Hugh Bayley (York, City of, Labour)

We expect the House to prorogue at about 4 o'clock, and the rules state that when the House prorogues, the proceedings in Westminster Hall finish immediately. I see that quite a number of hon. Members will be seeking to catch my eye during the debate, so I ask colleagues to bear in mind the likely time constraint.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

On a point of order, Mr. Bayley. Further to your comments, should the House prorogue, obviously no further comment will be allowed here, but the debate is on a very important report and the Government response to it needs a lot of debate. That is why the Government gave three hours for this debate. Should we not get three hours, is there any way in which this business could be brought back, so that the proper debate could take place in this Chamber?

Hugh Bayley (York, City of, Labour)

That is not a matter for the Chair. It is, of course, open to the usual channels to discuss future business in the new Session of Parliament. We are lucky to have one and a half hours, so let us make the most of the time available.

Norman Lamb (North Norfolk, Liberal Democrat)

The right hon. Gentleman says that he does not think anything has been wasted. In referring to the ethical imperative of ensuring that things are evidence-based, the report itself points out that when money is spent wantonly on initiatives that have not been properly thought through, that money is not going into other schemes that may well have a real effect. There is potential damage in that respect, and the report highlights that.

Derek Twigg (Halton, Labour)

Despite the fact that mortality rates have declined, in my constituency they are still above the national average. My right hon. Friend was about to discuss this point, but I want to be clear about it. Does he support the view that we should ensure that primary care trusts, health organisations and the other public bodies in a given area engage with the local population? That would mean that the available resources would all be used, and that the organisations worked together to ensure that things happened. Such engagement is a key factor for the local population in attacking inequalities and improving health.

Richard Taylor (Wyre Forest, Independent)

I shall be brief. I have questions on four topics—the role of secondary care in prevention; tobacco smuggling; personal, social and health education; and children's services.

Secondary care was mentioned by Mr. Barron, the Committee Chairman. I remember that on one of our visits to the States we met a physician in a hypertension clinic who was bemoaning the fact that he did not have the time to instruct his patients about their smoking and their obesity. We heard from ASH—Action on Smoking and Health—that only half of UK chest specialists have direct access to a stop-smoking counsellor, and we heard that there is a failure to use such services where they exist. We also heard that the chief executive of one PCT, Tower Hamlets, is trying to persuade secondary care services to play their part by providing public health intervention, particularly on stopping smoking and losing weight, and putting it high on everyone's agenda, even at board level.

The last few words of paragraph 152 of the Government's response are:

"Issues around secondary healthcare will be considered separately as part of the commitment to develop a post-2010 national health inequalities strategy."

What can the Minister do to persuade secondary care services to take on a prevention role much more quickly than that?

My second query is about tobacco smuggling. We heard graphic details about the amount of tobacco that is smuggled and the fact that it is the least well off smokers who use it. We also heard about the proportion of self-rolled cigarettes that contain smuggled tobacco. The issue has to be tackled immediately.

A British Medical Journal report told us that eliminating tobacco smuggling could save between 6,000 and 6,500 lives a year. When that is compared with the only 1,000 deaths a year that result from smuggled illicit drugs, it puts the matter into perspective. It is the least well off smokers who use such tobacco. Paragraph 232 in the Government's response states:

"The Government will give serious consideration to the Committee's comments on smuggling and the international tobacco control agreements, as part of the development of a new tobacco control strategy during 2009."

As 2009 is very nearly over, I am hoping to hear great things from the Minister about what the Government are doing about tobacco smuggling.

Let me turn now to personal, social, and health education. In our conclusions in the report, we said:

"We are pleased that, five years after we recommended it, Personal Social and Health Education (PSHE) is finally being made a statutory part of the national curriculum."

That has been a recurring theme in a number of our inquiries in the past. We are told in the Government's response that some recommendations require legislation and some can be taken forward immediately. Will the Minister tell us which of the recommendations relating to PSHE can be taken immediately? I do not subscribe to the belief that the nanny state is harmful; there are occasions when it is needed. When young people do not have parents who are doing the nannying, the state has an obligation to step in.

I move on to children's services. Sure Start has been mentioned by our Committee Chairman, and evidence is increasing about the benefits of the scheme. I have visited a Sure Start centre in my constituency; it is based in the heart of a most deprived community, and it is doing absolute marvels. Kids come in looking lost.

Peter Bone (Wellingborough, Conservative)

Does the hon. Gentleman agree that one of the problems of the Sure Start system is that it is not getting to the hard-to-reach cases? That is what the Sure Start centre in my constituency tells me. It is working well, but it is not getting to the very difficult and hard-to-reach groups.

Richard Taylor (Wyre Forest, Independent)

I am coming on to that in a moment, because that is one of my concerns, too. The Sure Start centre that I mentioned is at the heart of a deprived community and is doing marvellously. Last week, I opened a children's centre in Kidderminster, which has absolutely superb facilities. Its catchment area is supposed to tackle some 988 children, and the children come from extremely mixed areas. The centre provides stay-and-play facilities, dads' groups, which are crucial, and support and advice on a wide range of topics. It has links with nurseries, childminders and schools and, most importantly, it has outreach workers who aim to visit all 988 children.

The place was packed when I opened it, so I could not do an assessment of where all the children came from. There must be a huge temptation for the better-off families to use the centres because they have such super facilities. However, it is the silent voices that we so often try to find that must be tackled and made to feel involved in the children's centres because they are the people who really need them.

I had a briefing from the Royal College of Physicians for this debate. It desperately wants movement on a range of issues, including a reduction in obesity, the prevention of smoking and a reduction in alcohol consumption. Many of its examples of what is needed to promote healthy lifestyles for children are covered by PSHE and by what is provided by the children's centres. So we have the right aims and right tools in place. We must ensure that they are taken up by the people who need them.

I am not sure whether hon. Members realise, but there are proverbs that were written before the birth of Christ. One states:

"Train up a child in the way he should go: and when he is old, he will not depart from it."

We have just come round to realising the importance of what happens in childhood.

Howard Stoate (Dartford, Labour)

It is a pleasure to take part in this debate. I am a practising GP and take a great deal of interest in issues around the health of my constituents as well as my patients.

In recent years, the debate on health inequalities has focused almost exclusively on what we eat, drink and do—or, more specifically, what we do not do in terms of physical activity. Hardly any attention has been paid to the physical environment in which we live. It is as if we have collectively decided that with the advent of modern domestic plumbing, central heating, cavity wall insulation and so on we no longer need to spend time worrying about the environment in which we live.

Even though the dragons of poor sanitation and slum housing may largely have been slain in this country, it would be wrong of us to ignore the environment as an important issue. Unquestionably, people's housing conditions have improved, but the condition of their neighbourhoods leaves a lot to be desired and has not improved to the same extent. Living in badly maintained and badly planned neighbourhoods with inadequate infrastructure and amenities not only restricts people's ability to live healthy lives, but causes untold damage to their health and mental well-being.

A study published last year in Preventive Medicine found that areas perceived to be safer and more aesthetically pleasing can enhance mental health, while adverse effects were associated with road congestion and urban noise. Rates of psychiatric illness are also greatest in the most deprived areas, and the rates for psychoses map closely those for deprivation. Poorly maintained environments are also a cause of increased levels of stress and a greater susceptibility to heart disease, stroke, cancer and long-term chronic conditions.

Sustrans has reviewed the evidence of links between physical activity, health and social inequality and found that obesity, diabetes and cancer all affect people from deprived communities disproportionately. The link has primarily been made to the environment in which they live.

The recent Royal Commission on Environmental Pollution has also found plenty of evidence to show that living in deprived urban areas increases the risk of poor health outcomes, even after controlling for individual circumstances. So, a bad situation is made to seem much worse by the inevitable contrasts that people in poor neighbourhoods make between their own living conditions and those of richer people living down the road in much better provided and much better maintained areas.

There is plenty of evidence to back up such a view. My particular favourite is the example of Roseto, a blue-collar Italian-American community in Pennsylvania. Puzzled as to why Roseto's health outcomes were consistently better on average than those of neighbouring towns—despite the fact that Roseto was no wealthier than they—a team of researchers decided to take a closer look. What they found was a town that was different in character and appearance from anything else they had seen in Pennsylvania. Its residents did the same kinds of jobs as those in neighbouring towns; they ate the same diets; they took the same risks with their health; they even had the same disparities in income as the towns nearby. The difference was that it was almost impossible to detect income disparities by looking at the places in which people lived. The houses were the same size, the cars were the same and the clothes that the people wore were similar. It was virtually impossible to distinguish people's social position just by the appearance of either themselves or their houses. The report states:

"It was difficult to distinguish, on the basis of dress and behaviour, the wealthy from the impecunious in Roseto. Living arrangements—houses and cars—were simple and strikingly similar."

The researchers attributed that to a strong egalitarian sense of community among Roseto's residents that precluded ostentatious displays of wealth and frowned on any behaviour that might cause embarrassment or shame to the community's least affluent members. Clearly, when people's houses, cars and clothes are uniform across society, it has a beneficial effect on their health outcomes despite the disparities in income.

Sadly—this is the interesting part—it did not last. Once the first generations of primarily Italian-speaking residents died out and were replaced by English-speaking children and grandchildren who had the same cultural and moral values of other Pennsylvanian towns, Roseto's health outcomes soon began to slip. It is a very instructive example. It reminds me of the rather whimsical essay "The Socialist's Guide to Camping" by the late Oxford philosopher, GA Cohen. On a camping holiday, Cohen said, "there is no hierarchy" among people. They co-operate, share, generally act in ways that promote the collective good and take great pleasure in doing so. Although some tents may be bigger and brighter than others, or some people may have shinier, more high-tech camping gear than other people, it is much harder to detect the differences in wealth and status between families that mark them out in normal everyday life. So, for a brief, happy, life-affirming and health-enhancing moment, egalitarianism rules and our social differences are forgotten.

In the real world, however, it is not quite so easy to draw a veil over our wealth differences. That is not to say that we should not be trying to do so and indeed there are examples where people have succeeded in doing so. The fact that Britain is becoming more and more segregated geographically by class, age and wealth, as Professor Danny Dorling and his team from Sheffield university have shown, indicates to me that people are trying, consciously or unconsciously, to restrict the degree to which they are exposed to wealthier and supposedly more successful sections of society in their exclusive enclaves.

One way of addressing this issue is to invest more resources in improving the quality of the built environment in our most disadvantaged communities. Over the past 12 years, we have had a number of successes in this respect, but we need to do a lot more. For instance, the new deal for communities has helped to deliver a lot of schemes that have helped to improve the fabric and appearance of many disadvantaged communities, as well as helping to cut crime and improve access to jobs, education and health services. Crucially, local residents in those communities have been closely involved at an early stage in the design and implementation of many of those initiatives. Resident "ownership" is essential if schemes are to be sustainable in the long term and not require further investment at a later stage. The skills and confidence that residents develop as a result of their involvement in those schemes is not only good for their health and well-being but often encourages them to go on and set up further projects of their own. However, we need far more resident-led, area-based initiatives of that kind if we are to reduce health inequalities.

We also need to think much more carefully about health when we are planning new developments. Ever since the public health function was taken away from local authorities back in the 1970s, very few local authorities have spent much time thinking about the health implications of their planning decisions. That has to change if we are to create developments that actively encourage people to pursue healthy lives.

New developments with safe, well-maintained and attractive walking routes, play areas and parks are vital if we are to get people out of their homes and cars, and on to the streets. As with everything in life, it is a matter of motivation. Telling people that they need to take more exercise is easy; getting them to want to take more exercise is altogether more difficult. That is why the built environment is so important. If people look out of their windows and see a grey, badly maintained street scene, clogged with traffic, litter and dereliction, they will stay at home. On the other hand, if they look out of their windows and see trees, grass, nice paths and families out walking their dogs and their children, they will want to take part themselves, because otherwise they will feel left out of what is going on outside. That is a fundamental human condition.

In my area, which is in the Thames Gateway, the new Thames Gateway parkland initiative is a model of the approach that we should be taking. It recognises that creating attractive green spaces that are easily accessible and well integrated with the existing urban grain is a vital aspect of the area's long-term regeneration. The proposed A2 activity park, the improvements to the Darent valley path and the new Jeskyns community woodland are all good examples of this work in my area. What we need to do now is to extend that programme across other areas in the Thames Gateway. It is clear that many existing communities feel that much of the investment that has been directed at the Thames Gateway has simply passed them by. If we do not address that problem quickly, there is a grave risk that we will not achieve one of the central goals of the Thames Gateway regeneration strategy, which is to improve the quality of life and the life chances of the area's residents.

In short, if we want to improve people's sense of well-being and enhance their long-term health prospects, we can do no better than to spend time and money on improving the quality of the built environment in which they live.

Peter Bone (Wellingborough, Conservative)

I want to start, Mr. Bayley, by saying that it is a pleasure to serve under your chairmanship. I also want to congratulate Mr. Barron on how he introduced the report that we are discussing today and on how he carried out the inquiry into this issue. As usual, he did so with great diligence, hard work and fairness.

The report brings to the Government's attention the key problem that evidence-based activity needs to be undertaken in the future. One of the things that became clear to me during the inquiry was that there was a willingness to invest money in ideas but the Government had not necessarily worked out whether those ideas were the best ideas, nor had they found any way of establishing whether they were the best ideas.

I have a question for the Minister. One of the things that I struggled with during the inquiry was the issue of targeting resources. Let us say that my primary care trust has £10 million to use up and that it could spend that money on improving people's lifestyles, so that perhaps 1,000 people could live a year longer than they might otherwise have done. Those 1,000 people are middle class, active people who want to engage with the PCT. Alternatively, there are 50 people in the hard-to-reach group who would also see their life expectancy improve by a few years if that £10 million was spent on them. What should that PCT do? Should it help the greatest number of people or help the few people in the minority? I am not sure that saying that it is always right to try to close health inequalities is always the way forward, in practical terms.

We can take great pride in how successive Governments of all political persuasions have managed to develop the health service so that we all live longer. That is probably what we are looking for. We are certainly not looking to reduce the life expectancy of the well-off so that people who are much poorer live longer; clearly, that is not what we are trying to do. The aim of the debate is to increase life expectancy for everyone, while somehow also helping those people who are in the minority groups. I am not sure that our report takes us any nearer to striking that very difficult balance.

One of the things that the Government did that was very good was to introduce the national capitation formula. That is a method whereby every PCT receives a sum of money based on the criteria of its needs. In crude terms, a PCT would receive more money if it had more people with health inequalities. In my patch, for example, I have some very poor areas, where health inequalities are much worse than in other areas.

The problem, however, is that the Government have never funded to the national capitation formula. I have challenged the Government time and again on that, and the answer that I have received is, "Oh, we over-fund elsewhere". That is no answer at all to my constituents. For instance, my area does not have a hospital. However, if we had received the money that we would have got if the national capitation formula had been paid in full, we could have had a hospital, which could have helped those people who experience health inequalities.

So it seems to me that the Government were going in the right direction with the formula, but because they did not implement it—indeed, they still have not implemented it—Northamptonshire PCT is millions and millions of pounds short. For a long time, one of my arguments has been that, to get more fairness in the system, people should be funded fully in line with the national capitation formula. To use the excuse that more money is being paid to other people, as the Government have done, just does not work.

I also think that Tony Blair, when he was Prime Minister, had the right idea in wanting to bring our standard of health care up to the European average. There are still no benchmarks of quality care and outcomes, and that is a fundamental flaw that needs to be put right. However, the ex-Prime Minister got it wrong in thinking that if we just put the money into the health service, that would automatically improve it. Consequently, we have seen the funding for the health service go up to roughly £100 billion a year, which is twice as much in real terms as it was under the last Conservative Government. Unfortunately, outcomes, as measured by finished consultant episodes, have increased by only 20 per cent. So we have put 100 per cent. more money in, but got only a 20 per cent. improvement in outcomes.

That is the great criticism of the Labour Government; their hearts are in the right place, but they have failed dismally despite having had a golden opportunity to succeed. Someone, at some stage, has got to look at this massive budget and use it more effectively. We must know what the outcomes are and approach the issue evidentially, so that we can measure health inequalities. Furthermore, we must not only measure the health inequalities in this country, but compare them with those of our European colleagues.

If our European colleagues have much better success rates on strokes, we as a nation are suffering a health inequality, and we have to put that right. As the report says, we have to start with evidential measurements; we have to know what the measurements are so that we can know whether the money that we are putting in is actually working.

I want to conclude in a moment because we are short of time. I notice that the sitting on the Floor of the House has been suspended, so we might have been switched to live national television, which is only right and proper given that we are debating health inequalities and the Health Committee report. The right hon. Member for Rother Valley talked about taking local people's wants and needs into account. I have a big town in my constituency called Rushden, which funded an out-patient facility after the second world war in remembrance of those who had fallen. The hospital served by that facility was not in my constituency, but miles away in Kettering. When the Government changed the rules and gave us foundation hospitals, it became a foundation hospital.

That hospital has now closed the out-patient facility in my patch, despite the fact that the facility was funded by local people at the end of the second world war. That will increase health inequalities in my area because the facility was used by those who could walk to it—the 20 per cent. who did not have cars and who could not easily travel miles. Now that it has gone, however, they have to use taxis or get friends to transfer them to the nearest NHS facility, which is outside the constituency. That is a health inequality, and such things should be measured.

In conclusion, the report was helpful, and I hope that this Government and the next Government—whatever their political persuasion—will consider it seriously. The main point is clear: it is no good putting our finger in the air and thinking, "This is a good idea. Let's put a few million pounds behind it." We have to have the measurements to know whether initiatives are achieving anything; if they are not, we have to have the political courage to stop them and spend the money on something else.

Norman Lamb (North Norfolk, Liberal Democrat)

I have received a text message suggesting that we might have until 5 pm, so the Minister may have well over an hour to respond to the debate. I am sure that she will appreciate that opportunity, although the message may be entirely inaccurate.

Hugh Bayley (York, City of, Labour)

Order. Let me say for the benefit of hon. Members that I am also taking what soundings I can. I do not think that the debate is likely to end imminently, but I would be surprised if it went anywhere near half-past five. That said, I do not want to curtail what anybody wants to say, and I am sure that we all want to hear what all three Front Benchers have to say.

Norman Lamb (North Norfolk, Liberal Democrat)

Of course. I am grateful to you, Mr. Bayley.

I congratulate Mr. Barron on his introduction to the debate and on the work that he and his Committee have done on this incredibly important report, which highlights a number of crucial issues. Let me start by addressing the scale of issue that we face. This country has gross health inequalities. The report highlights the fact that the life expectancy of a girl born in Kensington and Chelsea is 10 years longer than that of someone born in the city of Glasgow. Sometimes, in the same city, the difference in life expectancy can be as much as 14 years, and we can see such gross inequalities in northern cities such as Sheffield. The really disturbing aspect is that these inequalities are getting worse. Over the past 10 years, the gap has increased by 4 per cent. among men and 11 per cent. among women. That should concern us all.

Mr. Bone rightly said that these things are relative and that the whole nation's health is getting better, but that should not satisfy us and we should not be comfortable with a society in which there is such a significant gap between rich and poor. Just because someone is born into a deprived community, they should not be condemned to a shorter life than someone who is born in the wealthier suburbs. Something is wrong somewhere.

Hon. Members may be aware of the important study that Richard Wilkinson published earlier this year. In a nutshell, his case is that inequalities in health and inequalities in outcome in areas such as education and crime are closely related to the extent to which a society is unequal. The more unequal the society, the worse the outcomes and the more inevitable the inequalities in mental and physical health, education and so on.

Potentially, that is a bit of a counsel of despair because it suggests that if we are stuck with an unequal society that has gross health inequalities, there will be little that we can do to change things unless we make that society more equal. I will come back to that. There is an overwhelmingly compelling case for us to address inequality in society and to look at the symptoms of that inequality. The Government have had a golden opportunity to tackle the extent to which society is grossly unequal, but the measurements are getting worse, not better. Furthermore—this is about political choices—can anyone really believe that the Conservative party, if elected, would have as an imperative the creation of a more equal society? I really think not.

Peter Bone (Wellingborough, Conservative)

You are wrong.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

You are wrong.

Norman Lamb (North Norfolk, Liberal Democrat)

Hon. Members say from a sedentary position that I am wrong, but when the Conservative party's one key tax proposal is to give millionaires a massive tax break on their estates, that does not suggest a commitment to a more equal society.

Irrespective of the extent to which we can tackle the inequality in our society, we have a duty to do what we can to address health inequalities in the existing system. At a time of austerity, when the Government's focus is on reducing the budget deficit, there is a real danger that the wrong decisions will be taken and that the cause of public health and reducing health inequalities will be damaged. In the aftermath of the 2005 general election, health budgets were squeezed and times were tough for the finances of the NHS.

As the Committee's report pointed out, cuts were made to mental health, public health programmes, staff training and so forth. This time, we must not allow constraints on public expenditure to result in crazy decisions that damage our chance of reducing health inequalities. The report notes that we have a seen a reduction in the number of public health specialists working in the NHS in recent years, while the number of administrators and other health professionals has increased. Why is that happening? When the importance of public health practitioners is as great as ever, why are we cutting their numbers?

The report makes a powerful case for the importance of evaluation and evidence, and it is pretty critical of the Government's record in that regard. It describes the failure to evaluate and the failure to base policy making on evidence as the

"most damning criticisms of Government policies".

Paragraph 3 of the conclusions says:

"The latest initiative on Healthy Towns has all the failings of previous policies, indicating that the Government has learnt nothing from past mistakes."

That is a depressing conclusion and suggests that nothing has been learned.

I intervened earlier on the right hon. Member for Rother Valley about the case for an ethical imperative to base policy on evidence. Paragraph 4 of the conclusions to the Select Committee report states:

"All the reforms we have discussed are experiments on the public and can be as damaging (in terms of unintended effects and opportunity cost) as unevaluated new drugs or surgical procedures. Such wanton large-scale experimentation is unethical"—

the Select Committee is accusing the Government of being unethical in their failure to base policy on evidence—

"and needs to be superseded by a more rigorous culture of piloting, evaluating and using the results to inform policy."

That is an incredibly important conclusion, and the Government must take it on board.

The report also refers, in paragraph 8 of the conclusions, to the NICE process, which we all like to think of as objective and evidence-based—something by which we approve drugs and procedures on the basis of evidence. However, the report makes the critical point that we do not evaluate what is lost when new drugs, for example, are introduced as a result of a NICE approval. The conclusion states that

"more needs to be known about the relative cost effectiveness of treatments and services that are displaced to fund the new treatments recommended by NICE."

If we approve something that is so costly that it throws out something very effective that is already in place, what we do is not evidence-based.

I think that the hon. Member for Wellingborough made the point, on the funding of primary care trusts, that the Government absolutely correctly introduced a new system, to base funding on need. No one could object to that. Yet they failed to implement it. They had the opportunity to begin to reduce the difference between historic funding and funding based on need, but they took no step in that direction. So there is still just as great a disparity, and year by year the cumulative effect of underfunding, in many communities, gets greater. Why, having introduced a system for basing funding on need, do the Government not implement it? That is another damning criticism.

The report refers also to the fact that funding that goes to primary care trusts and is intended for good public health initiatives to improve health and well-being often ends up being spent on acute care. That, I am afraid, comes down to the financial incentives in the NHS, and the failures of payment by results. There is now widespread recognition, including from senior people in the Department of Health, that there is an urgent need to reform payment by results. It is sucking funding into acute trusts and away from proactive programmes to improve health and well-being locally. It is essential that we seek urgently to reform that process.

We should also consider the work of Chris Ham and others, from Birmingham university. He puts forward the case for capitated budgets and integrated care organisations bringing GPs to work alongside other professionals in health and social care, so that they have responsibility for the whole budget for the care of patients and an incentive to keep their patients in better health and, particularly, to manage those with chronic conditions better. The funding of those organisations would reflect the level of deprivation and the health needs in the relevant communities.

We must also look much more smartly at the potential role of incentives in driving a change of behaviour, to ensure that the finances are used to address the problem more effectively than in the past. Julian Le Grand, who was an adviser to the former Prime Minister, Tony Blair, put forward the case, in a recent report, for incentivising commissioners to engage with this issue, and to work with local authorities across organisations to produce health and well-being programmes. That might include introducing cycle lanes, or all sorts of imaginative local things, but critically it would involve working with housing, community regeneration and education services, to achieve better outcomes. I visited the Norfolk's primary care trust website last week, to see what it offered for health and well-being, and how it was engaging the community, and I could find nothing. At the moment, the commissioners of health care are failing to grapple with the imperative of addressing the need for health and well-being, particularly in our most deprived communities.

Reference has also been made to incentives for professionals, and the qualities and outcomes framework system, which has made a difference. It has started to change behaviour, but we must surely ensure that QOF incentivises GPs on the basis of outcomes, not procedure. At the moment, payments are made when processes are gone through, not when outcomes are achieved.

Howard Stoate (Dartford, Labour)

I must take issue with the hon. Gentleman on that; most of the QOF measures are evidence-based. They are evaluated by NICE, which is now responsible for negotiating QOF on an annual basis. Most of them are to do with outcomes, such as lowering cholesterol. The number of people whose blood pressure is controlled, and the number whose diabetes is controlled in the long term is not a matter of process. The focus is now very much on outcome.

Norman Lamb (North Norfolk, Liberal Democrat)

I did start my point by saying that QOF had made a difference and had begun to change behaviour, but in areas such as obesity, which involves the measurement of the patient's weight, payment is not on the basis of reducing weight. Smoking is another example; telling a patient to set a date for giving up smoking, and going through certain processes, brings the payment. It is not given for getting the patient to give up smoking.

We must ensure that in all respects QOF is strictly related to outcomes, and that it plays a part in dealing with health inequalities. We also need to examine evidence from other countries, and perhaps insurance systems, to find out the potential value of incentives to change individuals' behaviour. Such initiatives are starting in parts of this country. Again, the use of incentives in deprived communities may begin to affect behaviour. We should be open to those opportunities. The report says that there is no assessment of how much we spend on tackling health inequalities, and the Government need to address that fact.

Finally, I want to mention early years. The report expresses concerns about the impact of Sure Start and children's centres so far. I am a strong supporter of Sure Start, which is an important initiative. I should be extremely concerned about any termination of that programme. However, according to the report there is limited evidence of impact. It expresses concern about the shift towards children's centres. If the programme is to be spread across all communities, will the focus on the most deprived communities be weakened?

The hon. Member for Wellingborough appropriately made the point that the focus needs to be on reaching the households that are hardest to reach. We are not doing so effectively enough. The Worldwide Alternatives to Violence Trust has done fascinating work on the absolute importance of early intervention, and the changes that can be made to life chances by making a difference in the first three years of life. We are not yet doing enough to make that a reality.

David Drew (Stroud, Labour)

I apologise for not being here for the rest of the debate, but we were trying to put the parliamentary reform recommendations to bed.

Does the hon. Gentleman agree—and he will know about this because his constituency mirrors mine—that one of the problems with early-years work is that children in deprived circumstances in very rural areas often lose out, and that we need to be smarter about the way Sure Start and children's centres reach out to them?

Norman Lamb (North Norfolk, Liberal Democrat)

I am grateful for that intervention, because it is an incredibly important point. Measures of deprivation inevitably end up focusing attention on the entrenched areas of deprivation in our inner cities, but they risk missing hidden deprivation in rural areas, which can often be exacerbated by inaccessible services, lack of public transport and so forth. We must be much more sophisticated in analysing where deprivation is, to ensure that people in rural areas do not lose out.

In conclusion, I reinforce the point that I want us to be honest in this debate. There are limits to what we can achieve in this country while we continue to maintain one of the most unequal societies in the developed world. The United States and Portugal are more unequal, but we are up there among the worst, and that has a significant bearing on health inequalities. Unless we address that, we will not tackle a critical problem discussed in the report that I find unacceptable in a civilised society.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

This is an important debate. I congratulate the Select Committee on Health, of which I have had the privilege of being a member for many years. When I first came to the House in 2005 and was asked what Committee I wanted to be on, there was only one answer: health. It took me a couple of months to convince the Whips, but I convinced them and joined the Committee. It is enormously important and considers the evidence very well, and it is exceptionally well chaired by Mr. Barron. I pay tribute to the Committee.

Interestingly enough, the report, when it first came out, drew on a lot of previous reports by the Committee, particularly its excellent report done at the time of the smoking debate. Without the Committee and its proposed amendments, the present legislation would not be on the statute book. I know that whenever the right hon. Gentleman speaks, he always likes to bring up smoking and how we can encourage more people to stop. It is an important issue that I know is close to his heart. Other reports include work on deficits and the funding formula. We looked at inequalities not just in socially and economically deprived parts of the country but in other parts of the national health service, to which I will return in a minute.

The issue of inequalities is nothing new. Beveridge was discussing health inequalities long before I was born, and the House has been discussing it for many years. Increasing progress has been made, but sadly, over the past few years, even according to the Government's own statistics, the situation has been falling back.

As we have heard today, the Government have had a golden opportunity, with more than £100 billion—there will be a debate about just how much, but it looks to be about £110 billion by the time the election comes—of taxpayers' money being spent on the NHS. The report highlights criticisms that have been around for some time, not just from political parties but from experts in the field, about how that money has been spent and why so little of it seems to get to the front line. The evidence in the report shows clearly that one reason is that it is really not known whether the money is being spent efficiently or is working.

The contributions that we have heard today have been eminently sensible. They show that the House really cares about the issue. It is not party political, although we have had a bit of banter. I was disappointed with Norman Lamb—I will call him my friend from the Liberal Democrats—who did a bit of pre-electioneering for a few moments, but he is better than that and he knows it, so I will not bother to comment on the silly remarks that he made.

Peter Bone (Wellingborough, Conservative)

My hon. Friend is making a powerful speech as usual. Am I right in thinking that only the Conservative party has guaranteed to increase spending on health?

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

That is absolutely right. I would have thought that anyone commenting on Conservative party policy would balance their arguments.

Norman Lamb (North Norfolk, Liberal Democrat)

Will the hon. Gentleman give way?

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

Certainly.

Hugh Bayley (York, City of, Labour)

Order. I remind hon. Members to concentrate on the issue of health inequalities.

Norman Lamb (North Norfolk, Liberal Democrat)

I am grateful, Mr. Bayley. Does the hon. Gentleman agree that the causes of health inequalities are largely beyond the NHS?

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

Absolutely, which is why my party, should we be lucky enough to be elected, will change the Department of Health to the Department of Public Health so that we can start locking other agencies into a better working environment. The report criticises the lack of joined-up government on such an important subject, so it agrees in many ways with me that we need to come together as a Government. Different Departments need to work together. The hon. Gentleman is absolutely right: no one Department can solve the problem, but Government can start to get there.

One of my concerns about the report is that although it is crucial that we consider social and economic deprivation, it is not just about deprivation in big cities; there are small pockets of deprivation in the most affluent parts of this great country of ours. We stand in the Palace of Westminster, while not far from here—probably literally within a couple of hundred yards—there is deprivation on the streets of this great city that we are not touching. We heard earlier, when hon. Members were discussing Sure Start, that there are people whom we are not getting to. Sure Start catches all, but it is not targeted at the families who desperately need it. That is one thing we need to look at.

Inequality is not just about social and economic deprivation. There are other kinds of inequality in the health service as well. Older people, for example, face inequalities that younger people do not face. As people get older—although, thank goodness, they are living longer—they start to suffer more problems. Are those problems being addressed in the right way? Is funding going directly to the patient? Is rationing of any description occurring? The accusation has been made in the press for many years that as people get older, the money does not necessarily follow them.

Sadly, ethnic minorities also suffer health inequalities. I accept fully that some ethnic minority groups live in the most socially deprived areas of this country, but others do not. There are issues involving language and how people are helped. At the Conservative party conference in Manchester this year, there was an interesting debate on how to reach groups of people in this country who not only do not speak English as their first language but do not speak it at all. Fantastic work on health inequalities is being done with the Bengali community around Brick lane, particularly with ladies who do not speak any English at all, on how to reach them to get them to come in for breast scanning, cervical smear tests and so on.

That sort of innovation in our communities is the way forward, rather than the Government knowing everything. I agree that the Government have a role, but it involves commissioning rather than, as in most cases, providing. The work done on Brick lane, interestingly enough, used a speaking card that was sent directly to the people whom the hospital thought were at risk. When the card was opened, the message in Bengali was, "You may be at risk; you need to come forward." Such things need to be considered for our GPs' surgeries and so on.

Dr. Taylor, as usual, brought expertise and knowledge from many years—I nearly said centuries—to the debate. I want to touch on one point that is close to the heart of the Chairman of the Select Committee and that we have debated—although, sadly, not for long enough—on the Floor of the House in Committee and on Report: smoking. It is the great pariah out there in our country that causes so many problems. In particular, I want to pick up on the point made by the hon. Member for Wyre Forest about the illicit smoking of tobacco products.

For many years, no matter which party has been in power, the Government have tried to reduce the number of people who smoke in this country. They have done so using many different measures, but mostly through duty and taxation. If we believe that to be right, as I do—I believe that if cigarettes were cheaper, more people would smoke more—how can it be right that millions of cigarettes are brought into this country duty and VAT-free and sold illicitly to whoever comes along at that particular moment in the marketplace, pub or club, without anyone checking their age or anything about them? That affects health inequality in this country in many ways.

Three main types of illicit cigarettes are sold in this country. The first is the new cheap whites, which look like cigarettes that are sold legally, but most of which are made in the eastern bloc and smuggled here. The second is the counterfeits, which concern manufacturers most because they do not make a profit from them. As hon. Members know, I have no truck with tobacco manufacturers and would be more than happy if they went bust tomorrow morning. The third is the simple black market cigarettes that are brought into the country. Those are the greatest problem. It is estimated—it is only an estimate because we really do not know—that they cost £3.6 billion in lost revenue, and there is lost VAT on top of that. That money could be used in public health programmes across the country or to help the Chancellor and Prime Minister fill the black hole of Government borrowing.

We should not only attack the drug barons who are moving into tobacco smuggling; we could tackle the issue immediately by changing how many cartons of cigarettes can legally be brought into the UK from other EU countries. It is often argued that that is a European issue. However, if we wanted to, we could set the level at as few as 40 cigarettes. Other countries have a level as low as 400 cigarettes, which is two cartons. Our current level is 3,500. Every day, Transit vans go to the continent and return with cigarettes that are supposedly for personal use, but which end up in the pubs and clubs in the towns of our constituencies. We could make 400 cigarettes the maximum that can be brought in from other EU countries, and deem anything more as being for use on the black market. We could do that tomorrow morning. That would send a strong message to the black market racketeers and move the smoking debate forward.

A few moments before this debate began, I was on the Floor of the House. The Minister noticed and was worried that I would be late. I was raising the issue of the proxy purchasing of alcohol because during a debate on smoking a couple of weeks ago, the Minister did not accept amendments on the proxy purchasing of cigarettes because they would not be enforceable. Proxy purchasing is a loophole whereby somebody who can prove that they are 18 buys a product and gives it to a minor, whether for profit or not. During today's debate on the Policing and Crime Bill, I asked the Under-Secretary of State for the Home Department, Mr. Campbell whether he thought such a measure would be enforceable. Sadly, he was not able to respond, but looked at me strangely. I said to him that if it is not enforceable, we should find a way of enforcing it so that we can protect our young people. It cannot be beyond the wit of a Government to bring in legislation that bans someone over the age of 18 from supplying cigarettes to a minor. That is an obvious thing we could do to tackle smoking and inequality.

The report is so big that I cannot cover it all. Another topical area it covers is food labelling. For years, the Government and the Food Standards Agency have gone back and forth on what should appear on the front of food packaging to protect the public and give them knowledge about what is in the products they buy. Guideline daily amounts and traffic lights have been considered, and still we wait. There is confusion in the industry and among consumers. Obviously, it would be helpful to have one kind of labelling on the front of all British food products that outlines how good they are for people, what percentage of the recommended daily intake they constitute and how much salt and fat they contain. I hope the Minister will say that that will happen.

Howard Stoate (Dartford, Labour)

Is the hon. Gentleman aware that one of the main reasons why we do not have uniform food labelling, which I am in favour of, is that many manufacturers and large supermarkets will not agree on a system that they can put up with? How does he think we could compel them to sort that out?

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

I have met many manufacturers and producers over the years, as have the Minister and the Select Committee. It is claimed that Europe will not allow us to compel certain things. Apparently, the traffic light system is not legal. We should accept that. However, the GDA system is legal. All the manufacturers seem to have agreed about GDA so why can we not come to an agreement? It would be more logical for a Government who want to protect the public to consider how we could do it, rather than prevaricate and say why we cannot.

Peter Bone (Wellingborough, Conservative)

If we passed legislation that required manufacturers to use one kind of labelling, it would be done. Nobody in the EU would do anything about it, such as fining us. Are we not in favour of bringing powers back from Europe?

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

Absolutely. Rather than go to war, it would be better to find something that can be done within EU law and do it. There is a type of front-of-pack labelling that could be used. We called for it in 2004 and are still waiting in 2009.

I would like to talk about the excellent report for longer, but I want to give the Minister longer than I have had so that she can respond to the questions of hon. Members. If she cannot respond, I am sure she will write to us with the answers.

Finally, obesity is a major issue. To be fair to the Government, some positive research has come out recently that shows a slow-down in obesity rates among children and youths. However, one report does not make the problem go away. As the hon. Member for North Norfolk said, it cannot be just the Department of Health that deals with this issue. However, it must drive it forward because ultimately, it has to sort out the mess caused by obesity. Hospitals are full of people suffering from acute illnesses caused by obesity. There is a social stigma attached to people who are obese, and ever-increasing amounts of bullying are being reported. All too often, the national and local press report the attempted or successful suicides of people who have been bullied because of their weight. That is fundamentally wrong. We must give every possible assistance to tackle obesity.

Christopher Fraser (South West Norfolk, Conservative)

I am listening to my hon. Friend carefully and listened to the other contributions while I was in my office. Does he agree that there is an obligation on supermarkets and food retailers to be more explicit about issues of obesity on the labelling of products that they sell, so that people have a proper idea of what they are eating and the consequences of doing so?

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

I agree completely. It fascinates me that manufacturers get away with some of the comments they make about how healthy their products are—particularly in TV advertising—when they are certainly not healthy.

Norman Lamb (North Norfolk, Liberal Democrat)

The hon. Gentleman is making important points about labelling. Does he agree that there is a powerful case for labelling on alcoholic products? On a related issue, does he think that minimum pricing for alcohol should be introduced? That is a key public health issue and is a recommendation of the chief medical officer. It is another area in which the Government have ignored the scientific advice they have received.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

We are continuing to look at the latter point and have not committed ourselves one way or the other on minimum pricing. As a Conservative, I find the whole concept of minimum pricing very difficult, but we will continue to consider the evidence.

I am becoming increasingly convinced that alcohol products should provide an indication of calorie content, because the simple fact is that if any of us or our partners were to go to any weight-reducing organisation, whether it is run by a local authority or is one of the national programmes, it would tell us that if we consume more than an average amount of alcohol, our weight will be difficult to control. I am a perfect example of that. Since I have given up drinking pints of one particular brand of alcohol—I will have to say that it is Guinness—I have lost in excess of two stone in six months. That was done on the advice of my cardiologist. Do I miss that particular form of alcohol enormously? To be truthful, yes. However, has giving it up helped me enormously? Yes, it has—it has cost me a few more pounds in suits, but I think it was worth while.

The Minister, the hon. Member for North Norfolk and I were at a meeting the other day; again, I am not going to advertise or pick on the hon. Gentleman for being rude at that meeting about my being overweight. It was fascinating to find out there that it can be fun for people to reduce their weight and improve how they feel, particularly in their youth, and that people's self-esteem completely changes. If there is one thing we can do on obesity, it is to stop stigmatising it and encourage people to enjoy themselves in controlling what they eat, particularly through portion size, and in burning off energy through exercise. If we can address that and make it fun, rather than making those people the pariahs of society—as, sadly, much of the media and fashion industry do—we will go a long way towards addressing the whole issue of health inequalities.

As I said, I would love to have spoken for much longer because the report deserves a debate. However, I am conscious that other colleagues have curtailed their speaking time so that the Minister has long enough to respond to the questions and important points raised. If she does not have time, I am sure we would all understand if she responds by writing to us during Prorogation.

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I congratulate my right hon. Friend Mr. Barron, the Chairman of the Health Select Committee, on ensuring that hon. Members have the opportunity to debate the Committee's vital report on the important issue of health inequalities.

At the outset, may I say that I am grateful to my right hon. Friend for his encouragement and support for the seriousness with which the Government take the matter of health inequalities? He has shown regard for the Government's approach and action, while making constructive contributions about how we might better improve. I am absolutely delighted to hear about the Rotherham Institute for Obesity, which Government investment has allowed to happen. I hope that I will get an invitation to visit the institute to see the good it is doing, because it is an example of the work that takes place across the country. People should be proud of that institution.

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

We have agreement and harmony on the issue already.

May I make some general points before referring to the specific matters raised, because I want to allow my right hon. Friend to have the last word, as is right and proper? Tackling health inequalities and improving the health of people in disadvantaged areas and groups has been a priority for the Government since 1997. A comprehensive evidence-based programme to tackle those inequalities has been put in place, including the first ever national target for 2010 on infant mortality and life expectancy at birth, which is backed by a national cross-Government strategy—the programme for action.

During the past 10 years, there have been significant improvements in life expectancy and in dealing with infant mortality for all groups and areas. As we have heard time and again in the debate, it is true that the target remains challenging, but it is also true to say that, as my right hon. Friend suggested, the target has helped us to focus our efforts.

Norman Lamb (North Norfolk, Liberal Democrat)

Will the Minister give way?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

Before I do so, it is worth saying that life expectancy has improved faster in the non-spearhead areas than in the disadvantaged spearhead areas. It is true that the gap has not narrowed as we would wish, but infant mortality is at an historic low level, even for disadvantaged groups. In each of the past three years, the gap has narrowed and if that trend continues, that aspect of the target will be met.

Norman Lamb (North Norfolk, Liberal Democrat)

That in itself is clearly encouraging. However, does the Minister accept that it is not just a question of the gap not narrowing? Overall the report states that, during the past 10 years, in terms of life expectancy, inequalities have increased by 4 per cent. for men and 11 per cent. for women.

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I do not share the doom and gloom of the hon. Gentleman—although I am sure that he did not intend to come across in quite that way—and I think it is important to show where progress has been made. Perhaps he will allow me to explain why I feel that we should acknowledge that this is a difficult matter to turn around and why it would be wrong of me to suggest otherwise.

I know that the Opposition say that targets are not the way to go, but on this matter I think we have some understanding that targets have allowed us to focus and move forward. However, I accept that there is more to do to deliver the target. We have a further two years in which to deal with that and we continue to promote progress through partnerships between local NHS organisations and local authorities. We support local action through national support teams and we use all available levers and processes to bring the health equalities message to the whole of Government, whatever Department that might involve.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

Will the Minister give way?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I will in one second. I want to say up front—this matter has been mentioned—that I very much look forward to Professor Sir Michael Marmot's report, who I recently had the opportunity to meet. His report will review health inequalities and will set us on a firmer footing for the development of a national cross-Government health equalities strategy.

Christopher Fraser (South West Norfolk, Conservative)

Will the Minister give way?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I will give way to Mike Penning first. The review will report to Ministers at the end of this year and will be published in the new year.

Before I take interventions, it is important that I set out the challenge. Health inequalities are extremely difficult to change. They start early in life and continue into not just old age, but future generations. These long-term trends cannot be reversed quickly; they need sustained effort. Health inequalities are the result of a complex and wide-ranging network of factors, some of which we heard about today. My hon. Friend Dr. Stoate particularly expressed that clearly. People who experience material disadvantage, poor housing, lower educational attainment, insecure employment or homelessness are most likely to suffer from poor health and an early death, compared with the rest of the population.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

I wish to make two very quick points. First, I heard the Minister say earlier that she is in agreement with the Chairman of the Select Committee. It is interesting to note that Mr. Barron is from the same party as her and that the Committee is Labour dominated.

However, the point I really want to make is to ask whether she will address the issue of the funding formula, which has been raised. As she says, inequalities must be addressed through an understanding of local needs. It is not just about money going into separate projects; we must deal with what my hon. Friend Mr. Bone talked about and what is happening in my constituency, where the primary care trust is not getting the correct funding formula based on its own formula, services are being closed and people are not getting the services they deserve. There are inequalities across the country.

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

The hon. Gentleman mentions a matter that I was coming on to—as did the hon. Members for North Norfolk (Norman Lamb) and for Wellingborough (Mr. Bone). I am happy to talk about that now.

Within the NHS, the target revenue allocations to primary care trusts are based on the fair funding formula, as we have discussed, and are recommended by the independent Advisory Committee on Resource Allocation, which directs funding to the areas of greatest need. We are committed to moving all PCTs towards their target allocations as quickly as possible, but that aim must be balanced against the need to ensure that all PCTs have sufficient and stable funding that supports their existing commitments and allows long-term planning, recognising the unavoidable cost pressures that all local health services face. Moving PCTs towards their target allocations too quickly would result in some rather painful cuts in services in some PCTs.

Peter Bone (Wellingborough, Conservative)

rose—

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

Perhaps the hon. Gentleman will allow me to answer some of his earlier questions.

It is important to remember that the allocations for 2009-10 and 2010-11 show an average PCT growth of something like 5.5 per cent. a year, with minimum growth figures of 5.2 per cent. in 2009-10 and 5.1 per cent. in 2010-11. The most under-target PCTs will benefit from the highest increases in funding. Over the next two years, the same PCTs' allocation will grow by more than 17 per cent., and they will end 2010-11 only 6.2 per cent. under target. That is a significant achievement by historical standards if one considers that at the start of 2003-04 the most under-target PCT was 22 per cent. below target.

Christopher Fraser (South West Norfolk, Conservative)

I am grateful to the Minister for giving way. I know that my hon. Friend Mr. Bone wants to pick up on the point that she just made, but I am picking up on an earlier point about health inequalities. Does she recognise that there are great inequalities across the country in relation to prostate cancer—an issue that I have raised with her before? Research carried out by the Prostate Cancer Charter for Action has found that in 96 of England's 529 constituencies the death rate from prostate cancer is well above average. Does the Minister recognise that that is not acceptable?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

The hon. Gentleman has previously secured a useful Adjournment debate on that issue, to which I responded. Of course, there are differences in responses to prostate cancer, but that issue is not simply about the inequalities that we are talking about today. There is a whole range of factors to consider, but I am sure that you would say, Mr. Bayley, that they would be better discussed in a relevant Adjournment debate.

I should like to return to the targets we have been discussing. By setting the 2010 national health inequalities target and by learning from experience, we have increasingly been able to show what works and have been able to develop evidence-based resources for local planners of public services. That is something that the Select Committee has been very keen on. In the June 2008 document, "Health Inequalities: Progress and Next Steps", we reconfirmed our commitment to setting out new and enhanced programmes for health inequalities and to ensuring that we have in place the structures and systems needed to support sustainable improvements in health inequalities.

Peter Bone (Wellingborough, Conservative)

Once again, we have heard the Government say that we have the national capitation formula that is based on the needs of particular areas, but they are not meeting those figures because they are overfunding elsewhere. If I had a pound for every time a Minister has told me, "We are closing this gap," I would be a very rich man, but there is no evidence that they are closing the gap. If it is closing and if we are going to get to the point at which we have the fair formula, will the Minister tell me the date on which that will happen?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I have already outlined the progress that has been made on that, and I assure the hon. Gentleman, as my colleague Ministers have, that we will continue to make progress.

Comments have been made about the bleak outlook before us, and I have expressed my concerns about the picture that the hon. Member for North Norfolk painted of the situation. The latest life expectancy data for 2006-08 showed an average increase in life expectancy in spearhead areas of 3.1 years for males and 2.1 years for females. The same figures showed an average increase across England of 3.3 years for males and 2.3 years for females, compared with 1995-97 baseline figures. As I have said, infant mortality is at an historically low level. We should acknowledge where there have been achievements.

Let me turn specifically to the Committee's report. I welcome the report and its call for more work on health inequalities, not least by proposing a 10-year extension to the life of the national target. I am glad that colleagues feel the target is useful, because it makes a difference. I also agree with the Committee about the need to do more to address inequalities. The report will help us sharpen our efforts on framing policy, delivering change and ultimately narrowing the inequality gap.

It might help hon. Members if I briefly outline some of the Government's actions on health inequalities. In 1997, the Government set up an inquiry, which was run by the former chief medical officer Sir Donald Acheson. The inquiry pulled together evidence on health inequalities, which showed a marked widening of the gap over the previous 20 years and made clear the link between health and wealth. Since then, we have established the first ever national health inequalities targets on infant mortality and life expectancy, we have developed an ambitious national health inequalities strategy, which is backed by 12 Departments, and we have incorporated the health inequalities message across public services to make it part of everybody's business. I think that those are stretching targets and demands. We are building on that work and developing a post-2010 cross-Government health inequalities strategy.

As we have heard today, the Government also have a strong record on taking action to address the causes of ill health, including on smoking, which is a real driver of inequality. I hope that all right hon. and hon. Members present will join me in welcoming the measures on tobacco control in the Health Bill, which prohibit the sale of tobacco from vending machines and will bring an end to the display of tobacco. Those measures will help to protect children from being new recruits to smoking and will help people to quit.

Norman Lamb (North Norfolk, Liberal Democrat)

The Minister has mentioned the Acheson inquiry and its recognition of the link between health and wealth, as she put it. Work on precisely that issue has been done by Richard Wilkinson, who I understand is soon to present a seminar to the Cabinet—a little late, sadly. Does she accept his case that if we are to make real progress we must address inequality within society?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

That is the theme that I have been trying to develop. It is true that inequality remains a challenge, but it is not true that no progress has been made. That is the only point to which I draw the hon. Gentleman's attention.

We know that it will not be easy to reverse the trend of widening health inequalities and to improve the health of all. There is no single formula or blueprint for tackling this matter, so the Government have had to blaze our own trail. We have built on the evidence in the Acheson report and have negotiated new directions in the business of government to give us the flexibility to meet the needs of individuals, communities and families. I repeat that by setting a target and learning from experience, we have been able to show what works and have been better able to develop evidence-based resources for local planners of public services.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

The Minister has talked about the measures in the Health Bill banning the sale of tobacco from vending machines—I understand that the Bill might already have received Royal Assent. I have nothing but admiration for the Chair of the Select Committee, who has for years advocated such a ban and has been involved in that argument time and again. However, at no time during the Bill's passage through the Committee and Report stages, during which time all the evidence was there, did the relevant Ministers say that the Government wanted to ban the sale of cigarettes from vending machines.

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

rose—

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

I have not finished. At the last minute, Ministers tore up their proposals and accepted proposals from Labour Back Benchers that have caused problems for the Bill, but have now been addressed. What made Ministers suddenly change their minds after the Bill had gone through Second Reading, Committee and Report? Why did they suddenly think, "Ah, we'll ban it today"?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

We have already had that argument. I know the hon. Gentleman still resents the effort the Government have agreed to make on tobacco control, but the fact is that the Bill was always written to allow either restrictions or a ban, as he knows. We said we would test the will of the House and that is what we did. Rightly, the House spoke and the Government gave effect to that. I gently suggest that it is time he accepted not only the will of the House, but the Government's efforts to protect young people from smoking and help others to quit.

Howard Stoate (Dartford, Labour)

May I say how welcome are the significant changes the Government have made since the Acheson report and the real improvements in policy? However, does the Minister share my regret that the previous Government's burial of the Black report and of the subsequent report by Margaret Whitehead in 1985 puts us at least 20 years behind the improvements that could have been made had we taken the issues more seriously earlier?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

My hon. Friend always makes clear and informed points. As I said earlier, health inequalities widened over those 20 years because of inaction, and now we are in a position—[Interruption.] Opposition Members may not like it, but there has been an improvement and, more importantly, there are moves forward. I am afraid the idea that all that can be turned around overnight is totally unrealistic.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

Will the Minister give way?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I would like to continue, because Opposition Members have raised several points already.

My right hon. Friend the Member for Rother Valley referred to evaluation. We have audited and reviewed the results of a range of programmes, including our own work on health inequalities, to make our effort on narrowing the gap more effective. I recognise that we need to strengthen policy and programme evaluations further and can assure Members that we have encouraged programme evaluation as part of our approach to tackling health inequalities so as to learn and do better.

With regard to the role of the NHS, we emphasised in our response to the Committee's report that the NHS has a key role to play through its planning and commissioning arrangements, but there are many major NHS programmes, such as those for cancer or coronary heart disease, that have a health inequalities dimension, as do the public health prevention programmes on smoking, alcohol and obesity. In primary care, improving access for and outreach to disadvantaged groups in areas is a priority. We also fund a range of specific initiatives to support the delivery of the national health inequalities target set out in our report "Health Inequalities: Progress and Next Steps."

The hon. Member for Hemel Hempstead stressed the importance, as I do, of cross-Government action. Our response to the Committee's report states, by way of agreement, that effective cross-departmental action

"is a hallmark of the Government's approach as shown from 2002/03 onwards through the Treasury-led cross cutting review and the Programme for Action. It has also included close working with individual departments particularly the Department for Children, Schools and Families (DCSF)...The learning process is bearing fruit. Ken Judge, a leading academic, has suggested that 'Perhaps the best example of a focused strategy with a clear action plan to achieve specified reductions in inequalities can be found in England'".

I believe that that judgment reflects recent developments, particularly with regard to infant mortality.

Health inequalities are everyone's business, and I wish to emphasise that we see effective partnerships across Departments. We monitor links between Departments on our wider ambitions in order to deliver a long-term, sustainable reduction in health inequalities. We do that through our regular status reports, which look at reductions in child poverty, improvements in housing and educational attainment, and reductions in deaths from cardiac heart disease and cancer. We are also working across Government on the Equality Bill to ensure that the link between socio-economic disadvantages and the other dimensions are fully accounted for in policy making.

Dr. Taylor referred to secondary care. Perhaps I can assure him that Professor Marmot's review will look at the key health factors contributing to health inequalities in primary and secondary care. The results of that review will be taken alongside NHS policy developments such as the Darzi report to contribute to what I hope will be a comprehensive post-2010 health inequalities strategy.

I am glad that the Committee welcomes the decision to make personal, sexual and health education a statutory part of the curriculum. Members will know that my right hon. Friend the Secretary of State for Children, Schools and Families has agreed to take forward the recommendations of the Macdonald review as soon as possible, and we will work with that Department to ensure that the work is carried out as soon as possible.

The hon. Member for Wyre Forest also asked about children's services, and there was much discussion on Sure Start. Having a centre in each community means that many more disadvantaged children and their families can benefit from those services, as I see happening in my constituency in Lincoln, which will help to end child poverty and improve community cohesion. Sure Start is an example of where we have learnt and further developed the programmes from their initial pilots, and they have continued to grow.

Richard Taylor (Wyre Forest, Independent)

With regard to Sure Start and children's centres, is there any way that the Minister and the Department can monitor the uptake by the disadvantaged families that we are so keen to involve, rather than the better-off who do not actually need the services?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I do not think that is necessarily a helpful distinction. I know from my own experience that the fact that all families can access those services removes stigma. One of the great successes of Sure Start has been that the promotion of breast-feeding, good parenting and good nutrition, for example, is not aimed only at the most disadvantaged.

Norman Lamb (North Norfolk, Liberal Democrat)

Will the Minister give way?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I will take one more intervention.

Norman Lamb (North Norfolk, Liberal Democrat)

The Minister said that Sure Start and children's centres are an example of how the Government have learned, but the Committee's report suggests otherwise. Has there actually been an evaluation of the impact of shifting from Sure Start to children's centres and spreading them across all communities, and was that effectively piloted? While it is fair to say that every mother needs guidance and support, surely if we are to address health inequalities we need to target that effort in the most disadvantaged communities. Is there any evidence that the policy is achieving that?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I am a little worried that hon. Members are suggesting that we should cut back on Sure Start. I know that it is the policy of the Opposition to close Sure Start centres and move the services elsewhere. I remember the pilot from way back, and I think that the Sure Start centres and services we see are extremely popular and well received.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

Will the Minister give way?

Gillian Merron (Minister of State (Public Health), Department of Health; Lincoln, Labour)

I will not give way because I want to allow time for my right hon. Friend the Member for Rother Valley to speak.

At the local level we do see changes. For example, the gap between women's life expectancy in Southwark and that of the rest of England has been not only narrowed, by closed completely: female life expectancy in Southwark has jumped from 78.7 years to 82.4 years, which is higher than the average life expectancy for England. In Manchester that gap for men is being closed: male life expectancy there has risen from 70.1 years to 73.8 years. Life expectancy in Hackney has increased faster than the English average for both males and females. If those areas can improve, so can others.

We remain committed to supporting local partners to tackle inequalities. There is much more to do if we are to retain and build on the progress we have made over the last few years and lay the foundations that the Committee rightly asks us to for a long-term and sustainable reduction in health inequalties in the future. That recognition has informed our decision to ask Professor Marmot to conduct the review, and he is the world's leading expert in that field. I am delighted that the Committee has welcomed that decision and emphasised the potential contribution that that work can make.

A key part of the work that Sir Michael will undertake for us in England will be to explore how to translate the evidence into promising areas for policy development, and what that will mean for delivery and implementation on the ground. It is exactly what the Select Committee is looking for. The review will provide a fresh and rich source of material that will be invaluable to the Committee and to the Government.

Health inequalities are persistent and difficult to change, but we remain committed to and focused on tackling this blight on the lives of people across the country. The learning from the past 10 years and the results of the forthcoming Marmot review will mean that we will be better placed than ever to deliver on our ambition of achieving a long-term, sustainable reduction in health inequalities.

Norman Lamb (North Norfolk, Liberal Democrat)

Will the right hon. Gentleman give way?

Norman Lamb (North Norfolk, Liberal Democrat)

I said clearly that despite the clear evidence in Richard Wilkinson's analysis in "The Spirit Level", we have a duty to do everything that we can to reduce the health inequalities that exist in our society here and now. Has the right hon. Gentleman seen that analysis, or the incredibly compelling evidence from international studies which show a clear link between income inequalities and health inequalities?

Howard Stoate (Dartford, Labour)

My right hon. Friend has basically agreed with what I said earlier, which is that it is more to do with perceptions. There are far more deeply rooted factors than simply wealth inequality. It is about how people perceive themselves and their role in society. That can have just as big an effect as material wealth in itself.

Michael Penning (Shadow Minister, Health; Hemel Hempstead, Conservative)

Over the years, we have assumed that fast-food outlets are something new. Of course, the big chains are new, but I grew up in north London and the east end of London in socially deprived areas, which have always had pie and mash shops, jellied eel shops, bagel shops and salt beef. The crucial difference now is the amount of exercise that is being done after people eat an amount of fast food.

Hugh Bayley (York, City of, Labour)

Despite the uncertainty about the time available, I think we have had a good debate about an important issue. I thank all hon. and right hon. Members who participated for exercising enough restraint to ensure that everybody who wanted to speak was able to do so.

Question put and agreed to

Sitting adjourned