Part of the debate – in the House of Lords at 8:08 pm on 27 October 2003.
My Lords, I congratulate the noble Lord, Lord Chan, on initiating this debate. While I do not have a particularly strong connection with the north-west region, when one looks at the figures it is clear that that region is uniquely deprived in terms of health inequalities. If anything, the noble Lord rather interestingly understated the problem. The North West still has the highest death rate of all the health regions in England. Breast cancer and male lung cancer rates continue to increase, in spite of falling national rates. Even the levels of lead found in drinking water are particularly high in the region.
There is also a marked contrast between the health of those living in affluent, professional areas—there are quite a number of them—and that of those living in the areas of lowest income, concentrated in urban locations and other areas of social housing. Rates of long-term illness and infant mortality in those lowest income areas are almost double those of the more affluent, professional areas.
Children in the North West are more likely than on average nationally to grow up in lone-parent households or those with no one in full-time employment, which is reflected in their relatively poor health. Further, the infant mortality rate is 6.5 per 1,000 live births, compared with a rate of 5.8 per 1,000 for the rest of the United Kingdom. Those are very significant figures and it is in that context that we need to look not only at issues of how to tackle health inequalities in the region, but also more generally to see what effect current government policies have had.
Back in 1997–98, all welcomed the Acheson report and inquiry. The White Paper, Saving Lives: Our Healthier Nation, which followed, marked a major recognition that health inequalities are not caused only by health factors, they are influenced by a whole range of other factors. The key aims of the report, which received a wide welcome, were: first, to improve the health of the population as a whole by increasing the length of people's lives and the number of years spent free from illness and, secondly, to improve the health of the worst-off in society and to narrow the health gap. Those were laudable aims that sought to put public health at the forefront of public policy.
Even today, no one argues with the setting of the four priority areas. It is interesting that one of those key areas was mental health, so cogently discussed by the noble Earl, Lord Listowel.
Following the report, in January 1998, the Northwest Partnership established a regional action for health task group. More recently, the North West Public Health Team, based in the Government Office for the North West in Manchester and part of the Department of Health, has areas of responsibility which include working with regional and local agencies as well as the NHS to ensure that the wider determinants of health are recognised in policies and activities. Those are direct echoes of the lessons of Acheson. I found most interesting the comments of the noble Baroness, Lady Massey, when she spoke of the possible over-medicalisation of health policy: this is—to use a favourite Treasury expression—an area where cross-cutting must take place into other areas of policy.
The second limb of the effort being made by the North West Public Health Team is that of supporting the NHS by providing professional leadership development and intervention where appropriate. That, too, is extremely important. Further, as was mentioned by the noble Lord, Lord Chan, the Investment for Health plan is being carried forward.
All those efforts are important, but what is probably the more vital piece of work is a national one, because it looked at what kind of policies are needed across a broad front to tackle inequalities. I refer to the 2002 Cross Cutting Review from the Treasury, which identified that, despite increasing prosperity and a reduction in mortality over the past 20 years, there are still significant differences in health status between regions, between different social groups and so forth. Those differences between social groups are quite extraordinary. For example, life expectancy at birth between men in social class one and those in social class five widened from 5.5 years over the period 1972–76 to 7.4 years in 1997–99. Those figures can be replicated in different areas of the country. A similar comparison can be made of death rates in the North West and those in the leafier parts of London such as Kensington and Chelsea and Richmond.
One of the key lessons to be learnt from both Acheson and the Cross Cutting Review is that policies are needed to tackle inequalities not only in geographical terms, but also between different groups within the population. A further lesson was reflected in the point made by the noble Baroness, Lady Greengross, concerning the gradient of those inequalities which has been identified.
That means that, laudable though they may be, efforts such as the neighbourhood renewal strategies which target the worst-off areas are all very well, but they do not necessarily address the extent of the needs of particular groups such as older people living on lower incomes, children and other groups. Particular challenges are also presented by the needs of black and ethnic minority groups, disabled people and so forth. One needs a dual strategy that addresses both regional and local inequalities as well as inequalities within groups.
Some of the studies carried out by independent groups into the progress that has been made are very interesting. Particularly interesting is the UCL study undertaken by Mark Exworthy and colleagues, which was funded by the Joseph Rowntree Foundation and published in March this year. Although they say that some progress has been made, they identify three key gaps. First, a lack of mechanisms to promote and ensure progress in policies to tackle health inequalities; secondly, a need for an independent, regular evaluation of the progress of policies in terms of their impact on individuals, intermediate markers of progress and targets; and, thirdly, a need to conduct and collate research studies on effective interventions and outcomes.
They make some extremely practical suggestions. First, the role of the Inequalities and Public Health Task Force could be revised; secondly, the terms of reference of the ministerial sub-committee on social exclusion could be amended to include tackling health inequalities; thirdly, that sub-committee could be required to produce an annual progress report for Parliament; fourthly, a special, cross-departmental Select Committee could be formed, drawn from relevant departmental Select Committees. This may be a little mechanical, but I suspect that it is needed in order to get a genuine cross-cutting approach. The language now is "cross-cutting". It used to be "joined-up government", but we are trying to achieve the same outcome.
On the evaluation front, a mechanism could be created—possibly under the auspices of a new Select Committee or the Audit Commission—to scrutinise and independently evaluate progress, and mechanisms could be introduced to enable local authority scrutiny committees to include health inequalities within their remit. Those are very practical suggestions.
At the last general election the King's Fund produced an interesting briefing paper on inequalities in health. It questioned whether government policies had really made a difference. It states that many of the government targets have been limited to counting death rates for major illnesses; that the NHS still employs the majority of its energies on healthcare rather than on health improvement; and that much of the work taking place is small-scale, short-term in nature and not properly bolted into communities.
So there is a prescription. There are some extremely useful ideas out there. The Government's intentions have always been extremely good in this area but we still lack the mechanisms to get power behind the policy—and that is what is needed.