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A few weeks ago, a fast-food chain announced that it would create 6,000 jobs. At the same time my colleagues on Leeds City Council explained that they were going to make about 300 staff redundant. When they were challenged on the “PM” programme, they explained that a number of their sources of funding and revenue from central government had been cut but that they were also suffering other losses of income, including loss of revenue from their swimming pools because people cannot afford to use them. That is a deeply depressing symptom of a recession, but I want to stress the importance of the public health agenda now and in the future.
The Faculty of Public Health defines public health as:
“The science and art of preventing disease, prolonging life and promoting health through organised efforts of society”.
To that one can add that the politics of it all is about providing the means to do so. At times of economic recession, it is easy to see public health as a soft target and an easy place in which to make cuts. However, I want to try to persuade the Minister that to do so
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In February 2009 the Health Select Committee in another place produced a fascinating report on health inequalities. It is a fair report and acknowledges that the Government have attempted to tackle health inequalities, have bravely set themselves demanding public health targets and have targeted resources at areas of deprivation. However, one of the most striking and compelling points made by the committee is that there is a lack of evidence with which to judge the effectiveness of the programmes that have been funded and their cost-effectiveness. The report says that, all too often, the Government rush in with insufficient thought and do not collect adequate data from the beginning. Frequently, objectives are unclear and policies are changed or implemented with such short timescales that meaningful evidence cannot be gathered.
If anything, the Health Select Committee understated the case. The ability to evaluate public health interventions and the lack of an evidence base for doing so not only affects the NHS and other government departments but hampers the work of the voluntary sector. I point out to noble Lords that the great bulk of public health and preventive work is carried out not by the NHS, or even by the state, but by charities and the voluntary sector. Their work is also seriously impeded by the lack of an evidence base.
Politicians of all parties are under no illusions whatsoever that, in future, public services will be under increased pressure. There will be an imperative to make sure that funding of services goes to the most efficient and effective. I particularly ask whether the Government agree with the Health Select Committee that Professor Sir Michael Marmot’s forthcoming review of health inequalities is an ideal opportunity to introduce new evaluation methods that are ethical and economical. Do the Government also accept that Sir Michael’s review should include work on inequalities in secondary care and, therefore, should review the payment-by-results framework?
The Government have done a tremendous amount of work on such matters as coronary heart disease and cancer. Not to acknowledge that would be churlish. We need from that work the evaluation data that enable us to see how the NHS can become more productive in future. My noble friend was right: the majority of work on public health is not done by the NHS at all; it is done by other government departments. The WHO Commission on Social Determinants of Health recently stated:
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“Communities, neighbourhoods and cities that ensure access to basic goods, that are socially cohesive, that are designed to promote good physical and psychological well-being, and that are protective of the natural environment are essential for health equity”.
Social reformers since the 19th century have been trying to persuade Governments of just that.
My colleagues in another place, Vince Cable and Nick Clegg, have stated repeatedly that a key part of our economic recovery will be investment in green technology and in such matters as environmentally sustainable housing. If there is to be a silver lining—and I am not Pollyanna, by any means—it will be that Governments rise to the challenge of making radical changes to the planning system and infrastructure development to bring about communities that have better health outcomes and reduce health inequalities.
In the short time available, I will mention one further matter. The Healthcare Commission, under the leadership of Anna Walker, ceased to be at the end of March. Its final report was on mental health and older people. It is an excellent report, which I commend to the House. I mention it because it is a public health matter to which very little attention is paid. As with other services, there is a lack of data, but the Healthcare Commission found in its research that, for older people, access to mental health services—and particularly to crisis and emergency mental health services—is wholly inadequate, just because those people are aged 65 and over. In times of recession, it is understandable that Governments put the bulk of their resources towards those members of the community who are most economically active, such as younger adults. However, older people are the biggest users of public services. I hope that the noble Baroness will encourage the department to look at the report’s recommendations, which are not really for large-scale further public funding. They are for better data and systems, so that existing services can be made better.
In 2004, Derek Wanless pointed out in his report on the National Health Service that, for the health of the nation to be drastically improved, public health and the awareness of individuals about what they could do to lead healthy lifestyles would be important. Five years on from that and standing as we are on the brink of a recession, it is even more important that his message about the priority of public health should be taken up by the Government.
4.50 pm
Earl Howe: My Lords, my noble friend Lady Knight is to be congratulated on her customary wise and incisive speech introducing this important topic. I am grateful to her for giving us the opportunity to debate it because, far-reaching as it is, public health is an area of policy that tends to receive less than its fair share of discussion in your Lordships’ House.
When defining “public health” to myself, I tend to go back to the words quoted by the noble Baroness, Lady Barker. Those words originated with the former Chief Medical Officer, Sir Donald Acheson, who, I remind the House, spoke of public health as,
- “the science and art of preventing disease, prolonging life and promoting health through the organised efforts ... of society”.
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That definition has been tweaked by the present Chief Medical Officer, who has brought in the more current subject headings of health inequalities, clinical governance and the management of risk. The distinguishing feature of public health is surely that it relates to initiatives that reach across populations and groups as opposed to the curative treatment of individuals. One could range far and wide to topics such as housing and education, even taxation, and still not stray off the subject of public health, but I should like to focus today on issues that fall directly within the Minister’s purview and on one in particular about which we have heard this afternoon: health inequalities.
If we seek to identify improvements in public health over the past 20 years, we can point to a number of successes. On what might be called the big ticket issues, life expectancy across the population is improving and infant mortality is falling. The rate of improvement is not as great as it is in some other western countries, but it is still an improvement. Among the major targets in public health policy, we can look with some satisfaction at the trends in smoking prevalence and the consumption of salt in the diet where, taking the bald averages, both are both going down.
However, there are other areas of public health where success has been more elusive. Sexual health is one, dental health is another and the one about which we hear quite a lot, obesity, is proving a very difficult nut to crack. The evidence on these three areas is that they are much more of a problem among lower socio-economic groups. That is the reason why part of the Government’s public health strategy has been to target specific areas of health inequality—that is to say, disease areas that affect certain subsets of the community most damagingly.
Health inequalities are a stark measure of a Government’s success in delivering good public health, so it is welcome that the Health Select Committee in another place has recently subjected this aspect of the topic to close scrutiny. Its report makes fascinating and sometimes depressing reading. Over the past 10 years, health inequalities have in fact widened, not only between the rich and the less well-off but also between the population as a whole and other sectors of the community who are seen as being harder to reach: ethnic minorities, those with mental health problems and the elderly. To call the Government’s record a failure because of the widening gap in inequalities would perhaps be overly harsh, because it is a tough test, but unfortunately the charge of failure begins to stick when we look at the committee’s findings elsewhere.
The committee’s most damning criticism relates to the Government’s whole approach to policy in this area. I would describe it as a lack of intellectual rigour. It is a story of eye-catching initiatives which are poorly designed and rushed into being without proper baseline information or clear objectives. Evaluation of these initiatives too often consists of simply examining the processes that have taken place and asking people what they thought of them. To compound the sin, there has been short-termism—changes of direction and a failure to maintain policy long enough to know whether it has worked. The net result, in the words of one witness, has been that,
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Indeed, large amounts of money have been poured into initiatives such as health action zones, healthy towns, healthy schools and the expert patient programme. What we get at the end of them is a series of inputs, throughputs and customer satisfaction measures. None of them has produced results that tell us what we need to know, which is what interventions actually work. Professor Ken Judge of the University of Bath put it quite brutally when he said:
“We end up with rich descriptions of what people are trying to do. These ... are then used as evidence of good practice because we do not have anything else and we slide inexorably from setting these things up essentially to the production of propaganda”.
The committee was uncompromising in its conclusions. It said:
“Such wanton large-scale experimentation is unethical, and needs to be superseded by a more rigorous culture of piloting, evaluating and using the results to inform policy”.
Of course, much of the public health agenda is delivered locally through PCTs, but here again there is cause for concern. The committee found that strategic health authorities and PCTs are not providing satisfactory leadership in public health. The number of senior public health specialists is falling. We have seen funds for public health siphoned off into other areas during times of budgetary pressure. My own view is that we need to look again at the idea of ring-fencing a goodly portion of the public health budget to prevent the same thing happening again.
More than that, when tackling health inequalities, there is a perception that many PCTs are simply unsure of how to spend their funding allocations to the best effect. If that is true, it again reflects poorly on the quality of leadership, not least national leadership. There is a drive by the Government to improve access to GP services, which is welcome. Equally welcome is the intention to rebalance the QOF towards public health goals. But other things have suffered. I am thinking particularly of early years intervention with mothers and young families, where the scope to combat health inequalities is considerable; yet the number of health visitors and midwives—the very professionals best placed to deliver help—has also been falling. NHS dentistry has been one of the Government’s stated priorities; yet, again, reality belies the rhetoric. Access to NHS dentists has gone down since the introduction of the new contract. None of this is exactly a story of stunning success.
Central to much of the effort in this area are health promotion campaigns. We have seen a succession of such campaigns over the years, a lot of them related to healthy eating. On the plus side, there is evidence that some of the key messages are getting through. As a nation we are eating more fruit and veg than we used to and taking more exercise. Our intake of alcohol is going down. But the key issue here is not the averages; it is whether enough of the right people are permanently changing their behaviour. The Minister will be aware that the King’s Fund has levelled some serious criticisms on exactly this point. It and others have stressed that one-off advertising campaigns cannot hope to change
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The rise in obesity continues, as does widespread alcohol abuse among teenagers. More than two-thirds of adults still do not know what exercise they should be doing, what amounts of alcohol are unsafe and even what a portion or fruit and veg consists of. If we are aiming to create, in the words of the Secretary of State, “a lifestyle revolution”, what can make us confident of doing that? In the final analysis, if we cannot improve public health, we will not be able to afford the NHS. That is why this debate is vital and why, in one form or another, we shall return to it over the months and years ahead.
5 pm
Baroness Thornton: My Lords, it is with great pleasure that I respond to this debate and to the opportunity provided by the noble Baroness, Lady Knight, to highlight the Government’s public health agenda. I congratulate her and other noble Lords on an interesting debate. She has drawn attention to issues of which the NHS is aware and is acting on, from matrons to the organisation of wards and infection control, which are of course of great importance.
I do not accept the failures in regulation alleged by the noble Baroness, given that in the past there was virtually no accountability for doctors and other medical professions at local level, which is why we have focused during the past 10 years on giving our regulators a wide range of toughened enforcement powers and have enabled the new commission to take direct and independent action against service providers that fail to meet essential levels of safety and quality which people are entitled to expect.
I entirely agree with the noble Baroness that we need to deal with mixed-sex wards. The Government have never denied that. The Secretary of State announced in January a six-month drive to eliminate mixed-sex wards in hospitals. Three cornerstones underpin the programme: a £100 million privacy and dignity fund; improvement teams established to help those hospitals with challenges in this area; and working to establish financial covers in the context of the contracting framework between PCTs and hospital trusts.
The Government’s approach to public health cannot be described simply by a list of initiatives. It is about how we deploy our health resources and the leadership that we provide in this area. Our leadership is a response to our passionate belief that good health is a shared priority from the bottom to the top of the nation. Our starting point was that in 1999, only 1.8 per cent of total health expenditure went on prevention and public health. We now spend more than 3.6 per cent—double that spent 10 years ago.
Not everyone sees that as a good thing. Earlier this year, my right honourable friend Dawn Primarolo, the Minister for Public Health, pointed out that there is a school of thought that there is no such thing as public health. According to that view, any intervention in public health and any act to give individuals or groups support, guidance or safeguards is somehow an attack on their liberty. She rejected that argument, and so do
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We believe that we have come a long way towards our aim to provide services that reflect changes in people's lifestyle, habit, environment and society. We believe that our campaigns are now much more sophisticated than they were in their targeting and their understanding of people's motivation to change. For example, the smoking campaigns funded by the Department of Health have been widely acclaimed by marketing experts in both the public and private sectors. However, as noble Lords have mentioned, those campaigns cannot work on their own. That is why Change4Life is rooted in research about people's behaviour and how they change their lives. It tells people how they can make positive changes as well as warning of the dangers of obesity. Clearly it is up to individuals what they eat, drink or smoke. It is not the Government’s intention to intervene unnecessarily or stand at their shoulder in the kitchen, as it were.
Our sexual health campaign has generated almost 1 million visits to the Condom Essential Wear website. More than half of 16 to 24-year-olds say that they are more likely to have a check up for a sexually transmitted infection as a result of seeing the advertising. We have already heard from the public and the media of lives saved following our stroke awareness publicity. Some may remember that I described FAST in your Lordships’ House, with visual aids. One clinician in Kent has reported seeing around 200 patients as a result of the campaign’s message. We estimate that the new cervical cancer vaccine will save the lives of up to 400 women a year.
There are other campaigns aimed at informing, supporting and empowering individuals and families to make healthy choices. These include seasonal flu immunisation, pandemic flu preparedness—I will refer to that again in a moment—stroke awareness, sexual health, HIV and having an NHS life check. All our major campaigns are evidence-based and subject to evaluation.
The noble Lord, Lord Addington, raised the issue of sporting and physical activity. Change4Life, launched in January 2009, focuses on pregnant women, parents of babies and toddlers and parents of pre-school and primary school children. In future years, we will see the development of programmes targeted at young people and adults. For example, £140 million was invested in our free swimming programme. The walking your way to health scheme, led by the Department of Health, Natural England and the British Heart Foundation, delivers nearly 2,000 walks to more than 30,000 people each week. We are determined that as part of our legacy for the Olympic Games, 2 million adults should be more active in 2012. This will include active travel, dance, gardening, and active conservation.
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The noble Lord kept asking me who is responsible for this. It is a cross-government activity. It can only be delivered across government. The Department of Health, for whose activities I am partly responsible for, has its part to play, as do all the other departments mentioned by the noble Lord. He also mentioned the sports and exercise consultants. We had an exchange about the importance of the provision of sufficiently qualified medical experts for the Games and about establishing consultants and medical facilities as part of the legacy of the Games.
The noble Lord, Lord Ramsbotham, made an eloquent comment about health in prisons. Like him, I am looking forward to reading the report of my noble friend Lord Bradley. I know that the Government will look very carefully at his recommendations. The challenge that we have—the noble Lord will be only too aware of this—is that, since 2006, all prison health services have been transferred to the NHS; we are mainstreaming their services. Therefore, our target is that prisoners receive the same standard of healthcare as we would expect in the rest of the community. However, we know that that is easier to say than deliver. Indeed, there is a great deal more to do.
Lord Addington: My Lords, are we going to hit the number of 72 consultants in sports and exercise medicine within the NHS?
Baroness Thornton: My Lords, the noble Lord knows that part of the 2012 delivery is that there has to be a sufficient number of sport and exercise medicine consultants. If I recall correctly, that is two medical experts per event during the Games. I will write to the noble Lord again about this if he so wishes, but I am not going to go into it in detail now. We have every intention of delivering both the legacy and the Games properly medically equipped.
I thank the right reverend Prelate for being so on message about the Government’s work in these uncertain times of the threatened pandemic. I take on board his comments about the need to be aware of the challenges of the asylum-seeking communities and other communities at this time of uncertainty. I also thank him for his support for our forthcoming debate on point of sale for tobacco. We take very seriously the issues of alcohol raised by the right reverend Prelate. There is good evidence that cheap alcohol is linked to people drinking more and subsequent harm to their health. It is important that any Government intervene to reduce harm without, as the right reverend Prelate said, unduly impacting on the majority of responsible drinkers. We are looking to develop the evidence base on that issue.
The noble Baroness, Lady Masham, raised the threatened influenza pandemic. All NHS organisations have comprehensive plans which they are now bringing into action at the appropriate level. Every resilient forum in England has validated pandemic-specific plans, which were outlined by my noble friend on Tuesday in the Statement and yesterday in answer to a Parliamentary Question. I will not go into a great deal
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The noble Baroness, Lady Barker, made a very good point about how we will use the next two years, and about the importance of investment in the public health agenda. We are considering the Marmot review and taking it very seriously. I agree with her that the Healthcare Commission’s final report was very important. I undertake to follow this through and to make sure that it is given proper consideration.
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