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4.49 p.m.

Baroness Turner of Camden: My Lords, I am grateful to my noble friend Lady Jay for introducing this debate and for the opportunity to participate. There is little doubt that poorer people are more likely to suffer from ill health than the better off. There have been numerous studies which would appear to confirm that. Some of that information has already emerged in the debate. It is useful to look at definitions of poverty. We are often told that we do not have much absolute poverty here, and that may be true if we are comparing with the desperately poor people of third world countries. However, it is useful to look at what Faith in the City says, a publication with which I am sure the right reverend Prelate is familiar. It states:


That final sentence is most important.

There is no denying that inequality has greatly increased in the UK since 1979. Indeed, the UN Human Development Report shows that Britain has the largest and fastest-growing income disparity of any industrialised country. The richest 20 per cent. have 10 times as much income as the poorest 20 per cent. This country has more than any other pursued what the UN calls "ruthless growth", where the already well-off benefit. Between 1979 and 1994-95, the poorest tenth of British households experienced a loss of 14 per cent. in their real income--that is, after housing costs--while the richest 10 per cent. improved their income by about 65 per cent.

That did not happen by accident or because of something now called globalisation, or because of membership of the EU. It happened because of positive policies initiated by the Government during the years of Conservative power. The Government have placed great faith in the "trickle-down" theory; that is, the idea that gains from economic growth for the wealthy will trickle down to the poorest parts of society. So we have had tax changes which benefit the rich at one level and at another the general tightening up of social provision in order to cut down on public spending at the lower level, plus a series of measures designed to weaken the ability of people in employment collectively to secure better terms and conditions.

The most marked effect has been on the lowest paid. Since the Government abolished wages councils, rates in the industries previously regulated by them have been reduced. According to a recent TUC survey, 1.3 million people in Britain earn less than £2.50 an hour. Furthermore, 342,000 people earn less than £1.50 an hour. Every year the taxpayer must find £2.4 billion in benefits for people who simply do not have enough to live on. So for such people, their reality is "poverty pay".

There is no doubt, however, that the major cause of poverty in Britain is unemployment. The Government have made great play of the most recent figures which indicate that unemployment is diminishing. However, as we have said from these Benches on many occasions, while we are always very glad to see improvements, the

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Government should not be surprised that there is some scepticism about the validity of the figures since they have changed the method of counting them so often. The claimant count is not an entirely reliable record of those without work and wanting it. This gives a figure of unemployed as 6.7 per cent. of the workforce, while the Labour Force Survey, which is another means of counting, puts the figure at 7.9 per cent.

Long-term unemployment, particularly among men in the former areas of heavy industry, remains a problem. Moreover, just over 15 per cent. of unemployed people leaving the claimant count moved on to sickness benefit. Those who do get other jobs are more likely to end up on the claimant register after a relatively short period. The Employment Audit concluded that the job opportunities on offer depend strongly on the length of time a person has been unemployed. The longer people have been unemployed, the less likely they are to enter permanent jobs, whether full-time or part-time.

The Government have frequently cited the decrease in the claimant count as being evidence that unemployment is being effectively dealt with by present policies. However, large numbers of newly created jobs are either part-time or temporary--perhaps better described as casual employment. Much of that is quite appallingly badly paid. There are frequently no non-wage benefits, such as sick or holiday pay. A man made redundant and forced to accept casual work as a rent-a-car driver, recently told the TUC that as a casual he did not receive holiday pay or entitlement to a pension and that his pay was only £2.45 an hour. Another man employed part-time on print finishing was receiving £2 an hour, again with no paid holidays or paid meal-breaks.

The entrepreneurial society, with the lack of any employment regulation at all and the pressure on the unemployed to take any kind of job after a period of unemployment, has certainly created a very happy environment for sweat-shop employers. As I indicated earlier, there is little doubt that poverty created by unemployment or low-paid employment is a prime cause of ill health. Unemployment undoubtedly increases stress and causes depression. We live in a society in which we tend to define ourselves by what we do. Those without work therefore automatically feel excluded. The World Health Organisation concluded after a survey of extensive literature on the subject that:


    "it is almost certain that unemployment damages mental health and probably that it also damages physical health".

Tuberculosis, the classic disease of poverty, is making a comeback after declining for most of this century. It is far more likely to spread among people living in overcrowded conditions. The rate of tuberculosis rose 12 per cent. between 1988 and 1992, but the increase was noticeable only among the poorest 30 per cent. of the population. The rate of infection of the poorest 10 per cent. rose by 35 per cent. Furthermore, if you are poor you are more likely to die earlier. The mortality rate for unemployed men who are unskilled is nearly three times that of employed men from the professional classes, a point which has been made today.

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Everyone should be concerned about the link between poverty and ill health for the obvious reason that it costs taxpayers more through increased NHS costs. Moreover, as the Victorians discovered in the last century, communicable disease can become established among the poor and then can be passed on throughout the rest of the community, ultimately threatening those who are not poor.

It also makes sense to deal with the problems arising from low pay. Why should the taxpayer subsidise sweat-shop employers through the social security system? Those are reasons why a minimum wage makes sense, despite what noble Lords opposite have said today. Far from reducing the number of jobs available, it could well increase them. It would force low paying employers to pay for the work that they want done. It is not true that the minimum wage is responsible for unemployment in a number of EU countries. Other considerations are involved in their unemployment statistics. Indeed, France has had a minimum wage since 1950, and for long periods during that time unemployment figures were not so high. It is quite wrong to say that if we introduced a system under which very low-paid people received at least a minimum standard there would be less work. I believe that the opposite will be true. We have already seen what has happened since the abolition of wages councils. People are working for appallingly low rates which are being subsidised by the benefits system.

Poverty and ill health resulting from unemployment and low pay actually costs us all far too much. I refer to NHS costs and social benefits and to the threat to the general health of the population. We can and should take steps to deal with these social evils.

4.58 p.m.

Lord Butterfield: My Lords, I hope that your Lordships will forgive me if I take a slightly different tack in the discussion. I am confident that everyone in the Chamber would like to alleviate the problem of some people in this country having poorer prospects as regards sickness. I wish to bring to your Lordships the idea that some--I do not say all--of people's ill health is due to self-inflicted, serious mistakes in judgment about what they are doing to their bodies and their health.

I was most impressed by the opening statement of the noble Baroness, Lady Jay. I am grateful to her for launching the discussion, which is close to my own heart.

I was very impressed by the speech of the right reverend Prelate the Bishop of Lichfield. I could not help but agree with so much of what he said. I believe that I could have spoken earlier in the debate. However, I make a personal point on that. One wonderful thing about coming in late is that one can make remarks to so many of one's colleagues and in that way improve one's friendships and collaboration in the House. Therefore, although I thought that I was to speak earlier, I am very happy to bat at number 13.

Many noble Lords have touched on the evidence as regards the relationship between income groups and illness. In a survey with which I was involved recently,

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I noticed that references were made to Quick and Wilkinson, who published in the Socialist Health Association Journal; to Whitehead, who published from the Health Education Authority, and Williamson from the Trafford Centre at the University of Sussex. Of course, that centre was set up in memory of a former Minister of Health in this House, although sadly he was Minister for only a very short time. This is not for the record, but he died from smoking. It is dreadful for that to happen to a doctor, but that is the truth.

Something which has been touched upon and appreciated in the debate this evening has been the question of poverty and ill health and the relative poverty in some developing countries. The question about the adverse effects of poverty not being so obvious in, for example, Africa, was rebutted in a way by those two remarkable men who worked in backward parts of the world--Cleave and Burkitt. They brought to us in this country the importance of fibre in the diet. That may perhaps have fended off the need to pay proper attention to the Black Report. I do not know, but I suspect so.

I am intrigued by the fact that policy has been framed on the studies of people who are extremely concerned and link closely with statistics on health. I am thinking about Tom McKeown, professor of social medicine at Birmingham, who underlined the importance of income and housing in relation to health. I am thinking about Sir George Godbar who was a doughty supporter of the poor. We have all heard of Sir Douglas Black today, but his successor, Acheson, and our present Chief Medical Officer, Dr. Cadman, are both very concerned about the relationship between income and health.

As a practising doctor, I was not a statistically- minded man. My approach has come from my experiences of a person-to-person relationship. I noted quite early on when I went to work at Guy's Hospital that I had one or two patients whom I could not convince of the devastating effects of smoking on their lungs. Perhaps the first time that I recorded real failure was when I wrote a prescription for a Mr. Baker who needed antibiotics to ward off infections on his chest when they overwhelmed him rather than waiting at home until he became sick and came to the hospital casualty department.

I remember on another occasion a man of immense wealth, an American with diabetes. Despite all I said to him, he put on a beautiful pair of new shoes, drove in his beautiful new Jaguar motor car to see his son-in-law who was a whisky distiller in Scotland. He was appalled when it was clear that he had early gangrene in his little toe as a result of those tight shoes. Man-to-man, one becomes very worried about health education when that kind of thing goes on, when one is doing one's best for the patient.

Another man whom I knew--and this is an aside but I cannot resist talking about him--was the harbour master at Virginia Beach in Virginia. While playing poker on Christmas Eve, he was infuriated by the chief of police who was cheating. He snatched his gun and shot him in the chest. Of course, he ended up in prison where he was a volunteer for some studies with

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which I was involved. He was gaoled in America with Al Capone's safe cracker. His punishment for the rest of his life was to know that he could crack any safe and walk off with the contents at the drop of a hat.

I wish to tell your Lordships that I became involved with the idea that behaviour is very important as regards ill health in the 1970s and the 1980s. I became involved with the Health Promotion Research Council in the late 1980s. I have been sending your Lordships copies of our reports which I expect quickly found their way into waste bins. But those of us who were concerned with that felt that we were doing some quite good work.

We found plenty of evidence that bad judgment and risk-taking have extremely adverse effects on health. We became more and more aware also that there was not quite such a close relationship as my good friend Douglas Black pushed between pay and remuneration and health. We found that those groups of people who had quite marked rises in their salaries--perhaps 30 per cent. or 50 per cent. over 10 or 20 years--very often were rapidly running towards obesity and diabetes. Since I have been interested throughout most of my career in diabetes, I am appalled that people between our first and second survey for the Health Research Trust were putting on between five and seven pounds and over an inch on their girth in just seven years. If that continues, that will lead to a great deal more diabetes which costs the health service something in the order of £0.5 billion per year.

Therefore, I am personally very anxious that we should develop more man-to-man or person-to-person attempts to improve health behaviour. I am sure that that is extremely important. The Moslems make the point that men dig their graves with their teeth. In the case of obesity and diabetes, that is certainly true. It seems to me that as we are all very concerned about this, it must be for someone like me to try to lead to some collaboration between us all. It is extremely important that we should get more help from those who know how to deal with individuals. My profession grew out of the Church. I believe that the Church and the medical profession should spend more time trying to improve health knowledge, education and behaviour.

There must be a big drive to help unemployed people. I do not know how that can be done. I believe that people from the Church can help, as can social workers. The Department of Health should perhaps work with the Home Office in that very important field. In helping criminals' families--a group very much at risk--again, there should be a link between the Department of Health and the Home Office. That might achieve much. We doctors and nurses must realise that the provision of such help must not rest solely on the professions. There needs to be a wide group of people who can provide support and who will work together towards that objective, irrespective of immediate political loyalties.

5.9 p.m.

Lord Ponsonby of Shulbrede: My Lords, I begin by thanking my noble friend Lady Jay for giving us the opportunity to discuss this very important subject. Some

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noble Lords have apologised for the excessive use of statistics in their speeches. I must warn your Lordships that I too shall use a lot of statistics but I shall not apologise for it. I believe that whoever said that there are lies, damn lies and statistics was quite wrong. When properly interpreted, statistics give a picture of truth that even the most backward-looking of governments or political parties cannot fail to ignore. I wish to talk about the effects of childcare on the family as a whole in relation to their health.

For many families today having children leads to poverty. In 1992-93, 33 per cent. of children were living in families with below 50 per cent. of the average income. In 1979, the figure was 10 per cent. According to that definition of poverty, some 4.3 million children live in poverty today--that is three times higher than in 1979. Moreover, 18 per cent. of children in two-parent families, some 185,000 children, are living on or below the income support level and 78 per cent. of children in one-parent families (some 184,000 children) are living on or below the income support level. One-parent families have a high risk of living in poverty. In 1990-91, 11 per cent. of the poor were one-parent families, whereas 6 per cent. of the population were one-parent families. Therefore, one-parent families are almost twice as likely to be living in poverty.

Poverty has an enormous impact on the lives of families. It affects what they eat, what they wear, their housing conditions and their safety. The Health of the Nation report, about which we have heard this afternoon, stated that life expectancy at birth is around seven years higher in social class I than in social class V. Recent research from the Family Policy Studies Centre has shown that, on current benefit levels, one-parent families who live in the poorest conditions, and who have lived in such conditions for some time, cannot afford to eat a healthy diet.

The DSS commissioned research from the Social Fund which showed that 35 per cent. of single parents on low incomes did not have adequate bedding for all members of their household. It also showed that 31 per cent. lack hot water, that 58 per cent. have inadequate heating and that 38 per cent. have dampness problems in their properties.

In order to support a family, most families need both parents to be in work. Currently six out of ten couples with dependent children have both parents in employment. The majority of mothers are in part-time work, many of them working very short hours. The lack of good quality, affordable childcare is an important factor in determining a mother's position in the labour market. There is only one childcare place for every nine children under eight years of age and there are about 800,000 children under 12 years of age who go home on their own after school every day.

Many women are unable to keep their jobs when they have children and, when they return to work, they return to jobs with much lower rates of pay. Childcare is an important factor in the process. Although there is a system for subsidising childcare for the low paid in the form of the childcare allowance, for those on family credit, few two-parent families benefit from this allowance.

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I turn now to statutory paid maternity leave, which is only 18 weeks in this country, and many women do not even qualify for that. There is no statutory paternity leave and that is out of step with standards in the rest of Europe. In addition, there is no right to introduce flexible working hours which would help so many parents. On top of all that, British men--as I know only too well--work the longest hours in Europe. That is no doubt partly to compensate for their wives' low wages. Indeed, I can say with some feeling that long hours do absolutely nothing for family life.

Single parent families face the particular problem of having to combine being a parent and providing an income for the family. I should point out that 90 per cent. of single parents are women and that 75 per cent. of single parents have to rely on income support. Poverty and ill health become a vicious circle. In the recent survey of single parents, one in six were unable to work because of ill health either of themselves or their children.

There are practical measures which can be taken to ease the situation for all parents, especially single parents; for example, enhanced maternity leave, the introduction of paternity leave and the increased availability of flexible working practices. Tackling the quality, the availability and the affordability of childcare would enable more parents, especially those on low wages, to support their families through work while ensuring a good quality of life for their children. These are not necessarily expensive measures but they would make an enormous difference to all parents in this country.

5.15 p.m.

Lord Desai: My Lords, I believe that being 15th on the speakers' list is a positive advantage, to follow what the noble Lord, Lord Butterfield, said. Perhaps I may start on a very different tack from that outlined by other noble Lords. I should begin by congratulating my noble friend Lady Jay on what has proved to be a most interesting and multi-faceted debate on aspects of poverty and health.

The interesting thing about the Black Report, which came out in about 1981, was that it pointed out to us that the effect of poverty on health persists despite much effort on the part of society to reduce it. I should like to cite one interesting statistic in that respect. My noble friend Lord Ponsonby told us that the difference in life expectancy of those in social class I and social class V is seven years. In America, a comparable difference between the life expectancy of a white male and a black male is 30 years; in other words, the life expectancy of the black urban male in the United States is below that of a man in Bangladesh.

The difference between life expectancies in this country and in America is a great achievement of the NHS. Let us not forget that fact. We cannot say that we have achieved nothing. The Black Report really said that despite making healthcare accessible independent of income--at least as regards medicinal care, while not mentioning other expenses--a national health service can achieve a great deal but it cannot achieve everything. On the other side of the equation is poverty,

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and a national health service cannot eliminate poverty. Indeed, poverty has to be tackled by other measures. That is a most important point with which to begin.

I turn now to the subject of definitions. Perhaps I may give your Lordships an historical account as regards defining poverty. Interestingly enough, the defining of poverty originated in this country in the 1870s when primary school education became compulsory. The fee for such education was one penny per week for each child. Local school boards had to make a decision and decide whether those children whose parents could not afford to pay should still be allowed to attend school. That is when the first poverty line was defined in this country. So the original concept of poverty concerned not so much the mundane considerations such as food and clothing; it concerned the life chances of children who could not go to school.

As my noble friend Lady Turner of Camden said, that amounts to exclusion. If you cannot send your child to primary school and all the other children in the neighbourhood can attend, your child is effectively excluded. That is why poverty matters. Indeed, it matters very much to me because, if you are born into a poor family or if your family becomes poor, it affects your life chances. Therefore, we must make other arrangements to ensure that the life chances of children are not affected by the poverty of the parents. As much as we have been able to do that in the provision of healthcare, we must also think how we can deal with the problem by way of other measures. That is what will make us a better society.

Many points have been raised by other speakers but perhaps I may just make one or two comments which are relatively complimentary. It is not true to say that demand for healthcare is unlimited; that we cannot afford it; and that, therefore, we must do something drastic to cut government expenditure. I have looked at Social Trends. I promised the noble Baroness who is to reply to the debate that I would not give too many statistics. I shall try to make a spiritual speech, as far as an atheist can make a spiritual speech. Social Trends shows that real government expenditure has decreased over the past 15 years by about £20 billion or 6 per cent., while real disposable income has risen by 50 per cent. Therefore, we are not spending unlimited amounts of money. Government expenditure is not out of control. If there is less government expenditure, yet we allow higher private incomes, while that is good for most people it hurts the poor the most.

If properly directed, government expenditure provides the poor with a cushion. This is where I think poverty and ill heath come together. One simple example of that is overcrowding in housing. Over the past 15 years we have spent only half as much on housing and community facilities as previously. Over the past 15 years the figure has decreased from £20 billion to £10 billion. However, we have had to spend considerably more on social security. Had we spent as much on housing as we used to, we would have had to spend less on social security and there would have been fewer health consequences. If people cannot afford good housing, they go into bad housing. Bad housing is more expensive because, ultimately, it leads to ill health.

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Of course the National Health Service bears the cost of ill health but that does not mean that society does not bear the cost of ill health. We have to remember to take not a Treasury view of costs and benefits but a more common sense view of costs and benefits. The noble Earl, Lord Russell, has always pointed out that if you make cuts somewhere, costs arise somewhere else; it is just that we do not see those costs arising.

We have tried to make economies in areas such as housing by, as it were, privatising it. That is helpful if one is an owner-occupier. However, it does not help if one does not have the means to buy a property. One has to resort to rented accommodation, which is expensive. Consequently people become homeless, live in hostels or accommodation which is not properly heated, is damp and which causes ill health. That is a cost.

I now wish to mention another hidden cost of ill health. About 4 per cent. of the labour force is absent from work due to sickness. The figure of 4 per cent. may not sound high but even if that 4 per cent. of people contributed 2 per cent. of GDP, that is £15 billion. That is not a small sum of money. Absenteeism is costing us that sum of money, despite having a good health service. We must look again at the issue of poverty. There has been a fall in the number of adult working males who are between the ages of 25 and 55. Jobs for the relatively unskilled have disappeared. Therefore we must systematically consider how we can restore jobs for the relatively unskilled. Sooner or later we shall once again have to grasp the nettle of restoring and increasing real public spending, because that is the best hope for the poor.

5.24 p.m.

Viscount Brentford: My Lords, I too wish to thank the noble Baroness, Lady Jay, for introducing this debate. As the noble Lord, Lord Desai, quite rightly said, it has been a most interesting and varied discussion covering a wide area. I apologise to the House and to my noble friend Lady Cumberlege in that I have a prior engagement this evening and will not be able to stay until the end of the debate.

Income levels are important for the health of families and of individuals right across the board and not only to those living in the most abject poverty. I refer to the two Whitehall studies of the Civil Service. This research has shown that those in the lowest ranks of the Civil Service are three times as likely to die in a given period as those in the senior ranks--the administrators. Similarly, there is a gradient. In each rank people are more likely to die in a given period than those in the rank immediately above. As I understand the research, income levels across the board affect people's health.

Similarly, men and women in the lowest grade of the Civil Service are shown to have six times more sick leave than those in the highest grade. I do not believe that even those in the lowest ranks of the Civil Service are people that we would consider to be living in real poverty. The higher one's income, the better one's health. That is common sense to me but it is something which needs to be pointed out in this debate.

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Why is it that the higher one's grade and one's income, the more likely one is to have better health? Many of the reasons for that have already been mentioned. The higher one's grade, the more likely one is not to smoke; the more likely one is to take exercise; the more likely one is to have a healthier diet and the more likely one is to have better resources as regards housing, transport, heating and diet. All those points have been well made and they are obviously relevant to one's health.

There are two other factors which are also relevant to health, one of which is called the psycho-social factor. To put that in English that I understand, I believe it means that an individual has support, affirmation and encouragement both at home and at work. Today I had lunch with a man with whom I discussed the need for the employees in an enterprise with which we are both involved to receive much affirmation and encouragement from those of us who are involved but do not work there. We all need that support and it is relevant to our health. The support I receive from my wife helps and encourages me. I am sure that it is conducive to better health than would be the case if I were without her. As I said, I believe this support is important for health. In this place we can all offer one another that support. We can offer that support to people in employment, to our families, to charities or whatever we are involved in. We can offer support and thereby contribute to the health of the nation.

The second factor I wish to mention--our income levels are relevant to this--is that those in unskilled and repetitive jobs are more liable to stress than those in high pressure, varied jobs. I found that piece of research interesting because it contradicted my own thinking. I had always thought that people who had high powered jobs working at great levels of intellectual capacity and physical pressure were most subject to stress. But it now appears that those in unskilled and repetitive jobs are more subject to pressure. They have less control over what they do; they have less variety in what they do; and less prospects for future development. I believe that all employers need to bear that in mind and endeavour to give everyone variety in what they do. That, again, will contribute to the health of the nation.

I referred to smoking. I am interested to read that people in the lower social groupings in the country are five times more likely to die from lung cancer than those in the top social groupings. That is a message we all need to hear.

Last week in this building, I listened to a talk about drugs. When one bears in mind that someone on drugs may have to pay out something like £500 a week, one can see that there are grounds for poverty let alone ill health in that situation, regardless of criminal tendencies.

Much healthcare in this country is equally available for all whatever their income group. I have recently seen the excellent provision by the NHS for a mother in the course of a birth--the hospital services, the midwives and the health visitors. Those services are available for all whatever their income level. I believe that the NHS does a magnificent job in that regard.

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I understand, too, from research that all social groupings visit GPs to a similar extent. However, the indications are that the lower social groupings make less use of available health resources. We have talked about the need for education on using the available resources, and in regard to behaviour patterns, exercise, and so on. Perhaps I may ask my noble friend Lady Cumberlege whether the NHS prioritises inner cities and other areas of deprivation to ensure that those people are encouraged to use the available health resources which the NHS provides.

The average income of the poorest 10 per cent. of the country has risen by nearly 50 per cent. in real terms in the past few years according to the DSS. That is encouraging. I know that the mortality rates among those in the lowest income levels are not good, as some noble Lords have said. That issue needs attention. But I believe that we are on an improving pattern. As the noble Earl said earlier, the poor are always with us. That is not a ground for complacency. Those words of Jesus Christ are a challenge to all of us to keep improving our standards. That is what I believe the Government are doing and what all parties seek.


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