Motion made, and Question proposed, That this House do now adjourn.—[Caroline Flint.]

2:44 pm
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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

It gives me great pleasure to open the debate on inequalities in health. Over the past 50 years we have seen impressive social, economic and health improvements in the United Kingdom. People from every class and every region are healthier and are living longer than ever before. The differences over time are striking. For instance, data for 1972–76 show that male life expectancy in the lowest social group was 66.4 years. That compares to a life expectancy of 71 years by 1997–2001. That is an indication that public health policies are having an effect on people's lives, as are treatment and new drugs.

However, the Government are not complacent. We need to do more about inequalities. We know how to improve life expectancy, but we need to ensure that all parts of society are benefiting. We know that families in poorer neighbourhoods are at greater risk of infant mortality, still die at a younger age and are likely to spend more of their lives in ill health. A man living in Manchester is likely to die nine years earlier than one living on the south coast of England. We know, too, that a man working as a manual worker in a factory is a third more likely to report a long-standing illness, compared with a man in a professional group, such as a doctor or a lawyer.

Social injustices like those are what brought me and many of my colleagues into politics, and are one of the reasons why we have given health inequalities a high priority now that we are in government. From the beginning, we were keen to set the record straight. One of the first things we did was to commission a comprehensive inquiry into the evidence on health inequalities. We invited a former chief medical officer to chair the inquiry. The result was the Acheson report, published in 1998. Acheson showed a significant widening of health inequalities between the 1970s and 1990s. The differential had increased two to three times between the highest and lowest social classes. It could be addressed only by focusing on the wide range of determinants—social, economic and environmental—that have an impact on health.

Acheson focused on programmes and priorities, but targets are important to focus attention on the problem, to stimulate action and to engage key players. In 2001, we set a national health inequalities target for England that called for a 10 per cent. reduction in the health gap for life expectancy and infant mortality. We extended this approach by including health inequalities as part of our key targets on heart disease, cancer and smoking. We have used the adoption of national targets as a way of influencing and shaping policy across the Department of Health, the health service and, importantly, other Government Departments, too.

In our target on smoking—the biggest cause of avoidable deaths—and our work to reduce smoking levels, we recognise that we cannot achieve our overall goal to reduce smoking levels without focusing on the hard-core group of poor smokers. Clearly, the decision of the House to ban smoking in all public places apart from a few exemptions, which was supported by Members from all parties, will make a huge contribution to tackling the problem, and took account of the concerns about health inequalities caused by partial restrictions on smoking in public places, particularly licensed premises.

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Crispin Blunt (Whip, Whips; Reigate, Conservative)

The hon. Lady ought to concede that it was the view of the House on a free vote that overrode the policy of her Department that was presented to the House on Second Reading—a policy that would have promoted health inequalities resulting from smoking.

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

As I said in the debate, the opportunity that we had to vote came about because Labour decided that we should legislate on the matter. I am pleased that there was a debate. It was healthy for democracy. It is a Labour Government who are doing more than any Government before to tackle the problems of smoking and the effects on others who do not smoke.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I get the impression that the hon. Lady might be moving away from telling the House in simple terms what has been the result thus far of the two national targets relating to life expectancy and infant mortality.

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

I intend to cover those issues, which are very complex. [Interruption.] Well, they are complex. The reality is that everybody from every social group is making progress in terms of their life expectancy. Our problem, which I am certainly not afraid to face up to, is how we deal with a situation whereby although everybody is living longer and improving their health, people who are better off and more educated take up the challenges of improving their health more quickly than those who are less well off and less educated. That is one of the reasons why we have to deal with the gap, of which I am fully aware.

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

I should like to make a little progress in the hope that I will deal with some of the points that the hon. Gentleman and the hon. Lady may make, but I will be happy to take interventions if I do not.

Following the adoption of the national target, health inequalities was chosen as the subject for a cross-Government review led by the Treasury. That review was designed to influence spending decisions across Government as part of a wider programme to address child poverty and promote social justice. Jointly chaired by the Department of Health and the Treasury, it brought together 18 Departments—from Department for Work and Pensions to the Department for Transport—and Government units and agencies. Together, they assessed progress and agreed priorities for action. For us, the role of the Treasury provided the catalyst for this cross-Government work and a new national health inequalities strategy.

That strategy—the programme for action launched in 2003—sets out four themes to tackle health inequalities: supporting mothers, families and children; engaging with mothers, families and children; preventing illness and providing effective treatment and care; and, importantly, addressing the underlying determinants of health. Those four related themes set out a programme to address health inequalities on a broad front, directed to the whole population and designed to ensure that responsibility for tackling health inequalities lies at the heart of all public services. That includes work on urban and neighbourhood renewal and on giving children from poorer families a fairer start in life through Sure Start. As well as focusing on the 2010 national target, the strategy seeks to address some of the underlying causes and determinants of health such as employment, education, crime, transport, early years support and homelessness. Our aim is to improve everyone's health, but to improve the health of the poorest fastest.

People living in disadvantaged areas usually have much lower expectations of the health care system and of their own health. On a recent visit, we met a 49-year-old man who, despite breathlessness, did not think that he was unwell. He said, "I'm not ill—I'm just getting old". Yet he was not even 50. Here we are in Westminster, where a man will most likely live until 76. If we travelled east on the Jubilee line to Canning Town, eight stops away, we would find that on average men live until 69—a seven-year difference. A shorter life expectancy means that families are robbed of parents and grandparents. Between 2002 and 2004, there were 13,700 additional deaths among 30 to 59-year-olds in the most deprived local authorities compared with the rest of England.

The status report on the programme for action published last August showed encouraging signs of progress on health inequalities, but recognised that a significant challenge remained. Following that report, we decided to commission a review of health inequalities, which was undertaken in conjunction with the Treasury. The review signalled a conscious decision to improve our performance and to ensure that we use the available evidence base to meet our targets. We have developed a model to deliver real improvements in public health in the short term that concentrates on averting early death. The model identifies the age groups we need to focus on—the 40 to 60-year- olds—the most common causes of early death, and the most effective treatments and interventions we can apply to prolong life.

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Ann Winterton (Congleton, Conservative)

The Minister is talking about equality of opportunity in health. Will she say a word about the inequalities in the postcode prescribing of Herceptin? Having had a constituency case in which we fought for a young woman to be given that treatment, it was obvious that people living two miles down the road in another area had it as of right. What equality was there between those two examples?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

We have clearly said and maintained that individual clinicians should consider with patients whether drugs such as Herceptin are an appropriate treatment choice, taking into account risks and medical history. We have also said that primary care trusts should not rule out treatments on principle, but should consider individual circumstances when reaching decisions and that they should not refuse to fund Herceptin solely on the ground of cost.

I am pleased to say that we have seen some huge improvements in other areas of cancer treatment in the past seven to eight years that have been of benefit to many people suffering from many different types of cancer.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

It would be courteous to my hon. Friend Ann Winterton to find out precisely what Government policy is. Clearly, primary care trusts in different parts of the country reach different decisions about whether they will fund Herceptin for breast cancer patients on the basis of their judgment of the clinical case rather than that of individual clinicians. Do the Government think that that is the right way to proceed? Do they accept that different decisions should be made in different parts of the country about an issue where a clinical judgment could potentially be made on a national basis?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

It would be inappropriate to direct PCTs to have a standard position on a drug that is not yet licensed or appraised. The PCTs have the opportunity to make choices about their policy on that particular drug and we have made that clear. As with many such matters, PCTs should deliver what they think is right for their local communities and should take into account clinicians' advice as well as other issues, such as guidance from the National Institute for Health and Clinical Excellence.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

It is a simple point. It is perfectly logical for the Government to have said that PCTs must make a decision on an unlicensed drug, but why did the Secretary of State interfere? Why did she say such things if her intention was not to send a message that Herceptin would be available for early stage breast cancer?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

I think that I am correct in saying that the Secretary of State was pointing out that cost was not the only factor that should be taken into account. Clearly, individual cases have to be suitable and other matters apply.

I want to return to my point about the major reasons for people dying an earlier death than we would hope. For example, circulatory diseases and cancer are responsible for approximately 50 per cent. of avoidable early deaths. Logically, it would be correct to focus on treating those diseases. However, as I said before, we should also target the underlying causes of ill health. Unemployment, the absence of support in early years, housing conditions, homelessness and other contributing factors mean that some individuals are more likely than others in their community or elsewhere in the country to suffer ill health.

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Graham Stuart (Beverley and Holderness, Conservative)

The Minister will be aware that poorer people in rural areas are statistically invisible, struggle to access services and are disproportionately affected by closures and cutbacks at community hospitals. If the Minister believes in reducing health inequalities, will she reverse the ongoing cuts to community hospitals and make the welcome rhetoric of the White Paper a reality?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

The hon. Gentleman is right to make the point about challenges in rural areas, particularly for those who might not have transport or who have low incomes. That is why health inequalities have to be tackled not only in urban areas but in other communities, and why programmes such as neighbourhood renewal funds are important.

On the hon. Gentleman's point about community hospitals, I cannot comment on his remarks about reversing cuts. One of the challenges is to meet the health needs of families, neighbourhoods and communities that are not getting the much closer and more personal health service that could make a difference and motivate them to consider aspects of their lifestyle that might affect their later years. One way of meeting that challenge is to examine the way in which some services could be provided closer to home.

My right hon. Friend the Secretary of State has said in recent debates that in areas where community hospitals or cottage hospitals have been identified for closure, it is important that the people involved in the planning arrangements take a hard look at the ways in which those hospitals could be refashioned or reorganised to provide services in the different ways suggested in the White Paper. I have taken part in a few Adjournment debates on this subject, and I am aware that some of the services being provided by the community hospitals are not necessarily the ones that most meet the needs of their community. It is important, whether in community hospitals or acute hospitals, to consider what is being provided and whether it meets people's needs. I hope that I have given the hon. Gentleman a full answer to his question.

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David Drew (Stroud, Labour)

May I say that my hon. Friend has got this absolutely right? One of the problems with rural areas is the disproportionate effect of funding being spread across the whole area and missing the pockets of real deprivation. This is made clear by the way in which some general practices operate. Will my hon. Friend take it from me that the best way to deal with this is—to use a horrible expression—to drill down and find out what the social and medical problems are in rural areas, and disproportionately to fund the people and places in greatest need? It is not fair that, too often, those people miss out because they do not have a voice. We hear the rhetoric that the funding is going to those people, but the reality is that it is not.

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

My hon. Friend makes an important point. One of the things that we can do at national level, in identifying this problem, is to ensure that the organisations that commission and provide services demonstrate how they are meeting the targets on health inequalities through the services that they provide and through the outcomes of those services. That is one way of incentivising local service providers, commissioners and GPs to understand the nature of the problems experienced by some of the people in their communities, and to look in different ways at the services needed to help us close the gap created by these inequalities.

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Philip Hollobone (Kettering, Conservative)

In north Northamptonshire, alcohol misuse is becoming an increasing problem. Is tackling that problem moving up the Minister's list of priorities?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

It is certainly there, along with a number of other issues, such as obesity and smoking. Alcohol is an interesting subject because there is evidence that its misuse takes place across different social classes. Yes, it is a problem for those in our poorest communities, but also for those who are better off. I am having discussions with the Ministers responsible for these matters in the Department for Culture, Media and Sport and the Home Office, and we are working with Ministers in the Department for Education and Skills on alcohol education in schools. We are also engaged in discussions with producers and retailers in the alcohol industry about what further information they could provide on packaging to inform people about safe levels of drinking. There is lot that we need to do to get people to understand the dangers. They might not think that they are drinking at an unsafe level, but, over time, they could develop real problems. This is an issue for young people, some of whom could have considerable health problems by the time they reach 30, if they do not reflect on the amount that they are drinking.

Several hon. Members:

rose—

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

I shall give way to my hon. Friend David Taylor, then to Mr. Cox. Then I would like to make some progress.

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David Taylor (North West Leicestershire, Labour)

I am grateful to my hon. Friend the Minister for giving way. One of the proudest achievements of our Government since 1997 is the establishment of the post of Minister with responsibility for public health, and a very successful one we have today, particularly in view of what happened earlier this week.

My hon. Friend has outlined a number of the significant gaps—between urban and rural areas, social classes, age groups, geographical areas and so on—but perhaps one of the most fundamental is a man-woman split. Will she say a little about the inequality that exists there in terms not only of the natural tendency of the male not necessarily to report or monitor his own health, but in some of the most fundamental diseases of all? An awful lot of investment has rightly gone into breast cancer, but less has gone into testicular and prostate cancer, where the outcomes for that extra £5 million, £10 million or £15 million would be even better. This is a difficult one, but what is she doing about it?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

I am involved in a great deal of work with organisations such as the Men's Health Forum to consider how we can encourage men to think about their health, and we are also considering innovative ways to use pharmacies and others to reach hard-to-reach groups whose members often do not come into GP surgeries. I understand that men are particularly guilty of that.

We are looking at other venues where it might be possible to get men to think about their health. For example, we have done some fantastic work with the Football Association and some good work is going on in football clubs up and down the country to engage men. Although men exclusively do not go to football, that is one way we can reach them.

I would like to say something further on the issue around gender, so I will come back to the hon. Member for Torridge and West Devon later. While we obviously need to look clearly at gender differences, there is some concern among women—we might be seeing some trends, as more women seem to be drinking more alcohol and smoking rates among women are also considerably high—that we need to address health issues arising from the change over the past 20 or 30 years in terms of taboos that existed for my grandmother and for my mother over women's lifestyles. I am not saying that that was all right or that it was rather judgmental, but there are consequences. We are seeing, because of that, some evidence that issues that were often seen as male health problems are starting to emerge among women as well. We must consider how best to deal with that too.

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Geoffrey Cox (Torridge and West Devon, Conservative)

On the point relating to rural areas, does the Minister agree that the national weighted capitation strategy is plainly inherently biased towards urban areas? Its assessment of additional need adopts indices that are clearly not applicable to poverty in rural areas, to which Mr. Drew referred. If it is inherently biased, and if the best method of capturing need in rural areas is being systematically missed, there will be increasing health inequality in rural communities. Is not that something that the Government should deal with urgently, and what is the Minister going to do about it?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

The basis of funding to primary care trusts is determined on levels of need and issues around population are taken into account, but this is an area that we keep under review. To give an example from my constituency, which is semi-rural as it contains mining villages, we have benefited from money we got through the rural bus grant to have bus services provided for some of our outlying villages. That has given many people an opportunity to reach some of the services in Doncaster. That provision has helped and it is a good example as it involves health in terms not only of rural areas, but of how other Departments and those agencies closer to where people live—whether the local authority or the strategic transport executives—take these issues into account. The regional development agencies also have a role to play in looking at supporting infrastructure in our rural communities.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

This is an interesting point. Does the Minister agree that using ward-based data in relation to deprivation in rural areas such as her constituency might indicate high levels of deprivation there, while in many other rural areas such data do not do so because smaller numbers of relatively poor people are hidden by larger numbers of relatively wealthy people? One method of dealing with that is for the national health service in particular, given that it is building up through GPs an enormous database of morbidity—knowing how many asthmatics there are, knowing how many diabetics and the like—to transfer from assumed to real data.

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

Data are important for planning and commissioning. I have had interesting discussions about how some GPs are breaking down their practice areas, not just on a ward basis but street by street, to target services on those who are most in need, rather than getting in touch with everyone. Some exciting work has been done in rural and urban areas. For example, particular ethnic minorities have been targeted, because of certain health needs, to good effect. One of the Department's challenges is how to enable those who commission and plan services to use social intelligence better to construct services and gain better value for money through more precise targeting.

I am sure that Mr. Lansley would agree that, having given record funding to the NHS, our challenge is to demonstrate that best value for money is being achieved. My right hon. Friend the Secretary of State visited Dudley the other week where better-quality services are having much greater impact and better outcomes, from less money, than the old services used to provide. I visited a sexual health clinic off the Tottenham Court road only last week, which provided good examples of changing the way in which services are provided to improve access and save money. There is a 48-hour waiting time target for those services, which is challenging but which some providers are meeting. It is an exciting area, and those who are planning and want to provide services need to think about how to reach people in a more targeted way. If they do, we will have a much greater opportunity to close the health inequalities gap.

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Crispin Blunt (Whip, Whips; Reigate, Conservative)

Does the Minister agree that the gist of what she is saying is that the best way to address health inequalities, particularly those produced by social deprivation, is through first-class primary care services and community care hospitals, whereas the elderly population are more likely to need access to good critical care services? Does she accept that that is a reasonable definition?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

In tackling health inequalities, it is critical to be clear which are the most vulnerable groups in the local community when it comes to suffering ill health. It is then a question of identifying the core components leading to those poor health outcomes. As to whether that is partly about changing what happens in the acute sector, there is probably room for improvement in hospitals. Provision in community hospitals is also part of the debate. But there are two other aspects. First, prevention can stop people getting ill in the first place or reduce illness. Secondly, people are living longer because technology has moved on and drugs are better, which is welcome—more people are surviving heart attacks and cancers. The question of provision for more long-term management of illnesses follows from that. Whether it should be done in hospital or in the community is open to debate. It is extremely important, however, that we consider outcomes, focus on what we are attempting to deliver and show clearly that what we are doing works. We need to be as robust in arguing for the activities that we encourage and support, especially in the context of public health, as are those in the clinical sector when it comes to operations and medicines.

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Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

Does my hon. Friend agree that although the average 65-year-old has more health needs than a younger person, some over-65s are very healthy? Average life expectancy in East Elmbridge and Mid Surrey is over 81, nearly 10 years higher than the average life expectancy for men in Cricket Green in my constituency. If we want to reduce health inequalities, should health services be concentrated where there are healthy 70-year-olds or where there are people 10 years younger whose health needs are far greater?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

My hon. Friend is right. As I have said, life expectancy is much lower in some parts of the country and in some parts of communities than it is elsewhere. I am pleased that many people are taking action to improve their health, and that should be encouraged. We should do as much as we can through the NHS to help people to help themselves and to make the right choices. We must also bear down on health inequalities, however, and recognise that they are not a case of "One size fits all". We need a much more targeted and focused way of addressing health inequalities among those who are most in need. We must direct services to their communities, so that they can be taken up easily. That will enable such people to change their lives in the same way as other, healthier people elsewhere.

We have recently added health inequality targets to our other health targets and incorporated them in the business of the NHS. As a number of Members have pointed out, the issue of health inequalities cannot just be tagged on to the work of the NHS; it must underpin that work. Our targets on heart disease, cancer and smoking now automatically include elements to reduce the health gap. I am pleased to say that we have already seen a 24.7 per cent. reduction in the heart disease gap, and a 9.4 per cent. reduction in the cancer gap.

Local action is the key to delivering our national programmes throughout England. That means engaging with local delivery partners such as local government, the local health service, the voluntary sector and community groups. Through improved NHS funding and the measures specified in "Choosing Health", the most disadvantaged areas, covering 28 per cent. of the population of England, received extra support and money to help them to tackle health inequalities. Those steps must be supported by measures that identify and reward performance and by other incentives that encourage action in both health and local government services.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

Will the Minister give way?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

I have already accepted a number of interventions, but if I make enough progress I may give way to the hon. Gentleman later.

Health inequalities exist everywhere, but we continue to emphasise the importance of making faster progress among the most deprived groups. We have therefore identified the 70 local authority areas with the worst health and deprivation indicators—the spearhead group. That epitomises our targeted approach and allows the creation of innovative public health programmes, such as the healthy schools programme and the provision of health trainers. Services are being tailored to the needs of local communities, and barriers to healthy living are being removed.

Local government is a key partner. We have agreed with local government a shared priority for healthier communities and reduced health inequalities. For the first time local authorities will be assessed, as part of the comprehensive performance assessment, on the action that they are taking to reduce health inequalities. The ongoing local area agreement process has enabled local authorities to embrace the agenda in their areas with enthusiasm. The White Paper offered the opportunity for more joint appointments of public health directors and for joint commissioning. We have recently made dealing with health inequalities the first of six top priorities for the NHS and have signalled our commitment to performance-managing the NHS more closely. We are also sharing best practice in areas that are delivering with those that are under-performing.

Government programmes to tackle child poverty and bring about neighbourhood renewal form an integral part of our strategy, but we also need to empower individuals to seize responsibility for their own health by improving socio-economic factors, thus giving them a reason to live and helping them to change their lifestyles. In the "Choosing Health" White Paper, we introduced health trainers—a new type of personal health support. They will be visible and accessible to local people, living and working in the communities they serve and providing "support from next door". We have engaged with nearly half the NHS to deliver, from April 2006, NHS health trainers in the areas of highest need. Having listened to people's concerns, we responded by announcing in the recent White Paper—"Our Health, Our Care, Our Say"—our intention to introduce NHS "life checks" at different points in people's lives.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I am grateful to the Minister for giving way, because this is precisely the issue on which I wanted to come in earlier. She is right to say that interventions must be rigorously examined in the same way as clinical procedures, which is one reason why the National Institute for Health and Clinical Excellence has taken over responsibility for such matters from the Health Development Agency. She will of course be able to quote the evidence that points directly to the need to appoint health trainers and to provide the life checks outlined in the recent White Paper.

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

The work on health trainers was developed by talking to those on the ground about how we can engage people who are not presenting themselves to services in the traditional way. We have asked—[Interruption.] I shall finish my sentence, if the hon. Member for South Cambridgeshire will allow me. We have asked different areas of the country to provide information on such services, and we will evaluate their impact. [Interruption.] Both the life check and health trainer initiatives emerged from the White Paper consultation process. We will establish an expert stakeholder group, which will examine how the initiatives will work.

This is not about adding more checks—there are already opportunities for different checks—or adopting a one-size-fits-all approach; nor is it just about sickness: it is about health and finding a practical, non-burdensome way of engaging with people at different points in their life and getting them to think about their health. [Interruption.] For some people, relatively little action will be required. Many will be able to carry out a self-assessment and will need nothing more. But for others, a health check might be the spur for health providers to think about the services that they should provide, and for the individual to consider how their lifestyle is affecting their future health.

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David Taylor (North West Leicestershire, Labour)

Is it not a bit much to have a constant stream of chuntering from Conservative Members while the Minister describes these initiatives? When they were in government, they denied the link between poverty and ill health. They suggested that elderly people should respond to fuel poverty simply by putting on an extra cardigan, and that people in northern constituencies such as hers should respond to an increase in the incidence of heart disease and other such illnesses by eating fewer chips. That is a very constructive and helpful public health policy, is it not?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

No, it is not. In fact, under previous Conservative Administrations the term "health inequalities" was not used; instead, the Department was expected to use the phrase "variations in health".

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Neil Turner (PPS (Rt Hon Ian McCartney, Minister without Portfolio), Minister Without Portfolio; Wigan, Labour)

My constituency has a four-star authority, a three-star primary care trust and a three-star hospital trust. However, social services are seriously underfunded and the PCT is £10 million below its target figure. I realise that you recognise the problem of health inequalities, but can you indicate—

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Michael Lord (Deputy Speaker)

Order. I gently remind the hon. Gentleman that he must use the correct parliamentary language when addressing a fellow Member.

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Neil Turner (PPS (Rt Hon Ian McCartney, Minister without Portfolio), Minister Without Portfolio; Wigan, Labour)

I apologise, Mr. Deputy Speaker. What action will the Minister take to ensure that the funding inequalities experienced by the PCT itself and in its work with the local authority are addressed?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

In areas where there is deprivation and various problems associated with a sizeable older population, the funding provided to local authorities and PCTs has taken such factors into account. However, there are opportunities for PCTs and local authorities to work more closely, and that needs to happen. We must also look at where resources are being directed, and decide whether they could be used differently to achieve better results. There are various good examples around the country of money being used better and achieving better outcomes. We do not micromanage the NHS from the centre, thank goodness, but we can give an oversight and provide access to the best information about what works. People like my hon. Friend and other colleagues will be able to use that information to ask their PCTs and local authorities why a system that produces results in other parts of the country is not being used to meet the challenges elsewhere.

I absolutely believe that it is very important not to underestimate the challenge posed by health inequalities. Our life expectancy target is deliberately challenging. We faced two problems when we set it—halting and then reversing a long-term trend. There is still a huge amount of work to be done, but I believe that the target is achievable, and am pleased to say that there are signs of positive change.

For example, 60 per cent. of the spearhead areas are making progress towards meeting the target and narrowing health inequalities. Of the 70 local authorities, 29 are on track to meet either the male or female elements of the target, and a further 13 are on track to meet both.

However, health inequalities are stubborn, persistent and difficult to change. Change will take time, but in our health and equality strategy we have identified a range of headline early-warning indicators, and other indicators. The most recent assessment of progress is set out in our status report published last August. Our latest robust data are for 2003, although of course work has been done since then. The figures show that health inequalities in respect of infant mortality and life expectancy were still widening, in line with the long-term trend. However, there are encouraging early signs of progress in key areas, such as reducing child poverty, improving housing quality and reducing inequalities in circulatory diseases.

As I said earlier, death rates from heart disease and strokes are falling. Importantly, the absolute gap between disadvantaged areas and the country as a whole has fallen by more than a fifth—22 per cent.—in the past six years. For example, a more targeted approach to tackling health inequalities among South Asian groups in Sheffield achieved a faster decline in heart disease mortality in deprived areas than in the rest of the city. The figures were 23 per cent. and 16 per cent., respectively.

We recognise that black and minority ethnic people experience inequality in health outcomes and in other social determinants of ill health. Therefore, we must also look at what is happening in our black and ethnic minority communities to make sure that the service is sensitive to the needs of the people who live there, irrespective of gender or ethnicity.

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Charles Walker (Broxbourne, Conservative)

The Minister is being very generous in giving away again, but does she agree that mental health is one of the greatest areas of inequality? The high-profile areas such as heart disease and cancer get a lot of coverage and support, but mental health is almost forgotten and seems to lag behind. What message will she give me to take back to my charities in Waltham Cross and Cheshunt concerning the support that the Government will give to help them deliver services that are critically important?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

The hon. Gentleman makes the very valid point that people who suffer from mental health problems often have other health problems that need to be attended to. They deserve to be focused on as much as anyone else in the health agenda, in terms both of prevention and of the provision of better services to meet their needs. However, we must ensure that other service providers—of housing, employment, education and so on—look hard at the different challenges that different groups face. As was mentioned in the debate the other week, people with mental health problems should certainly be able to feel that they have a right to be heard by those who provide other services.

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Rosie Cooper (West Lancashire, Labour)

I agree with Mr. Walker that some groups are denied access, with a resulting increase in health inequality. My example, which is analogous to the mental health example, is disability. My parents are deaf and from the age of four I used to do all the interpreting at any medical consultation that they had. The Government have done a tremendous job in tackling health inequalities—[Interruption.]

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Michael Lord (Deputy Speaker)

Order. The hon. Lady is making a legitimate intervention. Perhaps she can make her point quickly.

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Rosie Cooper (West Lancashire, Labour)

Thank you, Mr. Deputy Speaker. My point was that providing interpreting services or enabling teletext subtitle services on televisions help to get people such as my parents into hospital. My dad needed treatment, but when I arrived four hours later he was dressed to go home because he was bored and could not talk to anybody.

Photo of Caroline Flint

Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

My hon. Friend makes an excellent point, sharing the experience of her parents who had hearing problems. When we identify services and needs, it is important that we engage with people such as my hon. Friend's parents to talk about their needs, instead of just assuming that we know best, we will provide something and patients will have to lump it. That is not what people want from their health service. If handled properly and correctly, such engagement will provide savings, as well as better health outcomes. If we do not do that early, we could be storing up an expensive problem for later down the line.

I have been frank about the fact that there is more to be done in tackling health inequalities. We have set ourselves a challenging agenda, but we are committed to delivering it so that every citizen, regardless of where they live, their social class, ethnic group, disability, or any other challenge that they face as individuals, can expect the same opportunities for—even if they may be delivered in different ways according to their needs—and expectations of, good health.

3:32 pm
Photo of Andrew Lansley

Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I am glad to have the opportunity to follow the Minister and contribute to this debate. I thank the Government for making time available for it. It may be at the periphery of parliamentary time, but it is on the Floor of the House and we appreciate that. I am not sure how long it has been since the subject of tackling health inequalities has been debated. The Minister did not say that it was the Government's intention to have regular debates on the issue, but I hope that it is. It is certainly one of the priorities that my right hon. Friend Mr. Cameron set out for us at the beginning of the year.

It was the Government's intention to publish an annual status report on health inequalities, but the first report took two years. They said in July 2003 that the Department of Health would publish an annual report on health inequality indicators, related to the health inequality targets. The first was published in August 2005. A letter in the British Medical Journal in September described its publication as Labour's Black report moment, because it had been buried in the middle of August. Why did they do that? For the same reason that the Minister did not give the figures when I invited her to tell us the changes in the two national targets identified by the Government for measuring health inequalities. I do not see why not, because as she explained, the point of national targets is to focus people's attention on them, so it does not make much sense to publish them at a time when people will not notice them. Equally, if they are going in the wrong direction, the Government should be rigorous about what they will do to deal with that.

The figures are straightforward. The relative gap in life expectancy for men has increased by nearly 2 per cent. and for women by 5 per cent. The latest figures on infant mortality confirm the previously reported trend. Despite overall improvements, the relative gap between the routine and manual groups and the population as a whole has widened over recent years, since the target baseline. The overall infant mortality rate was five deaths per thousand live births, while the rate for those in routine and manual groups was six per thousand. In 2001 to 2003, the infant mortality rate in the latter group was 19 per cent. higher than in the total population; it was 16 per cent. higher in 2000 to 2002 and 13 per cent. higher in the baseline period, so the relative gap has widened—from 13 to 19 per cent.

The Minister said that it was important to look at the finer detail, but the detail she referred to showed things going in the right direction. However, the infant mortality rate among sole registrations—births registered only by the mother—rose to 7.4 per thousand live births, compared with 6.6 per cent. in 2002. In 2003, the mortality rate in the routine and manual social group rose to 6.1 per thousand, compared with 5.8 in 2002—an absolute rather than a relative rise in that one-year period.

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Graham Stuart (Beverley and Holderness, Conservative)

Have not the Government failed to deal with health inequalities and is not that why they did not meet their promises? Does my hon. Friend agree that the Minister should tell the House that that will not happen again? If the Minister's top NHS priority truly is to tackle the appalling gap between the poorest and the better-off in our society, she must set targets and meet them, and report to the House not annually but every six months. That is what she should do, rather than giving us waffle and rhetoric, while people at the bottom of our society are all too often let down by the Government.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I am grateful to my hon. Friend. In a nutshell, the burden of what I wanted to say is that, if one is to deal with health inequalities, it is vital to focus on the relative gap between the most and least healthy, and between the richest and the poorest. It is not good enough to elide aggregate progress and relative failure. For example, the Minister—as Ministers always do—talked about the absolute reductions in mortality from cancer and coronary heart disease, on a trend that I am sure she will not deny was pretty well established in the latter part of the 1970s for coronary heart disease and the early 1980s for cancer.

The point is that in all such trends we need to look at mortality rates and find the real inequalities. We may be making considerable progress on cancer treatments, but the relative gap may be widening. At the same time, there are many deaths from lung disease, which the Minister did not mention. The British Thoracic Society tells us:

"There are three times as many deaths from respiratory disease that are associated with social inequalities . . . than there are cancer deaths that are associated with social inequalities".

Social inequality in respect of the incidence of respiratory disease is much greater than that in respect of cancers. There is a gap. Eight times more deaths—3,800—are caused by respiratory disease as a result of social inequalities compared with the impact of such inequalities on coronary heart disease, which results in 500 deaths. The Minister did not mention this, but if people are talking about relative mortality rates and the things that bear on them to the greatest extent, they spend more time referring to lung disease than to cancers and coronary heart disease respectively.

Photo of Kevan Jones

Kevan Jones (North Durham, Labour)

I am impressed by the hon. Gentleman's conversion and that of Mr. Cameron to noting the policy importance of this issue—something that has been ignored in the past. If he and the right hon. Gentleman are so committed to tackling this issue, will he support the extra funding that the Government have put into doing so? Will he also support directing extra funds to places such as North Durham and Easington in County Durham, which have some of the greatest problems with health inequalities? Would a Conservative Government support us if other hon. Members and I asked for extra money to go there, rather than to the leafy suburbs that many Conservative Members represent?

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I am not quite sure what evidence the hon. Gentleman has to back the idea that I have somehow been converted. If he goes back, for example, to before the general election to the opportunity that I took in September 2004 to set out our policies on public health, he will find that one of the first things that I did was to say that that was our top priority. I said—and I would have done it—that if I had become Secretary of Sate after the election, I would be Secretary of State for Public Health and when we debated health inequalities, the Secretary of State would be here, not an Under-Secretary of State. I made it clear that that focus on public health was intended to improve not just health outcomes for the whole population.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

No. The hon. Gentleman will have to sit down.

The intention was not only to improve health outcomes in the whole population, but to increase the relative health of those who are poorest. Why did the Minister not just get up and say what the objective is? We agree that the objective of our policies is to improve the health outcomes of the people of this country and those of the poorest fastest. Why did the Minister not say that?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

I did.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

The Minister did not say that. That is what must be done and she is confusing the aggregate data—it is astonishing that she carries on doing so—on whether we are making progress in improving the health outcomes of the whole population with the question of whether the poorest and the least healthy people in this country are improving their health faster than the rest of the population. They are not, and the Government should acknowledge that fact so that they can do something about it.

I asked some questions about evidence, which is central to the issue. If there are two things that have bedevilled the tackling of health inequalities, the first is that we just cannot agree about the causes. Of course, poverty is one of the causes. David Taylor made a rather absurd proposition about that and then left. Of course, there are many causes: poverty, poor housing, environment, family structures, education, ethnicity and genetics. Those are all causes.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

Indeed, and we could say that there have been substantial shifts over recent generations. For example, one could go back 100 years when infectious disease led to 25 per cent. of the deaths in this country. The figure is now 1 per cent., and I hope it stays that way, touch wood. What lies at the heart of the debate is the fact that we must be aware—the Minister acknowledged this—that we must not only deal with those environmental issues and the physical and societal factors that cause ill health and inequality—

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I do not deny that poverty is included. The hon. Gentleman will be aware of the simple fact that the latest data in the family resources survey, which are from 2003–04, show that, in the lowest quintile by income, the ratio of the top to bottom quintile incomes has deteriorated compared with 1997–98. So not only are family incomes falling in the 2003–04 data, the situation of the poorest is slightly deteriorating compared with that of the richest. I do not know whether he wants to dispute that—maybe not.

The point that I was making is that if one takes the long view, which we have to do, those environmental factors, important as they are, are at risk of being overtaken by personal, behavioural factors. Even if we reduce income inequalities, reduce the number of people living in poor housing—as has happened—improve the environment and get rid of toxins in the air, which we have done because a Conservative Government introduced the Clean Air Act 1993, and eliminate or reduce the threat of infectious diseases, behavioural issues may still mean that some health inequalities are intractable and not reduced.

In some parts of the population obesity rates may be higher, drug taking may be higher, smoking may be more prevalent, alcohol intake may be higher and sexual health may be worse. [Interruption.] I do not dispute that the Minister said all these things. We have to focus on them and part of the purpose of today's debate is to try to get some agreement about the necessity of acting on both sides of the equation. In the past it has tended to be the case that Labour Members talk excessively about the environmental, physical and economic factors, and Conservative Members talk rather more about the behavioural factors. We must acknowledge that we have to do both, and make progress on both. We must also be aware that, over time, those behavioural factors have begun to show how intractable health inequalities are.

Mr. Jones asked about more money for Easington. Easington has more money. I cannot remember the precise figure, but it is about £1,200 per head for the primary care trust, and the figure in my constituency is £880, so Easington is getting more money. If shifting resources within the NHS were the answer to health inequalities, Scotland would be very healthy. The Minister did not mention this, but the lowest life expectancy in this country is in Glasgow, at 69.1 years for men compared with 80.1 years for men in East Dorset. I am not aware that East Dorset is thick with NHS resources.

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Kevan Jones (North Durham, Labour)

It was interesting to hear what the hon. Gentleman said about behaviour, but inequalities in parts of my constituency and other parts of the Durham coalfield were caused by the last Conservative Government.

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Kevan Jones (North Durham, Labour)

The hon. Gentleman may say that but, overnight, villages lost their economic heart, so there was increased worklessness, and things such as drug taking increased. I am sorry, but Mr. Lansley cannot stand here today and say that that Government do not have some responsibility for the poor health and inequalities that still exist in some of the former mining villages in County Durham.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I am not sure that the hon. Gentleman heard me say that the last Conservative Government had no responsibilities. Did I say that? Perhaps he would like to demonstrate where I said that.

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Kevan Jones (North Durham, Labour)

Is the hon. Gentleman then prepared to apologise to individuals and villages in the north Durham coalfield and other parts of County Durham for the last Conservative Government?

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I will certainly apologise for the fact that health inequalities did not narrow more under the last Conservative Government if the Minister will get up and apologise for the fact that health inequalities have widened since 1997. She is not going to do that, as the hon. Gentleman knows. I will not apologise—I have come across this point before—for what the last Conservative Government did. As it happens, I was not a politician at the time but a civil servant, and I stood next to Norman Tebbit when he signed the deal with Nissan to bring that business to Sunderland. The transformation of the north-east economy did not happen post-1997; it began in the mid-1980s. I know, because I was there.

If we are to tackle health inequalities, we must be aware of the serious problems coming down the line. The Minister referred, for example, to the incidence of smoking among young women. There is also the increase in consumption of alcohol among young women. I was talking recently to Professor Roger Williams, who treated George Best. He is seeing in his surgeries young people, and increasingly young women, who have liver disease which to all intents and purposes is irreversible. That will be an enormous burden of mortality and morbidity in years to come.

At the rate we are going, obesity will in three or four years overtake smoking as the principal cause of avoidable death in this country. The Minister will know that over the past 10 years—before the hon. Member for North Durham chastises me, this is not a trend that was established in 1997, although it has continued over the past eight years—the proportion of our population that is obese has risen from 16 per cent. for men and 13 per cent. for women to 26 per cent. for both women and men. Our children are getting fatter faster than any other children in western Europe.

If that does not change, we will have an epidemic of weight-related diseases such as diabetes, stroke and heart disease; we will have an epidemic of mental health problems as a result of drug abuse; we will have an epidemic of liver disease as a result of the consumption of alcohol; and we will have an epidemic of infertility and related disease—pancreatic inflammation in respect of chlamydia and related sexually transmitted infections. The Minister did not mention the fact that the number of sexually transmitted infections has doubled over recent years. These things have to be tackled.

The Minister did not talk either about the structure of public health services. One of the things that I said before the election was that we needed a new structure. We must ensure that the focus is institutional and financial as well as political, and it is not at the moment. There may be professional leadership from the chief medical officer—even if he had to fight Ministers in order to get through his view on smoking—but the service is not integrated. We have the functions of the chief medical officer on the one hand and those of the Health Protection Agency on the other. Out in the field, directors of public health in primary care trusts must be tearing their hair out trying to get public health messages through the chaos and noise of PCT reconfiguration. Before the PCT restructuring was mooted by the Government, directors of public health found their priorities pushed to the margin, with the single exception of stop-smoking services, to which the Government attached a target.

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Diana Johnson (PPS (Mr Stephen Timms, Minister of State), Department for Work and Pensions; Kingston upon Hull North, Labour)

Will the hon. Gentleman comment on the joint public health director of the PCT and the local authority in Hull, who has been able to get out a clear message to the local authority and health services in the area to promote things such as healthy school meals? We have free healthy school meals in all our primary schools, which leads to the issue of obesity which the hon. Gentleman mentioned. That is a positive thing, which Labour has delivered.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I am grateful to the hon. Lady for mentioning that point. She clearly has not read, and should read, Conservative party policy at the last election. It was the Conservative party's policy—my policy—that we should have jointly appointed directors of public health between the NHS and local government. [Interruption.] Is the Minister saying that that is now her policy? It is not actually her policy. It is happening in some places and it is welcome, but it should be a policy. We are here to debate the Government's policy and not what is happening only in some places.

Health improvement and preventive services are patchy in quality and variable in coverage across the country. That is not me saying that; the Government were saying that in their "Choosing Health" White Paper in November 2004. Why is that so? It is because there is no distinct, discrete organisational function or financial structure that ensures that public health is focused in individual localities. The Government do not even know how much money is spent on public health. They cannot measure it because it has been absorbed into primary care trust allocations. I have asked how much is being spent, but I have not received a reply. We also need evidence, and I have asked the Minister about the evidence for the things that were being thrown like bones to the press before the publication of the recent White Paper.

Surely health action zones were intended to be part of the piloting of innovative mechanisms for delivering improved public health and a reduction in health inequalities. Some Members no doubt remember the setting up of 26 health action zones across the country. Can the Minister tell me what happened to them and what the results were? The concluding comment in a draft report on the national evaluation of health action zones—it says that it is not for quotation, but I will quote from it—states:

"It remains to be seen whether these will impact on health inequalities in the longer term."

I will not try to quote from the rest of the report, because it is rather difficult to disentangle, but the thrust of it is that it is vital to influence the mainstream—something that was not done—and that, if one is going to achieve these things, it is vital to have a focus that is not interfered with by constant diktats on priorities from the Department of Health. Health action zones were not free of such interference, and were constantly being told what to do by the Department of Health.

Health action zones were set up as a gimmick, and the poor people charged with running them found that the zones were marginalised. There were other priorities and, in the end, the evaluation did not show that the zones had had much impact. That is the nature of the Government's approach—it is one gimmick after another. The Government announced lifestyle checks in the press prior to the publication of the White Paper, and the implication was that they were going to be of immense benefit. On every occasion that we have mentioned them, Ministers, including the Under-Secretary, have moved closer and closer to the proposition that they consist simply of reminding people at certain points to think whether they need to visit their doctor, and no more than that.

A great deal could be done that would be beneficial—and I keep telling Ministers so—but not necessarily at the age of 11, 18 or 50. If Ministers believe in the checks, where are the school nurses? Ms Johnson mentioned the initiatives that have been taken in Hull, but where are the school nurses that should be in every school so that health services have a consistent visible presence for young people between the ages of 11 and 18, and, indeed, under 11, and can encourage them to understand how they can improve their health and to understand the risks that they run. Those are precisely the things that impact on behaviour, and which are important in the most deprived areas of this country if we are to change the behaviour of young people in those areas.

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Rosie Cooper (West Lancashire, Labour)

I wonder whether the hon. Gentleman has heard of Healthworks and various programmes operated by the St. Helens and Knowsley primary care trusts. They operate what some people would describe as fitness checks. Others might call them very quick medicals. People are tested for their weight, cholesterol and various other things. Those tests give an indicative view of whether they should go to see their doctor. They do not take place in a surgery. In Knowsley, they take innovative form, as they take place in working men's clubs and youth clubs. The people involved in the programmes are attacking the health inequalities. That is the kind of thing that we need to push.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

Of course we need to reach out. Perhaps the hon. Lady was not in the Chamber when we discussed the White Paper when I said that the pharmacy contract was a very good example of such initiatives. It is perfectly possible for pharmacies to offer a range of opportunities, including cholesterol, chlamydia and blood sugar tests. I have seen, for example, what Lloyds pharmacy has done to promote diabetic testing among south Asian groups. There are many opportunities for such tests, and the pharmacy contract permits them. The problem is that the primary care trusts are not commissioning them. Pharmacies are keen to offer testing. That would be particularly beneficial for men, who go into pharmacies for various reasons. Given the large disproportion between women attending GPs' surgeries and men attending GPs' surgeries in the middle years of life, that would be a good way of offering men health tests. It is important that that is done.

The record that the Government published in mid-August last year shows a failure to achieve their national targets. They have not failed in every respect, but there are too many trends in the wrong direction. There are as many negative warning signals as positive ones. An improved public health structure is vital to overcome that.

Health inequalities include not only inequalities of outcome, but inequalities of access, which must be removed. There, too, the Government have recorded a significant level of failure. It would be excessive for me to list them all, so I shall highlight a few examples, such as the availability of drugs. There are inequalities in the availability of specific drugs such as Herceptin not only between primary care trusts in England, but between England and Scotland in respect of that and other cancer drugs.

There is also a substantial disparity between the United Kingdom and other countries. Not least because of the work of Cancer Research UK and other cancer charities, we have more and, I would argue, better cancer research than almost any other country in Europe, but is our take-up of cancer drugs in this country comparable to that in other European countries? No. We are slower to take up new drugs. That is deeply offensive to people in the UK. They contribute more than £40 million a year to cancer research, but the benefits of that do not flow through as fast as in other countries, unless people are willing to pay for treatment themselves.

There are disparities in access to dentistry. In my constituency there are virtually no opportunities to register with NHS dentists, and that is true of many other constituencies across the country. We have disparities in access to health services. We heard from my hon. Friend Mr. Stuart about community hospitals being shut down. That was happening but has been reversed, under the campaigning pressure that we brought to bear, but those hospitals are still not safe by any means. Especially for people in rural communities the length and breadth of the country, those hospitals—

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Ann Winterton (Congleton, Conservative)

I am grateful to my hon. Friend for raising that matter. It is vital for my constituency, which is predominantly rural—not just farmhouses dotted round the countryside, but small towns and large villages, where access to services at the district general hospital will be jeopardised by the future health care programme. Maternity, obstetrics, paediatrics and children's services may be removed in an area where one in six people does not own a car and there is no meaningful transport. Is that not another example of health inequalities between the rural and the urban areas?

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

My hon. Friend is right. We must address such inequalities of access and, like so many of the problems that we are discussing, that is not achieved merely through changes in the NHS. A wider range of changes are needed to tackle rural issues.At the outset, the Minister mentioned Sir Donald Acheson's report of 1998. Of 39 recommendations in the report, only three were directed to the national health service, so the problem goes wider than that.

In our earlier exchange about resource allocation, the Minister made some perfectly fair points but she did not answer the question. Resource allocation is still being decided across the country on the basis of assumed and aggregated data in respect of deprivation and age. We increasingly have data that would allow known morbidity in a community to be the basis on which NHS resources are allocated. I hope that the advisory committee on resource allocation will start to make those changes. That would make an enormous difference to many parts of the country.

At the same time, we should isolate the resources that have to go to any community to provide good-quality services to meet the levels of mortality and morbidity that are occurring in those places, and, as distinct from that, recognise the need for separate allocated resources to impact upon health inequalities and poor outcomes arising from a wide range of factors. That separation was part of our policy at the last election, and I am still convinced that it is right to have dedicated public health resources. Otherwise, we end up in the current situation, with, for example, dramatic disparities between the allocation of resources in England, Scotland and Wales. Because those resources are not necessarily being directed to public health outcomes in some places, they are not necessarily delivering the best health outcomes.

I saw an example of that when I was in Manchester last week. Hope hospital in Salford is taking large numbers of referrals from Northern Ireland, with referral letters going back to 2001. Northern Ireland does not have small amounts of money going into it for the provision of hospital services—it is just that it is extraordinarily inefficiently provided. It is evident that the shifting of resources across the country is not reducing inequalities of access or of outcome. It is all about delivering a reformed system.

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Geoffrey Cox (Torridge and West Devon, Conservative)

My hon. Friend may be aware of the report commissioned by the Department for Environment, Food and Rural Affairs in December 2004, in which the Institute of Rural Health reported on a survey of various agencies responsible for the collection of data from which funding decisions would subsequently be made. It said that the majority had no idea that they should be looking at rurality factors or collecting data against the definition of rurality, and were not gathering information that enabled anybody to distinguish between rural and urban areas and thus to make fair decisions for rural areas.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

I am grateful to my hon. Friend. I do recall that. My hon. Friend Dr. Murrison has published some material of his own on how we could deal with rural health problems and inequalities of access.

The principle of evaluating policies for their impact on health inequalities is established in theory, but it has to be carried out in practice—it is a rigorous process. Technically speaking, that is what the Acheson report recommended. I am not sure how well that has gone recently, given the inclusion of the Airdrie and Shotts provisions in the Health Bill at the end of last year.

Inequalities of access need to be tackled. The Government were right to point in their White Paper to the wide disparity in the availability of GPs in different parts of the country relative to their populations. I was entertained and impressed by the article from Simon Stevens, a former adviser at No. 10, who said that the language used in the White Paper exactly mirrored that used in 1920 in relation to the distribution of doctors across the country. These are intractable problems, but we have to tackle them—I make no bones about that. We have to ensure the availability of services in the community, notwithstanding whether GPs want to be self-employed principals in general practice in some parts of the country.

I want to close with one further thought. As I said earlier, it is always invidious to try to single out major disease groups, but the Government, right at the start of their time in office, singled out cancers and coronary heart disease. I know why they did it, and it was not a dishonourable thing to have done, as cancers and coronary heart disease were the largest and most avoidable killers. However, the time has come for there to be a wider range of clinical priorities and for their distribution to be much more determined by clinicians, practitioners and professionals than to be dictated by a narrow range of Government targets. Stroke is a classic illustration of that. The National Audit Office report identified many things that could be done today that would not only deliver substantial improvements but save more than 500 lives a year. That is the same number of lives that we set out to save in the Health Bill on Tuesday as a result of the changes to smoking. If the NHS took some of the necessary measures, such as immediate CT scans, 500 lives could be saved today. That would save the NHS money. It would not cost it any more; it would not only be value for money but would reduce the cost of treatment. The same, as I said, is true for lung disease and the availability of pulmonary rehabilitation, for example.

Such matters have to be dealt with, but for lung disease—for all that chronic obstructive pulmonary disease is a real killer—the disparities are striking. I was astonished to read that in the north and west mortality rates are 30 per cent. above the national average; in the south they are 30 per cent. below the average. Those are massive disparities. [Interruption.] Well, if the hon. Member for North Durham knows that, why is it not on the Government's priority list? Why is there no national service framework, since that is supposed to be how the Government have addressed such matters over the years? Why is the British Thoracic Society having to argue for a national service framework? Why has no national clinical director dealing with respiratory diseases been given the status of others? Why is there not pulmonary rehabilitation? Why do we not have routine spirometry in GP practices? If the hon. Gentleman wants those things to happen, why did he not intervene on the Minister to ask for them rather than intervening on me?

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Kevan Jones (North Durham, Labour)

I will not take any lessons from the Conservative party on COPD. The Government put in place the most generous compensation package for those miners whose health was ruined while the hon. Gentleman's Government refused to settle those claims for many years. It is a bit rich if he is trying to say that now.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

The hon. Gentleman should understand that I am not asking him to take lessons from me, but from the British Thoracic Society. I am sure that even those former miners would take the view that the fact that they have been given compensation does not mean that they should not receive the highest quality health services. Of course they should, and that is what we are arguing for.

To tackle health inequalities we require a focus on the evidence of the disease group from which those inequalities come, on the behavioural and environmental factors and on an understanding that relative inequalities will not necessarily be overcome, even if at the same time we—like countries across the world—improve aggregate health outcomes. As in the debate about Herceptin, if it is a national health service, the national part demands equitable access to services. It should not be distorted by the centre's failure to understand what clinical criteria should be applied on a consensual basis or by distorted funding from the Government to try to advantage some areas of the country. If we do all those things and improve the public health environment, I hope that in years to come a new Conservative Government will bring our reports back to the House and show that we have tackled and reduced health inequality.

4:13 pm
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Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

I am pleased that the subject of today's debate is tackling health inequalities because I have tried to address that issue in my constituency since my election in 1997. I have had first-hand knowledge of the Government's commitment to confronting and dealing with inequalities. Last week, more than 250 people from two council wards in the south of my constituency braved a freezing February evening to attend a small reception hosted by the London borough of Merton and me to thank my right hon. Friend the Secretary of State for saving their local general hospital, St. Helier. They wanted to thank her for listening to their concerns. Many were elderly or infirm and they had suffered for years as a result of inequalities in the health service, but they wanted to celebrate because they were so delighted that the health establishment's decision about where to locate a new hospital had been overruled in order to tackle health inequalities.

Inequalities in health care had become virtually unchallengeable by the end of 18 years of Conservative Government. My constituency is one of the most disadvantaged in our strategic health authority's catchment area, with some of the greatest health needs, yet through the 1980s and 1990s, when the axe had to fall, it was my constituency that suffered the cuts. As a local councillor, I spent many years campaigning against plans to close our local community hospital, the Wilson hospital in Mitcham. I led thousands of campaigners in the fight against the local authority, but eventually the Tories won and Mitcham and Morden lost its last community hospital. Thankfully, the campaign to reopen the Wilson has carried on, and now, eight years after Labour came to power, we have learned that we are finally going to get our Wilson back. The Wilson is only one example of how the health establishment targeted Mitcham and Morden. In the past few months, we have uncovered secret local authority plans, dating back to the mid-1990s, in which the authority proposed to close our nearest general hospital, St. Helier. Thankfully, it was unable to do so before Labour came to power.

The health establishment has scorned Mitcham and Morden for many years, and even now, despite many complaints from me, there is still no one who lives in Mitcham and Morden on any of the NHS boards that make decisions about the lives of the people living there. So I should not have been surprised when St. Helier came under threat again more recently. It was saved only after the intervention of my right hon. Friend the Secretary of State for Health.This is a salutary tale. St. Helier is not actually in my constituency, but it serves half my constituents. It is part of the Epsom and St. Helier University Hospitals NHS Trust, which covers Merton, Sutton, Epsom and beyond, and which was created when Epsom hospital got into financial difficulties and merged with St. Helier in the 1990s. Epsom hospital had been struggling for some time, and the health authority decided to look at remodelling health care so that there would be one main hospital and several smaller community hospitals.

The health authority argued that the site of the main hospital—the critical care hospital—was not important, as the community hospitals would take most of the people who normally go to hospital. A public consultation took place to determine whether there was agreement with the proposals, and it soon became clear that the main issue would be where to put the critical care hospital, which would house the area's accident and emergency services and acute services such as maternity and obstetrics.

My view is that the people who need critical care services the most are those who are the most disadvantaged and have the worst health. There is a strong link between social disadvantage, the need for emergency services, and health problems such as low birth weight and teenage pregnancy. As the vast majority of those with the greatest health needs live near St. Helier, I felt that having the critical care hospital there would be the best way to reduce health inequalities. Initially, the health establishment agreed—in its original assessment, it gave St. Helier a 7 per cent. higher score than a Sutton hospital site in Belmont.

The public seemed to agree, following the consultation. Although fewer people from disadvantaged areas take part in public consultations, and although my own surveys were repeatedly ignored, St. Helier emerged as the top choice among the public for the location of the critical care hospital. However, last January, local NHS managers voted to overturn the views of residents and to build a new critical care hospital in Belmont, a very well-to-do suburb in Surrey. That decision meant that St. Helier would lose its accident and emergency, maternity and other critical care services. Belmont is one of the wealthiest areas in the country and people living close to it have very high life expectancy, very good access to health care and very high levels of private health care.

Photo of Crispin Blunt

Crispin Blunt (Whip, Whips; Reigate, Conservative)

I am grateful to the hon. Lady for giving way. This might not be the last time that I seek to intervene on her, because the issue that she has raised affects half my constituents as well. Does she accept that the critical care hospital is going to have to serve 500,000 people, which is rather more than the populations of her constituency and mine put together, by some margin? Will she also explain to the House what particular health expertise she brings, given the advice that she has consistently been given by people involved in this exercise? That advice to the hon. Lady was summed up in this way:

"I am sorry we continue to fail to convince you that the local care hospitals will be a far more significant influence on addressing the acknowledged problems of health needs in your area than ever the Critical Care Hospital would be."

The result of her intervention, and the Secretary of State's decision, is that her constituents will not have a community care hospital addressing health inequalities; instead, they will get a critical care hospital that addresses the needs of 500,000 people.

Photo of Siobhain McDonagh

Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

My experience, as of Monday, is 46 years of living in the constituency, being a councillor for 18 years and being MP for the constituency for the past eight years. My experience is the same as anybody could have. I am willing to take any Member who is in the Chamber in my car to see my area and that represented by Mr. Blunt. Hon. Members will not need to be health professionals to see the differences.

Out of the 174 super-output areas covered by the East Elmbridge and Mid Surrey primary care trust, which covers the hon. Gentleman's constituency, only eight are below average in the index of multiple deprivation. I have counted at least 50 within just 3 miles of St. Helier hospital. I leave it to Members to judge whether the decision on locating a hospital should be based on 50 areas within 3 miles of a hospital or the eight within a PCT.

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Kevan Jones (North Durham, Labour)

Does my hon. Friend agree that one important thing in tackling health inequality is enabling residents to sit on PCT boards and health boards? Unfortunately, the Government have made a big mistake by setting up the NHS Appointments Commission, which is leading to self-perpetuating medical bureaucracies, which in turn lead to nonsensical decisions that ignore clear need among local people.

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Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

I fear that I agree with my hon. Friend that we have a real problem over who is on boards, who they represent and how representative they are. I cite my constituency as a prime example of that.

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Rosie Cooper (West Lancashire, Labour)

If PCTs go on to be foundation trusts and have their boards of governors, or membership councils, that deficit will be sorted out.

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Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

I agree with my hon. Friend, as I was a prime supporter of foundation hospitals precisely because of my constituency experience. This is the only way that people from Mitcham and Morden will get on any board of any hospital or health organisation in my area. Despite the fact—[Interruption.] I am always slightly overwhelmed by the condescension with which people's views are treated in this Chamber. I have first-hand experience of my constituency and how the health service works.

The decision was taken despite the fact that the area around St. Helier has the greatest health needs in the catchment area and the fact that people living there have up to 10 years less life expectancy than others. It was taken despite the fact that people living near St. Helier are the least likely to have a car and the most likely to need to go to hospital. It was taken despite the fact that those in the catchment area could reach St. Helier well within the critical golden hour that our health experts agree is crucial to survival, and despite the fact that more people could get to St. Helier within 20 minutes than to Belmont, and St. Helier has far better public transport.

Indeed, in looking at health inequalities, the programme board did not even consider access to a private car against access to public transport. In no example was the need for public transport ever taken into account. Losing those services from St. Helier would have affected not only the people in my constituency who need that hospital, but the other half of the area and the rest of south-west London because of the untenable pressure that would have been put on St. George's hospital, leading to even worse health services in another socially disadvantaged area of south London.

Due to the harm that would be done by health inequalities if Belmont was the location of the new critical care hospital rather than St. Helier, Merton council called in the decision. The issue of health inequalities did not seem important to the local health establishment. It did not even minute letters it received from 4,000 people back in 2003, saying that the most important thing when deciding where to locate health services is health needs. It allowed only 5 per cent. of its decision on where to put the critical care hospital to be based on health inequalities.

Then, to rub salt into the wounds, the health establishment scored St. Helier at 33 per cent. on health inequalities—just 3 per cent. higher than Belmont—yet the area around St. Helier has the lowest life expectancy, the most emergency admissions, the highest accident rate among children, the lowest level of general good health, the most people with long-term illness, the most babies born with low birth weights, the most people without access to primary care, the lowest incomes, the largest black and ethnic minority population, and the least likelihood of owning a car. Apparently, all of that was worth only 3 per cent. to the health establishment.

It would have been cheapest for patients if the hospital were at St. Helier, but that was not addressed by the health establishment either, even though Government rules say that the cost to patients must be included in its plans. Even the health establishment admitted that were the Belmont site chosen, people living in seven of the 10 most deprived postcodes in the region would have to travel further than they do at the moment. Despite public agreement and all the evidence supporting St. Helier, the health establishment discovered new evidence, which has since been discredited, and decided unilaterally to remove services from St. Helier.

In the face of that, the Government have demonstrated once and for all, to the whole NHS, that health inequalities matter. Merton council was brave to take on the powers that be and refer the decision to the Secretary of State, who was also brave, because she must have been under a lot of pressure from the health establishment, and the decision must have been close. She has come down firmly on the side of reducing health inequalities, however.

Photo of Crispin Blunt

Crispin Blunt (Whip, Whips; Reigate, Conservative)

I will address some of these issues if I have the opportunity to catch your eye later, Mr. Deputy Speaker. The hon. Lady has not addressed the central point of whether a critical care hospital that has to address the needs of half a million people is the appropriate vehicle for addressing health inequalities when the choice is between that and a community care hospital.

Photo of Siobhain McDonagh

Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

If I had the opportunity, I would ask the hon. Gentleman how many super-output areas in his constituency are in the most deprived quarter in England in the index of multiple deprivation. I understand that there are none in the whole county of Surrey. In fact, there are more super-output areas in Surrey in England's most affluent 0.5 per cent. than in the whole of the bottom 50 per cent. I would have thought that he would agree that just because inequality in Surrey means inequality between the fabulously wealthy and the merely well-off, that does not mean that Surrey needs better health services than constituencies such as mine, where the inequalities are between the poor and those who just get by.

Photo of Crispin Blunt

Crispin Blunt (Whip, Whips; Reigate, Conservative)

The hon. Lady should not seek to characterise my constituency, which she plainly does not know. In my constituency, Merstham and Preston—which will become part of the Reigate constituency after the next general election—are the two most deprived wards in Surrey, and the people who live there face particular social and economic challenges. If she knew my constituency better, she would not make such remarks. We all come to this place to represent the interests of our constituents—

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Michael Lord (Deputy Speaker)

Order. I am sure that the whole House is interested in this exchange, but the hon. Gentleman seeks to catch my eye, and might do so later, so I suggest that he contains himself until then.

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Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

I do not wish to test your patience, Mr. Deputy Speaker, but I said that there are no super-output areas in the hon. Gentleman's constituency that fall into the bottom quarter of wards in the multiple deprivation index. While I understand completely that some less-well-off areas in his constituency face challenges, those challenges are nothing like those faced in my constituency.

The 250 people who came to our celebration wanted to thank my right hon. Friend the Secretary of State for Health for her decision. They wanted to thank her for caring about the tens of thousands of people from disadvantaged areas whose health will now be improved by having a brand new hospital on their doorstep in St. Helier. That is why I am grateful for this opportunity to pass on the thanks of my constituents to the Government for being serious about tackling health inequalities.

4:29 pm
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Stephen Williams (Shadow Minister, Health; Bristol West, Liberal Democrat)

We have had a wide-ranging debate, although we have focused rather narrowly on Surrey in the past 20 minutes or so. I want to go back to where we left off on Tuesday night, when, collectively, we made probably the biggest advance in public health legislation for decades by passing a full ban on smoking.

The prevalence rates for smoking are illustrative of the wider health inequalities that exist throughout society. I looked at the statistics for the south-west of England. The highest prevalence of smoking is in my own city of Bristol, where it is 33 per cent., and the lowest is in an area that has been mentioned several times today, east Dorset, where it is 20 per cent. There are also great variations within areas. In the Henleaze ward in my constituency the figure is 12 per cent., while in the Knowle West ward, in Bristol, South, the constituency of the Paymaster General, it is as high as 56 per cent. Those wards are only about two and a half miles from each other. There is an enormous variation in quite a small geographic area. In broadly middle-class parts of the city, the prevalence of smoking is below 20 per cent. In working-class or deprived communities it is always over 40 per cent., and in some areas over 50 per cent. Throughout the city, the rates are higher among men than among women.

Perhaps the key vote on Tuesday night was on whether we should remove the exemption for private members' clubs. Several Members, mainly but not exclusively Conservative, said that attendance at a private club was a matter of choice. Had I been called to speak, I would have said that where people go in the evenings is often not a matter of choice. In many parts of the country, particularly south Wales, where I grew up, going to a private members' club rather than a pub is the norm. If we had not removed that exemption, health inequalities in such areas would have widened rather than narrowing.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

The prevalence of smoking is probably higher in Liverpool. Did the hon. Gentleman note that the Minister of State, Department of Health voted for the exemption?

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Stephen Williams (Shadow Minister, Health; Bristol West, Liberal Democrat)

That is interesting. I assume that the hon. Gentleman is referring to Jane Kennedy. I admit that I did not note that she voted for the exemption, but I am sure that the people of Liverpool will take careful note. As the hon. Gentleman will know, an excellent organisation called Smokefree Liverpool is promoting a private Bill to impose a full smoking ban throughout Liverpool—of course, it will not now be necessary—led by Liberal Democrat-controlled Liverpool city council.

Health outcomes are not always a matter of choice. They are often related to the accident of where people were born, their family circumstances, the occupation of family members, the housing in which they were brought up and the degree of poverty in their household. Mr. Lansley quoted from a briefing that I too received, from the British Thoracic Society, about chronic pulmonary diseases such as bronchitis, emphysema and asthma. Those diseases can often be linked with occupations in declining industrial areas. It is a complicated picture.

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Kevan Jones (North Durham, Labour)

In the days when I dealt with the tobacco industry, the great city of Bristol was a major producer of cigarettes. Might there not be a connection between the high incidence of smoking in the city and the manufacture of cigarettes there? Will the hon. Gentleman be calling for the closing down of the tobacco industry in Bristol?

Photo of Stephen Williams

Stephen Williams (Shadow Minister, Health; Bristol West, Liberal Democrat)

It is often dangerous to presume too much knowledge of areas represented by other Members. I do not know the hon. Gentleman's constituency, but I am sure that he knows more about occupational patterns there than I do. The smoking industry in Bristol went into decline a long time ago. I think that only very expensive top-of-the-range cigars are still produced in south Bristol, although the world headquarters of Imperial Tobacco is still there. The white-collar jobs remain in the Bristol cigarette industry, but the blue-collar jobs do not. The hon. Gentleman is partly right, however: the incidence of smoking in south Bristol can, to an extent, be linked with the fact that workers in the Wills factories were given free cigarettes almost as part of their pay.

What we did on Tuesday night to eliminate smoking in public places represents a big step towards narrowing health inequalities, but there is still much to be done. We need to deal with alcohol consumption, poor diet and other contributors to ill health.

One thing that has not been mentioned so far today is the location of health care services. The recent White Paper on community services contains an interesting section on what the Government call "under-doctored areas"—a phrase that I had not heard before. It includes a table showing the bottom 10 per cent. of areas in England in terms of the number of general practitioners per 100,000 of population. North Manchester PCT has 41, and Wigan PCT and Blackpool PCT each have 45. The accompanying map shows a clustering of low-level GP services in the north-west, south Yorkshire and Tyneside. Of course, they are the areas of greatest general deprivation in England, and they also have some of the worst health outcomes.

However, this is not just a north-south phenomenon. As is often quoted, Hastings is a pocket of poverty and deprivation on the south coast, so it is no surprise to discover that it has a GP rate of 46 per 100,000 people—a figure that matches those for the north of England. According to the Department of Health, a GP rate of 58 per 100,000 people constitutes under-doctoring. On comparing PCTs across the country, it is clear that rural and more prosperous urban areas have twice as many GPs per head of population as the bottom 10 per cent. of areas that I just mentioned. Interestingly, that distribution has not really changed since the NHS was formed in the 1940s. So Aneurin Bevan's vision of a health centre for every community in the country is still not that close to being realised, 60 years after he pioneered his service.

There is, therefore, a correlation between a low concentration of GPs and the worst health outcomes. Given that the general trend of the White Paper is to move the focus of health care away from secondary and toward primary care—and, we hope, toward preventive care as well—it is all the more important, as we undertake that switch, that PCTs with under-doctored areas be given the incentives and resources that they need to ensure that everyone has access to a GP.

As David Taylor—he is no longer in his place—said earlier, men are notoriously reluctant to visit their doctor. Teenage boys are often taken reluctantly to the doctor by their mothers, and men are often pressured into going by their partners. It is true that in many ways, men can be their own worst enemies, and not only in terms of visiting GPs. Men are three times more likely than women to become an alcoholic, and four times more likely to have a drug addiction. They are also more likely to be obese and to smoke. As the hon. Member for South Cambridgeshire said earlier, we should not overlook our responsibilities in this regard. It is not simply a question of the Government providing services; we must all behave responsibility. None the less, according to the most recent figures from the Office for National Statistics, male life expectancy is 76.3 years, whereas female life expectancy is 80.7 years.

The House Magazine, of which we are all doubtless avid readers, ran a supplement on men's health in its 30 January edition. It contained some interesting articles, including one by me.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

Quote yourself.

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Stephen Williams (Shadow Minister, Health; Bristol West, Liberal Democrat)

Do not tempt me. The introductory article was written jointly by Professor Nesse and Daniel Kruger, and the following quote sums up the situation:

"Being male is one of the largest demographic risk factors for early mortality".

Of course, disparities have always existed and are often due to different working patterns, warfare, child-rearing and so on. None the less, at the start of the 21st century, social class is still a factor affecting health outcomes, and men still die younger than women do. Indeed, men are twice as likely as women to develop one of the 10 most common cancers affecting both sexes, and especially bowel and lung cancer, but there remains a great disparity in outcomes in respect of cancers that are peculiar to gender. We heave heard about breast cancer already this afternoon in connection with the drug Herceptin. That debate highlights the fact that much more research is carried out into diseases that affect women than is the case with men, and that more drugs are available for women.

On my lapel, I wear a blue metal symbol, and I get asked every day what it means. I have to make sure that it is the right way up, as otherwise people think that it has something to do with the Scottish National party. In fact, it represents a man covering his testicles and is meant to highlight testicular cancer. The pink ribbon campaign has been a great success in raising awareness of breast cancer among women, and has raised vast amounts of money for research into treatment. We need to put much more effort into raising awareness and funds in respect of the diseases that affect men.

Bowel cancer affects both sexes. It can be treated successfully if it is caught early, but men are still more likely than women to die from it. Men in whom testicular cancer is detected early have a 90 per cent. chance of getting successful treatment. That shows that the advice and support given to people is very important, as is their level of awareness of their own health, but we also need to look at the disparities between the support and advice that are offered to disease sufferers.

A recent survey showed that 34 per cent. of prostate cancer patients were given relevant advice and support, whereas 70 per cent. of women suffering from breast cancer felt that they had been given adequate advice and support. Again, that may be due to men's reluctance to ask for advice and so does not necessarily represent a failing, but it is true that many more organisations exist to support the health of women.

I turn briefly to children. We know that there is a disparity in the funding for hospices for children and for adults, and a debate on that subject has been held in Westminster Hall. However, there is also a difference in the support that is given to children whose parents have an illness that may be terminal. I shall raise that matter when I visit Bristol Royal Hospital for Children tomorrow morning.

Health inequalities in this country arise between men and women and rich and poor, but inequalities due to race have not been mentioned much in this debate. The hon. Member for South Cambridgeshire mentioned the NAO report on stroke care, which was considered at last Wednesday's sitting of the Public Accounts Committee. A surprising fact that emerged from the report was that black and ethnic minority people are far more likely to die from strokes than are white people. No explanation of that finding was given, but it is clearly worth further investigation. Moreover, a black African person is 44 per cent. more likely to be detained under mental health legislation.

Last week, the Minister and I debated sexual health and HIV in Westminster Hall, where I said that it had been shown that 45 per cent. of new HIV cases in the city of Bristol in the past two years involve black African men. That is especially significant, given that they make up only about 4 per cent. of the population. When we attempt to tackle health inequalities, we must look at the awareness of certain groups in society. We must tackle their reluctance to discuss their diseases, try to remove the stigma attached to doing so, and encourage them to find professional help.

We need better access to services targeted at people who are at the greatest risk, and to ensure that interventions are made earlier. To that end, I welcome the Government's proposal, contained in the White Paper, to introduce so-called health MOTs or life checks, but I hope that they will be targeted at those most in need.

That raises questions about joined-up Government. I am a member of the Education and Skills Committee, which this week looked at how educational attainment varies between declining industrial areas and more prosperous parts of the country. In Bristol, the Bristol, West constituency has the highest uptake of higher education in the country, and the Bristol, South constituency has the lowest access to higher education. Educational attainment is also linked to poverty and therefore ill health.

In the early 1970s, statistics show that men were twice as likely to die young if they came from an unskilled group than if they came from a professional or managerial group. Thirty years on, they are three times as likely to die young. At the start of the 21st century, the difference in life expectancy between those who live in Dorset, which has been mentioned several times, and those who live in Manchester is 9.5 years for boys and 6.9 years for girls. The hon. Member for South Cambridgeshire mentioned Glasgow as an area where such health inequalities are starkly obvious, and I would add the south Wales valleys.

We have had a century of state intervention in health care under Governments and coalitions of all three parties. We have 150 years of public health legislation and worker protection laws. We have a society with greater wealth and prosperity, better homes and safer working conditions, and we are all living longer. Although rich and poor are living longer, the poor have not caught up with the rich. The gap has actually widened on some indicators under the Labour Government and there is still much more to do.

Several hon. Members:

rose—

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Alan Haselhurst (Deputy Speaker)

Order. Front Benchers have taken some 107 minutes of the total 186 minutes available for the debate. Seven hon. Members are seeking to catch my eye, which works out at a non-enforceable tariff of between seven and eight minutes each. I say that just for guidance.

4:46 pm
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Diana Johnson (PPS (Mr Stephen Timms, Minister of State), Department for Work and Pensions; Kingston upon Hull North, Labour)

I was fortunate enough last week to speak in the mental health debate and, listening to the debate today, I believe that the focus on public health and mental health has taken a step forward since 1997. For my constituency, public health is one of the key issues that we need to get right.

Mr. Lansley mentioned behaviour and I have an example in my constituency. When Hull city council meets, it has a tea break at about 4 o'clock, at which it used to serve tea and cream scones. The portfolio holder for health decided that it would be better to provide apples and a bowl of nourishing soup. As hon. Members can imagine, that decision caused uproar at the time, but it sent a clear message. We are trying to promote healthy eating habits in Hull and the change sent a very positive message. I pay tribute to Councillor Glew who is battling hard in Hull to put public health at the top of the agenda.

Hull is ranked ninth out of 354 local authorities and districts in England in terms of deprivation. It is surrounded by the East Riding local authority, which is ranked 208th. I wish to compare some of the acute health statistics and show the difference with what is happening in my area. Hull has major health risks, with a high prevalence of smoking, a high consumption of alcohol and a bad diet. Those lead to high rates of coronary heart disease, diabetes and cancer.

I wish to make four points. I want to discuss Hull's health statistics; Hull and East Riding, and the unfairness in the funding available; what is happening in Hull now; and the positive and good aspects of what has been done since 1997. As I mentioned earlier, the local authority and the two primary care trusts in my area have a joint director of public health in Dr. Wendy Richardson, who is doing a sterling job. She has just published her annual report for 2005, in which she compares the life expectancy of men and women living in Hull and in Hambleton and Richmondshire, a rural area of north Yorkshire. She found that life expectancy for a man in Hull was 4.1 years less than for a man living in that north Yorkshire patch, just an hour up the road by car, while life expectancy for a woman in Hull was 2.6 years less. The mortality rate for Hull is 120, on a UK average of 100, which means that our rate is 20 per cent. higher than in the rest of the country. In Hambleton and Richmondshire, the rate is 89, 11 per cent. below the average.

I was delighted that this week we took the bold step of banning smoking in all enclosed public places. In the most deprived wards of my constituency, about 50 per cent. of people smoke, when the national average is about 26 per cent., so smoking is a real public health issue in Hull. Smokers are likely to live seven years less than non-smokers. As we have heard, Liverpool is trying to promote itself as a smoke-free city, as is Hull, so it is an enormous boost for a majority of Members to say that getting rid of smoking in public places is absolutely the right thing to do.

Coronary heart disease in Hull is about 50 per cent. higher than in the rest of England, so I contacted the two PCTs in my area to ask them about acute care for people suffering from that disease. Compared with Hull, East Riding has a higher percentage of people aged 65 or over, but Hull has higher rates of deprivation, so after taking age into account one would expect mortality from coronary heart disease, as well as rates of treatment, to be considerably higher in Hull. Deaths from CHD are much higher in Hull, across all age groups and both genders, compared with East Riding. However, after taking age and gender into consideration, the rate of treatment for CHD is slightly lower for males and much lower for females in Hull, which is shocking.

Similarly, the number of hip replacements, after taking into account age and gender, is more than a quarter more for males in East Riding than it is in Hull. For females, the difference is even more dramatic: there are almost twice as many hip replacements—91 per cent. more—for females in East Riding, a much more prosperous area.

Given the health profile of my constituency and the health needs of my constituents, those figures show that something is not right: there are health inequalities. People who live in East Riding may be more able and willing to visit their GPs, state their needs and demand treatment, whereas perhaps people in Hull do not have the same background and cannot stand up for themselves and say what they need, but the contrast is stark in terms of health inequalities.

The PCTs in east and west Hull will break even in the current financial year, which is a tribute to the hard work of their chief executives, chairs and boards. However, the PCT that covers East Riding is massively overspent, so the strategic health authority has asked Hull PCTs to provide funding to meet its problems. Again, when we desperately want to put money into Hull and ensure that health inequalities are reduced, we must give money to a much more affluent, much healthier area to meet the mismanagement of health service finance there, and I am very concerned and upset about that.

For the coming financial year, the SHA has already indicated that the PCTs in Hull must top-slice about £7.5 million, so that it can be put into the SHA's funds. That is intended to cover the problems of the East Riding and other PCTs in the area. The Labour Government need to get to grips with the mismanagement of those PCTs that are not providing the best financial management that they need. We need to ensure that the turnaround teams that are going into PCTs make the fundamental, structural changes to ensure that the PCTs meet their financial commitments and do not overspend. Despite that, Hull has a proud record in tackling public health problems.

We have a spearhead PCT. I am proud that we have led the way with health trainers. Parents have become involved in Sure Start, which provides what is almost a buddy method of operating with young parents that has worked very well, and I understand that health trainers will do so too. They will get alongside people from their own communities and offer them expert advice and guidance about improving health. I mentioned earlier that we have a joint director of public health. That is a positive step.

Our local authority has led the way on the eat well, do well proposals, whereby our young people in primary schools receive free, healthy school meals. They also receive fruit at break time. There is a real commitment to instil in our young people the need to eat healthily from a young age. We have also had initiatives such as free swimming for children to get them to exercise and to maintain that throughout their lives. Of course, Hull is lucky that it is a flat city, so people can cycle around it easily. We have one of the highest numbers of people cycling to work in the country.

Excellent work is also going on in our teenage pregnancy unit. Gail Teasdale, in particular, has led the way in making that a positive way to get to grips with some of the deep-seated reasons why women choose to have children at a very early age. Our PCTs' smoking cessation rates are getting much better.

I also pay tribute to the vibrant voluntary sector that we have in Hull. It is doing a lot of work with the health community. In particular, the Age Concern building in Hull has a healthy living centre to encourage healthy lifestyles among our older population. It has a gym for the over-60s and it is an eye-opener to go in there and see people who are well beyond 60 on their exercise bikes and the treadmill. That is the kind of vibrant voluntary sector organisation that we want to promote and work with.

We have the gateway housing market renewal pathfinder in Hull, which is all about trying to get to grips with some of the deep-seated problems of poor health and ensuring that we have decent housing for everyone. Of course, I have mentioned Sure Start, but it has a really important role to play in making those early interventions and ensuring that young families and children get the very best start in life.

All hon. Members recognise that we cannot just leave this to the NHS. We must make a joint effort with local authorities, parents, families and the voluntary sector. We must have the money that has been properly allocated, especially in Hull, and I explained why we are not getting that at the moment. Of course, we are allocated a little more money at the beginning because of our health needs, but we do not get the full amount because of what happens elsewhere. We took a bold step this week. Let us carry on being bold in tackling health inequalities, thus ensuring that the health inequality gap narrows for the next generation.

4:58 pm
Photo of Crispin Blunt

Crispin Blunt (Whip, Whips; Reigate, Conservative)

I am delighted to catch your eye, Mr. Deputy Speaker, and to follow Ms Johnson, but I hope that she will understand that it is the speech of Siobhain McDonagh that I want to focus on in particular. I think that her contribution to the debate was sparked by the fact that I told her a couple of days ago that I wished to address the issue of Sutton and St. Helier in my remarks, and I shall try to keep them brief.

There is a substantial health and technical case against the Secretary of State's decision to overturn the recommendation of the local health community in Surrey and south-west London to site the new critical care hospital at Sutton rather than at St. Helier. The merits of that recommendation are substantial and it is the product of well over a year's work, with an enormous consultation process and the rest.

Photo of Siobhain McDonagh

Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

Does the hon. Gentleman agree that the majority of those who responded to the consultation were in favour of St. Helier hospital?

Photo of Crispin Blunt

Crispin Blunt (Whip, Whips; Reigate, Conservative)

That does not entirely surprise me because, if one examines the scale of the hon. Lady's House postage budget, one sees that she is one of the most efficient Members at using the allowance to contact constituents. I wonder how much of the effort to get individuals to reply to the consultation was hers.

I want to address the substance of the issue: the merits of the case. I hope that the merits of the case for Sutton against St. Helier will now be addressed judicially. There is only one way to overturn the decision of a Secretary of State in these circumstances—when the decision is perverse, unfair and, in my judgment, has been taken for reasons of party political advantage rather than because it best serves the health needs of the 500,000 people who will be served by the critical care hospital. That is to invite a judge to review the decision, and I hope that that judicial review process is now in hand to put right this manifest unfairness.

It is not that case that I particularly wanted to deal with but the use of the term "health inequalities" by the hon. Lady in her lengthy campaign to secure St. Helier as the site of the hospital. She simply could not answer the central point that I made to her in two interventions, a point that has been made repeatedly in different ways during this debate. Primary care services and community care hospital services are far more effective at tackling the issues arising from health inequalities, particularly those arising for social and economic reasons. That is especially true under the new model proposed for hospital services in the area served by the Epsom and St. Helier trust, which serves 50 per cent. of the hon. Lady's constituents and 50 per cent. of mine.

When I intervened on the Minister, she did not challenge that basic proposition. Rosie Cooper made clear the importance, in providing such care, of getting to working men's clubs and other such institutions, if one is genuine about drilling down through the community, as Mr. Drew put it, to address health inequalities.

It is unforgivable to put politics ahead of the genuine interests of our constituents. The reason I am so severe towards the hon. Member for Mitcham and Morden is that this is not the first time that this has happened to me and my constituents. I am afraid that we had a very similar case in 2001 when a Labour Secretary of State for Health decided to intervene in the provision of secondary care in the south of my constituency, imposing a moratorium on the reorganisation of services between Crawley hospital and East Surrey hospital. That cost the trust £10 million a year, delayed for three years the implementation of important advances in services for my constituents and has left the trust burdened with the largest deficit of any secondary health care trust in the United Kingdom. That is a direct result of the intervention of the Labour Secretary of State for Health for party political reasons. I have produced a full memorandum on the issue and I regret to say that I will have to repeat it for what has happened in the north of my constituency for my constituents there.

During all the hon. Lady's efforts to secure the siting of the new critical care hospital at St. Helier, the fact that a community care hospital would be a more effective way of addressing health inequalities was repeatedly explained to her.

Photo of Siobhain McDonagh

Siobhain McDonagh (PPS (Rt Hon John Reid, Secretary of State), Ministry of Defence; Mitcham and Morden, Labour)

I apologise to Members on both sides of the House for intervening again, but this is the last time I will do so. Who needs access to maternity care led by consultants? It is young women who smoke and have babies at an early age. Who needs access to an A and E department? It is people who do not have a GP. Those are the people in my constituency, so I certainly reject the idea that local care hospitals can meet the needs of my constituents and others surrounding the St. Helier site.

Photo of Crispin Blunt

Crispin Blunt (Whip, Whips; Reigate, Conservative)

Three miles away from the St. Helier site is St. George's hospital in Tooting, 4 miles away is the Kingston general hospital and 5 miles away is the Mayday hospital. A rather greater distance away is the East Surrey hospital, whose trust has the largest deficit in the country. As a result of the Secretary of State's intervention, 7,000 more people will present themselves at the A and E at that hospital and there will be 800 more in-patients, which will require an additional 25 permanent beds. That hospital cannot cope at the moment. The situation is bizarre. A simple examination of the map would suggest where the new hospital should be sited. The consequences for the 500,000 people who are to be served by the critical care hospital and for those whose services will be deflected to other hospitals should be taken into consideration.

The party political interest in having the big institution with the flag on it close to home is being disguised. Everyone when asked says that they want the critical care hospital close to them; it was the only common factor throughout the consultation process. That we all want it as close as possible comes as no surprise, but the hon. Lady should know, because she was told so repeatedly, that addressing health inequalities in her constituency and anywhere else is about the effectiveness of primary care and community care. Critical care hospitals serving 500,000 people are not as important in addressing health inequalities. She knows that, I know that and, far more importantly, all the health care professionals involved in putting together the proposal know that. Yet the Secretary of State has intervened to overturn the recommendation of all the health care professionals, contrary to the view of the consultants, doctors and everyone else who will be involved.

The really dispiriting thing is that if the hon. Lady succeeds—I sincerely hope that the last throw of the dice on behalf of my constituents in taking the issue to a judge will overturn the decision—the opportunity for a world-class hospital in association with the Royal Marsden in Sutton will have been passed up. That site would have attracted the very best doctors and consultants to serve the people whom both the hon. Lady and I represent. If the decision is allowed to stand, it will be a tragedy for 500,000 people.

It is a great shame that the hon. Lady has put the party political interests as she sees them in her constituency ahead of all the evidence about what is needed to address health inequalities. She has campaigned for an outcome that might suit her own political interests, but I regret to say that the health interests of her constituents, my constituents and everyone else who could have been served by a world-class institution on the Sutton site in association with the Royal Marsden will be so much the worse off.

5:09 pm
Photo of Andrew Gwynne

Andrew Gwynne (PPS (Rt Hon Baroness Scotland of Asthal, Minister of State), Home Office; Denton and Reddish, Labour)

I welcome the debate and am pleased to contribute to it. My constituency is in eastern Greater Manchester and covers two local authority areas. The first, Tameside, like much of east Manchester, contains a number of deprived areas, which consequently have serious public health problems. The second, Stockport, is considered one of the most affluent areas in north-west England, but, despite that, it must be recognised that there are areas of serious deprivation in Stockport, including parts of the borough that form my constituency. In socio-economic terms, they have much more in common with Tameside and east Manchester than with the prosperous areas of Bramhall and Cheadle in the south of the borough.

More than 100 years ago, at the height of the industrial revolution, the city fathers of Manchester sought to make a radical improvement in the health of the growing population by ensuring a supply of clean drinking water from the Lake district. Almost overnight, the rates of cholera and other preventable diseases plummeted. That, along with other sanitation services and the provision of public parks—I believe that one of the first municipal parks in the country was in Greater Manchester—was the first major step towards greatly improving public health in our major cities. With the introduction of the NHS in the late 1940s, there was a remarkable improvement in public health. I am proud of the fact that the former Denton urban district council was among the first councils to adopt the Clean Air Act 1956.

As a result of all those decisions, life expectancy has increased dramatically and our quality of life has been transformed from the standard that my grandparents' parents were used to. That said, health inequalities have continued, despite the steps forward over the past century. It is sad but true that to this day there remains a direct correlation between one's background, housing, environment and income, and one's health.

I am proud that the Government that I was elected to support committed themselves at the general election to

"tackle the long-standing causes of ill-health and health inequality by . . . tough targets to close the health gap to cut deaths in poorer communities and among poorer children".

That will have a massive impact on my constituents, and for the better.

Mr. Deputy Speaker, with your indulgence, I wish to focus on the work undertaken by agencies throughout Denton and Reddish to tackle issues of concern. First, as a result of the single regeneration budget round 5 funds, there has been tremendous investment in the regeneration of the most deprived parts of the constituency. In Haughton Green, SRB funding has enabled the provision of innovative community-based health services in a new joint community and health centre. The services are provided by numerous agencies, but come together under one roof to provide local people with access to housing and homeless services, local health services, benefit advice, access to the credit union, child care help and advice for young people, including advice related to tackling sexual health issues and teenage pregnancies. That superb facility has provided the local community with a new resource.

Adjacent to the Haughton Green community and health centre are the Haughton Green playing fields. Again, spearheaded by SRB 5 and the commitment of the neighbourhood forum and local councillors, major funding was secured to refurbish completely the rather derelict, overgrown waste of space. Through community consultation, a bid for doorstep green funding was secured and that public open space in an urban area that lacks good-quality open space has been transformed into a community asset to be proud of. Not only were the football pitches drained, new play areas for toddlers, children and teens, and a new floodlit multi-purpose games area were provided. Even the old bowling green was restored after being out of action for at least two decades. Now, the area is used by all the community. A bowling club has been established and the sports development unit at Tameside metropolitan borough council ensures that the state-of-the-art sports facilities are well used by local youths in particular. That is crucial, not least to ensure that the ticking obesity time bomb is diffused in communities such as Haughton Green.

I also want to highlight the impact that Sure Start is having in my constituency, offering access to a variety of services such as child care and health advice, providing new parents with the skills necessary to be a parent, and developing simple skills such as cooking. These are crucial in areas such as Haughton Green and other parts of Denton and Reddish. Sure Start is beginning to address long-standing problems and I am proud that my constituency will eventually benefit from six Sure Start centres. I point especially to the good work being done by Reddish Vale early years centre in the Stockport part of my seat, which provides all the services that I mentioned. It has undoubtedly been a resounding success.

I draw to the attention of the House the work of Tameside youth service and the Tameside and Glossop primary care trust in providing services to young people throughout the borough. Whether we like it or not, many teenagers find themselves in situations where they have access to alcohol and sometimes to drugs. Usually as a consequence of being under the influence of those substances, they may be more inclined to have, or be at risk of having, unprotected sex.

In connection with the borough's health targets and the crime and disorder partnership, the joint service offered by the PCT and the youth service provides local young people with an all-in-one support service on drug abuse, alcohol abuse and sexual health issues. As a result of the latter, teenage pregnancy levels in the borough are starting to show an improvement. I commend to the Minister the recent report of Tameside's health and education services scrutiny panels on teenage pregnancies, which describes in much more detail the progress being made in the borough.

Finally, I highlight the proposals of Tameside and Glossop primary care trust to devolve primary care services to local communities. Three primary care centres are being developed which will provide services far more locally than ever before. A range of services previously available at only the district hospital or outside the borough will be available in the state of the art new centres. Importantly in the context of the present debate, the centres will be located in some of the most deprived wards in the borough. One of the wards, St. Peters, which is partly in my constituency and partly in the constituency of Ashton-under-Lyne, is in the top 5 per cent. of deprived wards in the whole country.

The availability of services locally is important because too many people from areas like St. Peters do not have access to good services if those are not available in the communities. Whether because of low car ownership or poor bus services, if facilities are too far away, people will not access them, so I commend Tameside and Glossop primary care trust for taking the services directly to those communities.

Leading and responding to the debate is a Health Minister, and a very good one at that, but I could fill up the Front Bench for this, because tackling health inequalities is a responsibility not just of the Department of Health. I have spoken of the single regeneration budget, community regeneration, the crime and disorder strategy and sports development, but I could also mention the hundreds of millions of pounds being invested by New Charter Housing and Irwell Valley Housing through stock transfer, and by Stockport Homes through an arm's length management organisation, which will bring the area's housing stock up to the decent homes standards.

I could talk about the new schools being built and the innovative joint services being developed with the NHS and social services, or the new jobs coming into the area through redevelopment and regeneration schemes. Put simply, tackling health inequalities involves cross-cutting responsibilities. When that is looked at as a whole, the Government have much to be proud of.

5:18 pm
Photo of Geoffrey Cox

Geoffrey Cox (Torridge and West Devon, Conservative)

I shall try to be brief, as I know that others of my hon. Friends want to speak.

I listened to Andrew Gwynne with fascination. I have begun to realise what it must have been like for the little boy pressing his nose to the window of the pie shop, wishing he could get his hands on some of the goodies. I represent Torridge and West Devon, which is one of the most rural constituencies in England. In the few minutes of the House's time that I shall occupy, I shall concentrate on rural health inequalities.

The constituency that I represent cannot tell a story of such gladness and happiness as the hon. Gentleman has just recited. It is suffering cuts. Constituents who are in need of medical services often have to travel dozens, if not hundreds of miles to receive it. We have acute and primary care trusts in deficit. They are closing community beds, have shut down minor injuries units, and are considering further cuts on top of those. An acute hospital trust is £9 million in debt and two out of three primary care trusts are between £1 million and £3 million in debt. I know that the Government will say that mismanagement is almost certainly the only explanation for those predicaments, but I submit to the House that there is another, longer-term reason, and it has to do with the system of allocation of resources to rural areas in England.

On 10 January this year, my hon. Friend Peter Luff asked the Secretary of State to look again at the resource allocation system for rural PCTs. He was told that a review had been carried out by the advisory committee on resource allocation and that as a result,

"the formula takes account of the effects of access, transport and poverty in calculating health need in rural areas."—[Hansard, 10 January 2006; Vol. 441, c. 601W.]

However, things are definitely not all right. It is widely recognised by experts who have examined the subject that the indices of deprivation which partly govern the allocation of resources fail to capture rural health needs. The characteristics that make that so are reasonably well understood, although perhaps their quantitative effects are not. What is to blame is the national weighted capitation formula, which is based on the age distribution of the population, additional need, and unavoidable geographical variations in the cost of providing services. The indices adopted by the formula use inappropriate proxies for deprivation in rural communities, and research has highlighted an inherent bias towards urban areas.

It is absurd to apply to Torridge and West Devon a measurement that depends on car ownership. Everybody in the countryside who can possibly scrimp and save to buy a car will do so. It must be the same in the rural constituencies represented by Labour Members. If we adopt a proxy for rural health need that is based on car ownership, we will get a distorted picture of the needs in that rural area. It is absurd to base an assessment or measurement of health needs on the proportion of ethnic minorities in the seat. As we know, it is a documented fact that there are fewer ethnic minorities in rural areas, but that does not mean that there is less isolation, less poverty and less financial disadvantage. Nevertheless, that is the effect of the formula.

As we heard earlier, rural deprivation tends to be hidden, because people living in poverty in rural areas are dispersed across heterogeneous communities. Therefore, the indices that aim to define areas as deprived ignore profound and genuine need in rural areas. People in the countryside are a hardy breed. They are proud, self-reliant and independent-minded, and there is characteristically—a researched and documented fact—a low uptake of benefits. That, too, disguises the true level of deprivation in rural areas.

The costs of geographical variations are underestimated. Delivering services in rural areas is more expensive because of poor economies of scale, unproductive time spent travelling by health care professionals and patients alike, and additional telecommunication costs. There are additional expenses associated with transport, including higher fuel costs, providing mobile and outreach services, maintaining branch surgeries, dispersed community hospitals and providing training and support.

The Minister has said that the current formula for resource allocation to PCTs takes rural factors into account, but if one examines the fifth edition of the weighted capitation formula, which is an 88-page document, the word "rural" appears seven times in a single section about ambulance trusts. That document states, for example, that need is assessed with reference to the number of GP surgery visits, but people in rural areas do not go to their doctors as often as people in urban areas. In rural areas, GP surgeries often involve single-handed practices; people find it difficult to attend GP surgeries for want of transport; and cultural factors sometimes prevent people from admitting that they are ill. In rural areas, one cannot depend on the number of people who visit GPs to assess the primary medical services component.

Those are the reasons why the people of rural communities do not believe the Government when they talk a good game on delivering rural health services and tackling rural deprivation. The people do not believe them on health, and they do not believe them on education, which is another important factor in any assessment of deprivation. This year, the schoolchildren of Devon will receive £308 a pupil less than the national funding average, and next year they will receive £330 less, which is a function of the sixth worst education grant in the country. The people are entitled to doubt the Government's commitment to rural areas in the south-west.

A radical change in direction is needed. In countries such as Australia, Canada and even Scotland, rural adjustments are made, and it is accepted that the indices for the allocation of resources are flawed when they are applied to rural areas. In those countries, systematic research is conducted to capture those needs, and although the Government have made pious noises about compiling a rural database from which to make an accurate assessment of rural needs, little has been done.

In an earlier intervention, I referred to the December 2004 DEFRA technical report, which shows that most of the agencies from which DEFRA seeks information are simply not equipped to distinguish between the rural and the urban in the data that they collect. The health funding formula is based on the work of those agencies. Only last week, the Government's chief medical officer, Sir Liam Donaldson, said in the foreword to a booklet:

"We often think of life in rural areas as being something of an idyll, but there is now a wealth of evidence highlighting issues of rural deprivation social exclusion which has a potential impact on the health of those living in rural communities."

A concerted multi-agency approach is required, and every agency and every Department should ensure that information distinguishes between the urban and the rural. It is time for the Government to live up to the CMO's admirable sentiments.

The Government have wept crocodile tears over the plight of the countryside for eight and a half years. Farming and tourism are the twin pillars of the rural economy, but as farming has declined, English tourism has been undersold and the way of life in rural communities has been decimated by insensitivity and neglect, we have been told that it is all right, because Labour is concentrating on the things that matter to people in the towns and the countryside—education, health and poverty. However, those claims ring hollow when they are judged by the reality in the rural south-west, where people perceive a casual indifference to their areas.

If the real needs of rural people are not identified by a concerted and coherent effort, which I have discussed, health inequalities can only get worse. In Scotland and Wales, the devolved assemblies and their Executives recognise the importance of financial adjustments in the distribution of resources to their countryside communities. It is time that the Government did the same for England.

5:29 pm
Photo of Jeremy Hunt

Jeremy Hunt (Shadow Minister (the Disabled), Work & Pensions; South West Surrey, Conservative)

I wanted to contribute to the debate because there is a fundamental flaw in the way in which the Government approach health inequalities that leads to serious discrimination against two groups of people. Let us take as an example a child who goes to St. Mark's Church of England primary school in Godalming, in my constituency. Godalming is an affluent Surrey town, which in many ways represents the stereotype of Surrey towns alluded to by Labour Members. For the children who go to St. Mark's, the reality is different.

Of the children at the school, 35 per cent. have special needs. Teachers have told me that in some classes 80 per cent. of the children have special needs. One teacher told me of a child fed on nothing but rice for five days. Staff turnover is high, and although the school is now on the up it is a pocket of deprivation in an otherwise affluent area and has the same health needs as the inner cities. It is somewhere where social breakdown, a lack of education and a lack of money lead to less healthy diets and worse health outcomes.

How does the NHS funding formula, designed to tackle health inequalities, treat the families of those who go to St. Mark's? If they need elective surgery, they will have to wait two to three times longer than people in virtually any city or virtually anywhere the north of the country. They will wait 26 weeks for ear, nose and throat surgery, compared with a 13 week wait in Manchester. They will wait 25 weeks for breast surgery, compared with 15 weeks in Leicester. They will wait 36 weeks for trauma and orthopaedics work, compared with 12 weeks in Sedgefield.

The NHS funding formula punishes poor families in rich areas, because it can only deal in averages. How does it work in practice? In Guildford and Waverley we get an increase of about 3 per cent. because of the high proportion of elderly people. The market forces factor, because of the cost of health care, increases the funding by 7 per cent. However, the additional needs factor decreases our funding by 25 per cent. because we are apparently an affluent area. So, somewhere that spends 3 per cent. less than the national per capita average is told that it should spend 20 per cent. less. Who suffers? The families of children who go to places such as St. Mark's.

St. Mark's is 2 miles away from Milford hospital, a specialist rehabilitation hospital that the PCT is trying to close. If it is closed, the poverty in the area surrounding St. Mark's will get worse. If Haslemere hospital, just up the road, is closed—the PCT is consulting about removing all the beds—those who will suffer are not the wealthy people who can afford to go private but the pensioners on a basic state pension who do not have that choice. That is the madness of a system based on a mathematical average of health outcomes that cannot account for individual circumstances.

One more group is badly discriminated against. Every week, 90 severely disabled children are born in this country. The lives of 90 families are turned upside down. One would think that in the fourth largest economy in the world we would look after those people properly, but for many families the help and support they get is little better than it would have been 100 years ago. A system that funds to reduce the inequality of the outcome inevitably prioritises acute care over chronic long-term conditions. According to a Mencap survey, 48 per cent. of the parents of severely disabled children get no care from the state. A further 30 per cent. get less than two hours care a week from the state. Only 20 per cent. of such families are able to get any respite at all. The result is a cycle of deprivation. Often the father cannot cope and leaves the mother to bring up the disabled child on her own. She cannot possibly work in such a situation, so the social exclusion starts and gets worse.

Why does the health inequalities agenda fail? As my hon. Friend Mr. Lansley said, we share the objective of reducing inequalities. The agenda fails because of the neo-Stalinist focus on health outcome rather than on access to health care. If the objective is to equalise health outcomes so that people have the same life expectancy in Sheffield as they do in Somerset and in Bath as they do in Bolton, we have to be careful that a mathematical formula does not end up inadvertently denying health care to Surrey, Sussex and Hampshire to make people die more quickly there than they would in Sheffield, Manchester or Leeds.

That approach is flawed because it ignores the fact that health outcomes are the product of choice as well as of circumstance. It fails poorer families who happen to live in affluent areas and those with long-term chronic conditions because it prioritises outcomes, and those people have outcomes that will never improve. Most of all, the approach is flawed because it simply does not work. The point of targets is to motivate managers in organisations to decide on their priorities.

The national public service agreement on reducing health inequalities for heart disease, for example, talks of reducing mortality

"from heart disease, stroke and related diseases by at least 40 per cent. in people under 75, with at least a 40 per cent. reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a whole".

The crystal test of a target is whether an NHS manager can look at it and know what he or she should do next, but it is impossible to look at that target and know what should be done to achieve it. NHS mangers have similar targets for smoking, cancer, teenage pregnancy, obesity, infant mortality and mortality. These targets are failing, and that has been a fundamental element of this afternoon's debate. We all want to eliminate health inequalities, but we are failing to do so because the system of targets is over-focused on health outcomes and not focused enough on inequalities of access to health care.

I am generally suspicious of targets because I want a decentralised NHS in which local GPs and managers have the flexibility to determine the health needs of their own area. However, if we are going to use targets, there should be just one or two, related to absolute improvements in health outcomes for the lowest socio-economic groups, rather than a multiplicity of targets relating to relative improvements. We must prioritise equality of access to health care as much as equality of outcome. That is vital for the elderly on state pensions, for poor families—wherever they live—and for disabled people with chronic long-term conditions. They, after all, were the people for whom the NHS was set up.

5:37 pm
Photo of John Baron

John Baron (Shadow Minister, Health; Billericay, Conservative)

We have had a short but useful debate this afternoon, in which hon. Members on both sides of the House have highlighted the extent to which the Government have failed to address the issue of health inequalities.

Siobhain McDonagh understandably talked about local health issues, but failed to explain why health inequalities had actually widened under this Government. Stephen Williams explained how health outcomes were not simply a matter of choice. In referring to differing GP availability rates, he correctly observed that access was also important.

Ms Johnson said that life expectancy rates in Hull were poor compared with those in the rest of the country. She also talked about the need for better financial management by her local trusts. My hon. Friend Mr. Blunt passionately and rightly expressed his concern about the Secretary of State's intervention for political reasons in important health matters such as the siting of a new hospital, and about the adverse effect that that could have on his constituents.

Andrew Gwynne reminded us that the Conservatives Clean Air Act 1956 had contributed to better health outcomes, and I thank him for that. My hon. Friend Mr. Cox powerfully pointed out that the cuts in health services were closing community beds and minor injuries units to the detriment of his constituents. He talked about the need for the resource allocation system to be re-examined because of its apparent inbuilt bias against rural health needs. He said that his constituents were suffering accordingly, that the real needs of rural people were not being recognised, and that that situation needed to be corrected now.

Finally, my hon. Friend Mr. Hunt rightly pointed out that the NHS funding formula punishes poor families in rich areas and that a high percentage of carers in the families of those with long-term medical conditions are unable to get respite care. The need, therefore, is to address access to services as well as outcomes.

A good number of those and many other contributions made outside this place have made it clear that strategies to reduce health inequalities are not having the impact that we all want. Indeed, the Government's own figures, as was mentioned earlier, confirm that progress has not been made. The Department of Health's public service agreement target aims at reducing inequalities in health outcomes by 10 per cent. by 2010, as we have heard, using 1998 as a start date, as measured by infant mortality and life expectancy at birth—yet, as we have also heard this afternoon, a progress report made in August last year confirmed that those inequalities have widened since 1998.

The Government's figures are not the only statistics that highlight Labour's failure to tackle inequalities in health outcomes. According to a joint study by the universities of Bristol and Sheffield last year, there is a 10-year difference in life expectancy between the most affluent and the most deprived areas of the United Kingdom. There are many other such reports.

Clearly, those depressing statistics reflect patterns of poverty and social deprivation across the country. There is, of course, a link between poor health and poverty—something that was questioned by an hon. Member who is no longer in his place. I should perhaps say at this point that some of what the Minister has said risks creating the impression that she believes that only on her side of the House are there Members with a social conscience. Among those on the Conservative Benches, too, the wish to help the most vulnerable and disadvantaged in society is the reason we came into politics, but we sit on these Benches because we do not believe that big government and socialist dogma are the way to achieve that goal—quite the opposite.

Having said that, we should be careful of overstating the causal link between poverty and ill health. Unhealthy lifestyle is the more direct and relevant causal factor. The Government have still not done enough to persuade people in areas with the highest deprivation levels to adopt lifestyle changes that would do most to improve health outcomes. Smoking provides one worrying example. According to the Library, 17 per cent. of those in managerial and professional occupations smoke. The figure rises to 29 per cent. among those employed in the routine and manual sector.

Such simple facts powerfully argue for a much more ambitious public health and awareness campaign. Conservative Members pledged to put those themes at the heart of our policies if elected last year. The Government should now do the same. However, their public health record is poor. Indeed, it was described by the British Medical Association as "dilatory and disgracefully complacent" and a "calamity". Only recently, Ministers produced an unworkable smoking policy before being forced into a total ban by their own Back Benchers. Meanwhile, Labour has presided over accelerating obesity and sexually transmitted infection rates.

As well as disturbing regional variations in lifestyles and health outcomes, there are unacceptable postcode lotteries in access to services and treatments, which has been referred to on previous occasions. Cancer is one area in which the Government have claimed a great success. Indeed, there have been improvements in services and patient experience, but cancer still exemplifies inequalities of both kinds. In terms of outcomes, a recent Public Accounts Committee report highlighted persistent and unacceptable variations depending on where patients live. For example, the figure for lung cancer deaths is twice as high in the worst region compared with the best. Breast cancer death rates are 20 per cent. higher in some regions in the north than in others, which are mainly in the south. Men with prostate cancer have a 10 per cent. better chance of surviving for five years if they live in London or the south-east than in Trent and the northern and Yorkshire regions. That is on top of the inequality already suffered by men with prostate cancer, who report significantly poorer experience of care than patients with other cancers.

Uptake of drugs and technologies recommended by NICE also reflects wide variations, a fact recognised by the cancer tsar in a report back in 2004. We know that use of the breast cancer drug Herceptin one year after the NICE recommendation ranged from a staggering 90 per cent. of eligible women in Dorset to a dismal 16 per cent. in Essex. In relation to early-stage breast cancer, it is incredible that Ann Marie Rogers had to go to the High Court to clarify the Secretary of State's direction last autumn, in which she seemed to suggest that PCTs could not withhold the drug on consideration of cost alone. By not making additional resources available at the time, however, she might have done as much to exacerbate inequalities as to reduce them, particularly at a time of worsening deficits. The charity Breakthrough Breast Cancer commented:

"This drug could save the lives of 1,000 women a year and it is unfair and cruel for women like Ann Marie Rogers to know that it is money and their postcode that stands between them and this potentially life-saving treatment."

The whole situation is a nonsense caused by this Government.

The problem of regional variations in access to drugs and technology is not restricted to cancer. Photodynamic therapy for wet age-related macular degeneration was approved for use in the NHS in September 2003. Only last autumn, however, data presented by the Macular Disease Society and the Royal National Institute of the Blind showed that 30 per cent. of people in the UK who could have benefited from PDT had not been treated.

NICE was set up to address the postcode lottery in access to drugs and treatments. However, the Government must now address the postcode lottery in implementation of NICE guidance. In particular, they should follow the Conservative policy of ensuring that NICE appraisals are carried out in conjunction with a full resource implementation assessment, so that national guidance is realistic, implemented and successful. More broadly, NHS bodies should be subject to a statutory duty to implement NICE guidelines on standards of care as well as drugs and technologies. In a devolved health service, it is essential that patients are given clear entitlements to treatment. That will help particularly the 17 million patients who suffer from long-term medical conditions and who are increasingly realising that in a target-driven culture, conditions that are not targeted suffer unduly.

Chiropody services for elderly people and rehabilitation services for the visually impaired are two sad examples of the type of care for long-term conditions that suffers in a devolved service when Government targets are focused on the acute sector and politically sensitive waiting times. A survey by the Conservatives showed that more than half of chiropody services had recently raised the eligibility criteria for access to treatment, with the average department undermanned by a shocking 25 per cent. Meanwhile, with regard to the nearly half a million people in the country registered as blind or partially sighted, the Guide Dogs for the Blind Association has estimated that as many as 20 per cent. of local authorities have no dedicated rehabilitation services, with nearly 80 per cent. overall admitting that services were restricted due to a shortage of suitably qualified staff.

With an estimated half of all NHS trusts going into deficit, inequalities in local services and patient care are bound to increase. Hon. Members have already highlighted cases in their constituencies where services are being cut in order to balance the books. This latest development comes from a Government who spent years bombarding the NHS with targets and bureaucracy and then destabilised trusts with bungled reforms. The Government have not tackled health inequalities—in fact, they have widened in recent years.

By not implementing a strong public health programme and not radically improving the NHS, the Government have failed to break the link between poverty and ill health. All the evidence suggests that when unreformed state services do not perform as well as they should, the less well-off tend to be let down the most. Meanwhile, inequalities in access to services have also proliferated. As Conservative Members have argued, postcode lotteries will be ended only if NICE is given the tools and instructions to create a culture of standards and entitlements in the NHS. Until patients have those entitlements, health inequalities will continue to widen.

5:49 pm
Photo of Caroline Flint

Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

With the leave of the House, Mr. Deputy Speaker.

We have had a useful debate, and I have heard interesting contributions from Members on both sides of the House. One of the issues that have confronted the Government is 18 years of disinvestment in the NHS by Conservative Governments. During that time, services were cut in many areas. I understand that that included two dental training schools. Clearly it will take time to change a system that has suffered from underfunding and insufficient engagement for a generation.

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

No, because I gave way to the hon. Gentleman during my opening speech and he did not stay for the whole debate. [Interruption.]

Photo of Caroline Flint

Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

I think you will see in Hansard, Mr. Deputy Speaker, that I gave way extensively during my opening speech. As I now have less time than was taken by Mr. Baron, I want to make some progress.

Tackling public health issues is hugely important. The situation will not change overnight, but we must accept the challenges, some of which have embedded themselves over many years. There has been an increase in sexually transmitted infections, for instance, but in many other respects we live in a world that is very different from the world of 10, 20 and 30 years ago. I pay tribute to the Labour politicians who established the national health service, but their concept of the health service that was needed then was very different from the service that we need today.

Many other things have changed. Work has changed enormously. In my constituency, a mining constituency, the number of miners who suffer from respiratory disease is heartbreaking for those individuals and their families. At least the miners must be encouraged by the Government's decision to meet the claim for compensation for that industrial disease.

We in the Labour party have an historic commitment to fight for ways of tackling inequalities. That has meant fighting for safe working conditions, decent housing, a national minimum wage and—in earlier campaigns—clean water, public sewerage and public parks. Those campaigns are all part of the overall picture.

I think that all Members agree that, in general, everyone is living longer and everyone is healthier, but we must deal with the gap caused by health inequalities. One reason for that gap is the way in which services are being delivered, but there is another reason. It is interesting, but we have not much time in which to explore it. Research suggests that those who are better off and better educated can gain access more quickly to NHS services such as information and an understanding of how lifestyle choices affect health, and that that enables them to make choices more quickly. That is part of the problem. The more we provide such services, the more the better off take advantage of them before poorer people can do so. We must therefore provide services in a different way because there is no "one size fits all" solution. It is not enough to organise national education campaigns with advertisements on television, or to provide services on the internet. We need to find a better way of working in communities to give people the support that they need.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

Will the Minister give way?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

No.

Reference was made earlier to the need for people to feel confident about talking to their GPs, demanding services and making their voices heard. I am afraid that it is an indication of modern life that more affluent people are often more confident, shout the loudest and get the services, whereas poorer people perhaps have less confidence and do not. That is unacceptable. For some reason, GPs do not want to work in our poorest areas, which is also unacceptable. Perhaps they prefer working in more affluent communities.

Mr. Lansley asked about reductions in the incidence of cancer and coronary heart disease, and the reductions are 9.4 per cent. and 24.7 per cent. respectively. The figures are not absolute—they constitute a reduction in the gap between the average for England and the figure applying to the five most deprived areas. I accept that infant mortality has risen: it rose by 19 per cent. in 2001–03, and by 19 per cent. in 2002–04. That is unacceptable, but there was no increase during the second tranche, which I hope shows that the situation is not getting worse. [Interruption.] I have accepted that the figure has risen, but it has stabilised and we must try to reduce it.

On obesity, the hon. Member for South Cambridgeshire will be aware that we are doing a tremendous amount of work with the food industry and others on food labelling and the reformulation of food.

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Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative)

Will the Minister give way on that point?

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Caroline Flint (Parliamentary Under-Secretary (Health), Department of Health; Don Valley, Labour)

No, I am not going to give way.

We are doing important work with schools through the healthy schools programme, but, of course, another important factor is the choices that parents make for their children, which is why we have to work with families as well. I should also point out that status reports on health inequalities are published annually on the departmental website.

On public health structures, I am glad that the Conservatives agree with us about joint appointments, which we are encouraging. My first speech as Minister with responsibility for public health was made at the invitation of the Faculty of Public Health. I pointed out at its conference that, in my view, that is the direction in which we should go, and there some very good examples of such practice. However, we must recognise that it is more than just a question of appointing someone to serve the local authority and health services in a joint capacity; there must also be a change in the culture and mindset of all the organisations involved, so that they can work together. Local area agreements are important in that regard, and the consideration of health inequalities must form an integral part of the assessment of local authorities.

The health trainers programme is based on the Bandera study, which is a psychological behaviour change model. It shows that one-to-one, structured motivation techniques empower individuals to change their lifestyles. In our view, providing such services to those who are taking advantage of other forms of information and support is a good way forward. The National Institute for Health and Clinical Excellence is working closely with us on the development of the life checks model.

Respiratory disease is an issue that we take very seriously, and it is on our list of key interventions. However, circulatory diseases account for the largest proportion of excess deaths in spearhead areas: some 70 per cent. among males and 63 per cent. among females. By way of contrast, respiratory diseases account for some 18 per cent. of such deaths. However, we obviously all these issues seriously, and it is important to deal with them.

My hon. Friend Siobhain McDonagh told us about her area and the question of where the new hospital is to be located. It has to be acknowledged that the issue is not just health inequalities and services, but regenerating communities; the new hospital will play an important part in that regard. Stephen Williams talked about pharmacies playing a greater role, and this Government are providing such opportunities. Our proposal to allow pharmacies and nurses to play a greater role in prescribing will allow them to add to the role played by GPs; they will not replace GPs. They will add to the mix of people who can deliver health services in our communities. Men's health was also raised in the debate, but I dealt with that extensively in my opening speech.

I congratulate the councillor to which my hon. Friend Ms Johnson referred on her innovation. I welcome the fact that there is a joint director of public health in that area, but I hear what my hon. Friend says about East Riding, which does not have the same level of health inequalities as other areas, but seems to spend money rather more unwisely than does Hull itself. That is something that we should talk about more when we consider good management and delivery.

My hon. Friend Andrew Gwynne spoke well about what is happening in his area, and said that it is not just a matter of health for everyone. I think that Mr. Cox misunderstands health inequalities. I accept that rural areas face different problems, and we have trained the health trainers programme for Devon and Cornwall

It being Six o'clock, the motion for the Adjournment of the House lapsed, without Question put.

Photo of Peter Bone

Peter Bone (Wellingborough, Conservative)

On a point of order, Mr. Deputy Speaker. I seek your guidance on a matter of great importance. First, though, in the last debate the Under-Secretary of State for Health, Caroline Flint, inadvertently misled the House by saying said that I had not been present all the way through, when in fact I had.

On 30 November 2005, the Prime Minister said that no one had to wait more than six months for an in-patient operation. However, in a parliamentary written answer of 23 January this year, the Under-Secretary of State for Health, Mr. Byrne, said that the NHS now operates a maximum waiting time for admissions of six months for an in-patient operation—

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Alan Haselhurst (Deputy Speaker)

Order. I understand that the hon. Gentleman has raised this matter on a previous occasion. If so, it would be wholly inappropriate to raise it again on a point of order now.

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Peter Bone (Wellingborough, Conservative)

It has only just come to my attention that I received two answers to parliamentary questions on the same day that are massively contradictory.

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Alan Haselhurst (Deputy Speaker)

Order. The content of answers to parliamentary questions is not a matter of order for the Chair. I think that the hon. Gentleman will have heard Mr. Speaker advise on other occasions that such matters are matters of debate that should be pursued in other ways, either through further parliamentary questions or through the other parliamentary means that are open to hon. Members.