogether, usually to justify a small saving in the budget of the Department of Social Security. As noble Lords know, I suspect that on those occasions the Department of Social Security is exporting its costs and that the Minister is their unfortunate recipient.

Let us take the case of student health, which the noble Baroness, Lady Brigstocke, mentioned. I have observed among my pupils--I do not know whether they are a representative sample--that the amount of working time lost by ill health has approximately doubled since the loss of social security benefits in 1990. Among the people I should have been teaching this morning the figure reached 50 per cent., but that is not a statistically significant sample. It was only six people and therefore I put no weight on it.

We have a much clearer body of evidence about the effect on the street homeless. The expectation of life among the street homeless is only 42 years. Fortunately, we have not yet had a repetition of the crisis study of 1995 which found a rate of TB 200 times the national average. I hope we never do. Among the most recent

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studies we find that the excess mortality ratio for assault was 54.1 and the excess mortality ratio for suicide was 35. Suicide is one of The Health of the Nation targets and it deserves attention.

I hope the Minister has already read the Shelter study Go Home and Rest? It deals with the effects of homelessness on the National Health Service budget: inappropriate use of accident and emergency departments because the homeless have difficulties registering with a GP, difficulties to which the noble Baroness, Lady Masham of Ilton, drew the House's attention well before the Minister was even in the House. So the Government have had plenty of notice of the point.

The problem is the working of the financial targets. If the homeless move on and re-register with another doctor within a quarter of a year, the doctor does not receive a capitation fee. If they have a temporary registration, he gets nothing for vaccination fees or other fees.

All those disentitlements have costs. The House will not expect me to go through the catalogue. I am sure it knows them. They are all introduced in order to produce savings. The question is: are the savings greater than the costs incurred? That seems to me to be a question of considerable interest to us all. The Chinese walls in government statistics mean we do not know the answer. I think we should.

3.42 p.m.

The Lord Bishop of Lichfield: My Lords, I am fortunate to have an ordained colleague working in my diocese with me who happens, as well as being ordained, to be an NHS manager in one of our West Midlands health authorities. The person concerned has recently drawn my attention to a government document entitled NHS Priorities and Planning Guidance 1997-98. In it, one of the main NHS priorities is stated thus:

    "to ensure ... that integrated services are in place to meet the needs for continuing healthcare for elderly, disabled, vulnerable people and children which allow them ... to be supported in the most appropriate available setting".

Through my own observation, I see many examples where our regional health authorities are succeeding in some of that. I am told that people in Staffordshire and Shropshire live longer, fewer children die in infancy and many former dangerous illnesses are now treatable. At the moment I have immediate personal contact with an Alzheimer's sufferer and the district nursing services and social services are doing excellent and valuable work under the heading of that NHS priority.

I am grateful to the noble Baroness for this debate because I must go on to say that we also have in the diocese of Lichfield metropolitan boroughs which have the highest proportion of long-term unemployed anywhere in this country. One borough in my diocese ranks as the fourth highest nationally in its proportion of long-term unemployed. That borough moreover contains Pakistani and Bangladeshi communities which have unemployment rates more than three times higher than those of their neighbours.

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The close relation between long-term unemployment and various forms of ill health is well known. It was experienced in my family in the 1920s. Research by Moser back in 1987 revealed particularly high mortality rates among unemployed men, caused by such things as lung cancer and coronary heart disease. It revealed equally high mortality rates for their wives.

In particular, in the borough to which I refer, which is not alone in my diocese, unemployment is impacting seriously on people with physical disabilities and mental health problems. That is true in several of the communities where I serve. A recent study of patients with serious mental illness in one borough found that only 7 per cent. of the 400 patients surveyed had any kind of access to paid employment as they improved. In the terms of the noble Baroness's Motion, here surely is a case for action--for the local health authority, in partnership with the social services, firms and economic development partners, to develop new job opportunities of an appropriate kind for families struggling to rehabilitate relatives suffering either physical disability or mental illness. That is a perceived need in the area where I live and work. Those are precisely the kind of vulnerable people to whom the NHS and government document Priorities and Guidance 1997-98 refers.

I now wish to make a general point. I do not hold, nor do I imply, what has sometimes been called in your Lordships' House "a purely sociological explanation" of either ill health or of poverty itself. I have often noticed during debates in your Lordships' House the tension between those who stress the role of social factors in human ills and those who, on the other hand, stress personal responsibility. It is a real tension. Surely it is not a question of "either/or" but of "both and", yet in a complex interrelation. Ill health is caused by a complex mixture of the external social factors over which victims have no control and of personal choices at times by those victims and the groups to which they belong.

In 1992 the government White Paper The Health of the Nation set national targets for improvement in health. They included reducing the number of teenage conceptions, reducing levels of smoking among 11 to 15 year-olds and reducing the incidence of obesity among children and adults. Clearly, success in achieving such targets must lie partly in the region of human choices and the self-responsibilities of families and others. I wish to go further and claim that where I live such self-responsibility can rest successfully with local communities as well as with individuals in several areas of deprivation that I know of.

In one of the most deprived outer housing estates in the Stoke-on-Trent/Newcastle-under-Lyme conurbation, the local community and church have worked up a very successful single regeneration budget that is producing schemes which make a real contribution to raising the standards of health among some of the poorest families. The local people on the estate now have a community house which provides out-of-school clubs five nights a week; a childcare co-operative training scheme for local people to act as registered child minders; courses on family health, run by community dieticians, to offer advice on nutritional meals on low budgets; and so on. I question the secure continuity of such provisions, but

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I would not want to rub out of the equation the issue of self-responsibility and choices both of communities and individuals.

But the final word must remain with the serious ongoing challenge of the noble Baroness's Motion, both for the present Government and any new Government in the future. In particular, as the noble Earl, Lord Russell, said, we need resources for prevention rather than cure, and that applies to the unemployment link.

I conclude by referring briefly to two or three other areas. First, some of my most experienced priests, who have spent most of their ministries in urban priority areas, bitterly regret the loss of so many of the former statutory youth services which ran football clubs and youth clubs--just the kind of things which are vital contributions positively to the health of young people. Is action not needed there?

Secondly, I am glad to learn, and hope I understand rightly, that the use of bed-and-breakfast accommodation by local authorities is decreasing. But yet--the Children's Society report has proved it--there remain many children at risk in dirty overcrowded bed-and-breakfast accommodation. Parents, usually mothers, often find it impossible to provide an adequate diet and there is no space for the children to play. Homelessness, as well as long-term unemployment, is an enemy of health, and needs long-term solutions.

Thirdly, there is the importance of financially supported maternity leave. The birth of a child is surely a key event in the health story of any family. Yet in this country only a proportion of women receive earnings related to pay during maternity leave and for only six out of the 18 weeks of maternity absence itself. Would not some action there also protect good standards of family health?

Perhaps I may add a short postscript from the Bishops' Bench. For a religious mind--a Christian mind also--health and healing are fundamental to our understanding of the purposes of God. We see that in history in the figure of Jesus of Nazareth. Health is the strength to be fully human. It is, therefore, an issue which embraces not only the body but the conscience, the will and the soul. Therefore, at the centre of health must be faith. That is why the Church in poor areas is committed still to raising, as it did in other ages, the standards of health of the nation's poorest families.

3.53 p.m.

Baroness Symons of Vernham Dean: My Lords, I too thank my noble friend Lady Jay for introducing this important debate today. I offer my apologies to the House. I very much regret that I have to leave before the end of today's debate but I look forward to reading noble Lords' contributions in Hansard.

As the noble Earl, Lord Russell, pointed out, on occasions we can get a little hung up on definitions. But ill health can certainly be measured in death rates and in chronic debilitating illness, which renders individuals unfit to work or to lead a normal life. We all know too that the way in which poverty is defined is a subject of some controversy. We can perhaps all agree that those who are living homeless on our streets are by any

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definition living in poverty. But there is much poverty behind closed doors in this country, among families with young children and among the elderly.

Put plainly, according to the Department for Social Security's most recently published statistics, 9.9 million people in the United Kingdom--that is 17.4 per cent. of our whole population--relied on income support for all or part of their income in 1994. Again, according to the DSS, one person in four in this country is living on below half the average income after housing costs are taken into account, and of those 4.3 million are children. That figure has increased threefold since 1979, which is a deplorable statistic by any standard.

We all know that in any country poverty is a comparative term. But, according to the Government's own sources, the gap between the rich and the poor in this country has widened enormously in the past 20 years. The real weekly earnings for men in the bottom 10 per cent. of employees increased by 27 per cent. in the years from 1971 to 1993. Over the same period, the increase for those in the top 10 per cent. was 69 per cent.

In 1995, the Rowntree Foundation Report on income and wealth pointed out that incomes rapidly became less equal in the 1980s. It went on to say:

    "Britain needs a far-reaching programme of economic and social reform to avert the damaging consequences of a deepening divide between the rich and the poor".

So however we define poverty, the evidence is of a widening gap in earning power; and using the Government's own yardstick, more children are living in comparative poverty than was the case in 1979.

But we must acknowledge that an individual has responsibility for his or her health, as the right reverend Prelate pointed out. Taking enough exercise, eating properly and not smoking--a sensitive point in your Lordships' House--are straightforward enough; but poverty makes some of them more inaccessible. Poor housing means damp and insanitary living conditions. Lack of money means less heating and less nourishing food. It can, and for many old people does, mean a real choice between heating and eating.

Undoubtedly the taxation policy of the current Government has affected the poorest worst in that respect. The theory is that indirect taxation leaves the individual more choice on how to spend his or her income. But we all need to heat our houses in winter; that is not a matter of choice for anyone. It is certainly not a matter of choice for the elderly. It is shocking that in this country, even when the weather is mild, nearly 30,000 more susceptible elderly people die in the six winter months than die in the summer. It does not have to be like that. It does not happen like that in many countries, even those with far more severe winters than ours, such as Canada or Sweden. The elderly need to keep warm but thousands cannot afford to do so. Cold aggravates circulatory and respiratory problems, which in turn lead to bronchitis, pneumonia, heart attacks and strokes. In short, cold kills the elderly and too many of them are cold because they are poor.

Other difficulties may affect families with young children: diets which are low in fresh fruit and vegetables, and even the cost of water, which has risen

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by 37 per cent. since privatisation--three times the rate of inflation. Is it any wonder that the diseases of squalor, which most of us associate with Victorian Britain, have returned: scurvy, TB and scabies, the incidence of which has doubled in the past five years?

We can acknowledge that since the 1970s health in general has improved in all social classes. But the fact is that the mortality rates of the better-off have reduced faster than those of the less well-off. It is true throughout life. According to the BMA, a baby born to an unskilled manual worker is one-and-a-half times more likely to die before the age of one than a baby born to a manager or a professional.

In adult life we all now expect to live longer, but the widening gap in health remains. Non-manual groups have experienced a much greater decline in the death rates up to the age of 65 than their manual worker counterparts. The mortality rate among those up to the age of 65 is four times higher in the most deprived areas of our country than it is in the most affluent.

Of course, we all have a direct interest in our National Health Service, but perhaps I can make some personal points. Five years ago my husband was diagnosed as suffering from acute myeloid leukaemia. His life expectancy at the age of 38 was two months unless he responded to very aggressive chemotherapy, but even then the chances of his surviving another four or five years were about one in four or five.

He spent six months in hospital. I went to see him three times a day--not only because I wanted to but because I could afford to. I could afford the childcare at home. I could afford the taxi fare to the hospital. I could afford to take in three meals a day with me because the sterile food in the hospital was so unappetising. But so many people cannot afford to look after their family members in hospital in this way. We close our hospitals and, as a result, the families of those in acutely distressing situations simply cannot visit those who need them. Stress and loneliness are added to illness. The hidden cost of ill health bears hardest upon those on low incomes--financially yes, but also in terms of anxiety, stress and who knows, possibly their eventual chances of survival.

Of course, explaining the relationship between economic status and health is the subject of a great deal of research, much of which is still in progress. But that should not prevent an incoming Secretary of State, after the election, using the wealth of evidence we already have. Of course we need to address the reasons why the burden of ill health is associated so clearly with deprivation, but we need to address poverty.

We, on this side of the House, believe in a co-ordinated approach to the growing problems of health inequality. A cross-departmental strategy is needed so that all government departments are co-ordinated, not only on the policy but on the operational requirements to deliver that policy. In that respect the current way in which individual departments operate is too fractured, but primary health care and public health campaigns need to be combined with

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policy and strategy on education, on urban regeneration, on housing, on the environment and, of course, on job creation.

A new Labour Government will understand the need for frank and targeted public health campaigns, health education in our schools, setting targets to reduce water pollution in our towns and our cities, letting councils build houses which are properly heated and insulated, and introducing policies to get the long-term unemployed into work.

These are positive measures and when put into practice they will substantially improve the health of many in this country: many men, many women and many children.

4.4 p.m.

Lord Birdwood: My Lords, I would like to put down a marker right at the beginning of my short offering today, and that is a measure of my unease, verging on distaste, at the spectacle of a score of able-bodied Lords and Ladies of varying degrees of prosperity pronouncing on the problems of being sick and poor. And I must reinforce the point made by my noble friend Lady Brigstocke. It has always been a signature of the party opposite to claim ownership of compassion, and this Motion is no exception. Only socialist thinkers can empathise with poverty, we are told. It is like the extraordinary assumption of a few years ago that only the Left understood the consequences of nuclear conflict. The word which, again uneasily, comes to mind is "patronising" or perhaps it is "paternalistic". And let us not assume that "Nanny knows best" is the sole property of the Labour Party.

For something like 10 of the past 17 years of government the citizens of the United Kingdom have been fed a stream of hectoring, counselling, persuasion and sweet-voiced bullying from successive Health Secretaries about what to eat and how to take enough exercise. What is it about the British that thinks a government can change behaviour when all the evidence is that behavioural change percolates upwards from individual and collective social influences?

The noble Baroness has focused on a linkage between poverty and ill health. Note I said "a" linkage, not "the" linkage. There is always a problem, is there not, when issues like this are aired of where in the spectrum of intellectual rigour the body of a debate should rest? At one end there are the cold equations of the social statistician, and, as those in this House who have suffered in the past knew, nothing kills discussion more than a procession of numbers flowing from one or other of the Front Benches. As a listener one begs silently for humanity, for feeling, for the reality of being hungry or ill or in despair when force-fed those figures. But just as insidious is the anecdote masquerading as the general, pandering to the eye-blink attention span of the television audience or the newspaper reader who, our media masters believe, can only be captured by another outrage.

One understands the pressures which result in either. A single episode can illuminate a general injustice or blow away complacency. But statistics are not immune,

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as we all know too well, from political shading. And what I long for and still have never found in these areas is calibration. What is poverty? What is ill health? There are some stark measurable figures, of course, and the noble Baroness opposite has made them with exemplary lucidity. But I still feel a vacuum of forensic analysis of these issues.

To return for a moment to my point about linkage, the true pattern is a triangle surely, in which individual self-esteem or lack of it is the causal initiator. To give the Government their due, it surely cannot be ignorance any more, and you would have to be deaf and blind to escape the deluge of health advice from the media in all its colourings and techniques. Health sells, and don't all of us consumers know it!

I appreciate that previous speakers have not been trapped by the bell-curve fallacy and that we are concentrating on the demography at the end of Maxwell distribution. I cannot say the same of some of the pronouncements which come from other sources, where we are fed the nonsense about relative poverty or that everybody below the median point can be classified as poor.

The triangle I have just proposed of poverty, bad health and low self-esteem feels to me to be a valid model for our deliberations. If lack of material wealth were a cause of sickness, would not ill health be a necessary and sufficient condition always associated with lack of money? Observably, this is not so. So what is the variable? To my intellectual satisfaction I make the case for the lack of self-esteem. What this does is largely de-couple health from material ownership, except in so far as an individual who cares nothing for himself or herself will be more at risk.

What can a government do in this area? America certainly has a lesson for us in recent social policy in its utter rejection of a minimum wage by statute. I believe we can junk this rubbish idea once and for all, because getting into the world of work, in whatever way, at whatever reward, has social benefits. It has human consequences which go far beyond the material.

The American lesson is that all work works. And there is a correlation between American benefit policy and its much lower figure for the long-term unemployed. And now that we cannot put a cigarette paper, if your Lordships will forgive my metaphor in this of all debates, between the two main parties on education, I think that this subject has found its rightful high place in political priorities. Education is a key route to self-esteem and, therefore, in my proposition an essential precursor of the national well-being.

4.9 p.m.

Lord Addington: My Lords, I feel that I have far more in common with many of the ideas, if not the conclusions, of the noble Lord, Lord Birdwood, than I usually have with someone who addresses us from the other side of the House. I agree with his assumption that if we throw around statistics on this subject, as on many others, we shall find ourselves seeing nothing but statistics. I have received a good deal of briefing matter

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for the debate. I had to read through some of it several times in order to understand how those who produced the analysis actually see poverty.

Previous speakers have said that "poverty" is a relative term. It always has to be so. The links between poverty or lack of income and ill health are irrefutable. There is no dispute about that. The noble Lord, Lord Birdwood, said that much of that is down to low self-esteem or lack of education about health. I received a briefing from a group called the Life Project, working in the Wirral. It is interesting that a group from that part of the world has an input into our debate at the present time. The work carried out by the project shows what the problems are and what can be done to address them.

Primarily it shows that people on low incomes tend to have a bad diet and take little exercise. The food of those on low incomes--I make the assumption that these are people on low incomes and not people completely on the poverty line in the literal sense--tends to be cheaper and easier to prepare. The project also makes an interesting point about lack of exercise. We have an exercise culture for the first time in our society. We have the sense that "thou shalt be fit"; "thou shalt be fit in many different ways";"thou shalt be fit wearing certain items of clothing"; "if it isn't Lycra or doesn't have the right brand name, don't wear it in this place". Indeed, we even have brand names with regard to aerobic exercise. We have brand name step aerobics.

With that kind of pressure it is not that difficult to see why certain types of activity are associated with a level of consumption and economic activity. For the first time we see people taking exercise as a status symbol. That probably applies more to younger groups. In the older groups in society, where high activity or high explosion exercise or training for sporting events become less common, poverty or lack of funding are even more relevant. If you live in an unpleasant inner city you are far less likely to go for a nice, gentle walk. It is not fun to walk around grey, rotting, concrete blocks. Crime--or, more importantly, the fear of crime--may prevent you taking that walk. In addition, other kinds of gentle exercise such as gardening are difficult to carry out when you are dealing with a window box. What are you going to do--put it on your shoulder and walk around your house with it? Other activities such as golf may also be non-starters. Unless you happen to live in a certain part of Scotland and can pick up a half set of second-hand clubs cheaply, you do not have public courses available to you and you cannot afford the equipment.

The Life Project in the Wirral recognised these problems and went out to educate people on how to reduce their levels of ill health, obesity and high blood pressure. Those involved first tried to do this by going around in vans and handing out leaflets asking people to come and see them. Those who already had above average health--they were predominantly female--turned up to get advice on how to become healthier. Often when you are doing this you are preaching to the converted to come and listen to a sermon. That is what happens. Is it not always easier to listen to what we know about? We always turn up to hear it. So the

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Life Project did something different. It went to pubs at lunchtime with blood pressure testing devices and callipers to test body fat and carried out assessments. This was incredibly well received because those involved were going to people on the right level. They also discovered among people a frightening degree of ignorance about what happens to their bodies. Twenty per cent. of people thought that taking any exercise increased the risk of having a heart attack. One presumes that they were thinking of someone who is grossly overweight trying to run a marathon. In that case they were probably right, but the rest of the time they are not.

The Life Project also started to institute exercise patterns that were relevant to people. It instituted single sex exercise sessions for people who were very overweight and it provided special tuition. If you say to a 40 year-old woman who is four stone overweight that she should look like whoever is the equivalent of Jane Fonda in a modern exercise video, she will laugh at you, wander off and have another packet of crisps. You have to make things relevant. That was done by having the right type of training and by going out and becoming active.

This idea of addressing the problem is something we have to do. Whoever forms the government must address the fact that we have to try to make the message more relevant to people. Certain advertising campaigns--for instance, the heart campaign in which I am told that my heart is a killer--have missed the mark. You have to start talking to people. Unless we address this point and give better education to people in a way they can understand and, more importantly, identify with, all the advice given out by various Ministers and bodies will ultimately fall on deaf ears. We have to talk not at people but to them.

4.18 p.m.

The Earl of Sandwich: My Lords, I have worked for many years with voluntary and Church organisations like Christian Aid whose primary objective is the relief of poverty overseas. We were engaged, in the 1970s, in an international struggle whose motivation was based on the certainty of our own wealth and security in this country. Without going into the whys and wherefores, the situation today is markedly different, partly because of the reluctance of many of the supporters of those organisations to help abroad except in dire emergency, but mainly in the sense of our own ability to relieve poverty and ill health in our own country. I am not denying that in many specialised areas welfare programmes have expanded--infant mortality is well down and the social services have improved day by day--but I do not believe there is the same confidence as there was 20 years ago that the Government are actually on the side of the poorest communities--not the social services on the ground but the government, the national visible government.

In fact, if one visits north-east Coventry, as I was privileged to do when visiting a parish priest and I stayed for a night and met families, one gets a sense of deprivation such as that which exists in the

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third world and such as I have identified many times overseas, but not in this country. There is an acute sense of deprivation. I am very much in sympathy with what the right reverend Prelate said about long-term deprivation. After all, the social services and the Churches, however well equipped and however good the partnership, cannot deal with the problem instantly. There is also the long-term hardship of the many unemployed car workers and their families.

This sense of deprivation is well summed up in a few phrases contained in a recent report made by the Wildside Trust, which is one of those organisations that helps young people to escape from their urban environment into the countryside. It says:

    "As urbanisation spreads it is important that we recognise that ... lack of social cohesion often leads to destructive life styles and lack of care for the human and natural environment. People feel isolated and unable to make a difference ... Feelings of powerlessness lead to lack of action and increasing neglect".

As a measure of their concern and in response to what their supporters are saying, some overseas aid organisations have now built up a substantial anti-poverty programme in the United Kingdom as well. Some are now working closely with local authorities in urban areas, often those with ethnic minority populations where they have special expertise. That was mentioned by the noble Lord, Lord Northbourne, in our education debate together with what is happening very successfully in Tower Hamlets with the Bangladeshi community.

This Government are well aware of the advantages of working with non-government organisations in the health sector and of the necessity to support low-cost and innovative projects, which involve local communities more in their own care. That is a philosophy--almost a tradition in the voluntary movement--which applies universally, whether we are talking about a shanty town in India or in our own cities. But that does not mean that more and more primary healthcare services should be contracted out from the centre to a point where local government, so deprived of central funds, is forced almost out of existence.

I should like to mention some of the excellent projects of a particular charity with which I have worked; namely, Save the Children. Its achievements in the United Kingdom are much less publicised than its successful projects overseas. Those projects are specifically designed to promote positive change and partnership with the local authority and the community.

Perhaps I may give a few examples. Save the Children works with children and their families in the By-Pass Project in Bolton where it has set up a food co-operative to help young people to buy affordable healthy food such as fruit and vegetables. It is a simple project such as that already mentioned by the noble Baroness, Lady Brigstocke, which can make a great deal of difference. There is the Pennywell Neighbourhood Centre in Sunderland where a group of mums and new mothers can discuss concerns with a midwife. It also benefits from a loan scheme for parents on low income. There is also the Blackburn Young Families' Project in Scotland. Local women share their problems; look at ways of coping with stress and are also offered

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opportunities to take their children out. It is this encouragement of local initiative which is so important. The organisation, Save the Children, is only one of many. There are also health projects with prisoners' families, which include one of the most deprived groups of children in our population. I have mentioned the refugee communities, and, to give an example, the Vietnamese have benefited a great deal from this form of partnership.

In the voluntary sector it is people and not just money, which is the essential resource. Very small amounts of money are needed. Perhaps I may give noble Lords one tiny illustration. The charity called Kids VIP was started a few years ago because one young woman saw children loitering outside Winchester prison and decided to help them. I believe that there are tens of thousands of children in the families of prisoners. Today, that organisation runs creches in prisons all over the country and it is fully recognised as such by the Prison Service. Perhaps I may give one further illustration. Only a few hundred pounds can mean an enormous amount.

I end with what I believe are our international obligations under the terms of the UN Convention on the Rights of the Child. Many of the charities that I have worked with believe in these articles of faith. Briefly, Article 24 of the UN Convention states,

    "The right of the child to the enjoyment of the highest attainable standards of health".

Article 27 states,

    "The right of every child to a standard of living adequate for the child's physical, mental, spiritual, moral and social development".

In this short debate I hope that we are able to contribute one iota towards the UN Convention. Perhaps I may beg the indulgence of the House for having to leave for another appointment later in the afternoon.

4.25 p.m.

Baroness Hilton of Eggardon: My Lords, as already apparent from the debate that we have had so far, there are many factors linking poverty and health. The two that I intend to speak about are two environmental aspects of poverty: housing and air pollution. Poor housing has been linked to ill-health since the middle of the 19th century. The Public Health Acts of that century and the production of clean water, sewers, slum clearance and so on, had much more impact on health and life expectancy than medical treatments, which we tend to concentrate on today.

There is no coincidence in that long history of improvement that housing was the responsibility of the Ministry of Health until 1951. In contrast, the Government publication of 1992, The Health of the Nation, made no direct reference to the link between housing and health, although there is a general reference to the importance of healthy surroundings.

The survey of English houses of 1991 found that 7.6 per cent. of housing was unfit for human habitation, but that rose to 20 per cent. for dwellings in the privately rented sector, which are of course those generally inhabited by the poorest families. In addition to those, 20 per cent. of houses had problems

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associated with damp and 5 per cent. were in need of urgent repairs. I apologise for this use of statistics, but it is essential to drive home the particular point. Twenty per cent. of homes in England have an internal temperature below 12 degrees centigrade when the weather is freezing outside. It is generally agreed that a temperature of at least 17 degrees centigrade is necessary for health. Scandinavians and Americans would expect room temperatures to be very much higher even than that.

The poorest families, one-parent families and the elderly, are most likely to be living in poor, cold and damp accommodation. Studies in several cities--notably in Edinburgh, where climatic conditions are of course worse--have shown a clear association between damp housing and the fungus spores and moulds associated with damp and bronchitic, asthmatic and other illnesses in children. These chronic illness lead to frequent absences from school and all the potential ills of unemployment, crime and drug dependency that are often associated with poor scholastic performance. Illness is an additional factor that can only exacerbate the difficulties of a group of children that is often already educationally vulnerable due to overcrowding and poor living conditions.

Over the past 20 years there has been a decline in public spending on housing. In 1994 the UK was ninth out of 11 European countries for housebuilding completions. The balance of public spending on housing in this country has shifted towards means-tested housing benefit and away from support for capital and current spending by local authorities and housing associations. There has been no provision to improve our existing housing stock.

Moreover, as the building rate falls, less affordable rented housing in particular declines. Market forces--the law of supply and demand--which should be something dear to the heart of the present Government, ensure that rented housing becomes ever more expensive. The consequence is that more and more tenants become dependent on housing benefit, promoting the very dependency culture which the present Government deplore. Unless that trend is reversed, the health of the poorest 8 million to 9 million low-income householders will continue to decline, with an ever-widening gap between families of comfortable means in warm, well insulated houses and those condemned to bring up their children in cold, damp and overcrowded conditions.

An example of further misdirected spending is the announcement only three weeks ago of the award of nearly £7 million to Saatchi & Saatchi for a government-backed campaign directed at social classes A, B and C to persuade them to save energy by installing double-glazing and by insulating their homes. That £7 million targeted through the Home Energy Efficiency Scheme would have insulated 40,000 homes of the poor and vulnerable. The £7 million media campaign, moreover, follows directly on the heels of a £31 million cut in the grant-aid for energy-efficient measures for low-income householders.

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The other topic that I wish to address as particularly affecting poor families is air pollution. The current eduction of Social Trends acknowledges that,

    "the increase in the number of people with asthma, particularly young children, may be partly attributable to an increase in vehicle emissions".

It is estimated that the health costs of air pollution in our cities may amount to £3.9 billion per year and this is a problem that is rapidly getting worse. Over the past decade there has been a 73 per cent. increase in nitrogen dioxide emissions from motor vehicles, a 43 per cent. increase in carbon monoxide emissions and an 86 per cent. increase in black smoke. Research has shown that life expectancy is shorter for those who live or work near major roads. Poor families are more likely to be living in inner-city areas beside major commuter and commercial routes and are therefore more likely to have their health affected by air pollution, further exacerbating the other factors of damp and cold that I have already described.

If we are to live as one healthy nation, we must do more to improve our housing stock and to reduce air pollution by diverting people and freight from road to rail.

4.32 p.m.

Lord Astor of Hever: My Lords, despite what the noble Baroness, Lady Jay of Paddington, said, this debate is of interest to noble Lords on this side of the House. Seven speakers does not constitute a lack of interest. As president of the Motorsport Industry Association, I was interested to hear her party's commitment to ban tobacco advertising. Clearly, the noble Baroness has thought out the devastating effect that that would have on jobs in the motorsport industry--at this time, a real British success story.

It takes real chutzpah on the part of the Opposition--Labour and Liberal--to lecture us on action to raise the standards of health of the poorest families. So many of the local authorities they control fritter away money on their own wasteful schemes while front line services are cut, and the poor suffer.

I live in Kent, where the county council, a Left-wing old Labour Party, assisted by its weak Liberal allies, has dramatically and irresponsibly overspent its budget. Consequently it has imposed more cuts on services for the needy and vulnerable than any other county in England. However, it refuses to implement efficient savings or embark on a restructuring programme, as it has been advised to do by Price Waterhouse, the auditors. A memorandum sent to Liberal members by their leader states,

    "a large part of the budget pressures are a result of our own policy decisions".

As a long-suffering Kent resident commented to me,

    "they are not so much out of their depth as 3 miles from the shore".

The result is incompetence, debt, and chaos, and after seeing Labour and Liberal politicians at local level, I can anticipate what they may be like in government. Of course, the Shadow Chancellor has stated that there will be no extra funding, above what this Government

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have already set out, for the health and social security departments for two years, so clearly he considers that those departments are not underfunded by this Government.

The vast majority of people, spread across all sections of our population, are better off as a result of this Government's policy of promoting economic growth. The UK recovery since 1992 has been the strongest of any of our major European competitors. Britain is a magnet for inward investment and job creation, resulting in a great deal of social mobility and increased prosperity for all--not just top earners. Meanwhile Germany's unemployment figures have increased by half a million. But still New Labour is attracted by the social chapter, the minimum wage and job security deals, not to mention the Tartan tax for the Scots. Social costs are destroying jobs across all sections of the population in Germany. New Labour's fondness for the social market economy could lay waste the livelihood of hundreds of thousands of British families and will particularly hit the poor.

The Opposition are continually running down our social security system, but it does successfully focus resources on vulnerable groups, such as low income families, poorer pensioners, and sick and disabled people on low incomes. Benefits for most groups have increased by significantly more than the rate of inflation since 1979. Compared to 1988, an extra £1.5 billion a year is being provided in income related benefits for families with children. Poorer pensioners now receive an extra £1.2 billion a year. The least well-off pensioner couple is entitled to over £100 a week, as well as having their rent and council tax paid in full. Since 1979, over four times as much is being spent on helping disabled people as was spent by the last Labour Government.

The Department of Social Security is now testing whether in-work benefit assistance is effective in getting single people and those without dependent children, back to work. The Government have launched Project Work, an innovative programme offering job search help and practical work experience to people unemployed for two years or more. A current pilot scheme near me in Medway has so far been very successful. Family credit, which boosts the incomes of those with low or moderate earnings, is now providing help to a record 692,000 families, including nearly 305,000 lone parents, with an average award of over £55 per week. Recent changes have made family credit more accessible to lone parents who may have found it difficult to combine the longer working week with their family responsibilities.

The Labour Party tells us that a healthy diet is not possible on income support. I have discussed this with the Department of Health, which advises me that a wide range of foodstuffs is available at affordable prices within everyone's means. Food is cheaper in this country than most EU countries, particularly as food is subject to VAT in 12 of those countries. May I ask my noble friend the Minister if her department might consider issuing again an information leaflet with suggested cost-effective and healthy recipes? This need not be advice on what should be eaten, but what could be eaten. I know this has been done in the past,

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unsuccessfully, and that some people prefer an unhealthy diet, but I do feel it would be worth another effort. With imagination, exciting dishes can be made from basic and healthy ingredients.

The Government have just announced the publication of a new guide to community child health services, Child Health in the Community: A guide to good practice. This guide is being sent to health authorities, NHS trusts, community health councils and local authorities with a view to stimulating wide-ranging local reviews of the objectives and provision of community child health services.

The guide brings together policy statements and advice on good practice in child health surveillance, health promotion, school health services and community children's nursing. There has been a steady improvement in the overall health of the nation. Clearly there is always room for improvement.

Action can be carried forward specifically on three fronts: first, the pursuit of even greater economic prosperity; secondly, we must work towards increasing the understanding of variations in health status. To this end the Government are committed to launching a £2.4 million research initiative into variations; and, thirdly, specific initiatives towards particular vulnerable groups. It is a key Government aim to promote equitable distribution of health services throughout the UK and to ensure their availability to all social and ethnic groups. The Health of the Nation White Paper focuses efforts on those groups, and areas where particular effort is needed to achieve the targets set.

I believe that the Government's policies have been good for the people of this country, whatever their circumstances. I also believe the Government are taking effective action to continue the overall improvement in the health of all the nation's families.

4.41 p.m.

Lord Paul: My Lords, our distinguished colleague, my noble friend Lady Jay, deserves congratulations on having initiated this discussion. It is both important and unfortunately often neglected. It is a subject very close to my heart. Your Lordships may be aware of the circumstances which brought me to this country. That experience sensitised me as to how very important, how fundamental, health issues are for society. It is the enduring imprint of these personal concerns which has sustained my long interest in this subject and its larger implications.

I am a new boy here but I am surprised that the noble Lord, Lord Astor of Hever, whose side has been in government for 17 years, wants to palm off the problem and responsibility to the councils, and the Shadow Chancellor.

In an advanced industrial democracy it is sad that we should even have to discuss this issue. The right to good health is surely one of the most basic rights of a citizen. If we can develop sophisticated scientific systems for everything from military weapons to traffic control, should we not be able to provide and administer a system which assures consistent access to improving health care? We can transfer billions of pounds sterling

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around the globe through marvellous electronic gadgetry, yet we do not seem able to deliver satisfactory health care to working men and women in our neighbourhoods.

In human terms, that is irritating at best and tragic at worst. In economic terms, that has consequences which range from declining morale to declining productivity. Noble Lords who have been associated with various areas of manufacturing know how relevant is the relationship of morale to output.

We too often equate morale with economic incentives and rewards. Morale is also linked closely to physical and emotional health. All of us want to advance the British economy--all of us must then take a broader view of workers' well-being. And to do this we need to begin where action is most needed--at the bottom of the economic scale.

Nineteen centuries ago, the Roman poet-philosopher Juvenal suggested that we must all seek mens sana in corpore sano--a sound mind in a sound body. The same ethic is embraced by the old Indian concept of Yoga. The ancients, in their wisdom, understood how individual performance related to fitness of body and mind. With all the techniques and technologies available to modern society, we seem unable to grasp those truths today.

The conditions of life are now such that individuals have drifted away from those verities. It is surely the duty of the state to mobilise its resources and encourage non-governmental groups to make people aware of that and to take remedial action. Where else do we begin but at the most deprived level of our society--those who are unable to help themselves? Generally, it is the winners who get applause and attention. But if we neglect those less fortunate, if we cannot or will not encourage improvement in their standards of well-being, we risk a deterioration in the entire social fabric. The results will be devastating. Poverty, enduring poverty, is both a human tragedy and the most debilitating sickness which afflicts a nation.

In that context, I need not remind your Lordships of the startling decline in social indicators in several Eastern European countries recently, and the resulting national disintegration. I hope that the nations of Western Europe, including our own, will learn from those situations and not follow in those pathetic footsteps. Perhaps it is more true today than at any other time to say that a physically ailing state is an economically ailing state; and an economically ailing state is always a study in human misery.

We live at a time when it is fashionable to talk of individual enterprise, self-motivation and personal initiative, but all such endeavour is predicated on human energy. We surely cannot expect those who are unable to afford the nutrition and care which begets that vigour to generate it. No longer is this an issue peripheral to society or to the economy. It does concern working people most directly, but it profoundly affects all classes and the future of this country. That is why I hope that it will engage the attention not only of this House but of everyone who wants a better Britain. No price, my Lords, is too much to pay for that.

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